Q. On the flow sheet, it lists preterms and transfers in a different category. So, when compiling stats, I still include them, even if they delivered in another hospital? Or do they have their own numbers? If we only charted births at the birthing centre, our numbers would be much better.

A. Yes you must include them but in their own category. For BFI designation we are looking at your births and how you provide follow up support for families including those that are transferred in. Keep the data on the transfers in and the preterm babies. Because you also provide follow up they will add to your case when it is shown that you get them to be totally breastfeeding once under your care.

They are not exclusively breastfeeding once they have had ANY formula since birth.

Q. So, I can see that getting an OB, Ped, L&D nurse, Mat floor Nurse, from at least BGH onto our committee could help the hospital transfers, too.

A. Absolutely and will strengthen your case that you are collaborating widely to improve health outcomes by affecting practise up-stream.

Q. Exclusivity at 6 weeks – that’s what we are aiming for, right?

A. We are looking at your facility’s practice - initiation rate, exclusive on discharge from the unit and breastfeeding rate (any and exclusive) at 2/3 weeks and then again around 6 months. This is because we are aiming for increased breastfeeding initiation, exclusivity and duration rates. Your facility will know how best to gather this data depending on when you have contact with clients. Also a plan for how you will monitor duration – e.g. maybe when babies come for inoculations at 4-6 months? For those babies born in the facility - keep track of reasons for supplementation - if it's a medical indication they count with your exclusives.

Q. So, if they are d/c from hospital back into our care already being supplemented (they all are), if we get them exclusively bf by 6 weeks, that will count?

A. Yes it counts as it shows your supportive best practise - but they are not exclusive. Show all your numbers as it pulls all the puzzle pieces together and gives you direction to provide better services when you can identify reasons for the drop off.. This is the value of the BFI :)

Q. We are a tertiary care facility with ~5000 deliveries per year - with lots of staff of various levels. One of our challenges is providing 20 hours of BF related education to all staff who provide hands on BF care. We do not have the budget for all these nurses to take the 20 hour course - although this is happening at some of the smaller hospitals.We do have an 8 hour BF orientation for new staff - and continuing education through the year - but difficult to add up to 20 hours. So - my question to you is related to how your hospital delivered or ensured access to this level of education in a big facility??

A. Having a certificate from a recognized 21 hour breastfeeding course has been a necessary qualification for any Nurse who was looking to work on the Family Birthing Centre, Special Care Nursery or paediatrics since about 1997. The Nurse was required to show her certificate as completed and this was to be completed before being hired or at least within 6 months of being hired. When we took on the goal of becoming baby friendly our Nurse Educators with the help of a few LC's took on the role of teaching the 20 Unicef Breastfeeding Course "in house" for those who had not completed a course or who were new hires. Our Director supported this as part of our mandate to become baby friendly. The course was offered for free to the Nurse (we do charge when outsiders take our course) and I believe that the Nurse takes the course on her own time as this is a requirement of her being employed in this setting. Because this was a very important part of the process the cost to the hospital was never considered a barrier. We teach the course every Fall for those who need the course and it is open to any Nurse at the hospital. We have had a few Nurses from Emerg take it too which is great as they see babies in Emerg with feeding issues too. I can honestly tell you that the Director of our Maternal Newborn and Child Program never once ever said, "How much is this costing?" She believed that being Baby Friendly was important for our patients and supported the BFHI 100%.

Q. I am seeking clarification about the provision of artificial baby milk ( ABM) information to clients prenatally. When a PHN is delivering one to one prenatal services, and she has determined that the client has made an informed decision to feed ABM once her baby is delivered, is it appropriate to provide information on the safe preparation, storage and feeding of ABM?

A. It is a requirement of BFI that mothers who have made the informed decision are given the info they need on safe bottle/formula feeding in a one on one situation. Written materials are not provided by industry nor do they mention brand names.The responsibility we have is to ensure the parents have had the info to make an informed decision.

Q. Is it possible to speak with an Assessor or someone who would know exactly how the steps are interpreted when it comes time for assessment?

A. The assessment process includes a preassessment.During the preassessment an assessor is assigned to work directly with the facility wanting to undertatke the BFI. If at any point you have questions before you start the preassessment please feel free to contact the assessment committee.

