EMPower Best Practices Skills Competency Course Objectives and Outline (eLearning Course and Skills Competency Verification)

Overall Objectives of EMPower Best Practices eLearning Course:

• Identify competencies and performance indicators outlined by the World Health Organization and UNICEF in the Baby-Friendly Hospital Initiative 
• Acquire foundational skills of effective communication, equitable care, and cultural humility to apply to all patient interactions
• Apply the acquired knowledge, skills, and confidence and respond to clinical situations related to evidence-based care in birthing, lactation, and infant feeding

Section: Preface and Disclaimer

1. Preface
2. Disclaimer

Preface and Disclaimer Section Estimated Learning Time: 5 minutes/ 0.08 hours

Section: Introduction

                Introduction Section Objectives:

• Describe the EMPower Best Practices Project
• Use the EMPower Best Practices eLearning program

Introduction Section Outline:

1. About EMPower Best Practices
2. Course Objectives
3. Course Orientation and Navigation
4. Course References and Resources

Introduction Section Estimated Learning Time: 15 minutes/ 0.25 hours

Section: Overview: National Trends and Guidance

National Trends and Guidance Section Objectives and Related Performance Indicators

• Describe national breastfeeding trends 
• Explain national initiatives that and actions that have lead to breastfeeding improvements 
• Identify The Ten Steps to Successful Breastfeeding 
• Define the Baby-Friendly Hospital Initiative  

National Trends and Guidance Section Outline:

1. Why Breastfeeding Matters: The Evidence and National Efforts
   1. Breastfeeding is critical to our health as a nation
   2. Breastfeeding saves lives
   3. Breastfeeding protection, promotion and support are essential
   4. Breastfeeding and long term health
   5. Breastfeeding decreases breast cancer risks
   6. Breastfeeding matters for all families: Black and Hispanic children who experience sub-optimal breastfeeding are at greater risk for childhood disease
   7. Improving maternity care and breastfeeding support: History of efforts
      1. U.S. Department of Health and Human Services (HHS)
      2.  Centers for Disease Control and Prevention (CDC), Joint Commission
      3. Surgeon General’s Call to Action to Support Breastfeeding
      4. 2010 Patient Protection and Affordable Care Act
      5. Healthy People Objectives
      6. Dietary Guidelines for Americans
2. Current Breastfeeding Rates and Trends
   1. Percentage of U.S. Children Who Were Ever Breastfed and Exclusively Breastfed, by Birth Year
   2. Percentage of Breastfed Children Who Were Supplemented with Infant Formula, by Birth Year
   3. Rates of Any and Exclusive Breastfeeding by Age Among Children Born in 2017 in the U.S.
   4. Healthy People 2020 Progress and 2030 goals
3. Racial Disparities in Breastfeeding, Maternal, and Newborn Outcomes
   1. Historically marginalized/ minoritized racial and ethnic populations tend to have poorer health status and outcomes
   2. Data
      1. Infant mortality rates by race and ethnicity
      2. Maternal mortality rates by single race and Hispanic origin
      3. Breastfeeding data by race and ethnicity
4. The Framework for Improvement: The Ten Steps to Successful Breastfeeding
   1. Definition and endorsement of The Ten Steps to Successful Breastfeeding
   2. Introduction of each of The Ten Steps to Successful Breastfeeding
5. The Baby-Friendly Hospital Initiative
   1. Definition of the Baby Friendly Hospital Initiative
   2. Orientation to Baby-Friendly USA (BFUSA)
   3. How to achieve and sustain Baby-Friendly Designation
   4. Data
      1. Percentage of Baby-Friendly Designated facilities in the United States
      2. Baby-Friendly growth and contributing factors
6. Test your Knowledge: National Trends and Guidance

Overview: National Trends and Guidance Section Estimated Learning Time: 60 minutes/ 1 hour

Section: Foundational Skills: Applying Effective Communication, Equity, Cultural Awareness, and Humility

                Foundational Skills Section Objectives and Related Performance Indicators

• Describe 4 pillars of effective communication
• Explain how racism, bias, and discrimination contribute to racial and ethnic disparities in maternal and newborn outcomes
• Demonstrate skills in practicing cultural humility 
• Explain how person-centered care contribute to improved quality of care
• Demonstrate at least 3 aspects of listening and learning skills when talking with a parent
• Demonstrate at least 3 ways to adapt communication style and content when talking with a parent
• Demonstrate at least 2 ways to encourage a parent to share their views, taking time to understand and consider these views
• Demonstrate at least 3 aspects of building confidence and giving support when talking with a parent

Foundational Skills Section Outline:

1. Foundations of Effective Communication and Person-Centered Care
   1. Pillars of effective communication
      1. People
      2. Message
      3. Context
      4. Listening
2. Understanding How Racism Creates Health Disparities
   1. Definitions
      1. Race
      2. Ethnicity
   2. How racism impacts pregnancy outcomes
   3. Definitions
      1. Equity
      2. Equality
      3. Justice
      4. Inclusion
   4. Definitions of different types of racism
      1. Racism
      2. Interpersonal racism
      3. Institutional racism
      4. Structural racism
      5. Systemic racism
      6. Internalized racism
3. Bias and Discrimination
   1. Definition of discrimination
      1. Racism
      2. Sexism
      3. Ageism
      4. Ableism
      5. Classism
      6. Heterosexism
   2. Definition and types of bias
      1. Explicit bias
      2. Implicit bias
      3. Microaggressions
      4. Measuring and identifying your own bias
4. Cultural Humility for Improved Quality of Care
   1. Cultural competence verses cultural humility
   2. Three dimensions of cultural humility
      1. Lifelong learning and critical self-reflection
      2. Recognize and challenge power imbalances
      3. Institutional accountability
5. Foundational skills case study
6. Test your knowledge: Foundational skills
7. Foundational skills resources and job aids

