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Minnesota Breastfeeding Friendly Maternity Center Designation
STEP 9 Application
To apply for completion of STEP 9:
Complete this form electronically using Adobe Acrobat or Adobe Reader 10.0 or later.
Save this PDF form to your computer and submit by email as an attachment to
[email protected], along with the Cover Sheet, any supporting documentation,
and the other applications for additional steps that your facility has completed. See the
Application Instructions on the MDH web page for more details.
Note: When asked to attach a document or enter text, it is acceptable to provide a link to
a current web page. An attachment is also an acceptable alternative to entering text
directly on this form. For all attachments, provide a file name and a brief description in
the Supporting Documents Table at the end of this application form.
STEP 9: Give no pacifiers or artificial nipples to breastfeeding infants.
Breastfeeding mothers are educated about how using bottles and pacifiers may interfere
with establishing breastfeeding when introduced during a baby's first month of life.
When a mother requests that her breastfeeding infant be given a bottle or pacifier, staff
explore the reasons for her request, provide education on the potential consequences,
and offer alternate methods for feeding (e.g. spoon or cup) or soothing her baby. If the
mother still requests a pacifier or bottle, the education process and informed decision are
documented.
Pacifiers are only used in specific situations, including: 1) to provide comfort and decrease
pain during procedures (pacifier is discarded after procedure), 2) for infants in special
care / NICU who are tube-fed, and 3) for special medical reasons that are clinically
appropriate. If medically indicated, fluid supplementation is given using an alternate
feeding method (e.g. cup or spoon).
At least 80% of the breastfeeding infants leave the facility without ever using bottle
nipples or pacifiers. If they have used a bottle or pacifier, their mothers have been
informed of the risks.
NOTE: Facilities that are interested in pursuing designation from Baby-Friendly USA, Inc.
should refer to their specific guidelines and criteria here.
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9.1 a. What percent of breastfeeding babies are using pacifiers?
%
b. This percentage is based on:
an Estimate - Explain Method:
a Patient Chart Review
an Alternative System - Specify:
c. Are breastfeeding mothers informed by the maternity care staff
about the risks associated with the use of pacifiers?
Yes
No
Provide copies of educational materials used.
d. How is this education documented in the medical record? Explain below.
9.2 a. What percent of breastfeeding babies are using bottles topped with
artificial nipples?
%
b. This percentage is based on:
an Estimate - Explain Method:
a Patient Chart Review
an Alternative System - Specify:
c. Are breastfeeding mothers informed about the risks associated
with feeding newborns from bottles?
Yes
No
Provide copies of educational materials used.
d. How is this education documented in the medical record? Explain below.
9.3 When healthy, full-term breastfed babies are supplemented (with
infant formula or expressed breast milk), are mothers encouraged to
use an alternate feeding method (e.g. spoon or cup), rather than a
bottle? Explain below.
Yes
No
Provide copies of educational materials used.
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STEP 9: Supporting Documents Table
File Name
Brief Description
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