Q. For #6, I need confirmation that this step would still have the mother be the ultimate decision maker on the feeding of her baby. So, a mother could of course at any time decide to provide formula to her baby and that would be supported by hospital staff. I understand that this step would prevent nurses or other professionals from providing formula to an infant without consent of the mother which is great. Is this the correct interpretation of this step?

A. If you read the indicators (available on the BCC website) you will note that the focus of the Baby-Friendly Initiative is informed decision-making by families. WHO/UNICEF recognized that in many situations in the past, formula was given to babies without consent or formula was suggested by staff for non medical reasons. The purpose of Step 6 is to ensure several things:

• parents receive enough support and information during pregnancy and postpartum to be able informed decisions - they know both the importance of exclusive breastfeeding and the risks that formula or unnecessary supplements pose for infants.
  
• parents who make informed decisions receive appropriate care and support. For example, their babies too, go skin to skin especially during the first hour after birth (Step 4)
  
• parents using formula receive information to enable them to use, provide and store it as safely as possible

You are correct in that this step prevents health care providers from providing formula without consent.

Q. For #9, I know that a lot of staff and mothers feel that this step is a bit out-dated and often pacifiers are useful for infants, including breastfeeding infants. Would this be allowable if a mother chose to provide her infant with a pacifier (or with an artificial nipple if she was formula feeding)? Does it just mean that hospital staff will not provide pacifiers or artificial nipples without a mother's request and consent?

A. I am not sure why your staff would think this step is out-dated given the ongoing literature that indicates that soothers and teats can be problematic for breastfeeding infants. One reference I have attached by Peter Blair (BMJ 2009) refutes the possible benefit of a soother in relation to SIDS. Again, the BFI does not direct what mothers do. Rather, it provides direction to health care providers in giving evidence based care. Health care providers need to provide information about potential concerns with soothers and teats and provide alternative strategies. Parents may choose to use a soother but health care providers should not provide them with or without consent. There are exceptions. Premature infants who cannot yet breastfeed may benefit form a soother during painful procedues or while being gavage fed. The focus of BFI is healthy term infants.

If a mother is solely formula feeding she can of course use a bottle.

Q. I am wondering if you have a work sheet for estimating the cost of infant formula used at the hospital. As well is there a more detailed information sheet re same other than the global criteria attached to Step 6

A. I am unaware of a worksheet such as you have requested. Generally, we look for an appropriate amount of formula for the less than 75% of babies who might receive it (assuming at least 75% exclusive breastfeeding rates) thus about (25% of the birth rate of the hospital) x (average length of stay) x (500mls to allow for wastage). This gives a ball park figure for the amount of formula at wholesale pricing. An additional cost factor is the cost of feeding paraphenalia (bottles and teats).

Q. One of our larger hospitals has recently moved their C/Ss to the regular operating room well away from labour and birth area. The staff on the maternity floor are working to inform recovery room staff about the importance of skin-to-skin and early breastfeeding. There is resistance to having the babies in the recovery area (increase risk of infection , who will monitor baby etc)?

I know that the dads can do the skin to skin until mother is back on unit but I would appreciate hearing from hospitals that have been able to initiate some skin to skin in recovery area. (Do partners remain in recovery area with mom and baby? Is there a maternity nurse who remains with mom and baby?). The main obstacle that I see is the need to have a nurse stay with mom and baby as this will be a staffing issue.

A. The question about infection - actually, Lars Hanson's book: The Immunology of Human Milk would argue authoritatively that removing the baby form the mother puts the baby at greatest risk of infection. Monitoring of the baby is easiest to do when kept skin to skin with the mother.

In our institution fathers remain with mother and baby - but we have a PAR for maternity patients only. Other facilities of which I am aware have: a very small (2 bed ) recovery area on the maternity unit for c/s births: a combined PAR but the maternity nurse goes to PAR with the mother/baby dyad.

Q. Our hospital here is using foley cups for cup feeding and is asking for cleaning protocols.The Foley rep says they are single use only. Wondered if your hospital has a policy around cup use and cleaning?

A. We use the disposable plastic med cups to cup feed. We do not have a policy for cleaning and reusing them: rinse the cup with plain water and reuse - with the same baby of course. There has never been an issue with this practice.