Foundational Skills Section Estimated Learning Time: 210 minutes/ 3.5 hours

Section: Critical Management Procedures to Support the Ten Steps to Successful Breastfeeding

                Critical Management Procedures Section Objectives

• List at least 3 products that are covered by the International Code of Marketing of Breast milk Substitutes
• Describe at least 3 ways a direct care provider/direct care staff protects breastfeeding in practice
• Describe at least 1 way a direct care provider/direct care staff member should respond if offered information provided by manufacturers and/or distributors of products within the scope of the code
• Describe at least 1 type of financial or material inducement that might be offered to a direct care provider/direct care staff member by a manufacturer and/or distributor of products within the scope of the code
• Describe at least 1 harm of a direct care provider accepting financial or material inducements
• Explain at least 2 ways that the facility ensures that there is no promotion of infant formula, feeding bottles, or teats in any part of facilities providing maternity and newborn services, or by any of the direct care providers
• Describe at least 2 elements that are in a facility’s comprehensive infant feeding policy
• Explain at least 3 ways that the infant feeding policy affects direct care provider’s/ direct care staff member's work in providing safe, equitable, and appropriate care
• Explain at least 2 reasons why monitoring of hospital practices is important to ensure quality of care
• Explain at least 2 ways practices are monitored in this facility

Critical Management Procedures Section Outline

1. Compliance with the International Code of Marketing of Breast Milk Substitutes
   1. Description of the International Code of Marketing of Breast Milk Substitutes
   2. The scope of The Code
   3. The importance of The Code
   4. Provisions of The Code
2. The Importance of a Comprehensive Feeding Policy
   1. Step 1B of the Ten Steps to Successful Breastfeeding states:  Have a written infant feeding policy that is routinely communicated to staff and parents
   2. Elements of a comprehensive infant feeding policy
      1. The Ten Steps to Successful Breastfeeding
      2. International Code of Marketing of Breast Milk Substitutes
      3. Support to all families regardless of feeding choice
      4. Details about how the facility monitors progress
   3. The impact of policies in daily work
3. Ongoing Monitoring, Quality Improvement, and Data Management Systems
   1. Step 1 C.  Establish ongoing monitoring and data-management systems.
   2. Data collection concepts and considerations
   3. Definition of quality improvement
4. Step 2: Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding
5. Test Your knowledge: Critical management procedures
6. Critical management procedures resources and job aids

Critical Management Procedures Section Estimated Learning Time: 60 minutes/ 1 hour

Section: Lactation Basics

                Lactation Basics Section Objectives

• Identify anatomical parts of the breast/ chest involved in lactation
• Describe physiology of lactation hormones
• Explain physiology of milk production and flow
• List the contraindications to providing parent's own milk
• List credible resources to reference when inquiring about the safety of a medication for use during lactation
• Describe at least 2 parental and 2 infant risk factors associated with delayed lactogenesis II
• Describe at least 1 professional medical reference or resource for identifying medications that are safe/compatible for use during lactation 

                Lactation Basics Section Outline

1. Lactation anatomy and physiology
   1. Structures of the breast/chest involved in lactation
   2. Hormones of lactation
   3. Stages of milk production
   4. Risk factors for delayed onset of milk production
2. Contraindications to breastfeeding
3. Medication use and lactation
   1. Vaccinations, medications, and drugs during lactation
   2. Risk resources
4. Lactation basics case study
5. Test your knowledge: Lactation basics
6. Lactation basics resources and job aides

Lactation Basics Section Estimated Learning Time: 60 min/ 1 hour

Section: Step 3: Discuss the Importance and Management of Breastfeeding with a Pregnant Woman and Their Families

                Step 3 Section Objectives

• Engage in a conversation with a pregnant person on 3 aspects of the importance of feeding human milk
• Assess at least 3 aspects of a pregnant person’s knowledge about lactation to fill in the gaps and correct inaccuracies
• Engage in a conversation with a pregnant person about at least 4 care practices a parent/infant dyad will experience at the birthing facility that will support lactation
• Engage in a conversation with a pregnant parent regarding at least 3 reasons why effective exclusive feeding of human milk is important

Step 3 Section Outline

1. Goals and benefits of prenatal infant feeding education
   1. Breastfeeding and human milk
   2. Birth practices
   3. Anticipatory guidance
2. Global and professional recommendations for infant feeding
   1. American Academy of Pediatrics (AAP) recommendations
   2. World Health Organization recommendations
   3. Benefits of continued breastfeeding and human milk
3. Benefits of human milk
   1. Benefits for baby/ infants
   2. Benefits for breastfeeding women
4. Practices that can help get breastfeeding off to a good start
   1. Immediate skin-to-skin contact
   2. Rooming-in
   3. Feeding on cue (on demand)
   4. Newborn feeding patterns
   5. Effective positioning and attachment
5. Step 3 case study
6. Step 3 resources and job aids

