Master of Ceremonies

Jessica M Gordon, PhD Florida Coalition President Housekeeping Items

• Itinerary • Restrooms • Breaks & Snacks • Cell Phones • Lunch • Continuous Education • Speaker Disclosure Opening Remarks

Dr. Parimi, JHACH Maternal Fetal Neonatal Institute Keynote speaker

Celeste Philip, MD, MPH Florida Department of Health Surgeon General and Secretary Breastfeeding Friendly Recognition

Krista Schoen Florida Department of Health Bureau of Child Care Food Programs Objectives

 Identify the goals of the breastfeeding friendly child care initiative  Understand the process to follow to earn the breastfeeding friendly recognition  Identify future needs and ways to help promote/expand program

7 Why?

CDC Breastfeeding Report Card 2016

Indicator Florida National Average Ever Breastfed 81.1% 81.1% BF at 6 mos 47.3% 51.8% BF at 12 mos 24.6% 30.7% Exclusive BF at 3 mos 44.9% 44.4% Exclusive BF at 6 mos 18.4% 22.3%

8 How?

Florida Breastfeeding Coalition + Florida Department of Health = Collaboration!

9 Breastfeeding Friendly Recognition

 Recognize breastfeeding friendly child care facilities  Provide educational opportunities  Enhance providers’ awareness of the importance of breastfeeding

10 What Does Breastfeeding Friendly Mean? Facilities:  Welcome and encourage breastfeeding  Provide a supportive environment for to continue to breastfeed when returning to work or school  For families and staff  Have accurate written materials available to  Feed on cue, not by schedule  Staff are trained in the benefits of breastfeeding and how to store/handle milk  Have a written policy regarding a commitment to breastfeeding

11 www.floridahealth.gov/ccfp www.flbreastfeeding.org

12 Storage Guidelines

13 Breastfeeding Friendly Self-Assessment

1. Your facility welcomes and encourages breastfeeding  Facility encourages mothers (including employees) to nurse during the day  There are breastfeeding posters/materials on display  There are learning/ materials available that normalize breastfeeding (e.g. children’s books with pictures of babies or animals nursing)

14 Breastfeeding Friendly Self-Assessment

2. You provide a supportive environment for mothers to continue to breastfeed when returning to work or school  Parents are told about the facility’s commitment to encouraging breastfeeding  Families receive written information about breastfeeding (not created by formula companies)  A quiet, comfortable place to nurse or pump is available for moms (including employees)

15 Breastfeeding Friendly Self-Assessment

3. Accurate written materials are available  Staff is familiar with materials and local support available (, WIC, etc.)  Staff refer moms as appropriate

16 Breastfeeding Friendly Self-Assessment

4. You feed infants on cue, not by schedule  Breastfed babies do not receive any food or drink (other than ) unless indicated by parents.  Ask moms what to do if breast milk supply is gone or if baby is hungry and mom is expected to pick up child soon

17 Breastfeeding Friendly Self-Assessment

5. All staff are trained in the benefits of breastfeeding and how to store/handle milk  Staff show a positive attitude towards breastfed babies – not that they are “more difficult”  Staff are familiar with proper breast milk storage and handling

18 Breastfeeding Friendly Self-Assessment

6. You have a written policy regarding a commitment to breastfeeding  Staff are familiar with the breastfeeding policy  Policy is available for staff and parents to review  Sample policies available on Florida Breastfeeding Coalition (FBC) website: www.flbreastfeeding.org or the Florida Child Care Food Program website: www.floridahealth.gov/ccfp and also on the following slide

19 20 Collaboration

21 Breastfeeding Friendly Recognition Data

 Total number of certificates awarded: 233  200 centers  33 day care homes  Includes 28 centers and homes that do not participate on the CCFP

22 Most Downloaded Materials Title of Product August Downloads Total Downloads Breastfeeding and Work: A Guide 9,998 11,724 for Moms Tools for Moms Returning to 2,915 3,652 Work Employee Rights Workplace Flyer 85 249 Feeding Tips for Breastfed Babies 59 225 in Childcare Facilities Magnet

23 Contacts

Krista Schoen Florida Child Care Food Program Florida Breastfeeding Coalition Board Member [email protected] 850-245-4444 x. 2853 www.floridahealth.gov/ccfp

Esther March Singleton Florida Breastfeeding Coalition Board Member Broward County Breastfeeding Coordinator 954-467-4700 x. 4309 [email protected] www.flbreastfeeding.org

24 Thank you!

www.flbreastfeeding.org

www.floridahealth.gov www.floridahealth.gov/ccfp

25 Sustaining Breastfeeding Friendly Communities Panelist

Breastfeeding Friendly Birthing Facilities LaChelle Reece, RN, BSN, IBCLC Heidi Agostinho, PhD, IBCLC Angela Monk MPH RN IBCLC Carol Lawrence, PhD. MS, BSN, RNC-OB, CBC Nancy Travis, MS, BSN, RN, BC, CPN, CBC

Breastfeeding Friendly Pediatric Practices Cara Cannon, MD, MS & Cindy Wallace CPNP, ARNP, IBCLC

Breastfeeding Friendly Child Care & Workplace Designation Stephanie Markefta, PhD Krista Schoen, MS, RD, LD Nancy Faul BS, IBCLC, RLC Using CDC mPINC Hospital Report to Make Change

North Florida Regional Healthcare Heidi Agostinho, PhD, IBCLC LaChelle Reece, RN, BSN, IBCLC Agela Monk RN. MPH. IBCLC

©2010 North Florida Regional Healthcare 2 7 What is the mPINC Report?

 National survey of  Helps hospital meet Joint Maternity Care Practices Commission Core Measure  Measures feeding for breastfeeding practices, policies, and requirements 79.94% staffing expectations in  Ensure hospital staff is place at hospitals that trained in infant feeding care provide maternity services and grades them  Improve continuity of

 Used by Hospitals, States care and Local agencies to  Celebrate what we are monitor and help hospitals doing well to improve practices NFRMC 2015

D D D Plans For Improvement Create continuity of care among healthcare team

 Increase new staff training to  Identify what we do 18 hours of breastfeeding right education

 Eliminate  Increase current staff unnecessary training/education to 5 hours/year supplementation  Decrease use of pacifiers-  Create new practice goal to remove pacifiers for hypoglycemia except for painful procedures and NICU use

 Review and improve  Monitor reasons for practice around supplementation with hyperbilirubinemia corrective action  Market free online breastfeeding class Glucose Gel for Hypoglycemic Infants

Issues we aimed to impact What we found

 Exclusive Breastfeeding Rates  Easy to implement

 Introduction of foreign protein  On average blood glucose increased by 18.5 points after  Patient satisfaction 1st administration

 Only a small % needed a second administration rd  If an infant needed a 3 administration they typically needed to be admitted to NICU

 Fewer physician calls

 Improved quality of care

 Happy families, nurses, and doctors References

North Florida Regional Medical Center mPinc Report Implementing a Protocol Using Glucose Gel to Treat Neonatal Hypoglycemia Nurs Womens Health. 2016 Feb-Mar;20(1):64- 74. doi: 10.1016/j.nwh.2015.11.001. Epub 2016 Feb 12. Lactation Office 352-333-5315 34 to OB, CBC OB, - Bright! Golden Hour Golden the Shining Shining Support Breastfeeding Breastfeeding Support Using Using Friendly Birthing Practices Practices Birthing Friendly Nancy Travis, MS, DFB CPN, BSN, RN, CBC, BC, Nancy Travis, 4/22/17 Carol Lawrence, PhD. MS, BSN, RNC PhD. Lawrence, Carol

#3400.159 Rev. 10/16 Definition of the Golden Hour

Webster defines The Golden Hour as: The hour immediately following traumatic injury in which medical treatment to prevent irreversible internal damage and optimize the chance of survival is most effective

Birth of a newborn is a potential medical emergency. What we do in the first hour after delivery can be the difference in how a baby transitions into this world!

35 Key Components of Golden Hour

• Place infants skin-to-skin immediately (within 5 minutes) after the birth

• Delay non-essential care, such as infant bathing, weighting, infant measurements- head circumference and length, open visitation, holding by family members, medications, and hypoglycemia screening until after the Golden Hour was completed and preferably until the infant has breastfed for the first time

36 Skin-to-skin Skin-to-skin contact immediately after birth as an evidence-based nursing intervention that promotes the well-being of mothers and their term newborns.