Step 3 Section Estimated Learning Time: 70 minutes/ 1.2 hours

Section: Step 4: Facilitate Immediate and Uninterrupted Skin-to-Skin Contact

                Step 4 Section Objectives

• Explain 3 reasons why immediate and uninterrupted skin-to-skin is important for the birthing parent
• Explain at least 3 reasons why immediate and uninterrupted skin-to-skin is important for the infant
• List at least 3 reasons why skin-to-skin should NOT be interrupted 
• Explain at least 2 reasons when skin-to-skin could be interrupted for medically justifiable reasons
• Explain how to maintain skin-to-skin during transfer of birthing parent and infant to another room or other recovery area
• Demonstrate at least 3 points of how to routinely implement immediate, uninterrupted skin-to-skin between birthing parent and infant regardless of method of birth
• Demonstrate at least 3 safety aspects to assess during skin-to-skin during the first 2 hours postpartum, regardless of method of birth
• Engage in a conversation with a breastfeeding/chestfeeding parent, including at least 3 reasons why suckling at the breast in the first hour is important, when the baby is ready
• Demonstrate at least 3 aspects of safe care of the newborn in the first 2 hours post-birth
• Describe to a parent at least 3 prefeeding behaviors babies show before actively sucking at the breast/ chest

Step 4 Section Outline

1. Importance of immediate skin-to-skin contact
   1. Definition of skin-to-skin contact
   2. Benefits of immediate skin-to-skin contact
2. Immediate skin-to-skin practices and early newborn feeding behaviors
   1. Routine procedures that should be delayed
   2. Routine procedures at delivery
   3. Skin-to-skin after vaginal deliver
   4. Skin-to-skin after cesarean
   5. Recognition of early feeding cues and staff assistance
3. Safety considerations during immediate skin-to-skin care
   1. Standardization of safe skin-to-skin following delivery
   2. Components of safe positioning for the newborn while skin-to-skin
   3. Monitoring assessment during skin-to-skin care
   4. Sudden Unexpected Postnatal Collapse (SUPC)
4. Step 4 case study
5. Test your knowledge: Step 4
6. Step 4 resources and job aids

Step 4 Section Estimated Learning Time: 50 minutes/ 0.8 hours

Section: Step 5: Support Mothers to Initiate and Maintain Breastfeeding and Manage Common Difficulties

                Step 5 Section Objectives

• Describe at least 6 essential issues that every lactating parent should know or demonstrate.
• Describe at least 2 maternal and infant risk factors associated with delayed lactogeneis II
• Engage in a conversation with a parent regarding 2 elements related to infant feeding patterns in the first 36 hours of life
• Describe to a parent at least 4 signs of adequate transfer of milk in the first few days.
• Examine a full breastfeeding/ chestfeeding session observing at least 5 points
• Demonstrate at least 3 aspects of how to help a parent achieve a comfortable and safe position for breastfeeding within the first 6 hours after birth and later as needed during the hospital stay.
• Demonstrate how to help a parent achieve an effective and comfortable latch, noting at least 5 points.
• Demonstrate to a lactating parent how to hand express human milk, noting 8 points.
• Help a parent achieve a comfortable and safe position for breastfeeding/chestfeeding with a preterm, late preterm, or weak infant noting at least 4 points
• Engage in a conversation with a breastfeeding/chestfeeding parent of a preterm, late preterm, or low-birth-weight infant not sucking effectively at the breast, including at least 5 point
• Engage in a conversation with a parent regarding at least 4 different ways to facilitate breastfeeding to prevent or resolve most common conditions of the lactating breasts (sore nipples, engorgement, parent who thinks she doesn’t have enough milk, infants who have difficulty sucking)

Step 5 Section Outline

1. Latching, positioning, and assessment
   1. Characteristics of good positioning
   2. Characteristics of good latch/ attachment
   3. Helping a breastfeeding parent
2. Eating patterns and getting enough milk
   1. Normal newborn feeding patterns
   2. Signs that a newborn is getting enough milk
3. Common conditions of lactation
   1. Nipple soreness and management
   2. Breast pain
   3. Engorgement
   4. Blocked ducts
   5. Breast infections
4. Expressing human milk
   1. Demonstration of milk expression techniques
   2. Human milk storage and handling guidelines
   3. Cases of prolonged parent/ newborn separation
5. Preterm and late preterm infants
   1. Terminology and definitions
   2. Lactation management and considerations of the late preterm and early term infants
6. Step 5 case study
7. Test your knowledge: Step 5
8. Step 5 resources and job aids

Step 5 Section Estimated Learning Time: 120 minutes/ 2 hours

Section: Step 6:  Exclusive Breastfeeding, Except when Medically Indicated

                Step 6 Section Objectives

• • Explain at least 3 aspects of appropriate storage of human milk
  • Explain at least 3 aspects of handling of expressed human milk
  • List at least 2 potential contraindications to human milk feeding for a baby and a lactating parent 
  • Describe at least 4 medical indications for supplementing breastfed newborns: 2 parental indications and 2 newborn indications, when breastfeeding is not improved following skilled assessment and management
  • Describe at least 3 risks of giving a breastfed newborn any food or fluids other than breast milk, in the absence of medical indication
  • For those few health situations where infants cannot, or should not, be fed at the breast/chest, describe the alternatives to use, in order of preference
  • Identify 3 high-risk infant populations that may warrant extra precautions to protect against severe infections associated with powdered infant formula 
  • Engage in a conversation with a parent regarding at least 3 reasons why effective exclusive human milk feeding is important
  • Engage in a conversation with a parent who plans to feed their baby formula, noting at least 3 actions to take
  • Demonstrate at least 3 important items of safe preparation of infant formula to a parent who needs that information