Providing the with the opportunity to hold her Bottle? infant in skin-to-skin contact after birth can provide a sense of control and empowerment to the mother- increased maternal satisfaction and confidence. Implementation • Began 2003 at Cape Coral Hospital - desire to be more patient-family centered • Nurses – presented at staff meetings • Binder and tools for additional education • Pediatrician & OB champions • Provider education • Implemented system-wide • Challenges: provider resistance; rush to weight, bathe, pass around… The Results

100.0% Exclusive Breastfeeding Skin-to-Skin First Hour

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

39 References • American Academy of , American Heart Association. (2011). Neonatal resuscitation textbook (6th ed.). Elk Grove Village, IL: Author. • Bergman, N. J., Linley, L. L., & Fawcus, S. R. (2004). Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatrica, 93, 779-785. doi: 10.1111/j.1651- 2227.2004.tb03018.x • Christensson, K., Bhat, G. J., Amadi, B. C., Eriksson, B., & Höjer, B. (1998). Randomised study of skin-to-skin versus incubator care for rewarming low-risk hypothermic neonates. The Lancet, 352, 1115. doi: 10.1016/S0140-6736(98)00028-2 • Galligan, M. (2006). Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN, 31(5), 298-304. Retrieved from Pubmed database. • Gouchon, S., Gregori, D., Picotto, A., Patrucco, G., Nangeroni, M., & Di Giulio, P. (2010). Skin-to-skin contact after cesarean delivery: An experimental study. Nursing Research, 59, 78-84. doi: 10.1097/NNR.0b013e3181d1a8bc • Gray, L., Watt, L., & Blass, E. M. (2000). Skin-to-skin contact is analgesic in healthy newborns. Pediatrics, 105(1), e14-e19. doi: 10.1542/peds.105.1.e14 • Marin Gabriel, M.A., del Rey Hurtado del Mendoza, B., Jimenez Figueroa, L., Medina, V., Iglesias Fernandez, B., Vazquez Rodriguez, M., Escudero Huedo, V., & Medina Malagon, L. (2013). Arch Dis Child Fetal Neonatal Ed, 98(6), F499-503. • Meek, J.Y. & Noble, L. (2016). Viewpoint: Implementation of the Ten Steps to Successful Breastfeeding Saves Lives. JAMA Pediatrics, Epub, p. E1-2. doi:10.1001/jamapediatrics.2016.2015 • Moore, E. R., Bergman, N., Anderson, G. C., Medley, N. (2016). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, (5). Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003519.pub4/full • Nolan, A., & Lawrence, C. (2009). A pilot study of a nursing intervention protocol to minimize maternal-infant separation after cesarean birth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 38, 430-442. doi: 10.1111/j.1552-6909.2009.01039.x • Stevens, J., Schmied, V., Burns, R., Dahlen, H. (2014). Immediate or early skin-to-skin contact after caesarean section : A review of the literature. Matern Child Nutr. DOI: 10.1111/mcn.12128. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24720501

• Velandia, M., Matthisen, A., Uvnäs-Moberg, K., Nissen, E. (2010). Onset of vocal interaction between parents and newborns skin-to-skin contact immediately after elective cesarean section. Birth Issues in Perinatal Care, 37(3), 192-201. doi: 10.1111/j.1523-53X.2010.00406.x Maintaining a Breastfeeding Friendly Pediatric Practice

Cara Cannon, MD, MS Cindy Wallace, ARNP, IBCLC Lakeland, FL Lakeside Pediatrics Structure

• 2 Locations – 1 with extended hours – Weekend hours – Walk-in weight check available daily – Providers available by phone 24/7 • Triage nurse available during business hours with face-to- face or messaging access to all providers • 7 MDs – 5 full-time – 1 in IBCLC training • 6 ARNPs – 4 full-time – 2 are IBCLCs – 1 interested in IBCLC training at some point – Our first IBCLC was staffed in 2009 (Christine…..) Breastfeeding Support • All breastfeeding newborns seen daily by MD at LRH prior to discharge – Receive IBCLC support from LRH LCs • All breastfeeding newborns seen in the office the day after discharge and daily, if needed, until nursing well – Referred to lactation provider if any issues – 1 day breastfeeding plans • Lactation room available at each location stocked with breastfeeding pillows, nipple shields, nipple pads, syringes, SNS, changing station • Lactation appointments available daily Monday through Saturday (LLL trained help available Saturday mornings) Breastfeeding Support

• Lactation Committee of MDs, ARNPs, MAs that meets quarterly – Breastfeeding policy, Nursing Anniversary bulletin board – Tracking breastfeeding rates – Staff training (Providers and MAs) – Communication with LRH Lactation consultants – Also members of Polk County Breastfeeding Network • Bi-Monthly Patient Support Groups – Saturday morning and Thursday evening – WIC Peer Counselor, MA available for weight checks • Handouts available – 1 day breastfeeding plan, storing breastmilk, suck training, all-purpose nipple ointment, engorgement, etc. Improving and Maintaining Breastfeeding Rates • Increasing awareness about • Working on efficient and breastfeeding accurate data collection – Lakeside website – Difficulty with EHR – Prenatal meet and greets • Polk County Breastfeeding • Education of moms and families Network – Easy access to lactation appointments – Support groups – Availability via phone through triage MA • Education of providers and staff – Breastfeeding friendly policy • Training modules – Eliminating use of formula started by the practice unless medically necessary – Lactation education at provider operations meetings Obstacles to Improving Breastfeeding Rates

• Prenatal education of moms and families – Breastfeeding rates at local hospital are generally poor • LRH with plan to become Baby-Friendly Hospital – Importance of support/education in the first 3 days • Education regarding mother’s expectations, pumping, what’s in formula and when is it necessary • Daily follow up is difficult for some families • Communication between outside hospitals, hospital lactation consultants, NICU, and our practice • Time constraints of MDs and ARNPs • Reimbursement for lactation appointments MORSANI COLLEGE OF MEDICINE MORSANI UNIVERSIT Y OF SOUTH F LORIDA UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE

COLLEGE OF PUBLIC HEALTH UNIVERSIT Y OF SOUTH FLORIDA

BreastfeedingCOLLEGE OF NURSING Friendly Childcare UNIVERSIT Y OF SOUTH FLORIDA Designation: COLLEGE OF PHARMACY PerceptionsUNIVERSIT Y OF SOUTH from FLORID CenterA Administrators and Staff in the Tampa Bay Area

SCHOOL OF PHYSICAL THERAPY & REHABILITATION SCIENCES UNIVERSIT Y OF SOUTH FLORIDA

Stephanie L. Marhefka, Ph.D. © United States Breastfeeding Committee

Our Practice Is Our Passion Purpose & Methods • Explore administrators’ perspectives regarding designation from the Florida Breastfeeding Friendly Child Care Initiative (FBFCCI) • Randomly selected licensed childcare centers • Semi-structured interviews with childcare center administrators (CCAs) (n=28) • Staff surveys (n=108) MORSANI MORSANI COLLEGE OF MEDICINE COLLEGE OF MEDICINE MORSANI MORSANI UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE © Sara D. Davis

COLLEGE OF PUBLIC HEALTH COLLEGE OF PUBLIC HEALTH UNIVERSIT Y OF SOUTH FLORIDA Our Practice Is Our Passion UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF NURSING COLLEGE OF NURSING UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF PHARMACY COLLEGE OF PHARMACY UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

SCHOOL OF PHYSICAL THERAPY SCHOOL OF PHYSICAL THERAPY & REHABILITATION SCIENCES & REHABILITATION SCIENCES UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA Results

Number of CCAs Number of CCAs interviewed who had heard about FBFCCI

MORSANI MORSANI COLLEGE OF MEDICINE COLLEGE OF MEDICINE MORSANI MORSANI UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE

COLLEGE OF PUBLIC HEALTH COLLEGE OF PUBLIC HEALTH UNIVERSIT Y OF SOUTH FLORIDA Our Practice Is Our Passion UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF NURSING COLLEGE OF NURSING UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF PHARMACY COLLEGE OF PHARMACY UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

SCHOOL OF PHYSICAL THERAPY SCHOOL OF PHYSICAL THERAPY & REHABILITATION SCIENCES & REHABILITATION SCIENCES UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA MORSANI MORSANI COLLEGE OF MEDICINE COLLEGE OF MEDICINE MORSANI MORSANI UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE

COLLEGE OF PUBLIC HEALTH COLLEGE OF PUBLIC HEALTH UNIVERSIT Y OF SOUTH FLORIDA Our Practice Is Our Passion UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF NURSING COLLEGE OF NURSING UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF PHARMACY COLLEGE OF PHARMACY UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

SCHOOL OF PHYSICAL THERAPY SCHOOL OF PHYSICAL THERAPY & REHABILITATION SCIENCES & REHABILITATION SCIENCES UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA Breastfeeding Duration

Breastfeeding Exclusivity The best time for How important is it babies to start that all parents wait eating solid food is vs until infant is at least when they are 2-3 6 months old to start months old solid food

FALSE: 11.1% IMPORTANT: 65.7% MORSANI MORSANI COLLEGE OF MEDICINE COLLEGE OF MEDICINE MORSANI MORSANI UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE © United States Breastfeeding Committee