Step 6 Section Outline

1. Importance of exclusive breastfeeding
   1. Review of benefits
   2. When supplementation is indicated                
2. Common medical indications for supplementation
   1. Weight loss
   2. Hypoglycemia
   3. Hyperbilirubinemia
   4. Macronutrient supplementation
   5. Maternal indications
3. Handling, storing, and feeding expressed human milk
   1. Safe handling practices
   2. Safe storing practices
4. Safely preparing and handling infant formula and bottle-feeding practices
   1. Safe preparation of infant formula
   2. Preparation of powdered infant formula
   3. Safe bottle-feeding practices and techniques
5. Step 6 case study
6. Test your knowledge: Step 6
7. Step 6 resources and job aids

Step 6 Section Estimated Learning Time: 90 minutes/ 1.5 hours

Section: Step 7: Practice Rooming-In 24 Hours a Day

                Step 7 Section Objectives

• • Describe 2 aspects involved in creating a safe environment for rooming-in 24 hours a day
  • Describe 2 situations: 1 for the parent and 1 for the infant, detailing when it is acceptable to separate birthing parent and infant while in the hospital

• • Engage in a conversation with a parent regarding 2 aspects related to the importance of rooming-in 24 hours a day
  • Demonstrate at least 3 safety aspects to assess when mother and baby are skin-to-skin during postpartum hospitalization, regardless of method of birth
  • Engage in a conversation with a birthing parent separated from their preterm or sick infant regarding at least 2 reasons to be with their infant in the intensive care unit

Step 7 Section Outline

1. Importance of rooming-in
   1. Definition of rooming-in
   2. Benefits of rooming-in
2. Safety considerations and medical indications for separation
   1. Situations where it is appropriate to separate a birthing parent and baby
   2. Patients that may be at risk for unsafe rooming-in practices
   3. Interventions when rooming-in safety is a concern
   4. Maintaining a safe environment
   5. Sick and premature infants in the NICU
3. Step 7 case study
4. Test your knowledge: Step 7
5. Step 7 resources and job aids

Step 7 Section Estimated Learning Time: 10 minutes/ 0.3 hours

Section: Step 8: Support Recognition and Response of Infant Feeding Cues

                Step 8 Section Outline

• • Describe at least 2 early feeding cues and 1 late feeding cue
  • Describe at least 4 reasons why responsive feeding (also called on-demand or baby-led feeding) is important independent of feeding method
  • List at least 2 aspects of responsive feeding (also called on-demand or baby-led feeding) independent of feeding method
  • Describe at least 4 elements to assess when a parent says that their infant is crying frequently
  • Engage in a conversation with a parent of a preterm, late preterm or vulnerable infant (including multiple births) regarding the importance of observing at least 2 subtle signs and behavioral state shifts to determine when it is appropriate to feed

Step 8 Section Outline

1. Early and late feeding cues
2. Importance of feeding on cue
3. Preterm and late preterm infants
4. Other considerations for staff
5. Step 8 case study
6. Test your knowledge: Step 8
7. Step 8 resources and job aids

Step 8 Section Estimated Learning Time: 20 minutes/ 0.3 hours

Section: Step 9: Counseling on the Use and Risks of Feeding Bottles, Teats, and Pacifiers

                Step 9 Section Objectives

• • Describe at least 2 alternative feeding methods other than feeding bottles
  • Describe at least 4 elements of anticipatory guidance to give to a mother on calming or soothing techniques before or as alternatives to pacifier
  • Describe when the acceptable time is for introducing a pacifier with a breastfeeding infant, with regards to SUID/SIDS reduction strategies
  • Demonstrate to a parent how to safely cup-feed their infant when needed, showing at least 4 points
  • Describe to a parent at least 4 steps to feed an infant a supplement in a safe manner
  • Engage in a conversation with a parent who requests feeding bottles, teats, pacifiers, and soothers without medical indication, including at least 3 points

Step 9 Section Outline

1. Artificial nipples, alternative feeding methods, and safety considerations
   1. Risks of artificial nipples
   2. Alternatives to soothing a fussy infant
   3. Pacifier use and safe sleep
   4. Alternative feeding methods and techniques
2. Step 9 case study
3. Test your knowledge: Step 9

Step 9 Section Estimated Learning Time: 20 minutes/ 0.3 hours

Section: Step 10: Coordinate Discharge so that Families Have Timely Access to Ongoing Support

                Step 10 Section Objectives

• • Describe at least 2 locally available sources for timely infant feeding information and problem management
  • Describe at least 2 ways the health care facility engages with community-based programs to coordinate messages about infant feeding and offer continuity of care
  • Describe at least 3 postpartum/parental warning signs for a parent to contact a health care professional after discharge
  • Engage in a conversation with a parent regarding at least 4 different ways to facilitate breastfeeding in order to prevent or resolve most common conditions of lactation (sore nipples, engorgement, parent who thinks they don't have enough milk, infants who have difficulty sucking)
  • Develop individualized discharge feeding plans with a parent to include at least 6 points
  • Describe to a parent at least 4 warning signs of infant undernourishment or dehydration that warrants contact with a health care professional after discharge

Step 10 Section Outline

1. Continuity of support post discharge
   1. Recommendations on follow-up support post facility discharge for newborns
   2. Recommendations on follow-up support post birth for birthing parents
   3. Warning signs and when to contact a provider
   4. Community engagement and support for facilities
2. Step 10 case study
3. Test your knowledge: Step 10
4. Step 10 resources and job aids

Section 10 Section Estimated Learning Time: 10 minutes/ 0.2 hours

Course Completion

1. Course Feedback Form
2. Certificate of completion download

Total Estimated Learning Time for EMPower Best Practices Course: 800 minutes/ 13.3 hours

Time Estimate Summary:

EMPower Best Practices Skills Competency Course Objectives and Outline (eLearning Course and Skills Competency Verification)

Overall Objectives of EMPower Best Practices eLearning Course:

• Identify competencies and performance indicators outlined by the World Health Organization and UNICEF in the Baby-Friendly Hospital Initiative 
• Acquire foundational skills of effective communication, equitable care, and cultural humility to apply to all patient interactions
• Apply the acquired knowledge, skills, and confidence and respond to clinical situations related to evidence-based care in birthing, lactation, and infant feeding

Section: Preface and Disclaimer

1. Preface
2. Disclaimer

Preface and Disclaimer Section Estimated Learning Time: 5 minutes/ 0.08 hours

Section: Introduction

                Introduction Section Objectives:

• Describe the EMPower Best Practices Project
• Use the EMPower Best Practices eLearning program

Introduction Section Outline:

1. About EMPower Best Practices
2. Course Objectives
3. Course Orientation and Navigation
4. Course References and Resources

Introduction Section Estimated Learning Time: 15 minutes/ 0.25 hours

Section: Overview: National Trends and Guidance

National Trends and Guidance Section Objectives and Related Performance Indicators

• Describe national breastfeeding trends 
• Explain national initiatives that and actions that have lead to breastfeeding improvements 
• Identify The Ten Steps to Successful Breastfeeding 
• Define the Baby-Friendly Hospital Initiative  

National Trends and Guidance Section Outline:

1. Why Breastfeeding Matters: The Evidence and National Efforts
   1. Breastfeeding is critical to our health as a nation
   2. Breastfeeding saves lives
   3. Breastfeeding protection, promotion and support are essential
   4. Breastfeeding and long term health
   5. Breastfeeding decreases breast cancer risks
   6. Breastfeeding matters for all families: Black and Hispanic children who experience sub-optimal breastfeeding are at greater risk for childhood disease
   7. Improving maternity care and breastfeeding support: History of efforts
      1. U.S. Department of Health and Human Services (HHS)
      2.  Centers for Disease Control and Prevention (CDC), Joint Commission
      3. Surgeon General’s Call to Action to Support Breastfeeding
      4. 2010 Patient Protection and Affordable Care Act
      5. Healthy People Objectives
      6. Dietary Guidelines for Americans
2. Current Breastfeeding Rates and Trends
   1. Percentage of U.S. Children Who Were Ever Breastfed and Exclusively Breastfed, by Birth Year
   2. Percentage of Breastfed Children Who Were Supplemented with Infant Formula, by Birth Year
   3. Rates of Any and Exclusive Breastfeeding by Age Among Children Born in 2017 in the U.S.
   4. Healthy People 2020 Progress and 2030 goals
3. Racial Disparities in Breastfeeding, Maternal, and Newborn Outcomes
   1. Historically marginalized/ minoritized racial and ethnic populations tend to have poorer health status and outcomes
   2. Data
      1. Infant mortality rates by race and ethnicity
      2. Maternal mortality rates by single race and Hispanic origin
      3. Breastfeeding data by race and ethnicity
4. The Framework for Improvement: The Ten Steps to Successful Breastfeeding
   1. Definition and endorsement of The Ten Steps to Successful Breastfeeding
   2. Introduction of each of The Ten Steps to Successful Breastfeeding
5. The Baby-Friendly Hospital Initiative
   1. Definition of the Baby Friendly Hospital Initiative
   2. Orientation to Baby-Friendly USA (BFUSA)
   3. How to achieve and sustain Baby-Friendly Designation
   4. Data
      1. Percentage of Baby-Friendly Designated facilities in the United States
      2. Baby-Friendly growth and contributing factors
6. Test your Knowledge: National Trends and Guidance

Overview: National Trends and Guidance Section Estimated Learning Time: 60 minutes/ 1 hour

Section: Foundational Skills: Applying Effective Communication, Equity, Cultural Awareness, and Humility

                Foundational Skills Section Objectives and Related Performance Indicators

• Describe 4 pillars of effective communication
• Explain how racism, bias, and discrimination contribute to racial and ethnic disparities in maternal and newborn outcomes
• Demonstrate skills in practicing cultural humility 
• Explain how person-centered care contribute to improved quality of care
• Demonstrate at least 3 aspects of listening and learning skills when talking with a parent
• Demonstrate at least 3 ways to adapt communication style and content when talking with a parent
• Demonstrate at least 2 ways to encourage a parent to share their views, taking time to understand and consider these views
• Demonstrate at least 3 aspects of building confidence and giving support when talking with a parent

Foundational Skills Section Outline:

1. Foundations of Effective Communication and Person-Centered Care
   1. Pillars of effective communication
      1. People
      2. Message
      3. Context
      4. Listening
2. Understanding How Racism Creates Health Disparities
   1. Definitions
      1. Race
      2. Ethnicity
   2. How racism impacts pregnancy outcomes
   3. Definitions
      1. Equity
      2. Equality
      3. Justice
      4. Inclusion
   4. Definitions of different types of racism
      1. Racism
      2. Interpersonal racism
      3. Institutional racism
      4. Structural racism
      5. Systemic racism
      6. Internalized racism
3. Bias and Discrimination
   1. Definition of discrimination
      1. Racism
      2. Sexism
      3. Ageism
      4. Ableism
      5. Classism
      6. Heterosexism
   2. Definition and types of bias
      1. Explicit bias
      2. Implicit bias
      3. Microaggressions
      4. Measuring and identifying your own bias
4. Cultural Humility for Improved Quality of Care
   1. Cultural competence verses cultural humility
   2. Three dimensions of cultural humility
      1. Lifelong learning and critical self-reflection
      2. Recognize and challenge power imbalances
      3. Institutional accountability
5. Foundational skills case study
6. Test your knowledge: Foundational skills
7. Foundational skills resources and job aids