COLLEGE OF PUBLIC HEALTH COLLEGE OF PUBLIC HEALTH UNIVERSIT Y OF SOUTH FLORIDA Our Practice Is Our Passion UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF NURSING COLLEGE OF NURSING UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF PHARMACY COLLEGE OF PHARMACY UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

SCHOOL OF PHYSICAL THERAPY SCHOOL OF PHYSICAL THERAPY & REHABILITATION SCIENCES & REHABILITATION SCIENCES UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA Conclusions

 Marketing

 Advisory group of staff and administrators

 Accessible education and stigma-reduction training

 Cost-effective and sustainable quality controls

MORSANI MORSANI COLLEGE OF MEDICINE COLLEGE OF MEDICINE MORSANI MORSANI UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE

COLLEGE OF PUBLIC HEALTH COLLEGE OF PUBLIC HEALTH UNIVERSIT Y OF SOUTH FLORIDA Our Practice Is Our Passion UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF NURSING COLLEGE OF NURSING UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF PHARMACY COLLEGE OF PHARMACY UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

SCHOOL OF PHYSICAL THERAPY SCHOOL OF PHYSICAL THERAPY & REHABILITATION SCIENCES & REHABILITATION SCIENCES UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA References 1.Schott, W. (2012). Going back part-time: Family leave legislation and women’s return to work. Population research and policy review, 31(1), 1-30. 2.English Application for Breastfeeding Friendly Child Care facility. Retrieved from http://www.floridahealth.gov/programs-and-services/childrens- health/child-care-food-program/nutrition/_documents/breastfeeding- friendly-application.pdf 3. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science, 4(1), 1. MORSANI MORSANI COLLEGE OF MEDICINE COLLEGE OF MEDICINE MORSANI MORSANI UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE UNIVERSIT Y OF SOUTH F LORIDA COLLEGE OF MEDICINE

COLLEGE OF PUBLIC HEALTH COLLEGE OF PUBLIC HEALTH UNIVERSIT Y OF SOUTH FLORIDA Our Practice Is Our Passion UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF NURSING COLLEGE OF NURSING UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

COLLEGE OF PHARMACY COLLEGE OF PHARMACY UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA

SCHOOL OF PHYSICAL THERAPY SCHOOL OF PHYSICAL THERAPY & REHABILITATION SCIENCES & REHABILITATION SCIENCES UNIVERSIT Y OF SOUTH FLORIDA UNIVERSIT Y OF SOUTH FLORIDA Presented by: Nancy Faul BS, IBCLC, RLC Florida Breastfeeding Coalition Board Member, BCB The Process to Earn Florida’s Breastfeeding Friendly Employer Award

. Businesses evaluated based on set of criteria for three levels of breastfeeding support: . Gold, Silver, Bronze

. As of today, 135 businesses have received recognition for the Florida Breastfeeding Friendly Employer Award . Gold : 76 Silver : 19 Bronze : 15 35

30 Florida Breastfeeding 25 Friendly 20 2010 2011 Employer 15 Awards 2012 10 2013 5 2014 2015 0 2016 2017 www.flbreastfeeding.org/business-case-for-breastfeeding/ Resources & References

• www.womenshealth.gov/breastfeeding/employer- solutions/index.html • Business Case for Breastfeeding: http://mchb.hrsa.gov/pregnancyandbeyond/breastfeeding/ • Supporting Nursing Moms at Work: Employer Solutions http://www.womenshealth.gov/breastfeeding/employer- solutions/index.html Panelist Discussion Break, Posters & Exhibitors Breakout Session 1 : Promoting Breastfeeding through Advocacy and Policy Change

Navigating Medicaid Coverage Florida Breast Pump Consortium

Combating Maternal Fatigue in Women Choosing to Breastfeed their Well/Term Infant Michelle Colkitt, BSN, RN, CBC

An Update on National Safe Sleep and Breastfeeding Recommendations Joan Meek, MD, RD, IBCLC, FAAP 3rd Biannual Florida Breastfeeding Coalition Conference Navigating Medicaid Breast Pump Coverage Presented by The Florida Breast Pump Consortium Learning Objectives At the end of this presentation the learner will:

1. Recognize public health benefits of breastfeeding 2. Explain the goal of the Florida Consortium for Medicaid Coverage of electronic breast pump coverage 3. Outline steps taken by the consortium to achieve the coverage of electric breast pump for Medicaid recipients 4. Identify how to narrow the gaps in breast pump coverage for Medicaid recipients.

SECTION 1:

PUBLIC HEALTH BENEFITS & NEED FOR BREAST PUMPS

Marcia Schulz, MSN, RNC-OB, IBCLC BayCare Donor Milk Program Coordinator Enhances maternal-child bonding, BREASTFEEDING reduces risks of breast cancer, obesity, communicable diseases and PUBLIC HEALTH expenditures associated with health BENEFITS related incidences preventable by breastfeeding.

If 90% of US families complied with exclusive breastfeeding recommendations, the US would save $13 billion/year in healthcare cost & prevent an excess of deaths - mostly in infants.

Among premature infants, the nutritional benefits of exclusive human milk feedings: Support optimal growth and development, while immunologic components reduce risks of necrotizing enterocolitis, sepsis and death. FDA Statement

“Women find it convenient, or even necessary, to use a breast pump to express and store their breast milk once they have returned to work, are traveling, or are otherwise separated from their baby. A breast pump can be used as supplement to breastfeeding and some pumps are designed to mimic the suckling of a nursing baby.” AAP RECOMMENDATIONS

American Academy of Pediatrics (AAP) currently defines optimal infant nutrition as:

• Exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.

Facilitating access to electric breast pumps, supports current AAP recommendation for infant nutrition. BREAST PUMP COVERAGE Currently 32 states include breast pumps in the Medicaid durable medical equipment fee schedule. BREAST PUMP COVERAGE-Cont. Over 50 % of births in Florida (205,000 births annually) are covered by Medicaid health plans. SECTION 2:

THE CONSORTIUM TAKES ACTION

Jessie Gordon, PhD, ARNP Florida Breastfeeding Coalition and Outpatient Provider PURPOSE

Expand Florida Medicaid Coverage to include dual electronic breast pumps

Promote the maternal and neonatal health care benefits of sustained breastfeeding EXPECTED OUTCOMES

Sustaining the benefits of long term breastfeeding for Medicaid recipients can affect infant mortality and neonatal outcomes among a well-known population to have lower breastfeeding rates and limited access to lactation services and breast pump equipment. METHODS

A workgroup was formed to address eligibility and equipment standards regarding a breast pump Durable Medical Equipment (DME) policy for the state of Florida.

Participants of the workgroup had years of professional experience servicing mothers requiring lactation and breast pump services. METHOD – cont. Members of the consortium drafted a letter signed by over 100 health care providers in Florida about the importance and medical benefits of expanding Medicaid breast pump coverage.

The letter was sent to the Secretary to secure a meeting with her staff, in which the consortium presented a 30 minutes Power Point presentation with recommendations. OUTCOMES

DME Fee Schedule first included breast pumps on June 20, 2016 and are STILL included in the 2017 schedule

Policy recommendations to mitigate reimbursement was drafted by the consortium and sent to the manager at AHCA for consideration. Florida Consortium Advocacy Members SECTION 3:

NARROWING THE GAPS

Clint Shouppe, BayCare State Government Relations Manager and Maureen Crissy, Eastern Regional Sales Manager GAPS

Community knowledge of the current coverage or prior authorization process to obtain this benefit remain unknown and complex.

A workshop addressing the policy for breast pump reimbursement is scheduled for spring/summer of 2017.

Step 1: Request a pump

Provide mom a prescription

Direct moms to their insurance provider for DME information

Preauthorization required Step 2: File a complaint If access to a pump is denied:

Click here https://apps.ahca.myflorida.com/smmc_cirts/ to let ACHA know—this is the only link they track claims! You may also:

Call toll free 1-877-254-1055 to file via phone or

Go to: https://apps.ahca.myflorida.com/smmc_cirts/

EVERYONE - Doctors, nurse practitioners, lactation consultants, WIC employees and patients or family should complete file!

QUESTIONS? Florida Consortium Advocacy Members Marcia Schulz, St Joseph’s Women’s Hospital Donor Milk Program Coordinator [email protected] Jessie Gordon, Florida Breastfeeding Coalition and Outpatient Provider [email protected] Clint Shouppe, BayCare State Government Relations Manager [email protected] Rebecca Dewitt, St Joseph’s Women’s Hospital NICU Lactation Consultant [email protected] Pat Lindsey, Florida Lactation Consultation Association and Outpatient Consultant [email protected] Rico Gordon, John Hopkins All Children’s Hospital Laboratory Manager [email protected] Maureen Crissy, Eastern Regional Sales Manager [email protected] Kristy Sasser, Medela Business Continuum Specialist Southeast Region [email protected] REFERENCES

1. American Academy of Pediatrics.(2012).Breastfeeding and the Use of Human Milk. Pediatrics, 129(3), e827-e841. doi: 10.1542/peds. - 3552

2. Mass, S.B. (2011). Supporting breastfeeding in the United States: the Surgeon General's call to action. Curr Opin Obstet Gynecol. Dec;23(6):460-4. doi: 10.1097/GCO.0b013e32834cdcb3.

3. Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O'Hare, D., Schanler, R. J., & Eidelman, A. I. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506. doi: 10.1542/peds.2004-2491

4. Ganapathy, V., Hay, J. W., & Kim, J. H. (2012). Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeed Med, 7(1), 29-37. doi: 10.1089/bfm.2011.0002

5. New York State Department of Health Recommended Minimum Standards for NYS Medicaid Coverage of Breast pumps. https://www.emedny.org/ProviderManuals/DME/PDFS/DME_Procedure_Codes.pdf

6. Wouk K, Chetwynd E, Vitaglione T, Sullivan C. (2016). Improving Access to Medical Lactation Support and Counseling: Building the Case for Medicaid Reimbursement. Matern Child Health J. Aug 17.

7. Herold R, Bonuck K. (2016). Medicaid IBCLC Service Coverage following the Affordable Care Act and the Center for Medicare and Medicaid Services Update. J Hum Lact. Feb;32(1):89-94. doi: 10.1177/0890334415599164.

8. Chetwynd E, Meyer AM, Stuebe A, Costello R, Labbok M. (2013). Recognition of International Board Certified Lactation Consultants by health insurance providers in the United States: results of a national survey of lactation consultants. J Hum Lact. 2013 Nov;29(4):517- 26. doi: 10.1177/0890334413499974. Epub 2013 Aug 20.

9. Academy of Breastfeeding Medicine Annotated Bibliography Going Home Protocol. (2016). Retrieved on-line Sept 2016. http://www.bfmed.org/Media/Files/Protocols/Going%20Home%20Annot%20Bib%202012.pdf

10. Fugate K, Hernandez I, Ashmeade T, Miladinovic B, Spatz D. (2015). Improving Human Milk and Breastfeeding Practices in the NICU. J Obstet Gynecol Neonatal Nurs. May-Jun;44(3):426-38; quiz E14-5. doi: 10.1111/1552-6909.12563. Epub 2015 Apr 1. Combating Maternal Fatigue in Women Choosing to Breastfeed their Well/Term Infant

Michelle Colkitt, BSN, RN, CBC Learning Objectives

Describe the Pattern of Maternal Fatigue Postpartum

List the Impact of Maternal Fatigue on Infant and Maternal Health

Discuss Ways to Combat Maternal Fatigue

State Methods that Sarasota Memorial Hospital has Utilized in Preventing Maternal Fatigue Review: Current Breastfeeding Recommendations

The American Academy of Pediatrics (AAP), American Congress of Obstetricians and Gynecologists (ACOG), and World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life due to extensive mutual benefits for the mother and newborn. Breastfeeding Rates

Exclusive Breastfeeding Rates in 2014 100. 80. 60. 79 77 40. United States 41 20. 39 19 18 0. Initiation 3 6 Percentage of Newborns of Percentage Months Months ***Data from Center for Disease Control Postpartum Fatigue

“An overwhelming sense of exhaustion that is accompanied by decreasing capacity for physical and mental work at the individual’s usual level,”

–NANDA, 2005-2006 Impact of Maternal Fatigue on Premature Weaning

Most women who initiate breastfeeding wean earlier than initially planned (ACOG, 2016). Brown and associates (2014):

✤ The leading reason mothers cited they weaned was inconvenience/fatigue due to breastfeeding.

✤ A specific reason cited was not associated with a length of time. Milligan and associates (1996):

✤ speculated that mothers would be more successful breastfeeding if they had lower levels of fatigue. Reviewing the Research

Article Study Design Evidence Level and Quality

Brown et al., 2014 Longitudinal, Correlational study Level III, quality a

Cross Sectional, Correlational Groer et al., 2005 Level III, quality a Study Milligan, Flenniken, and Pugh, Quasi Experimental Level II, quality b 1996

Pugh and Milligan, 1998 Randomized Control Trial Level I, grade b

Parks, Lenz, Milligan, Han, 1999 Longitudinal, Correlational study Level III, quality b

Qualitative Study using Taylor and Johnson, 2010 Level III, quality b Exploratory/Descriptive design

Troy and Dalgas-Pelish, 2003 Randomized Control Trial Level I, quality a

Wambach, 1998 Longitudinal, Correlational study Level III, quality a Discussion

When do you find new moms are most fatigued and ready to quit breastfeeding? Pattern of Maternal Fatigue

Wambach (1998): Only included women with term, healthy newborns and had given birth vaginally. Measured fatigue at three, six, and nine weeks using:

✤ the Multidimensional Assessment of Fatigue (MAF) (conbach’s alpha reliability 0.89-0.93)

✤ the Lee Fatigue Scale (conbach’s alpha reliability 0.93-0.96). Concluded: maternal fatigue peaks at three weeks postpartum and declines by six weeks postpartum Pattern of Maternal Fatigue

Troy and Delgas-Pelish (2003): Looked at self-care interventions to decrease fatigue between two and six weeks postpartum The sample size was sixty women who had delivered vaginally to healthy, term newborns. Feeding methods were mixed (not an exclusive breastfeeding sample). The fatigue sub scale of visual analog scale-F (cronbach alpha ranged from 0.91-0.96) was utilized Conclusion: fatigue levels were highest three-four weeks postpartum. Pattern of Maternal Fatigue

Troy and Johnson (2010): Study focused on open end questions to explore how mothers cope with fatigue. Sample size was fifty-nine women (multipara and primipara included). The women also had mixed feeding preferences. Not an exclusive breastfeeding population. Conclusion: maternal fatigue may linger up to eighteen months post . Persistent Maternal Fatigue

Persistent fatigue (up to eighteen months after delivery) cannot be predicted by demographic characteristic such as: ✤age ✤material status ✤infant sex ✤delivery method ✤feeding method ✤employment status (Parks et al., 1999) “Being a mom has made me so tired. And so happy.”

–Tina Fey Are NICU moms at Higher Risk for Maternal Fatigue? Brown and associates (2014) published that mothers with newborns admitted to the neonatal intensive care nursery (NICU) were more likely to quite breastfeeding within the first week postpartum compared to women who had healthy/term newborns.

These mothers may be a greater risk for fatigue because of breast pumping schedules and commuting to visit their newborns while hospitalized. Increasing Breastfeeding Success in the NICU at Sarasota Memorial Hospital Mothers who have a newborn admitted to NICU have access to: a hospital grade pump immediately after delivery and are educated on hand expression. a lactation consult (automatically entered on all NICU babies) a hospital grade breast pump loaner program (free of charge) for NICU moms without access to a breast pump at home. Increasing Breastfeeding Success in the NICU at Sarasota Memorial Hospital

Private NICU rooms, allowing for parents to spend the night.

Being encouraged to kangaroo stable newborns (dads too!).

Donor milk program. Newborns less than 32 weeks and/or less than 1500 grams are eligible to receive donor breastmilk. Impacts of Maternal Fatigue on Maternal and Newborn Health Impaired Immunology: A. Greer and colleagues (2005) found that mothers who had higher fatigued levels had lower IgA levels in blood serum and breastmilk samples. B. Newborns of fatigued mothers had more symptoms of infection (Greer et al., 2005) C. Mother with higher fatigue also report more symptoms of illness (Parks et al., 1999) Decreased Milk Supply A. Mothers with increased fatigue levels had lower levels of prolactin (Greer and colleagues, 2005). Impacts of Fatigue on Maternal and Newborn Health

Decline in Mental Wellness: A. Higher levels of maternal fatigue was associated with higher rates of depression (Wambach,1998). B. Corwin and colleagues (2005) research also demonstrated that there is a significant correlation between postpartum fatigue and postpartum depression. C. In Pugh and Milligan’s study (1998) stated that depression levels at fourteen days postpartum was predictive of early breastfeeding weaning. Negatively impacts newborn development: A. Decreased hand-eye development in the newborn of a mother persistently fatigued (Parks et al., 1999). Combating Maternal Fatigue: Side Lying Breastfeeding

Milligan, Flenniken, and Pugh (1996) compared new mother’s fatigue levels after completing side lying breastfeeding position and sitting breastfeeding position.

Mothers, with a vaginal delivery, reported lower levels of fatigue when breastfeeding in a side lying position compared to a sitting position

Limitation: a small sample size (only twenty women in a community hospital). Combating Maternal Fatigue: Visits with a Community Health Nurse and Access to an International Board Certified Lactation Consultant (IBCLC)

Milligan and Pugh (1998), research focused on an outreach intervention program to decrease fatigue and breastfeeding difficulties. Sixty primiparous women were recruited from a community hospital. Half the women were in the intervention group and half in the control.