Foundational Skills Section Estimated Learning Time: 210 minutes/ 3.5 hours

Section: Critical Management Procedures to Support the Ten Steps to Successful Breastfeeding

                Critical Management Procedures Section Objectives

• List at least 3 products that are covered by the International Code of Marketing of Breast milk Substitutes
• Describe at least 3 ways a direct care provider/direct care staff protects breastfeeding in practice
• Describe at least 1 way a direct care provider/direct care staff member should respond if offered information provided by manufacturers and/or distributors of products within the scope of the code
• Describe at least 1 type of financial or material inducement that might be offered to a direct care provider/direct care staff member by a manufacturer and/or distributor of products within the scope of the code
• Describe at least 1 harm of a direct care provider accepting financial or material inducements
• Explain at least 2 ways that the facility ensures that there is no promotion of infant formula, feeding bottles, or teats in any part of facilities providing maternity and newborn services, or by any of the direct care providers
• Describe at least 2 elements that are in a facility’s comprehensive infant feeding policy
• Explain at least 3 ways that the infant feeding policy affects direct care provider’s/ direct care staff member's work in providing safe, equitable, and appropriate care
• Explain at least 2 reasons why monitoring of hospital practices is important to ensure quality of care
• Explain at least 2 ways practices are monitored in this facility

Critical Management Procedures Section Outline

1. Compliance with the International Code of Marketing of Breast Milk Substitutes
   1. Description of the International Code of Marketing of Breast Milk Substitutes
   2. The scope of The Code
   3. The importance of The Code
   4. Provisions of The Code
2. The Importance of a Comprehensive Feeding Policy
   1. Step 1B of the Ten Steps to Successful Breastfeeding states:  Have a written infant feeding policy that is routinely communicated to staff and parents
   2. Elements of a comprehensive infant feeding policy
      1. The Ten Steps to Successful Breastfeeding
      2. International Code of Marketing of Breast Milk Substitutes
      3. Support to all families regardless of feeding choice
      4. Details about how the facility monitors progress
   3. The impact of policies in daily work
3. Ongoing Monitoring, Quality Improvement, and Data Management Systems
   1. Step 1 C.  Establish ongoing monitoring and data-management systems.
   2. Data collection concepts and considerations
   3. Definition of quality improvement
4. Step 2: Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding
5. Test Your knowledge: Critical management procedures
6. Critical management procedures resources and job aids

Critical Management Procedures Section Estimated Learning Time: 60 minutes/ 1 hour

Section: Lactation Basics

                Lactation Basics Section Objectives

• Identify anatomical parts of the breast/ chest involved in lactation
• Describe physiology of lactation hormones
• Explain physiology of milk production and flow
• List the contraindications to providing parent's own milk
• List credible resources to reference when inquiring about the safety of a medication for use during lactation
• Describe at least 2 parental and 2 infant risk factors associated with delayed lactogenesis II
• Describe at least 1 professional medical reference or resource for identifying medications that are safe/compatible for use during lactation 

                Lactation Basics Section Outline

1. Lactation anatomy and physiology
   1. Structures of the breast/chest involved in lactation
   2. Hormones of lactation
   3. Stages of milk production
   4. Risk factors for delayed onset of milk production
2. Contraindications to breastfeeding
3. Medication use and lactation
   1. Vaccinations, medications, and drugs during lactation
   2. Risk resources
4. Lactation basics case study
5. Test your knowledge: Lactation basics
6. Lactation basics resources and job aides

Lactation Basics Section Estimated Learning Time: 60 min/ 1 hour

Section: Step 3: Discuss the Importance and Management of Breastfeeding with a Pregnant Woman and Their Families

                Step 3 Section Objectives

• Engage in a conversation with a pregnant person on 3 aspects of the importance of feeding human milk
• Assess at least 3 aspects of a pregnant person’s knowledge about lactation to fill in the gaps and correct inaccuracies
• Engage in a conversation with a pregnant person about at least 4 care practices a parent/infant dyad will experience at the birthing facility that will support lactation
• Engage in a conversation with a pregnant parent regarding at least 3 reasons why effective exclusive feeding of human milk is important

Step 3 Section Outline

1. Goals and benefits of prenatal infant feeding education
   1. Breastfeeding and human milk
   2. Birth practices
   3. Anticipatory guidance
2. Global and professional recommendations for infant feeding
   1. American Academy of Pediatrics (AAP) recommendations
   2. World Health Organization recommendations
   3. Benefits of continued breastfeeding and human milk
3. Benefits of human milk
   1. Benefits for baby/ infants
   2. Benefits for breastfeeding women
4. Practices that can help get breastfeeding off to a good start
   1. Immediate skin-to-skin contact
   2. Rooming-in
   3. Feeding on cue (on demand)
   4. Newborn feeding patterns
   5. Effective positioning and attachment
5. Step 3 case study
6. Step 3 resources and job aids