This was a randomized control study where subjects in the experimental group were visited twice in their home by a community health nurse (on day 3-4 and twelve) and telephoned by an IBCLC on day five postpartum (Pugh and Miligan, 1998).

Fatigue scores were significantly higher in the control group (p<0.5) at two weeks postpartum (Pugh and Milligan, 1998). By six months postpartum, 50% of the experimental group was still breastfeeding compared to 27% of the control group (Pugh and Miligan, 1998). IBCLCs and CLCs in the United States

Graphic from CDC Breastfeeding Report Card, 2014 Bedside Nurses as Lactation Experts

Over 90% of bedside nurses working in Labor and Delivery, Mother Baby, and NICU are Certified Breastfeeding Counselors (CBCs).

CBC certification involves a sixteen hour course over a period of two days

This allows bedside nurses to assist mothers with breastfeeding challenges. Outpatient Breastfeeding Support

Connecting new mothers to breastfeeding resources is crucial because the inpatient stay in often less than two days. Sarasota Memorial currently has a weekly breastfeeding support group hosted by an IBCLC.

What outpatient, breastfeeding resources are new mothers using in your area? Combating Maternal Fatigue: “Looking After Me”

Taylor and Johnson’s (2010) qualitative/descriptive study included fifty-nine women ranging in age from twenty-forty. Women were asked what they were doing to decrease fatigue since giving birth, what they have been doing most often to decrease fatigue, and if this was useful (Taylor and Johnson, 2010).

Theses questions were asked of participants at six, twelve and twenty-four weeks postpartum (Taylor and Johnson, 2010).

One of the themes that emerged was “looking after me.” These interventions included: A.Exercise B.Going to Bed Early C.Taking a Nap D.Conserving Energy Combating Maternal Fatigue: Managing the Load Another theme that emerged from Taylor and Johnson’s (2010) study was managing the load to decrease maternal fatigue. These interventions included: A.Developing a Routine B.Having Realistic Expectations for Self C.Getting Help from Others Turning Research Into Best Practice

• Educate new mothers with vaginal deliveries of term/well babies that they will likely feel most fatigued at 3-4 weeks postpartum.

• Some mothers in your practice may be consistently fatigued up to eighteen months postpartum.

• Recognize the health risk to mother and baby of maternal fatigue.

• Educate new mothers on ways to decrease fatigue: side lying breastfeeding, exercise, prioritizing sleep, developing a routine, having realistic expectations of self, etc.

• Connect new mothers to breastfeeding support groups and IBCLCs in your area. References

Brown, C., Dobbs, L., Legge, A., Bryanton, J., ans Semenic, S. (2014). Factors influencing the reasons why mothers stop breastfeeding. Canadian Journal of Public Health, 105(3), 179-185. Center for Disease Control and Prevention. (2014). Breastfeeding Report Card United States/2014 Retrieved from http://www.cdc.gov/breastfeeding/pdf/ 2014breastfeedingreportcard.pdf Groer, M., Davis, M., Casey, K., Short, B., Smith, K., & Groer, S. (2005). Neuroendocrine & immune relationships in postpartum fatigue. Maternal Child Nursing, 30(2), 133-138. Milligan, R.A., Flenniken, P.M., & Pugh, L. (1996). Positioning intentions to minimize breastfeeding fatigue in breastfeeding women. Applied Nursing Research, 9(2), 67-70. Pediatrics, A. A. P.(2012). Breastfeeding and the use of human milk. Policy statement. Pediatrics, 129(3), e827-41. Parks, P.L., Lenz, E.R. Milligan, R.A., & Han, H.R. (1999). What happens when fatigue lingers for 18 months after delivery? Journal of obstetric, gynecologic, & neonatal nurses. 28, 87-93 Pugh, L., & Milligan, R.A. (1998). Nursing intervention to increase the duration of breastfeeding. Applied Nursing Research, 11(4), 190-194. Taylor, J., & Johnson, M. (2010). How women manage fatigue after childbirth. Midwifery, 26, 367-375. References The American Congress of Obstetricians and Gynecologists, ACOG. (2016). Optimizing Support for Breastfeeding as Part of Obstetric Practice. Committee Opinion, 658.

Troy, N.W., & Dalgas-Pelish, P. (2003). The effectiveness of a self-care intervention for the management of postpartum fatigue. Applied Nursing Research, 16(1), 38-45.

Unicef. (2015). Breastfeeding. Retrieved from http://www.unicef.org/nutrition/index_24824.html

Wamback, K. (1998). Maternal fatigue in breastfeeding primiparae during the first nine weeks postpartum. Journal of Human Lactation, 14(3), 219-229.

World Health Organization. (2016). Breastfeeding. Retrieved from http://www.who.int/topics/ breastfeeding/en/ An Update on National Safe Sleep and Breastfeeding Recommendations

Florida Breastfeeding Coalition 3rd Biannual Conference Sustaining Breastfeeding Friendly Communities April 22, 2017

JOAN YOUNGER MEEK, MD, MS, RD, FAAP , FABM , IBCLC

CHAIR, AAP SECTION ON BREASTFEEDING

PAST - CHAIR, UNITED STATES BREASTFEEDING COMMITTEE

PROFESSOR, CLINICAL SCIENCES

ASSOCIATE DEAN, GRADUATE MEDICAL EDUCATION

FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE DISCLOSURES

I have no disclosures relative to this presentation. Learning Objectives

Identify key recommendations from the AAP Safe Sleep Statements. Describe potential risks associated with bed sharing. Provide guidance to breastfeeding families on best sleep practices. Unintended Consequences of Current Breastfeeding Initiatives

Sudden unexpected postnatal collapse (SUPC) ◦ 400 case reports, 1/3 in first 2 hours of life, rest in first week Expressed concerns with BFHI, risks of maternal exhaustion, co-sleeping, prone sleeping ◦ Step 4, skin-to-skin ◦ Step 6, exclusive breastfeeding ◦ Step 7, rooming in ◦ Step 9, shouldn’t delay pacifier introduction for 304 weeks Questioned wisdom of Surgeon General’s Call to Action to increase Baby-Friendly Hospitals, mPINC and CDC support Government and accreditation agencies should promote safe sleep, not BFHI

Bass JL, Gartley T, Kleinman R. Unintended consequences of current breastfeeding initiatives. JAMA Pediatr. 2016;170(10):923-924. Implementation of the Ten Steps to Successful Breastfeeding Saves Lives

Implementation of BFHI increases breastfeeding exclusivity Skin-to-skin ◦ Increases breastfeeding rates and exclusivity ◦ Promotes physiologic stability ◦ Decreases hypothermia, hypoglycemia, and stress Saves 823,000 lives per year (Lancet) Maternal exhaustion due to long labor, epidurals with slowed progression of labor and C/S KEY: ◦ Baby needs separate sleep surface ◦ Monitoring of mother and baby are important ◦ Staff and parental education Early introduction of the pacifier associated with decrease in any and exclusive breastfeeding rates

Meek JY, Noble L. Implementation of the Ten Steps to Successful Breastfeeding Saves Lives. JAMA Pediatr. 2016;170(10):925-926. doi:10.1001/jamapediatrics.2016.2015 Sudden Unexpected Postnatal Collapse Increased risk Recommendations: ◦ neonatal infection ◦ Postnatal health teams should ◦ congenital heart disease emphasize ◦ PPHN ◦ Safe and early skin-to-skin ◦ Metabolic defects ◦ Safe breastfeeding initiation ◦ anemia ◦ Secure positioning Prone positioning Early skin-to-skin without adequate surveillance

Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: A review of cases, definitions, risks, and preventive measures. Transl Stroke Res. 2013;4:236–47. Sudden Unexpected Postnatal Collapse Increased risk Recommendations: ◦ neonatal infection ◦ Postnatal health teams should ◦ congenital heart disease emphasize ◦ PPHN ◦ Safe and early skin-to-skin ◦ Metabolic defects ◦ Safe breastfeeding initiation ◦ anemia ◦ Secure positioning Prone positioning Early skin-to-skin without adequate surveillance

Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: A review of cases, definitions, risks, and preventive measures. Transl Stroke Res. 2013;4:236–47. Prevention of Sudden Unexpected Postnatal Collapse

Education of the parents of infant’s well-bring and need to maintain airway patency Supine positioning Avoid bed sharing, prone sleeping, soft bedding, face down, and covering of the head Non-obtrusive surveillance of the newborn by caregivers aware of SUPC Continuous clinical supervision of at-risk mothers (primiparous, alone, and exhausted) Medical supervision of skin-to-skin with mother who is sedated or has infection Medical supervision of skin-to-skin with infant with distress of concern of infection

Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: A review of cases, definitions, risks, and preventive measures. Transl Stroke Res. 2013;4:236–47. Safe Sleep in the Neonatal Period

**SUPC, falls Positioning: Skin-to-skin decreases stress ◦ Visualize face ◦ Neutral, sniffing position Risk stratification ◦ Head to the side and uncovered Monitor continuously ◦ Neck straight ◦ Legs flexed

Feldman-Winter L, Goldsmith JP; Committee on Fetus and Newborn; Task Force on Sudden Infant Death Syndrome. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics. 2016;138(3):e20161889. Baby-Friendly USA August 22, 2016

Greater number of the Ten Steps in place, the greater the likelihood of breastfeeding

Staff training and observation should be implemented using NRP guidelines

https://www.babyfriendlyusa.org/get-started/the-guidelines-evaluation-criteria Improving Safe Sleep Practices for Hospitalized Infant

QI Project to improve adherence to safe sleep practices ◦ Multidisciplinary team ◦ Improve nurse knowledge with education ◦ Increase in infants sleeping in a flat, empty crib Did not show statistical difference in post-discharge practices

Shadman KA, Wald ER, Smith W, et al. Improving Safe Sleep Practices for Hospitalized Infants. Pediatrics. 2016;138(3):e20154441. Immediate and Sustained Skin-to-Skin Contact for the Healthy Term Newborn After Birth: TrainedAWHONN health Practice care professional Brief in attendance during the first 2 hours after birth Assure ◦ Proper positioning ◦ Maternal and newborn safety ◦ Physiologic indicators

Association for Women’s Health, Obstetric and Neonatal Nurses. Immediate and Sustained Skin-to=Skin Contact For the Healthy Term Newborn After Birth: AWHONN Practice Brief Number 5. J Obstet Gynecol Neonatal Nurs. 2016 Nov-Dec; 45(6):842-844. doi: 10.1016/j.jogn.2016.09.001. Infant Assessment (RAPP)

Respiratory Effort Activity Perfusion Position

Ludington-Hoe SM, Morgan K. Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. NAINR. 2014;14(1):28-33. Infant Assessment (RAPP)

Respiratory Effort ◦40-60 breaths/minute ◦Regular ◦No increased work of breathing ◦No grunting, flaring, retracting

Ludington-Hoe SM, Morgan K. Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. NAINR. 2014;14(1):28-33. Infant Assessment (RAPP)

Activity ◦Document state ◦Asleep, quiet alert, active alert, crying ◦Nonresponsive—needs resuscitation

Ludington-Hoe SM, Morgan K. Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. NAINR. 2014;14(1):28-33. Infant Assessment (RAPP)

Perfusion ◦Pink ◦May be mottled if cold ◦Acrocyanosis is normal ◦ABNORMAL: pale, gray, dusky, cyanotic

Ludington-Hoe SM, Morgan K. Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. NAINR. 2014;14(1):28-33. Infant Assessment (RAPP)

Position ◦Neck midline ◦Flexed body position ABNORMAL: limp

Ludington-Hoe SM, Morgan K. Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. NAINR. 2014;14(1):28-33. Safe Positioning Check List

Mother or provider of SSC is in reclining position, not flat Infant's back is covered and hair is dry Infant is well-flexed on provider's chest Infant's shoulders are flat against provider's chest Infant is chest-to-chest with provider, not over a breast Infant's head is turned to one side Infant's face can be seen Infant's nose and mouth are visible and uncovered Infant's neck is straight, not bent

Ludington-Hoe SM, Morgan K. Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. NAINR. 2014;14(1):28-33. SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Sleeping Environment

Back-to-sleep Firm sleep surface Recommend breastfeeding, reduces risk of SIDS Room sharing No loose bedding Avoid smoke, alcohol, and illicit drugs Consider pacifier, but delay in breastfed infant until breastfeeding firmly established

AAP TASK FORCE ON SUDDEN INFANT DEATH SYNDROME. SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics.2016;138(5):e20162938. References

Bass JL, Gartley T, Kleinman R. Unintended consequences of current breastfeeding initiatives. JAMA Pediatr. 2016;170(10):923- 924. Meek JY, Noble L. Implementation of the Ten Steps to Successful Breastfeeding Saves Lives. JAMA Pediatr. 2016;170(10):925-926. doi:10.1001/jamapediatrics.2016.2015 Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: A review of cases, definitions, risks, and preventive measures. Transl Stroke Res. 2013;4:236–47. Feldman-Winter L, Goldsmith JP; Committee on Fetus and Newborn; Task Force on Sudden Infant Death Syndrome. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics. 2016;138(3):e20161889. Shadman KA, Wald ER, Smith W, et al. Improving Safe Sleep Practices for Hospitalized Infants. Pediatrics. 2016;138(3):e20154441. Association for Women’s Health, Obstetric and Neonatal Nurses. Immediate and Sustained Skin-to=Skin Contact For the Healthy Term Newborn After Birth: AWHONN Practice Brief Number 5. J Obstet Gynecol Neonatal Nurs. 2016 Nov-Dec; 45(6):842-844. doi: 10.1016/j.jogn.2016.09.001. Ludington-Hoe SM, Morgan K. Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. NAINR. 2014;14(1):28-33. AAP TASK FORCE ON SUDDEN INFANT DEATH SYNDROME. SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics.2016;138(5):e20162938 Baby-Friendly USA, https://www.babyfriendlyusa.org/get-started/the-guidelines-evaluation-criteria Breakout Session 2 : Innovations in Sustaining Long Term Breastfeeding

Community Partnership, Hospital visits and WIC Peer Counselors Esther March Singleton MBA, BSN, BHS, IBCLC

Provider Needs for Sustaining Breastfeeding in Obstetric & Pediatric Offices Sophia Hector MPH, CPH Healthiest Weight Florida and Baby Steps to Baby Friendly Katie Williams MPH

Putting Patient First: billing insurance companies for lactation visits Annette Leary, RN, BSN, IBCLC FLORIDA DEPARTMENT OF HEALTH BROWARD COUNTY WIC

Community Partnership, Hospital visits and WIC Peer Counselors

Esther March Singleton MBA, BSN, BHS, IBCLC 139 Objective:

Participants will be able to demonstrate how disparities in breastfeeding can be reduced through peer and professional support; how community collaboration creates a culture of breastfeeding sustainability.

Esther March Singleton MBA, BSN, BHS, IBCLC 140 DOH- BROWARD BREASTFEEDING PROGRAM

STAFF BREASTFEEDING TRAINING • All WIC staff who provide direct services to clients complete 27 hours of breastfeeding training and at the minimum two hour updates yearly.

• In addition, Breastfeeding Peer Counselors complete an additional 50 hours of training using the “Loving Support Through Peer Counseling A Journey Together” curriculum. • 60-minute monthly educational sessions • QA monitoring/observations linked to performance evaluations BREASTFEEDING PROGRAM

• Breastfeeding Peer Counselor • Peer Counselors are mothers with breastfeeding experience. • Trained to provide breastfeeding information and support to mothers with whom they share characteristics, such as language, race/ethnicity, and socioeconomic status. • They use peer-to-peer support in group settings and one- to-one counseling by telephone calls, clinic and/or hospital visits. BREASTFEEDING PEER COUNSELOR PROGRAM

Peer Counselor training topics include: • Helping Moms say YES to Breastfeeding! Overcome Common Barriers • How to Talk with Moms About Breastfeeding • Encouraging Exclusive Breastfeeding • Participant-focused counseling techniques BREASTFEEDING PROGRAM

■ FUNDING

– USDA-FNS WIC GRANT

– LOVING SUPPORT THROUGH PEER COUNSELING GRANT

– NACCHO GRANT WIC Broward- EMHC Breastfeeding Initiation Rates by Quarter 90.0% 88.1% 88.2% 87.6% 88.0% 87.1% 87.3%

86.0% 85.3% 83.8% 84.0%

82.0% 80.7% 81.1% 80.2% WIC-EMHC 79.4% 79.7% 80.0% 78.7% 78.9% State 78.0%

76.0%

74.0%

72.0% Apr-Jun '15 Jul -Sep '15 Oct-Dec '15 Jan-Mar '16 Apr-Jun '16 Jul- Sep '16 Oct - Dec'16 ACTIVITIES Prenatal - Breastfeeding Support

• Prenatal Breastfeeding Education • Initial prenatal visit Nutrition Staff educates client on the benefits of breastfeeding. • Second prenatal visit client attends a breastfeeding education class. • Follow up visits before delivery provide breastfeeding education to prepare the client to successfully breastfeed. • Client is provided with the warm-line (breastfeeding help-line phone number)available for after hours breastfeeding support in multiple languages. ACTIVITIES POST-PARTUM SUPPORT

Post-Partum Breastfeeding Support Peer Counselors make post-partum follow up calls using the client’s expected delivery date. FL-Wise, the WIC data system, allows entry of the client’s expected delivery date and reports out daily those clients expected to deliver. Breastfeeding clients calling the Call Center are referred to the appropriate peer counselor by trained Call Center staff. All staff enter a follow up date into the FL-Wise data system to ensure continued breastfeeding support. ACTIVITIES POST-PARTUM Hospital Peer Counselors

• Peer Counselors provide basic breastfeeding information and assistance at bedside • Meet new moms to facilitate later phone follow-up • Follow-up with moms for seamless care

DOH- Broward WIC Program has Memorandums of Agreement with three Broward County Hospitals Increase Initiation through Hospital Partnership

Identified a need to expand WIC Breastfeeding Peer Counseling program into birthing hospitals.