Step 3 Section Estimated Learning Time: 70 minutes/ 1.2 hours

Section: Step 4: Facilitate Immediate and Uninterrupted Skin-to-Skin Contact

                Step 4 Section Objectives

• Explain 3 reasons why immediate and uninterrupted skin-to-skin is important for the birthing parent
• Explain at least 3 reasons why immediate and uninterrupted skin-to-skin is important for the infant
• List at least 3 reasons why skin-to-skin should NOT be interrupted 
• Explain at least 2 reasons when skin-to-skin could be interrupted for medically justifiable reasons
• Explain how to maintain skin-to-skin during transfer of birthing parent and infant to another room or other recovery area
• Demonstrate at least 3 points of how to routinely implement immediate, uninterrupted skin-to-skin between birthing parent and infant regardless of method of birth
• Demonstrate at least 3 safety aspects to assess during skin-to-skin during the first 2 hours postpartum, regardless of method of birth
• Engage in a conversation with a breastfeeding/chestfeeding parent, including at least 3 reasons why suckling at the breast in the first hour is important, when the baby is ready
• Demonstrate at least 3 aspects of safe care of the newborn in the first 2 hours post-birth
• Describe to a parent at least 3 prefeeding behaviors babies show before actively sucking at the breast/ chest

Step 4 Section Outline

1. Importance of immediate skin-to-skin contact
   1. Definition of skin-to-skin contact
   2. Benefits of immediate skin-to-skin contact
2. Immediate skin-to-skin practices and early newborn feeding behaviors
   1. Routine procedures that should be delayed
   2. Routine procedures at delivery
   3. Skin-to-skin after vaginal deliver
   4. Skin-to-skin after cesarean
   5. Recognition of early feeding cues and staff assistance
3. Safety considerations during immediate skin-to-skin care
   1. Standardization of safe skin-to-skin following delivery
   2. Components of safe positioning for the newborn while skin-to-skin
   3. Monitoring assessment during skin-to-skin care
   4. Sudden Unexpected Postnatal Collapse (SUPC)
4. Step 4 case study
5. Test your knowledge: Step 4
6. Step 4 resources and job aids

Step 4 Section Estimated Learning Time: 50 minutes/ 0.8 hours

Section: Step 5: Support Mothers to Initiate and Maintain Breastfeeding and Manage Common Difficulties

                Step 5 Section Objectives

• Describe at least 6 essential issues that every lactating parent should know or demonstrate.
• Describe at least 2 maternal and infant risk factors associated with delayed lactogeneis II
• Engage in a conversation with a parent regarding 2 elements related to infant feeding patterns in the first 36 hours of life
• Describe to a parent at least 4 signs of adequate transfer of milk in the first few days.
• Examine a full breastfeeding/ chestfeeding session observing at least 5 points
• Demonstrate at least 3 aspects of how to help a parent achieve a comfortable and safe position for breastfeeding within the first 6 hours after birth and later as needed during the hospital stay.
• Demonstrate how to help a parent achieve an effective and comfortable latch, noting at least 5 points.
• Demonstrate to a lactating parent how to hand express human milk, noting 8 points.
• Help a parent achieve a comfortable and safe position for breastfeeding/chestfeeding with a preterm, late preterm, or weak infant noting at least 4 points
• Engage in a conversation with a breastfeeding/chestfeeding parent of a preterm, late preterm, or low-birth-weight infant not sucking effectively at the breast, including at least 5 point
• Engage in a conversation with a parent regarding at least 4 different ways to facilitate breastfeeding to prevent or resolve most common conditions of the lactating breasts (sore nipples, engorgement, parent who thinks she doesn’t have enough milk, infants who have difficulty sucking)

Step 5 Section Outline

1. Latching, positioning, and assessment
   1. Characteristics of good positioning
   2. Characteristics of good latch/ attachment
   3. Helping a breastfeeding parent
2. Eating patterns and getting enough milk
   1. Normal newborn feeding patterns
   2. Signs that a newborn is getting enough milk
3. Common conditions of lactation
   1. Nipple soreness and management
   2. Breast pain
   3. Engorgement
   4. Blocked ducts
   5. Breast infections
4. Expressing human milk
   1. Demonstration of milk expression techniques
   2. Human milk storage and handling guidelines
   3. Cases of prolonged parent/ newborn separation
5. Preterm and late preterm infants
   1. Terminology and definitions
   2. Lactation management and considerations of the late preterm and early term infants
6. Step 5 case study
7. Test your knowledge: Step 5
8. Step 5 resources and job aids

Step 5 Section Estimated Learning Time: 120 minutes/ 2 hours

Section: Step 6:  Exclusive Breastfeeding, Except when Medically Indicated

                Step 6 Section Objectives

• • Explain at least 3 aspects of appropriate storage of human milk
  • Explain at least 3 aspects of handling of expressed human milk
  • List at least 2 potential contraindications to human milk feeding for a baby and a lactating parent 
  • Describe at least 4 medical indications for supplementing breastfed newborns: 2 parental indications and 2 newborn indications, when breastfeeding is not improved following skilled assessment and management
  • Describe at least 3 risks of giving a breastfed newborn any food or fluids other than breast milk, in the absence of medical indication
  • For those few health situations where infants cannot, or should not, be fed at the breast/chest, describe the alternatives to use, in order of preference
  • Identify 3 high-risk infant populations that may warrant extra precautions to protect against severe infections associated with powdered infant formula 
  • Engage in a conversation with a parent regarding at least 3 reasons why effective exclusive human milk feeding is important
  • Engage in a conversation with a parent who plans to feed their baby formula, noting at least 3 actions to take
  • Demonstrate at least 3 important items of safe preparation of infant formula to a parent who needs that information