Memorandum of Agreement (MOA) implemented to provide in- hospital Peer Counselor to WIC mothers post delivery.

A job description, scope of practice and Peer Counselor Hospital Curriculum training curriculum were developed. 4 Peer Counselors were trained.

Broward County Health Department is an equal opportunity provider.

Esther M Singleton MBA, BSN, BHS, IBCLC 149 Hospital Memorandum of Agreement ACTIVITIES Our Community Partners

Conduct monthly meetings with our community Partners through the Broward County Breastfeeding Coalition:

Broward County Health Department is an equal opportunity provider.

Esther M Singleton MBA, BSN, BHS, IBCLC 151 COMMUNITY PARTNER ACTIVITIES

Community partners and “Healthiest Weight Florida’s DOH-Broward WIC have Baby Steps to Baby Friendly come together to develop Initiative” to increase breastfeeding initiation and strategies and action steps duration rates. for the business case for breastfeeding.

DOH-Broward WIC is providing guidance and DOH-Broward WIC provides support to all birthing hospitals in Broward County breastfeeding training to our to become Breastfeeding community partners. Friendly. COMMUNITY PARTNERSHIP ACTIVITIES

In order to reach the target population in the NACCHO Grant DOH – Broward WIC partners with the following organizations:

Community/religious organizations

Breastfeeding support groups in collaboration with Healthy Mothers Healthy Babies

Community Support Breastfeeding Groups (Sister Chat) in collaboration with the Urban League

Breastfeeding care management in community hospitals.

WIC clients are referred to community partners for home visits. (Visiting Nurse Partnership and Healthy Start) WIC Broward- EMHC Breastfeeding at 26 weeks Duration rates by Quarter

45.0% 42.3%

40.0% 36.8% 37.3% 33.4% 35.0%34.5% 33.8% 34.0% 34.7% 35.0% 31.6% 32.1% 30.0% 28.5%

25.0% 23.0% 19.9% WIC-EMHC 20.0% State

15.0%

10.0%

5.0%

0.0% Apr-Jun '15 Jul -Sep '15 Oct-Dec '15 Jan-Mar '16 Apr-Jun '16 Jul- Sep '16 Oct - Dec'16

154 Contact Information

THANK YOU!!

Esther March Singleton, MBA, BSN, BHS, IBCLC

Office: (954) 467-4700 Extension 4309

[email protected] Breastfeeding Rates Quality Improvement Project: Provider Breastfeeding Survey

FLORIDA DEPARTMENT OF HEALTH-HILLSBOROUGH COUNTY SOPHIA HECTOR MPH,CPH STD PROGRAM MANAGER

FLORIDA DEPARTMENT OF HEALTH IN HILLSBOROUGH COUNTY BREASTFEEDING QUALITY IMPROVEMENT PROJECT

156 Florida Department of Health – Hillsborough County Breastfeeding Quality Improvement Project

QUALITY IMPROVEMENT PROCESS PLAN - DO – CHECK - ACT Objective:Increase the breastfeeding rates at 15 - 30 days for breastfeeding mothers in Hillsborough County by 5% by June 30, 2016. The process will be considered from the start of any prenatal breastfeeding education through thirty days after the birth of the baby.

FLORIDA DEPARTMENT OF HEALTH IN HILLSBOROUGH COUNTY BREASTFEEDING QUALITY IMPROVEMENT PROJECT 157 Provider Characteristics Specialties Obstetrics/ Gynecology n = 20 45.5% How comfortable are you addressing breastfeeding concerns? Level of Comfort Obstetrics/Gynecology Pediatricians Family Pediatrics n = 20 45.5% Medicine Family Practice n =4 9% 5 - Very 28 35 33 Comfortable Types of Practice Residency Affiliated 27.3% 4 39 30 33 3 17 30 0 Group 13.6% 2 11 0 34 Solo 4.5% 1 – Very 5 0 0 Hospital Clinic 18.2% Uncomfortable Community Health Center 6.8% No Answer 0 5 0 Hospital Clinic/ Residency 4.5% Affiliated Group/ Hospital Clinic 6.8% Group/ Residency Affiliated 18.2%

*A total of 147 providers were asked to complete the survey, out of which 44 providers responded

FLORIDA DEPARTMENT OF HEALTH IN HILLSBOROUGH COUNTY BREASTFEEDING QUALITY IMPROVEMENT PROJECT In addition to talking with patients, what materials do you currently use to educate patients about breastfeeding? (Please check the ONE best response for each statement) Materials currently used by Physicians to educate patients about breastfeeding 18

16

14

12

10

8

6

4

2

0 Posters Handouts/Fact Referral List of Websites Videos Other Sheets Lactation Consultants and Educators

Obstetrics/Gynecology (n=20) Pediatrics (n=20) Family Medicine (n=4)

FLORIDA DEPARTMENT OF HEALTH IN HILLSBOROUGH COUNTY BREASTFEEDING QUALITY IMPROVEMENT PROJECT Top 5 Most Common Breastfeeding Concerns from Patients Top 3 Ways Physicians Address Breastfeeding Concerns by Specialty Obstetrics/Gynecology (n=20) Obstetrics/Gynecology (n=20) Refer to other lactation support staff within my n=19, 95% -on difficulties n=19, 95% practice Nipple pain/soreness n=19, 95% Counsel the patient on the complication n=17, 85% Baby not satisfied n=18, 90% Concerns about milk supply n=17, 85% Refer to support group within the community n=14, 70 % Medication interactions n=16, 80% ( such as La Leche League and Others) Pediatrics (n=20) Refer to support group at a hospital n=14, 70 % Concerns about milk supply n=20, 100% Latch-on difficulties n=19, 95% Pediatrics (n=20) Nipple pain/soreness n=19, 95% Refer to other lactation support staff within my n=17, 85% Medication interactions n=17, 85% practice Baby not satisfied n=16, 80% Counsel the patient on the complication n=16, 80% Family Medicine (n=4) Discuss other feeding options with client n=15, 75% Latch-on difficulties n=4, 100% Nipple pain/soreness n=4, 100% Family Medicine (n=4) Concerns about milk supply n=4, 100% Counsel the patient on the complication n=4, 100% Diet during breastfeeding n=4, 100% Discuss other feeding options with client n=3, 75% Baby not satisfied n=3, 75% Refer to support group within the community n=3, 75% ( such as La Leche League and Others)

FLORIDA DEPARTMENT OF HEALTH IN HILLSBOROUGH COUNTY BREASTFEEDING QUALITY IMPROVEMENT PROJECT Current literature indicates the The following is a list of potential What are your preferred formats to following potential barriers breastfeeding topics that Registered Dietitians, receive STAFF education on the topics physicians face in supporting Registered Nurses, and Lactation Specialists you identified. breastfeeding. Which barriers do can provide for STAFF education. you encounter in your practice? CHECK YOUR TOP 3 CHOICES. Time limitations during each patient’s visit n = 37 Proper latch and positioning technique n = 32 Lunch and Learn n = 25 Need more information about available resources n = 29 Milk production/milk supply n = 25 Web-based training n = 22 Lack of family support - 27 Drug safety while breastfeeding n = 15 Hand-outs/pamphlets n = 13 Limited training in breastfeeding management n = 23 Breastfeeding benefits n = 12 Website n = 11 Reimbursement concerns n = 18 Sore or cracked nipples n = 12 Folder/Pocket Guide n = 7 Patient no show n = 11 The nutritional difference between breast milk and formula n = 9 None of the above n = 1 Other n = 3 Milk expression and storage practices n = 9 Other n = 0 Mastitis n = 4 None of these topics n = 1 Not interested in receiving staff training n = 1

FLORIDA DEPARTMENT OF HEALTH IN HILLSBOROUGH COUNTY BREASTFEEDING QUALITY IMPROVEMENT PROJECT How Florida is Working to Increase Breastfeeding Initiation

Katie Williams, MPH Program Manager, Healthiest Weight Florida Bureau of Chronic Disease Prevention Division of Community Health Promotion Florida Department of Health Collective Impact Approach

Birthing Facilities

Early Care & Communities Education Centers 6 Healthy Places Health Care Settings Schools

Worksites

2 Baby-Friendly Hospital Initiative  Global standard for hospital care to support breastfeeding, with the Ten Steps to Successful Breastfeeding at its core1  Benefits  Increases breastfeeding rates which improve health outcomes & health care cost expenditures  Adds marketing & branding potential  Meets Joint Commission measures for accreditation  Aligns with patient-centered care delivery  Improves patient satisfaction2  Florida currently has 11 Baby Friendly Hospitals

1. World Health Organization/UNICEF. (1989). Protecting, Promoting and Supporting Breast-feeding: The Special Role of Maternity Services. Geneva: World Health Organization. 2. Centers for Disease Control and Prevention (CDC). (2011). Vital Signs: Hospital Practices to Support Breastfeeding --- United States, 2007 164 and 2009. MMWR. Morbidity and Mortality Weekly Reports. Retrieved from https://www.cdc.gov/mmWr/preview/mmwrhtml/mm6030a4.htm Baby Steps to Baby Friendly  Recognition Models  Baby-Friendly Hospital Initiative through Baby Friendly USA  Florida Breastfeeding Coalition’s Quest for Quality Maternity Care Award  Project Participants  Phase I (2015): 27 Hospitals in 15 Counties  Phase II (2016): 41 Hospitals in 26 Counties  Phase III (2017): 60 Hospitals in 31 Counties  Phase IV (2017-2018): TBD

165 Baby Steps to Baby Friendly Results

166 Florida Healthy Babies  Baby Steps to Baby Friendly  Motivation and incentive  Catalyst for community engagement  Improving breastfeeding rates  Rural Breastfeeding Pilot Project  Social Marketing Project  Continued support for Florida Breastfeeding Coalition

167 Annette Leary RN, BSN, IBCLC Helpful Websites https://www2.aap.org/breastfeeding/files/pdf/FederalSupportforBreastfeedi ngResource.pdf https://www.healthcare.gov/coverage/breast-feeding-benefits/ https://www.nwlc.org/sites/default/files/pdfs/final_nwlcbreastfeedingtoolki t2014_edit.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555840/ http://www.bestforbabes.org/insurers-not-allowed-deny-coverage- breastfeeding-mothers/ https://breastfeedchicago.org/insurance-reimbursement-of-lactation- expenses/ https://www.hrsa.gov/womensguidelines/ Break, Posters & Exhibitors State Breastfeeding Coalition & Task Force Round Robin

North Florida Bay County Breastfeeding Task Force Sandy McCroan, IBCLC

Central Florida Tampa Bay Breastfeeding Task Force Elizabeth Good & Rachel Romero Pasco Hernando Breastfeeding Task Force Felicia Deluca & Jennie Rae Lanziero

South Florida Broward Breastfeeding Coalition Esther March Singleton MBA, BSN, BHS, IBCLC Palm Beach County Breastfeeding Coalition Becket Miller, BA, RN, BSN, IBCLC, RLC Dr. Heather Shaffer – Chair Bethany Willis, IBCLC - Treasurer Family Practice Physician Rainbow Pediatrics

Sandy McCroan, IBCLC – Co-Chair Bethany Clark, IBCLC – Secretary FDOH Bay County WIC FDOH Bay County WIC GETTING THE WORD OUT

• Created Posters for Pediatricians Office • Delivered Breastfeeding Educational information to OB/GYNs offices GOT BREASTFEEDING PROBLEMS? CALL • Shared Breastfeeding Classes, Support 850-747-5775 CALLS ANSWERED BEFORE, DURING Groups and Event on Breastfeedbay’s AND AFTER BUSINESS HOURS! LOOKING FOR A BREASTFEEDING FRIENDLY CHILDCARE PROVIDER OR EMPLOYER VISIT THE FLORIDA BREASTFEEDING COALITION, INC Facebook Page AT FLBREASTFEEDING.ORG • Magnet with Breastfeeding Hotline Number given to ALL Breastfeeding Mothers Delivery in Bay County

Visit Breastfeedbay on Facebook #breastfeedbay BREASTFEEDING EVENTS

 Bay County’s Breastfeeding Week Celebration and “Big Latch On”  Quarterly Breastfeeding Socials COMMUNITY BREASTFEEDING EDUCATION

CHILDCARE AND EMPLOYERS BREASTFEEDING DISPARITIES  Breastfeeding Friendly Childcare Education Trainings and  NACCHO GRANT Recognition Program  Focus Group  Breastfeeding Friendly Employer  New Bethel Baptist Church Round Education and Recognition Table Discussion Program IT TAKES A VILLAGE

Florida Department of Breastfeed Bay Health - Bay County Breastfeeding Task Force for WIC Staff Bay and Surrounding Counties

176

Created by Jennie Rae Lanziero April 2017 A New Taskforce with BIG Goals

• Joining with Citrus County to become the Florida West Coast Breastfeeding Task Force! • Getting the word out to community members and professionals • A new logo and website is in the works • A BIG Latch On event is in the planning stages to be hosted in Pasco County August 2017 Logo Design by Marilyn Michaels of TheLightBox Photography Inc. Outreach Events!

• Storybook Forest Event at Crews Lake Park in Pasco County

• Provided a breastfeeding friendly environment to attendees of the event to ensure breastfeeding families had a place to sit, cool down and breastfeed their babies. Chairs were available for breastfeeding mothers and their families to sit down while breastfeeding. We also provided breastfeeding resource materials for the community in Pasco and Hernando counties. The book theme for our tent was Mama’s Milk by Michael Ross and we had a game where children matched animals feeding their children to encourage learn through play and increase awareness in breastfeeding –Leonne DansoOdei Storybook Forest Event

March 25, 2017

Photo credits to Felicia Deluca, Jennie Rae Lanziero, and Amy Fritsch More Outreach Events…

Hernando County Sheriff’s National Victorious Life Church Annual Night Out Community Egg Hunt • A family fun community event! • A family fun community event (25,000 expected to attend) • Held at the Target on Aerial Way, Spring Hill • Field in front of Cobb Theater, Wesley Chapel, • October 1, 2016 FL • April 8, 2017 Bayfront Health Spring Hill Hospital Women’s Expo • A family event for women and children • April 2, 2017 World’s Biggest Baby Shower Hernando

Photo Credits to Mary Becker A Bright Future in the Making…

• We were honored to be recognized by Staywell as their Community Partner in the month of March! • A luncheon and plaque was awarded to the Pasco Hernando Breastfeeding Taskforce

• We are excited about what the future holds as the Florida West Coast Breastfeeding Task Force! • Join our current Facebook page at: https://www.facebook.com/PascoHernandoBreastfeedingTaskforce Addressing Breastfeeding Disparities & Prejudices through Lactation Leadership – Part 1 Felisha Floyd, BS, CLC, IBCLC Jessica Gordon, PhD, ARNP, CLC

. Personal Insights . Increase effectiveness of communications with others . Build stronger teams

. Joys . Values . Strengths . Irritants . Aggravations . Stressors . Empathy . Understanding another person’s pint of view . Sympathy . Feeling the way another person feels

Filters are Different!! THAT’S OK!!!!

. Klasner, A. E. (2015). PACE Palette: Teaching Interpersonal and Communication Skills. Journal of Graduate Medical Education, 7(2), 293. http://doi.org/10.4300/JGME-D- 14-00588.1 . Newman, J. W. (1995). Release Your Brakes! E-book: https://www.paceorg.com/produc t/release-your-brakes-ebook/ . The PACE® Palette Leader’s Guide (1992). https://www.paceorg.com/produc t/the-pace-palette-leaders-guide/ Addressing Breastfeeding Disparities & Prejudices through Lactation Leadership – Part 2 Jessica Gordon, PhD, ARNP, CLC

http://www.leadershipchallenge.com/about-section-our-approach.aspx

. Kouzes, J. & Posner, B. (2012). The Leadership Challenge: how to make extraordinary things happen in organizations. 5th edition. San Francisco, Ca: Wiley. . Leadership Challenge Application FREE . http://www.leadershipchallenge.c om/about-section-our- approach.aspx Recognition & Closing Remarks Our Conference Committee

• Jessie Gordon, Conference Chair - Florida Breastfeeding Coalition (FBC) President • Cathy Gillespie - Exhibitor Coordinator - Former LLL Leader & FBC Board Member • Pat Lindsey - Registration Coordinator - FBC Founder and current Treasurer • Esther March-Singleton - Abstract Coordinator - FBC Programs Coordinator • Krista Schoen - FBC FL DOH Representative - Public Health Nutritionist at FL DOH • Erin Gluff, Perinatal Services Supervisor, Healthy Start Johns Hopkins All Children's Hospital • Kimberly Williams Brown - Project Director, Healthy Start at John Hopkins All Children’s Hospital • Katie Williams - Healthiest Weight Florida Manager, Florida Department of Health • Felisha Floyd - FBC Advocacy Chair Special Thanks To Our Volunteers & Sponsors: Please complete your evaluations and thank you for supporting nursing mothers!