Step 6 Section Outline

1. Importance of exclusive breastfeeding
   1. Review of benefits
   2. When supplementation is indicated                
2. Common medical indications for supplementation
   1. Weight loss
   2. Hypoglycemia
   3. Hyperbilirubinemia
   4. Macronutrient supplementation
   5. Maternal indications
3. Handling, storing, and feeding expressed human milk
   1. Safe handling practices
   2. Safe storing practices
4. Safely preparing and handling infant formula and bottle-feeding practices
   1. Safe preparation of infant formula
   2. Preparation of powdered infant formula
   3. Safe bottle-feeding practices and techniques
5. Step 6 case study
6. Test your knowledge: Step 6
7. Step 6 resources and job aids

Step 6 Section Estimated Learning Time: 90 minutes/ 1.5 hours

Section: Step 7: Practice Rooming-In 24 Hours a Day

                Step 7 Section Objectives

• • Describe 2 aspects involved in creating a safe environment for rooming-in 24 hours a day
  • Describe 2 situations: 1 for the parent and 1 for the infant, detailing when it is acceptable to separate birthing parent and infant while in the hospital

• • Engage in a conversation with a parent regarding 2 aspects related to the importance of rooming-in 24 hours a day
  • Demonstrate at least 3 safety aspects to assess when mother and baby are skin-to-skin during postpartum hospitalization, regardless of method of birth
  • Engage in a conversation with a birthing parent separated from their preterm or sick infant regarding at least 2 reasons to be with their infant in the intensive care unit

Step 7 Section Outline

1. Importance of rooming-in
   1. Definition of rooming-in
   2. Benefits of rooming-in
2. Safety considerations and medical indications for separation
   1. Situations where it is appropriate to separate a birthing parent and baby
   2. Patients that may be at risk for unsafe rooming-in practices
   3. Interventions when rooming-in safety is a concern
   4. Maintaining a safe environment
   5. Sick and premature infants in the NICU
3. Step 7 case study
4. Test your knowledge: Step 7
5. Step 7 resources and job aids

Step 7 Section Estimated Learning Time: 10 minutes/ 0.3 hours

Section: Step 8: Support Recognition and Response of Infant Feeding Cues

                Step 8 Section Outline

• • Describe at least 2 early feeding cues and 1 late feeding cue
  • Describe at least 4 reasons why responsive feeding (also called on-demand or baby-led feeding) is important independent of feeding method
  • List at least 2 aspects of responsive feeding (also called on-demand or baby-led feeding) independent of feeding method
  • Describe at least 4 elements to assess when a parent says that their infant is crying frequently
  • Engage in a conversation with a parent of a preterm, late preterm or vulnerable infant (including multiple births) regarding the importance of observing at least 2 subtle signs and behavioral state shifts to determine when it is appropriate to feed

Step 8 Section Outline

1. Early and late feeding cues
2. Importance of feeding on cue
3. Preterm and late preterm infants
4. Other considerations for staff
5. Step 8 case study
6. Test your knowledge: Step 8
7. Step 8 resources and job aids

Step 8 Section Estimated Learning Time: 20 minutes/ 0.3 hours

Section: Step 9: Counseling on the Use and Risks of Feeding Bottles, Teats, and Pacifiers

                Step 9 Section Objectives

• • Describe at least 2 alternative feeding methods other than feeding bottles
  • Describe at least 4 elements of anticipatory guidance to give to a mother on calming or soothing techniques before or as alternatives to pacifier
  • Describe when the acceptable time is for introducing a pacifier with a breastfeeding infant, with regards to SUID/SIDS reduction strategies
  • Demonstrate to a parent how to safely cup-feed their infant when needed, showing at least 4 points
  • Describe to a parent at least 4 steps to feed an infant a supplement in a safe manner
  • Engage in a conversation with a parent who requests feeding bottles, teats, pacifiers, and soothers without medical indication, including at least 3 points

Step 9 Section Outline

1. Artificial nipples, alternative feeding methods, and safety considerations
   1. Risks of artificial nipples
   2. Alternatives to soothing a fussy infant
   3. Pacifier use and safe sleep
   4. Alternative feeding methods and techniques
2. Step 9 case study
3. Test your knowledge: Step 9

Step 9 Section Estimated Learning Time: 20 minutes/ 0.3 hours

Section: Step 10: Coordinate Discharge so that Families Have Timely Access to Ongoing Support

                Step 10 Section Objectives

• • Describe at least 2 locally available sources for timely infant feeding information and problem management
  • Describe at least 2 ways the health care facility engages with community-based programs to coordinate messages about infant feeding and offer continuity of care
  • Describe at least 3 postpartum/parental warning signs for a parent to contact a health care professional after discharge
  • Engage in a conversation with a parent regarding at least 4 different ways to facilitate breastfeeding in order to prevent or resolve most common conditions of lactation (sore nipples, engorgement, parent who thinks they don't have enough milk, infants who have difficulty sucking)
  • Develop individualized discharge feeding plans with a parent to include at least 6 points
  • Describe to a parent at least 4 warning signs of infant undernourishment or dehydration that warrants contact with a health care professional after discharge

Step 10 Section Outline

1. Continuity of support post discharge
   1. Recommendations on follow-up support post facility discharge for newborns
   2. Recommendations on follow-up support post birth for birthing parents
   3. Warning signs and when to contact a provider
   4. Community engagement and support for facilities
2. Step 10 case study
3. Test your knowledge: Step 10
4. Step 10 resources and job aids

Section 10 Section Estimated Learning Time: 10 minutes/ 0.2 hours

Course Completion

1. Course Feedback Form
2. Certificate of completion download

Total Estimated Learning Time for EMPower Best Practices Course: 800 minutes/ 13.3 hours

Time Estimate Summary: