Protecting, Promoting And Supporting Breastfeeding: A Practical Workbook For Community-based Programs - 2nd Edition

Our shared vision…

"Canadian communities will foster environments where breastfeeding is the easiest choice for all women and their children."

Joint vision of the Breastfeeding Committee for Canada and the Canada Prenatal Nutrition Program

Table of Contents

Chapter 1: Introduction


This workbook is intended to assist communities to identify strategies and specific actions to protect, promote and support breastfeeding in a population health context. Population health recognizes the social, physical, economic and individual factors that influence a woman's decision to breastfeed, and her ultimate success with breastfeeding.

For almost 20 years, the Canada Prenatal Nutrition Program (CPNP) has been dedicated to the promotion and support of breastfeeding among vulnerable populations across Canada. As a cornerstone of the program, thousands of hours of breastfeeding expertise have been both gained and shared at CPNP locations. This Workbook reflects that experience and provides an understanding of the challenges faced by those promoting breastfeeding in a community setting.

Staff, volunteers and participants involved in community-based programs often have opportunities to influence and support wider community breastfeeding initiatives. A mother's ability to initiate and sustain breastfeeding is enhanced when service providers in her community work together. This workbook was created to encourage that and to promote community support and recognition of breastfeeding as an important public health issue with huge capacity to improve the health of Canadians.

Both the first and second editions of this workbook were created through a partnership between CPNP and the Breastfeeding Committee for Canada (BCC). Throughout the process, numerous organizations and individuals involved in the protection, promotion and support of breastfeeding across Canada provided valuable feedback, comments and suggestions. Many thanks to all who contributed!

"Breastfeeding is the unequalled way of providing ideal food for the healthy growth and development of infants, and has a unique biological and emotional influence on the health of both mother and child. For breastfeeding to be successfully initiated and established, mothers need the active support during pregnancy and following birth, not only of their families and communities, but also of the entire health system."
World Health Organization (Who). Protecting, Promoting and Supporting Breastfeeding: the Special Role of Maternity Services. Geneva: a Joint Who/Unicef Statement, 1989

As you read through the workbook, you may find that the language level varies and sometimes becomes quite technical. This is because many community based programs are delivered through collaborative teams that include a spectrum of both professional and lay workers. We hope we have designed an accessible workbook which will be useful to anyone, regardless of background or training. We also hope that you find the workbook stimulating and that it enhances your knowledge of the more complex issues related to breastfeeding. A sound knowledge of breastfeeding requires continuous learning. We hope you will bring to the workbook what you already know, and take from it what you need.

Best wishes in your efforts to reach an important global goal: Exclusive breastfeeding for the first six months, and continued to two years or longer, with appropriate complementary foods.

Though this is not yet the reality for most Canadian families, it is important to keep the ideal in mind so that eventually, the "best" choice becomes the "easiest" choice for all women and their children.

How to Use This Workbook

The core of the Workbook focuses on nine strategies to support, promote and protect breastfeeding. For each strategy there follows a number of suggestions on how to apply it.

Throughout the Workbook, a number of "Stories" and a section titled "Food for Thought" attempt to capture what has been learned from the research and experience of CPNP projects across Canada. The experience was gathered from a variety of sources: meetings; conferences; a National "Think Tank" on breastfeeding; the national evaluation; teleconferences and on-line discussions; and from regional and local evaluation activities such as participant focus groups and case studies.

Quotes from "Stories" give examples of actions or activities that groups have found effective to protect, promote and support breastfeeding. The "Food for Thought" section provides responses to questions and challenging issues related to breastfeeding that arise from time to time. While these responses represent current thinking on these issues, watch for further developments as we continue to expand on our knowledge and experience of breastfeeding.


Protection of Breastfeeding...

All women are enabled to make informed decisions about infant feeding, free from the influence of formula or related industry marketing practices, and that their right to breastfeed anytime, anywhere is protected.

Promotion of Breastfeeding...

Program staff, participants, the broader health system and the community are kept up-to-date on the importance of breastfeeding and find opportunities to promote it.

Support for Breastfeeding...

Women receive information and support from all sectors of the community to overcome any barriers to breastfeeding they may experience or perceive.

Canada Prenatal Nutrition Program: Guiding Principles

Mothers and Babies First

The health and well-being of the mother and baby will be the primary consideration in the planning, development and implementation of CPNP.

Strengthening and Supporting Families

Families have the main responsibility for the care and development of their children. All parts of Canadian society share the responsibility for creating supportive environments for mothers and their infants.

Equity and Accessibility

All children are entitled to equal rights and opportunities to develop to their full potential regardless of their culture, language and socio-economic status. As such, programming will be rights-based and sensitive to the social, cultural and linguistic diversity of the mothers and infants they are designed to serve.

Community Based

The community plays a key role in the design and delivery of health promotion programs for pregnant women and their infant facing conditions of risk. Promising practices will be innovated and adapted at the community level to address persistent and emerging public health issues.


Partnerships and collaborative activities at the community level are essential to the development of an effective and coordinated range of health promotion programs for pregnant women and their infant facing conditions of risk. CPNP will work in partnership with other services in the community.


Program funding will be directed towards increasing access to and addressing gaps in the network of services and supports targeting children and their families facing conditions of risk, and will build on existing structures and processes.


Programming will be flexible to respond to different needs in each community and to the changing needs and conditions of mothers and their infants in those communities.


CPNP will include a strong national evaluation component to provide for the development of knowledge and expertise in community-based promotion, prevention and intervention programs for women facing conditions of risk.

Chapter 2: Strategies for Protecting, Promoting and Supporting Breastfeeding


  1. Create breastfeeding friendly sites
  2. Keep staff up-to-date
  3. Empower mothers to make informed decisions
  4. Respect the needs of mothers who choose not to breastfeed
  5. Identify barriers and explore solutions
  6. Sustain support beyond initiation
  7. Include families, partners and friends
  8. Encourage peer breastfeeding support
  9. Engage the community as a partner

Taking Action on Strategies

Each strategy provides a number of practical suggestions on how to apply it, based on experience and best practice. You are not expected to do these all alone. In a population health approach, health is achieved through actions on the levels of individual, family, community, system and society. It is through collaboration and partnership with your community that your program can contribute to reaching our shared vision:

"Canadian communities will foster environments where breastfeeding is the easiest choice for all women and their children."
BCC/CPNP Joint Partnership


  • Under each strategy, check off the suggestions which currently apply in your program
  • Add additional strategies that may be unique to your program or community
  • Revisit the list from time to time to check the progress in your community
  • Find ways to keep this workbook 'alive'
    • Put it in a ring-binder; add your own notes
    • Bring it often to staff meetings and display excerpts for reminder or discussion

Strategy 1: Create "Breastfeeding Friendly" Sites

.... Provide a comfortable space for breastfeeding participants and their families

.... Provide a private space for breastfeeding for mothers not wishing to breastfeed in an open setting

.... Ensure educational and promotional materials displayed or distributed follow the WHO/UNICEF International Code of Marketing of Breastmilk Substitutes (See: Chapter 5)

.... Display posters and written materials with positive breastfeeding images and messages

.... Ensure staff are familiar with the Breastfeeding Committee for Canada's Integrated 10 Steps Practice Outcome Indicators for Hospitals and Community Health Services (See: Chapter 5)

.... Ensure that formula industry samples and gifts--including free formula--are not distributed by staff or volunteers to pregnant women and new mothers (See: "Food For Thought" in Chapter 3)

.... Encourage all staff and volunteers to express positive and enthusiastic attitudes towards breastfeeding

.... Support all mothers who wish to breastfeed or express/pump breastmilk in the workplace or at school

.... Create or acquire a list of community resources for breastfeeding and be familiar with referral procedures

From our stories we are learning...

... women need information and support to breastfeed successfully.

"I could not have survived without you! Your program gave me the support and information I needed to successfully breastfeed my child for 6 months and be reassured that I could do it."

This 21 year old mother of a 7 month old struggled with breastfeeding when she first came home from hospital. Her baby refused her breast, had a poor latch and began to lose weight. With the help of videos, books and demonstrations, the CPNP program provided what this mother needed to turn the breastfeeding relationship around.

Strategy 2: Keep Staff up-to- Date

.... Develop ready access to qualified resource people who are available in the community

.... Include training related to breastfeeding attitudes, knowledge and skills in staff orientation and continuing education plans

.... Provide staff access to accurate, up-to-date, easy to understand breastfeeding resources on-site

.... Create opportunities for staff to discuss current breastfeeding issues (See: "Food For Thought" in Chapter 3)

.... Offer staff opportunities to resolve personal concerns about breastfeeding

.... Familiarize staff with provincial/territorial guidelines, where they exist

.... Promote partnerships to ensure consistent information and to share community based knowledge and experience

From our stories we are learning...

...that when staff are confident in their knowledge and skills, breastfeeding mothers and babies benefit.

"As a resource mother in a rural setting it is vital that we have workshops and regular training sessions to ensure that our knowledge and skills of breastfeeding are accurate and up-to-date. We often have limited access to other breastfeeding resources such as lactation consultants and La Leche League groups in our region. As my knowledge and skills improve I feel so much more confident in the support I am giving to pregnant women and breastfeeding moms. Recently I had an opportunity to attend a workshop on breastfeeding in another province. I came back totally rejuvenated--excited about my ability to help the moms in our program."

Strategy 3: Empower Mothers to Make Informed Decisions

.... Give women time to think about breastfeeding as a realistic option

.... Discuss breastfeeding early and often throughout prenatal and postnatal contacts

.... Keep facts about breastfeeding clear and simple

.... Use hands-on, non-judgmental activities to build knowledge and skills (See: "Small Group Activities" in Chapter 4)

.... Provide information about the importance of breastfeeding as well as the cost and risks of not breastfeeding

.... Provide participants with a realistic understanding of what to expect when they first breastfeed

.... Explore myths, false information, and concerns with participants

.... Consider the culture of participants, respect cultural traditions associated with breastfeeding, and sensitively educate participants about traditions that can impact breastfeeding (See: "Food For Thought" in Chapter 3)

From our stories we are learning...

... about the value of talking about breastfeeding early and often to all pregnant women.

"I started out bottle-feeding in the hospital, and then on the second day I changed my mind and tried breastfeeding. All of the drop-ins where you talked about breastfeeding worked... I didn't try breastfeeding with my first."
A mother speaking to CPNP staff

"We had completed about four sessions on breastfeeding and some of the moms were complaining that they had enough information on breastfeeding. This story tells us that even though some information gets said over and over, it can make a difference in what the mom chooses for her baby. Keep the key messages strong and clear at each drop-in."
CPNP staff member providing context

Strategy 4: Respect the Needs of Mothers Who Choose Not to Breastfeed

.... Provide equal access to postnatal support programs to all prenatal participants

.... Ensure all postnatal participants feel valued regardless of how they feed their baby (See: "Food for Thought" in Chapter 3)

.... Seek approaches to support women in need regardless of whether they breastfeed or not

.... Support participants who do not meet their original breastfeeding goals

.... Provide accurate information about safe formula feeding on an individual basis--when it is clear a woman is not breastfeeding

.... Ensure participants who bottle-feed their babies, understand how to feed their baby in a nurturing way

.... Develop a strategy to respond appropriately to women facing circumstances where the baby may not receive breastmilk or enough appropriate formula (See: "Food For Thought", Chapter 3)

From our stories we are learning...

... that continuing prenatal milk coupons after the baby's birth only for moms who breastfeed can send the wrong message.

It gives a negative (almost punitive) message to moms who do not breastfeed and some moms said they had to quit breastfeeding when they no longer received the milk coupons. [Some moms thought the milk was essential for producing quality breastmilk and if they couldn't afford to continue drinking milk they couldn't afford to continue breastfeeding.]

Mothers choose to formula-feed for various reasons... particularly if they have experienced abuse in the past... These moms are sometimes among the most vulnerable and perceive that they are not valued for their decision and their reasons.

We do not want to infer that the coupons are an essential aid to breastfeeding but to convey the message that every mother's health and nutritional status is important after birth. We want to have every mom continue to come in for coupons and support while 'she gets back on her feet'.

Strategy 5: Identify Barriers and Explore Solutions

.... Ensure staff are sensitive to the possible impact of issues like poverty, sexual abuse, body image,  family history or adolescent culture on the decision to breastfeed

.... Ensure participants feel free to disclose, without risk of being judged, any behaviours that could impact negatively on breastfeeding

.... Create a climate that encourages flexible, creative solutions to barriers

.... Ensure women in need of counselling or other support receive it

.... Sensitize participants to the impact that some hospital practices can have on early breastfeeding (Example: Practices such as immediate skin to skin contact and rooming in have been shown to increase breastfeeding initiation and duration rates. Other practices such as the giving of formula gift packs interfere with breastfeeding success.)

.... Discuss common breastfeeding concerns before they occur

.... Invite peers, elders or others who have successfully combined breastfeeding with work, school or other perceived barriers to participate

.... Refer participants for further support if needed

See: "My Breastfeeding Plan" in Chapter 4

From our stories we are learning...

... barriers to breastfeeding such as poor self-image, adolescent culture and sexual abuse can be overcome.

"I'm breastfeeding my baby anywhere, anytime. I'm comfortable with my body. I don't care who sees me. I love breastfeeding and it doesn't cost me anything."

This young 15 year old mother was definite that she would never breastfeed her baby because she was uncomfortable with her body.

When women are unfamiliar with breastfeeding they usually state that they plan to formula feed.

However, as we learned in this story, the decision may not be firm. Through her participation in CPNP, she received information about breastfeeding during pregnancy and emotional support to help her overcome worries about modesty. She continues to give support as a role model to other young mothers in the program.

Strategy 6: Sustain Support Beyond Initiation

.... Celebrate small breastfeeding successes on a regular basis

.... Encourage women to participate as long as possible in the postnatal period

.... Link new mothers to peers who have breastfeeding experience through trained peer outreach workers, volunteer mother-to-mother support groups, home visits and telephone contacts

.... Create partnerships with available community resources--including dietitians/nutritionists, community health nurses, lactation consultants, La Leche League, among others--to develop or strengthen:

  • In-hospital breastfeeding support - including visits by CPNP staff when possible and appropriate
  • Telephone contact for breastfeeding mothers in the first 24 hours after discharge
  • Ongoing 24 hour support for breastfeeding mothers
  • Peer or mother-to-mother support initiatives
  • In-home visits
  • Community breastfeeding clinics
  • Knowledge and skill with the hand expression of breastmilk
  • The availability of pumps and other breastfeeding related equipment for women who need them
  • Access to safe donor breastmilkFootnote 1
  • Use of WHO growth charts to monitor infant/child growth

See: "My Breastfeeding Plan" in Chapter 4

From our stories we are learning...

... about the importance of one-to-one follow-up.

"I would not have continued breastfeeding if I had not received a home visit and a follow-up phone call for support."

This mother of three young children was experiencing common challenges with early breastfeeding: sore nipples, engorgement and an unsettled baby. Her husband was away working at this time and she was alone without any support. Timely support with a home visit and phone call by the CPNP staff made a difference. It helped her overcome her concerns and have a positive breastfeeding experience.

Strategy 7: Include Families, Partners and Friends

A supportive partner, family member, or friend plays a key role in the success of breastfeeding. When a mother feels supported she is more likely to feel confident and empowered with her choice to breastfeed.

Types of Support

Resources - Assisting with information seeking and problem solving

Practical - Assisting with childcare and household tasks

Emotional - Providing empathy and understanding

Positive Feedback - Validating the commitment to breastfeed

SOURCE: Adapted from Abbass Dick, Jennifer. #1 Source of Support: Assisting Fathers in Supporting Breastfeeding Mothers. 21st National  Breastfeeding Conference 2011. Toronto, Ont.

.... Offer breastfeeding education for family members (grandparents, elders, partners, siblings) and friends

.... Create opportunities for other family members who have breastfed to share their breastfeeding stories with participants

.... Provide practical ideas to family members and friends to support the breastfeeding mother and baby

.... Identify where women lack support from partners and/or family members and explore alternatives such as mother-to mother support groups

See: Small Group Activities in Chapter 4

From our stories we are learning...

... about the influence of families.

A 23 year old mother of a 4 year old daughter said:

"I didn't breastfeed my first child, but I want to try for this baby. I'm afraid how my daughter will react. She might think it is gross."

While this woman watched a breastfeeding video at a CPNP drop-in, the 4 year old climbed onto her lap and watched too. After a couple of minutes the child took her doll and began to imitate the breastfeeding mother on the screen. "Like this, right mom." She said as she positioned her doll. The mother visibly relaxed and when the new baby was born, she breastfed him.

Strategy 8: Encourage Peer Breastfeeding Support

.... Encourage breastfeeding on-site

.... Enable participants who have successfully breastfed to share their experiences with others

.... Nurture social support through group activities not directly related to breastfeeding

.... Explore successful peer support models, curricula and possible funding sources with staff and partners

.... Ensure existingpeer support staff and volunteers receive defined roles, orientation, education, ongoing support from professionals and adequate resources

.... Ensure breastfeeding support networks in the broader community understand participants' realities and actively support their inclusion in existing services

.... Provide support to overcome barriers such as transportation and child care to women who want to participate in community networks

See: My Breastfeeding Plan in Chapter 4

From our stories we are learning...

... about the importance of peer outreach support.

One young woman recovering from addiction had this to say:

"The outreach worker came to my home... and I feel this made a huge difference during the pregnancy... I was very lonely and isolated and I really felt I was able to connect to the outreach worker and make a link to the community... I am a recovering addict. I now have just a year off cocaine. Today I am a breastfeeding mom of a healthy, 17 lb. 5 month old baby girl. I volunteer with my baby... I'm helping [other breastfeeding mothers] in the community that helped me."

Strategy 9: Engage the Community as Partner

.... Develop community awareness of activities to protect, promote and support breastfeeding

.... Share and promote program resources with other community groups

.... Enable participants to access breastfeeding resources in the broader community

.... Support women to breastfeed in public

.... Establish partnerships with schools, businesses, local government and others in the community

.... Respond publicly to infant feeding issues that arise in the community (e.g. letter to the editor)

.... Participate in activities like World Breastfeeding Week to increase the visibility of breastfeeding

.... Advocate for accessible, affordable and safe human donor milk in your region

.... Provide your community based program's perspective to local, regional or provincial breastfeeding or perinatal committees

.... Support the attainment of "Baby Friendly" status for local hospitals, birthing centres and community health services

.... Encourage and support research regarding breastfeeding rates and strategies to reduce disparities

From our stories we are learning...

... about the need to overcome gaps in breastfeeding support.

"As a pilot project, the maternity hospital in our community recently hired an Aboriginal woman to provide in hospital breastfeeding support and at home follow-up to other Aboriginal women at delivery. One of our outreach staff met her while visiting a CPNP participant in hospital. She invited the hospital-based lactation support worker to come to the CPNP drop-in and speak directly to the women there. Now she comes on a regular basis and connects with the moms while they are still pregnant. The hospital is exploring the possibility of more funding to keep the service going."

Moving Towards a Breastfeeding Friendly Community...

The development of strong partnerships is essential in the creation of a breastfeeding friendly community. Exploring the breastfeeding rates and trends in your community, collaborating with stakeholders, and working together to create a positive breastfeeding environment benefits everyone. Step by step you can help your community become a breastfeeding friendly place to live, work and play.

A Breastfeeding Friendly Community would feature the following:

  • All hospitals and community health agencies delivering maternity services are designated "Baby Friendly" by the BCC or provincial BFI Authority.
  • All heath care facilities and community agencies protect, promote and support breastfeeding.
  • Health care institutions and community health agencies work together to increase the availability of breastfeeding support.
  • Education is provided about breastfeeding as the natural and normal method of infant feeding.
  • Information is given to the community as a whole about the importance of breastfeeding and the risks of not breastfeeding.
  • Attitudes within the community that perceive bottle-feeding as the norm are addressed and education is directed at changing these attitudes.
  • Communities recognize the importance of supporting the mother-baby relationship.
  • All public and private facilities including parks and recreation centres, restaurants and stores support the need to be mother and baby-friendly.
  • Work settings promote breastfeeding through the provision of extended maternity leave and/or providing facilities for mothers to express milk and maintain their breastfeeding relationship.
  • Support is given to women who do not meet their breastfeeding goals to resolve their feelings and to find the most suitable alternatives.

ADAPTED FROM: Jones F, Green M. British Columbia Baby-Friendly Initiative. Resources Developed Through the BC Breastfeeding Resources Project. Vancouver: BC Baby-Friendly Initiative, 1996 and updated in 2006.

Chapter 3: Food for Thought - Addressing Challenging Issues Related to Breastfeeding

This section provides responses to some of the challenging issues related to breastfeeding that arise from time to time. These responses represent current reflections based on research and the experiences of about 325 CPNP projects across Canada. As we continue to expand our knowledge and experience of breastfeeding, watch for further developments on these and other issues.

Issue 1. Vitamin D

Should Breastfed Babies and Mothers Who Breastfeed Receive a Vitamin D Supplement?

Vitamin D is a nutrient that helps the body to build and maintain strong bones and teeth. Vitamin D is made by our bodies when our skin is exposed to the sun. Our ability to make enough vitamin D, however, is limited by things like the use of sunscreen, dark skin colour, air pollution, limited sun exposure during winter months and spending less time outdoors. This is especially true for babies, as we are advised

to protect their delicate skin from direct sunlight due to the risk of skin cancer.

Another source of Vitamin D is supplementation. A daily vitamin D supplement of 10µg (400 IU) is recommended for exclusively and partially breastfed infants, from birth. A single vitamin D3 supplement (without other vitamins) in a liquid (drop) format is recommended.

Without a Vitamin D supplement, an infant's vitamin D stores will become low, putting the baby at risk of serious health issues such as rickets, a disease that affects bone growth in children.

Non-breastfed babies (that is, infants who are fed only commercial infant formula) do not need a vitamin D supplement because it is added to infant formula, so they get enough from the formula to meet their needs.

To protect her own vitamin D stores, it is recommended that pregnant and breastfeeding women follow the advice in Canada's Food Guide to consume 500ml (two cups) of milk or fortified soy beverage every day.

What Does This Mean for Community Based Programs?

Current data tells us that those least likely to give vitamin D supplements to their infants include:

  • single/divorced/separated/widowed mothers
  • black mothers
  • mothers with a lower household income
  • mothers with a lower education level

Participants of community-based prenatal/postnatal programs, such as CPNP, often fit the above description. Efforts should focus on raising awareness, especially among these groups.

The cost of the vitamin D supplements may be an issue. Some families may qualify for subsidized supplements. For example, First Nations or Inuit people may be eligible to receive vitamin supplements through the Non-Insured Health Benefits Program.

In addition to vitamin D supplements for babies, strategies should respond to the possibility that the mother's vitamin D supply could be low. This respects the CPNP Guiding Principle "Mothers and Babies First." Giving pregnant and breastfeeding women milk, milk coupons and vitamin supplements can improve the mother's vitamin D status and ultimately could contribute to improved vitamin D stores of future babies at birth.

Some regions are developing guidelines to apply the national recommendation to local needs. For more information on how the national recommendation or regional guidelines apply to women and babies in your community, please consult the nutritionist or dietitian supporting your project, or your regional health authority.

SOURCES: Health Canada. Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months--A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada. 2012.

Health Canada. Vitamin D and Calcium: Updated Dietary Reference Intakes. 2010. (Retrieved from on 2012.Aug.21)

Issue 2. Infant Formula

Should Community Based Programs Participate in the Purchase or Distribution of Infant Formula?

Providing formula to a woman who is bottle-feeding, has run out of formula and can't afford to buy more, is sometimes offered as a compassionate response. However, pregnant women and their families need to know about the health, nutritional and financial costs of not breastfeeding before deciding how they are going to feed their babies. If women think that a supply of formula is available free, it has been shown to affect their choice of feeding method. The Supplemental Nutrition Program for Women, Infants and Children (WIC) in the U.S., (which has an overall breastfeeding initiation rate of only 63%Footnote 2) has been strongly criticized for giving out free formula to low income women on-site.

It is important for staff and volunteers in community based projects to think about what is missing in the community that would make breastfeeding "easier." Efforts should be directed toward decreasing these barriers to breastfeeding. Involve community partners. This will help improve breastfeeding rates in your community and lessen disparities.

Women who come to community based programs are often faced with financial or food insecurity that affect their ability to buy formula. Rather than giving formula directly, a better use of resources could include providing food, food coupons, recipes and ingredients, good food boxes and encouraging collective buying and community gardens.

These approaches put "Mothers and Babies First," help decrease the stress of food shortages, and free up the family's own money to buy formula if needed.

Still, in spite of these strategies, staff sometimes see women who are desperately short of resources, and they fear for the adequacy or appropriateness of the baby's diet. In these situations it is best to work with partners whose work is less directly tied to the protection, promotion and support of breastfeeding and develop an emergency response approach for babies at risk. Referral to a family physician, paediatrician, and/or dietitian may be appropriate. Linking the mother with the local health unit and area food banks may also be helpful.

There are a few rare situations where breastfeeding is not best for the baby and/or mother. Health Canada's Nutrition for Health Term Infants outlines the few infant and maternal conditions where breastfeeding should be partially or totally avoidedFootnote 31. Human milk banks provide the best substitute for a mother's own milk when the baby does not have a condition that necessitates the feeding of a specialized infant formula. In Canada there are currently three human milk banks (Vancouver, Calgary and Toronto) and more being established. Usually the donor milk is prioritized for sick, hospitalized neonates who are the most vulnerable because of limited availability. Support for the establishment of more human milk banks should be encouraged. Until then, sharing of breastmilk that has not been properly screened and processed should be discouraged.

Some women decide to formula feed even though there is no medical reason not to breastfeed. Staff working with expectant mothers in community based projects can facilitate informed decision making by helping each woman explore what is acceptable, feasible, affordable, sustainable and safe (AFASS) in her circumstances. Information given to the woman should be current, accurate and free from commercial influence. Referral to the woman's health care provider or public health nurse may be appropriate. Sensitivity to the woman's feelings, wishes and concerns is important and her preferences need to be respected.

Issue 3. Incentives for Breastfeeding

Should the Continuation of Milk Coupons or Other Maternal Food Supplements After the Baby Is Born Be Tied to a Mother's Decision to Breastfeed?

As part of a comprehensive nutrition program, most CPNP projects provide food supplements prenatally--very often including milk or milk coupons. Postnatally, many projects continue giving food supplements, but sometimes only to those mothers who breastfeed. The practice of tying food supplements to the decision to breastfeed is well-intended and is usually done to strengthen the nutritional status of the mother. It is also one way projects can manage on limited resources.

However, some CPNP projects are questioning the ethics of linking the continuation of food supplements to breastfeeding within a population already living with poverty, food insecurity and hunger. CPNP projects recognize that some women are faced with many barriers when it comes to choosing to breastfeed and sustaining breastfeeding, and many are seeking ways to value all women regardless of how they feed their babies.

Anecdotal reports from CPNP projects suggest that project staff is mixed in their views on whether or not providing incentives influences initiation and duration of breastfeeding. Some suggest that while the coupons may affect the initial decision to breastfeed, it is questionable whether a little extra food keeps breastfeeding going in the long run. On the other hand, it appears that in programs where the mother's breastfeeding status determined whether or not she receives the incentive/support items, staff were more likely to believe that providing the support items increased duration of breastfeeding, program participation and healthy eating practices. Overall, staff tend to view the incentives as a nice reward or "treat" for the mother.

The use of food supplements, coupons, gifts and prizes are often cited in research literature as "incentives" or ways to encourage women to breastfeed. Research suggests that effective programs for low income, socially isolated women should attend to basic needs such as food, clothing, transportation, child care and social support. Indeed, many CPNP projects use these supports, as well as gifts and prizes, as a way of nurturing and valuing all participants.

There is, however, not enough research evidence to demonstrate that providing incentives such as food supplements to "at risk" women increases initiation and duration rates. There is some evidence to suggest that providing a breastfeeding support item, such as a breast pump to low-income women who plan to return to work early, may increase duration of breastfeeding. Offering other incentives such as food, food coupons and gift certificates may increase program participation and may indirectly affect breastfeeding initiation rates through the education and support received.

The challenge in community based programs is to respond to participants' needs in ways that respect and empower them. If women feel they are being rewarded because they choose to breastfeed, and not rewarded if they do not breastfeed, they may feel unfairly judged by project staff for their decision. This could undermine a participant's trust or self-esteem.

The practice of providing an incentive, such as a milk coupon, only when a woman attends the program or accepts a visit with a public health nurse or support worker has also been questioned. Incentives encourage attendance, but the real goal is for the woman to become involved in the program and become an active participant.

All new mothers benefit from a range of strategies including food, but they also benefit from professional, peer, family and community support. Preparing food together builds self-esteem and develops skills. Eating together breaks isolation, promotes friendship and establishes equity. Going home with a recipe and ingredients increases food access and reinforces learning. Activities like these can be part of a comprehensive strategy provided to all participants.

Some programs have worked with community partners to provide crucial peer support to respond to the many barriers that affect women's infant feeding decisions and experiences. Others share stories of generous contributions from partners, community groups, local businesses and service clubs that include donations of baby quilts, hand knitting, groceries, hair cuts, personal care services or products, transportation and swimming pool passes. Such contributions can be made available to all participants regardless of infant feeding choice, and can help stretch project resources further.

Issue 4. Support for Bottle-feeding Mothers

What Can I Do to Support Mothers and Babies Who Are Bottle-feeding Breastmilk or Formula?

Some mothers decide to bottle-feed their baby at some feedings while others decide to bottle-feed at all feedings. The option of bottle-feeding the baby its mother's breastmilk should be explored except in the few cases where the feeding of breastmilk is not advisedFootnote 4. Many mothers are aware of the health benefits of breastfeeding and decide to express or pump their breastmilk for baby. This should be encouraged since any amount of breastmilk the baby gets has a positive impact on the health of the baby. When a mother is thinking about feeding breastmilk by bottle she should be directed to discuss this with her health care provider. It is important that she receives accurate information about hand expression/pumping, the storage and use of breastmilk, the cleaning of equipment and potential challenges to breastfeeding.

It is important that mothers make an informed decision when considering formula feeding. Not breastfeeding has health risks for babies and mothersFootnote 5. Mothers need to know about the risks and weigh them against the perceived benefits of formula feeding. Knowing the risks also helps the mother provide her baby with safe and informed care.

Mothers who decide to formula feed need to know about types of formula, formula preparation and storage, selecting appropriate feeding equipment such as bottles and nipples, the cleaning of feeding equipment, and safety issues such as expiry dates and formula recalls. The only acceptable substitute for breastmilk is commercial infant formula.

For information on the use of breastmilk substitutes visit:

For clear instructions about formula preparation and storage visit:

All mothers who decide to bottle-feed should still be provided with information about: the importance of providing their baby with skin to skin contact, feeding baby in response to infant hunger cues, recognizing signs of fullness, and bottle-feeding in a way that ensures baby's comfort and safety.

Issue 5. Cultural Influences

How Can I Support Mothers When Cultural Traditions Are Impacting Breastfeeding?

Culture can affect the way a woman regards childbirth, postpartum, breastfeeding and parenting.

Staff of community-based programs must adopt a flexible approach when working with women of different cultures. It is important to learn about each woman's beliefs and cultural practices. Suggestions can often be adjusted to meet the needs of the woman and empower her to have a satisfying breastfeeding experience.

Cultural practices can affect a woman's perceptions about breasts and breastfeeding such as the acceptability of breast exposure, the initiation and frequency of breastfeeding, where to breastfeed, the duration of breastfeeding and when to wean, and even related issues such as how often an infant is held or carried, how the infant is carried (eg. in arms, in a carrier, or an infant seat), and where infants are placed when not being held.

All cultures have practices that work for and against breastfeeding. No one culture has the best breastfeeding practices.

What to Do?

Do not try to change culturally based practices unless the practice is extremely detrimental.

Provide clear, accurate information in a climate of acceptance. Discrediting beliefs that the woman has had, perhaps for her entire life, can upset the woman and her family and can harm the woman's relationship with you and the program. Linking a new mother with a woman from her culture who is breastfeeding, or who has breastfed, is a great way to provide support.

In some cultures decision making is the responsibility of the family unit rather than the individual. Decision making can also sometimes be the responsibility of the eldest woman or man in the family. When talking with a woman about breastfeeding it is important to include the people whom she identifies as being important in her life.

Here is an example of how a cultural practice can positively impact breastfeeding. Some cultures consider the first 40 days as a time for the mother to rest and focus on herself and the baby. Often the mother receives extra personal attention from family and close friends. There is no expectation for her to get back to normal quickly. This practice supports breastfeeding because the mother is encouraged to rest, regain her strength, and learn how to take care of her baby, including infant feeding. Often others take on the responsibility of completing household chores, running errands, and looking after older children. "Mothering the mother" helps the new mother learn to mother her baby.

Aboriginal Perspective on Breastfeeding

Aboriginal communities have a long history of support for breastfeeding mothers and their families. There are many excellent resources available that honour the Aboriginal perspective on breastfeeding. Several Aboriginal communities have developed unique resources for breastfeeding women and their families that explore breastfeeding and childrearing practices from the wisdom and experience of community elders. The key message for all staff is that, to be effective in encouraging breastfeeding in Aboriginal communities, staff should seek opportunities to speak with the elders of the community to learn from their teachings and beliefs around breastfeeding.

Here is a story from a Resource Mother with a Healthy Baby Club in Newfoundland and Labrador. This story shows the importance of mentoring and how this can be done at Healthy Baby Club meetings.

As Aboriginal mothers, we have learned many of our life skills from our mothers and grandmothers. Sharing knowledge through storytelling is a big part of our culture. We believe that mentoring is a powerful and effective teaching tool.

For many years we have encouraged mentors that were part of our Aboriginal Family Centre Healthy Baby Club to come into our groups to talk with mothers and their support people about breastfeeding, early parenting and lessons they have learned.

We hold breastfeeding casual afternoons and mothers bring their babies and toddlers and talk to the prenatal group about breastfeeding. They see the baby/child feeding. It gives the mothers a chance to ask questions to the mentor. Our discussions are all about encouraging, supporting and overcoming barriers. We are our own support group and we continue to grow!

It is not hard to put together a mentoring group. Sessions can involve fathers, support people and professional resource people such as Public Health Nurses. We encourage all Healthy Baby Clubs to think about adding mentoring to their program.

Selected Aboriginal Resources: Breastfeeding Wisdom

The Breastfeeding Guidebook: a Practical Guide to Common Breastfeeding Concerns

A message from elders:

"Breastfeeding... traditionally nutritious" "Mamuk is Mumuk"

Yes, "mamuk is mumuk," breastmilk is good food! In February 1998, at a workshop in Yellowknife, our elders reminded us that breastfeeding is the most natural thing to do. Jane Dragon an elder from Fort Smith and Mary Tagoona from Baker Lake shared their breastfeeding messages.

What do you feel are the benefits of breastfeeding for the women of today?

Jane: "Breastfed babies are more secure and strong. They also smell good and don't get rashes. When babies get sick, if they are drinking mother's milk they don't get sick for long or as often. Breastfeeding makes a bond between mother and baby because only the mother can feed the baby. This means the mother will spend lots of time holding and caring for the baby. It is important to breastfeed--it's the way to go."

Mary: "I encourage breastfeeding to the young mothers because it's the most healthy way. Breastfed babies are healthier and they look better by appearance. Also they don't burp as often and they don't vomit as often. They also don't get a sore stomach as often. Most of all they look stronger than the bottle fed babies. Their skin doesn't look as saggy. Breastfeeding helps to bond the mother and baby closer together."

How long did women breastfeed babies?

Mary: "It would depend how the child is, sometimes we would breastfed for 2 or 2½ years. If the child is weak we would breastfeed longer. One of my children was not able to drink anything except my own milk so I breastfed for 6 years."

How would elders like yourself teach the young mothers to look after themselves and about breastfeeding?

Jane: "We would tell them that breastfeeding is easy. There are no bottles and no fuss. Breastfed babies are cuddly people."

EXCERPTED FROM: The Breastfeeding Guidebook: A Practical Guide to Common Breastfeeding Concerns. Prepared for Prenatal and Postnatal Nutrition Programs in the Northwest Territories, 1998.

Nonasowin - Breastfeeding Good Medicine

"Breastmilk, the ideal perfect food containing nutrients perfectly BALANCED for life giving..."

"Breastmilk is considered Mother Nature's vaccine as it gives the foundation for the future of the baby..."

"Breastfeeding is an enriching and learning experience that teaches patience, closeness, giving full attention and warmth. A true sense of love and affection develops a loving bond and a feeling that has been described as being "One in Spirit"..."
Rosella Kinoshameg, Breastfeeding Benefits for Community and Nation

Teaching... "At the beginning of their walk here on earth, the most important nurturing, nourishing protection that they need is Do-Do-Sha-Bo (Breastmilk)..."

Protection... "The mother shelters and protects the baby with her breastmilk. The father and extended family protect the mother/child relationship through support and caring..."

Strength... "A community and nation that takes the responsibilities of breastfeeding seriously, that honours and respects the needs of the birthing women to have the time and support they need in order that breastfeeding is established, is a nation that cares about the long term health of its people..."--Carol Couchie

EXCERPTED FROM: NONASOWIN, Written by Jody Pemberton, Union of Ontario Indians, 1995.

Continue the Tradition... Breastmilk: the Best Choice for Mother and Infant

"Nursing my baby is a way to continue nurturing the spiritual bond I have with my son. Nursing is a way for me to provide love, security, warmth and food to Elleas all at once..."
Janna Nicholas, Tobique First Nation, New Brunswick

EXCERPTED FROM: Continue the Tradition... Breastmilk: The Best Choice for Mother and Infant, a promotional brochure with testimonials from Mi'kmaq Nations in Nova Scotia and New Brunswick, Health Canada, FNIHB, Atlantic Branch, 1994.

So You Want a Healthy Baby

"It is very important in the traditional teachings to breastfeed the baby. You have the natural bonding immediately... I would advise the young women to connect with their elders and to get some teachings on how to parent and how to look after their babies."
Margaret Lavalee

"In the traditional community, everybody was responsible for the well being of the children."
Jules Lavalee

EXCERPTED FROM: So you want a healthy baby, a booklet written by Patricia Martens, Fort Alexander Health Centre, Pine Falls, Manitoba, 1996.

Additional Aboriginal specific resources can be found in Chapter 6: Breastfeeding Resources

Chapter 4: Activities to Support Breastfeeding

A Breastfeeding Plan

Encourage Breastfeeding and Overcome Barriers

Creating a breastfeeding plan can help an expectant mother take an active role in making plans around the feeding of her infant. The mother can use the plan as a tool when discussing her wishes with health care providers. The plan can also be used as a reference in situations where the mother may not be immediately available to discuss her wishes about the feeding of her baby such as a mother who requires a general anaesthetic when giving birth. It is important for the mother to realize that the plan must always take in account her safety and well-being as well as that of her baby. Circumstances may arise that make it necessary for the plan to be revised. Even then, a return to the plan or parts of the plan is often possible.

"My Breastfeeding Plan", found on the following pages, provides a template of a breastfeeding plan that covers from the moment the baby is born until weaned. Please feel free to make copies of this resource to share with expectant mothers and program participants.

My Breastfeeding Plan - Participant Resource

My name is [Name] and I plan to exclusively breastfeed my baby.

If I am unable to answer questions about my choice to exclusively breastfeed, please speak with my partner [Name of Partner] or my care provider [Name of Care Provider].

Immediately after my baby is born...

.... I want my baby placed skin-to skin with me for at least 1 hour.

.... I want to watch my baby for signs that my baby is ready to feed.

.... I want my baby to breastfeed and be left skin-to-skin with me until the completion of the first feeding.

.... If I am unavailable or not able to be skin-to-skin with my baby for a medical reason, I wish my baby to be placed skin-to-skin with [Name of Chosen Person].

.... If my baby requires special care, I wish to hold my baby skin-to skin as soon as my baby is well enough.

During my stay at the hospital/birthing centre...

.... I want to exclusively breastfeed my baby.

.... I want to room-in with my baby 24 hours per day.

.... I want to watch my baby for feeding cues and feed my baby at the first signs of hunger.

.... I want to be offered assistance with breastfeeding within 6 hours of delivery and as needed.

.... I want my support person, [Name of Support Person], to be welcome to stay with me as I wish, day and night.

.... If my baby needs to be separated from me, I wish to be shown how to express or pump my breastmilk.

.... If there is a medical reason for supplementing my baby, I want to speak to someone about expressing or pumping my milk and feeding my milk to my baby.

.... If my baby needs to be supplemented, I wish to make an informed decision about how to supplement.

When i get home...

.... I will continue to exclusively breastfeed my baby.

.... I will watch my baby for feeding cues and feed my baby in response to these cues.

.... I will be sure that my new baby feeds at least 8 times in 24 hours.

.... I will watch that my baby is passing urine and stool often enough.

.... I will have my baby checked by a health care provider within the first week.

.... I will have my baby weighed on a baby scale within the first week.

.... I will ask my health care provider to use the growth charts provided by the WHO. (

.... I will give my baby a vitamin D supplement every day.

If I have any questions or concerns about breastfeeding, I will call:

  • Breastfeeding specialist:
  • My friend who successfully breastfed:
  • Local health unit:

Websites I can access for more information include:

As my baby grows...

.... There will be times when my baby wants to feed more often and longer.

.... I will breastfeed my baby in response to my baby's hunger cues.

.... I will drink when I feel thirsty, eat healthy meals and snacks when I feel hungry, and rest when I feel tired.

When I need a break for awhile, 2 things that I can do are:

When I am tired and need help from family or friends, I will call:

When I feel like I want to spend time with other mothers, I will go to:

  • mother support group such as La Leche League
  • breastfeeding clinic

I know...

.... That I am making enough milk for my baby, even though I can't see how much my baby is getting.

.... That it is normal to sometimes feel like I've just fed my baby and my baby wants to feed again.

.... That my baby is changing all the time and is unlikely to follow an eating or sleeping schedule - that will come later.

.... That breastfeeding is more than food and it is okay to comfort my baby by breastfeeding.

.... That if people say things to me that are discouraging, I will trust in my body and my baby and that I am doing the right thing.

At around 6 months...

.... My baby needs only my breastmilk for the first 6 months.

.... In addition to breastfeeding, I can start offering solid foods once my baby is ready.

.... I can check out these websites to learn more about giving my baby solid foods:

.... I can also call my local health unit at:

Signs of readiness include:

  • Better head control.
  • Ability to sit up and lean forward.
  • Ability to let the caregiver know when they are full (i.e. turns head away).
  • Ability to pick up food and try to put it in their mouth.

At Around 12 Months...

.... I can continue to breastfeed my baby for two years or longer and wean when either of us is ready.

.... I can continue to breastfeed if I return to work or school.

.... I know that there will be a time of transition for me and my baby.

To help with the adjustment of going back to work or school, I can try the following tips:

.... Adjust the times that my baby breastfeeds to before and after I attend work/school.

.... Express and store breastmilk for the times that I am away.

.... Talk to my boss/school about my return and ways to support breastfeeding.

.... Make arrangements so that I can breastfeed or express/pump my milk while at work/school.

.... I can also call the breastfeeding specialist in my area for help and advice:

.... I can check out the information on the following website: OPHA - Creating a Breastfeeding Friendly Workspace

Deciding to wean...

My child will begin to wean from breastfeeding when he/she is ready. My body will reduce the amount of milk it produces gradually. Weaning will happen naturally.

If I need or want to stop breastfeeding before my child is ready, I will:

  • .... Plan ahead, choosing a non stressful time.
  • .... Decrease breastfeeding gradually so my breasts do not become sore.
  • .... Be ready to give my child more comfort and cuddles.

SOURCE: My Breastfeeding Plan is adapted from Texas Department of State Health Services WIC Program "Every Ounce Counts".

Small Group Activities

Activity 1. Breastfeeding Linkages

This activity helps participants learn about the importance of breastfeeding and provides an opportunity to discuss the risks of formula feeding. Collect objects that represent the importance of breastfeeding/risk of formula feeding and place in a basket or bag. Have each participant pick an object from the bag and tell the group about the object's link or connection with breastfeeding.


  • Wallet - breastfeeding saves money
  • Tape measure - breastfeeding helps mother lose weight that she gained during pregnancy
  • Tooth brush - breastfeeding promotes healthy tooth and jaw development
  • Garbage bag - breastfeeding is environmentally friendly
  • Picture of ear or otoscope - breastfeeding protects against ear infections
  • Thermometer - breastfed children have fewer illnesses
  • Report card - breastfed children have higher IQ
  • Sanitary pad - mothers who breastfeed have less risk of hemorrhage
  • Picture of a heart - breastfeeding promotes bonding
  • Immunization card or vaccine packaging - breastfed babies have more antibodies and a heightened response to immunization
  • Pregnancy test kit - for some women breastfeeding may delay the return of fertility (Note: be sure not to give the impression that breastfeeding is a foolproof method of contraception)

Activity 2. Could You See Yourself in This Picture?

The main goal of this activity is to explore pregnant and breastfeeding mothers' concerns and anxieties about breastfeeding. Show images of women breastfeeding in different settings. You may wish to use the video clip Nursing is Normal (please see the section titled "Useful Staff Resources"). Ask the group if they could see themselves breastfeeding in any of these settings. This usually gets the group sharing their feelings about issues such as: breastfeeding in public places, modesty, breastfeeding in front of family and friends, freedom and lifestyle issues.

Activity 3. I Can

This activity works well in a group prenatal session. It provides an opportunity to clarify the myths and false information about breastfeeding. Start with a coffee can and cover the label with appropriate paper. Fill the can with positive statements about breastfeeding, beginning with "I can". On the plastic lid of the can write "I Can." Pass the can around and encourage each mother to pick out a paper and read it to the group. Discuss any concerns brought up by the statements. Some suggestions for the statements:

  • I CAN still have a social life when I nurse my baby.
  • I CAN make good milk for my baby even if I eat junk food.
  • I CAN nurse my baby even if I need to be away for part of the day.
  • I CAN include my partner in the care of my breastfed baby.
  • I CAN breastfeed my baby even if I get a poor start in the hospital.
  • I CAN breastfeed my baby even if I have small breasts.
  • I CAN nurse my baby even if I smoke. (Note: be sure to emphasize that no one should smoke around a baby. Smoking should be done outdoors while the baby is supervised inside.)

SOURCE: Over 200 Meeting Ideas, Over 150 Discussion Questions. Compiled by Bev Pack, edited by Mary Beth Doucette, La Leche League International, and Martha Peelor, La Leche League, Ohio South, 1983.

Activity 4. My Feelings

The purpose of this activity is to identify and discuss breastfeeding issues with a group of pregnant mothers. Hand out a "My Feelings" activity sheet or write statements on a flip chart for the group. Ask the group to complete the statements on the "My Feelings" sheet. When completed the facilitator collects the papers and reads some of the responses without identifying individuals. Keep track of the issues that were identified and use these to focus your discussion on breastfeeding.


  1. "I want to breastfeed because"
  2. "I am worried about"
  3. "I am looking forward to"
  4. "I/we can go to [Person/Location] if I need help"

SOURCE: North Kingston Community Health Centre. The Special Delivery Club Kit (Third Edition). Kingston: Ontario, 1997.

Activity 5. My Feelings Adaptation

Adapt the activity if there are below literacy skills in the group. An envelope is labelled "Breastfeeding Makes Me Feel..." and several possible feelings that could complete the sentence are written on strips of paper and placed inside. When the envelope is circulated, each woman pulls out "a feeling" - not necessarily "her feeling" - and shows it to the group. The facilitator reads the feeling aloud and the group discusses whether or not they share or have overcome that feeling. Feelings included can be both positive and negative such as "confident;" "close to my baby;" "like a good mother;" "gross" or "like a cow."

Activity 6. Loss of Freedom: Will Breastfeeding Tie Me Down?

Many women choose to formula feed their babies because they worry that breastfeeding will tie them down. This is a big issue for young mothers, especially if they are returning to work or school.

1. Invite guests to your group who have successfully combined breastfeeding and a return to work or school. Mothers can have their questions and concerns answered by others with similar life experiences.

2. Another option is to take time as a group to explore breastfeeding promotion pamphlets, posters and videos for pictures that reinforce the idea that breastfeeding mothers are "not tied to the home." Highlight the activities that the mothers are engaged in; most are busy travelling, going to school, out with friends or out in their communities. There are few women dressed in nightgowns in their beds suggesting the need to stay home and breastfeed. This will help pregnant mothers to see that breastfeeding mothers are active in their communities and breastfeeding does not have to "tie a mother down."

Activity 7. Engorgement: a Demonstration With a Balloon!

Many women have difficulty with breastfeeding around the time that their "milk comes in." Occasionally the breasts become "over-full," leading to problems getting the baby to take the breast and sore nipples for the mother. Use a balloon to show the effect of engorgement (an over-full breast) on the ability of the baby to latch on well and drink from the breast. A fully inflated, tight balloon is difficult for the baby to grasp and get a deep mouthful of the breast. The nipple flattens out and is more easily damaged.

Compare the tight balloon with a softer, less full balloon. Show how the softness makes it easier for the baby to take the breast. The areola (darker area surrounding the nipple) should be soft like your cheek, not hard like your forehead when latching the baby onto the breast.

Activity 8. the Eating Patterns Game

One of the most frequent reasons mothers give for stopping breastfeeding early is their feeling that they don't have enough milk. This game was developed by Linda Smith, a lactation consultant and childbirth educator in Dayton, Ohio. One of the most difficult challenges facing new mothers is their concern about a breastfed baby's need for frequent, unrestricted time at the breast. Often, the baby's frequent feedings are seen by the new mother and her family as a sign that the baby is not getting enough breastmilk. The Eating Patterns Game is a fun way to show that even adults feel the urge to eat more often than every four hours. It is an effective way to teach the importance of frequent and baby-led nursing.

GOAL: To fully appreciate the baby's need for frequent feedings.

BEST AUDIENCE: Groups of about 10 people. This game works well in nearly any group, from high school students to parents and health professionals.

TIME REQUIRED: 10-20 minutes

PROPS NEEDED: paper and pencil, golf ball

HOW TO PLAY: Everyone needs paper and pencil. Think about a day when you had free access to food. Write down what time it was whenever you ate or drank anything. Even water counts. Count drinking fountains, coffee breaks, snacks, meals. Average the time between eating or drinking episodes. Now draw a diagram of the size of the newborn's stomach (50 cc or golf ball size). Now somewhere on your paper figure out what your weight would be doubled. And name a prize you would dearly love to win.


  • How often did you eat or drink?
    • Average 1-3 hours
  • How long did the meals take?
    • Average 20-30 minutes. Why would you ever want to take longer than this to eat a meal (conversation social time, relaxing, etc)?
  • How do you feel if you are truly hungry or thirsty and can't get food or water?
  • Does skipping a meal teach you to go longer without food or make you more desperate for food?
  • Are you trying to gain weight?
    • To earn your prize all you have to do is double your weight in five months.
  • What will you do if you are already averaging 1-3 hours and you aren't gaining weight?
    • Discuss answers offered as they apply to infant needs (eat more often, constantly, at night, eat higher calorie food (hindmilk), don't postpone meals, no water instead of calories, take your time at meals, avoid exercise).

SOURCE: Reprinted with permission from Linda J. Smith, 1996, Bright Future Lactation Resource Centre, 6540 Cedarview Court, Dayton, Ohio, USA 45459-1214.

Activity 9. Baby's Stomach Size

The size of the newborn's stomach is a key learning point as it helps parents to understand the need for smaller, more frequent feedings and that the time between feedings will increase as baby grows. A simple, hands on way to teach this same concept, especially for people who learn visually or by touch was shared by a CPNP project. Measure out ¼ cup, ½ cup and 1 cup of flour and wrap each amount separately and securely into plastic packets. Pass them to moms to touch and feel the weight while you explain: "This is how much the baby's stomach can hold at one week, at one month and at one year." Another idea is to use common objects to represent baby's stomach size. The pamphlet, 10 Valuable Tips For Successful Breastfeeding, suggests using a shooter marble (5-7 ml.) for day 1, a ping pong ball (22-27 ml.) for day 3, and a large chicken egg (60-81 ml.) for day 10.

SOURCE: Public Health Agency of Canada, 10 Valuable tips For Successful Breastfeeding, 2009.

Activity 10. Take It and Make It Exercise

You need:

  1. mostly full glass of water
  2. empty glasses & a pitcher of water

Pour the water to demonstrate:

  • Baby takes all - the breast makes it all again = Pour all the water into another cup.
  • Baby takes formula - the breast makes less the next time = Pour ⅔ of water into an-other cup
  • Mom expresses while she is away from baby - baby takes her milk - the breast makes the same amount = Add back the water
  • Baby is on a growth spurt = Pour out some water
  • Baby nurses more often - mom's supply picks up = Add some water

SOURCE: IBCLC (International Board Certified Lactation Consultant)

Activity 11. String Demonstration of a Lifetime

Many new mothers feel overwhelmed with life with a new baby and wonder if they will ever have time for themselves again. The newborn period is a time of significant adjustment and change. Taking care of baby, our families and ourselves will probably consume every available minute. It is helpful to remember how short a time this will last. Life is never quite going to re-turn to the way it was, but then things will get easier as days, weeks and months pass. Divide a long piece of string into 8 sections for 80 years and then divide the first 10 years into 1 year sections. This experience helps parents to see how the newborn period is relatively short in one's lifetime.

Activity 12. Night-time Feeding for a Formula-feeding Mother and Breastfeeding Mother

This is a fun "eye opener" for a group prenatal session. The group could develop a story about a new mother just home from the hospital and her experience with feeding her infant in the middle of the night. Encourage the group to share a step by step process of the experience for a mother formula-feeding and for a breastfeeding mother. The story could be developed on a flip chart. Suggested ideas for the story: new mother, two days postpartum, bedroom on the third floor of an older home, kitchen on the first floor, winter time, mother is alone with the baby. If the group is very comfortable with one another, you may find a couple of people willing to role play the two scenes. This is an excellent way of demonstrating visually the ease of breastfeeding.

Chapter 5: Historical and Reference Documents

International Code of Marketing of Breastmilk Substitutes

  • The International Code of Marketing of Breast Milk Substitutes is a set of recommendations adopted by the World Health Assembly (WHA) in 1981 to protect and promote appropriate infant and young child feeding practices.
  • The Code focuses on the regulation of marketing infant formula and products associated with bottle feeding. All types of infant formula and follow-up formula, bottles, artificial nipples and pacifiers/soothers, and baby foods directed to infants under 6 months of age are covered by the Code.
  • The aim of the Code is to protect and promote breastfeeding.
  • The Code recommends that formula be available when needed, but not be promoted.

The Code Includes These 10 Important Provisions:

  1. No advertising of these products to the public.
  2. No gifts or free samples to mothers.
  3. No promotion of products in health care facilities.
  4. No contact between baby milk company sales personnel and mothers.
  5. No gifts or personal samples to health workers.
  6. No words or pictures idealising artificial feeding, including pictures of babies, on the labels of the products.
  7. Information to health workers should be scientific and factual only.
  8. All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding.
  9. Unsuitable infant feeding products, such as sweetened condensed milk, should not be promoted for babies.
  10. All products should be of a high quality and take account of the climatic and storage conditions of the country where they are used.

SOURCE: WHO/UNICEF. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Assembly, 1981.

Resolutions of the World Health Assembly

The WHA is the decision-making body of the World Health Organization (WHO). A number of WHA resolutions have been adopted since 1981 that refer to the marketing and distribution of breastmilk substitutes. These resolutions were necessary because of changes in marketing practices over the years. The resolutions clarify and/or strengthen the Code and must be considered in the interpretation of the Code. The WHA resolutions related to infant feeding can be found at (retrieved 2012.March.09)

Putting the WHO Code into Practice

The Code is a recommendation of the WHA but it is not law. It does, however, carry a strong ethical and political weight. Unfortunately, there are many violations of the Code in both developed and developing countries around the world, including Canada. Research shows us that violations of the Code result in lower breastfeeding initiation and duration rates.

Examples of How the WHO Code Can Be Put into Practice:

  • Be sure that any information about infant feeding that you give to families is factual and not from an infant formula company or the baby food industry. Even though these companies have booklets and pamphlets about breastfeeding, bottle-feeding, and giving baby solid foods, the information is often misleading. Often the material sounds supportive of breastfeeding but housed within the counselling tips and recommendations are subtle messages that undermine breastfeeding. (Example: A brochure from an infant formula company discusses breastfeeding in a way that makes breastfeeding sound difficult and bottle-feeding sound like a great way to help Dad bond with his new baby).
  • Do not use or display any printed materials or items (booklets, posters etc.) that promote brand logos or advertise products covered by the Code.
  • Always choose non-industry people to talk to families attending your program. When manufacturers and sales representatives do presentations to the public the information is biased and supports their product. (Example: Sales representatives are interested in increasing the sales of their product. Often they make their product sound superior to other similar products available in the marketplace. It is important for parents to choose products best suited for their baby. This is best done with the assistance of their health care provider.)
  • Be cautious when suggesting websites to families. Parent clubs and help lines associated with manufacturers and distributors of products covered by the Code provide an easy way for companies to promote their products to the public. (Example: Many websites associated with manufacturers of products covered by the Code have opportunities for parents to give contact information. When parents provide their personal information they then receive information about the product and/or coupons for products made by the manufacturer. Some manufacturers also sell their lists of contacts to others. All of these activities help them market their products to the public.)

The BFI: Canadian Context

BCC BFI Integrated 10 Steps Practice Outcome Indicators for Hospitals and Community Health Services: Summary

In Canada, the Baby Friendly Hospital Initiative (BFHI) is called the Baby-Friendly Initiative (BFI), reflecting the continuum of care that extends beyond the hospital. Experience with the implementation and assessment of the BFI in Canada led to the development of the BFI Integrated 10 Steps Practice Outcome Indicators for Hospitals and Community Health Services.

Developed by the Breastfeeding Committee for Canada (BCC), the integrated 10 steps describe the international standards for the WHO/UNICEF Global Criteria within the Canadian context and provide a single set of criteria for both hospitals and community health services.

Below are the WHO/UNICEF 10 Steps that have been interpreted to reflect the Canadian context.

The WHO 10 Steps to Successful Breastfeeding (1989) and the Interpretation for Canadian Practice (2011)

Step 1

WHO: Have a written breastfeeding policy that is routinely communicated to all health care staff.

Canada: Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.

Step 2

WHO: Train all health care staff in the skills necessary to implement the policy.

Canada: Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.

Step 3

WHO: Inform pregnant women and their families about the benefits and management of breastfeeding.

Canada: Inform pregnant women and their families about the importance and process of breastfeeding.

Step 4

WHO: Help mothers initiate breastfeeding within a half-hour of birth. WHO 2009:

Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.

Canada: Place babies in uninterrupted skin-to-skin* contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: encourage mothers to recognize when their babies are ready to feed, offering help as needed.

*The phrase "skin-to-skin care" is used for term infants while the phrase "kangaroo care" is preferred when addressing skin-to skin care with premature babies.

Step 5

WHO: Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

Canada: Assist mothers to breastfeed and maintain lactation should they face challenges including sepa-ration from their infants.

Step 6

WHO: Give newborns no food or drink other than breastmilk, unless medically indicated.

Canada: Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.

Step 7

WHO: Practice rooming-in--allow mothers and infants to remain together 24 hours a day.

Canada: Facilitate 24 hour rooming-in for all mother-infant dyads: mothers and infants remain together.

Step 8

WHO: Encourage breastfeeding on demand.

Canada: Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.

Step 9

WHO: Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

Canada: Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).

Step 10

WHO: Foster the establishment of breastfeeding support groups and refer mothers to them on dis-charge from the hospital or clinic.

Canada: Provide a seamless transition between the services provided by the hospital, community health services and peer support programs. Apply principles of Primary Health Care and Population Health to support the continuum of care and implement strategies that affect the broad determinants what will improve breastfeeding outcomes.

The Code

WHO: Compliance with the International Code of Marketing of Breastmilk Substitiutes.

Canada: Compliance with the International Code of Marketing of Breastmilk Substitutes.

SOURCE: Breastfeeding Committee for Canada. Summary: Integrated 10 Steps Practice Outcome Indicators For Hospitals and Community Health Services, 2011.

Chapter 6: Breastfeeding Resources

Every province and health region in Canada has breastfeeding resources. Connect with your local public health unit to learn about the resources in your area. A listing of public health offices and regional health authorities can be found on the Canadian Public Health Association website.

Points to Consider When Evaluating Breastfeeding Resources

1. Tone

  • Does the resource have the right tone for the population that you are working with?
  • Do the graphics, words and overall feel of the resource portray breastfeeding in a positive way?
  • Do the images and text focus on positive choices rather than negative choices?
  • Does the resource show respect, understanding and convey hope?

2. Credibility

  • Is the resource a credible source of information?
  • Is the information current?
  • Is the information accurate? Evidence based?
  • Is the information from a source that is free of influence from industry (i.e. manufacturers or distributors of infant formula, bottles, nipples and pacifiers/soothers)?
  • Does the resource include references?

3. Messages

  • Are the messages the right messages that you want to convey?
  • Does the resource have clear objectives?
  • Do the objectives meet the needs of the population you are working with?
  • Do the messages show the importance of breastfeeding as well as the risks of not breastfeeding?
  • Do the messages portray breastfeeding as normal?
  • Do the messages encourage breastfeeding exclusively during the first 6 months of life and continued breastfeeding after the introduction of solid foods for 2 years and beyond?
  • Do the messages support informed decision making around infant feeding?
  • Are the messages empowering to expectant and postpartum mothers?
  • Do the messages agree with the WHO Code and subsequent WHA resolutions?

NB. Written materials should not be given to women or their families/support persons if they contain information about formula feeding. This information should be provided in a separate document on an individual basis to women who have made an informed decision not to breastfeed.

4. Readability

  • Is the resource easy to read and understand?
  • Is the reading level consistent with the reading level of the participants in your community-based program?
  • Is the resource available in the languages of the participants?
  • Does the resource present basic information?
  • Are the key messages easy to find?
  • Is the information clear?
  • Do the messages conveyed by the visual images match the text?

5. Images

  • Are the images inclusive and comfortable for everyone?
  • Are there images of women breastfeeding?
  • Are the images clear and reflect that breastfeeding can be learned and is a positive experience?
  • Do the images depict newborns, older infants and children breastfeeding?
  • Do the images reflect the diversity of the Canadian population? This can include age, gender, culture, family structure etc.
  • Do the images attract attention but not offend or alienate anyone?
  • If you are working with one specific population, it is always best to include resources with images that represent and speak to that population.
  • Do the images agree with the WHO Code and subsequent WHA resolutions?

NB. Resources including posters, pictures, videos and teaching sheets should be free of commercial endorsements for formula, bottles, nipples and pacifiers/soothers.

Final Points to Consider:

  • Ask the participants in your community-based program what they thought of the resource and how it could be improved.
  • Always think through any possible negative consequence of using the resource and try to reduce or minimize these consequences if you can.
  • It is helpful to summarize the feedback from the participants and keep it on file to help guide you when you use the resource again.

ADAPTED FROM: Best Start. Checklist For The Development of Resources on Preconception, Prenatal, and Child Health, 2006 and Breastfeeding Committee for Canada. Appendix 5.2 - Breastfeeding Education Materials for Families Checklist, BCC Integrated Ten Steps Practice Outcome Indicators, 2011.

Useful Parent Resources


Breastfeeding Matters
Best Start by Health Nexus. Funded by Government of Ontario. 2011.

The Womanly Art of Breastfeeding La Leche League International. 8th edition. Illinois: La Leche League International. 2010. ISBN-10: 1905177402; ISBN-13: 978-1905177400

Books With Testimonials from Mothers

The Breastfeeding Café
Behrmann, Barbara. 2008.
ISBN 0-472-06975

Available only in French: Près du coeur : témoignages et réflexions sur l'allaitement. Sous la direction de Lysane Grégoire et Marie-Anne Poussart. 2008. ISBN-10: 2890912752; ISBN-13: 978-2890912755


10 Great Reasons to Breastfeed Your Baby
Public Health Agency of Canada.

10 Valuable Tips For Successful Breastfeeding
Public Health Agency of Canada.


A prenatal on-line program: A new prenatal life. (Includes a breastfeeding component).

Baby Friendly Newfoundland and Labrador

(Infant Feeding Action Coalition to protect, promote and support breastfeeding)


International Breastfeeding Centre (Dr. Jack Newman)

International Lactation Consultant Association
(finding a lactation consultant (IBCLC) in your area)

La Leche League Canada
Telephone: 1-800-665-4324

French only website:
(Féderation Nourri-Source Quebec - information, mentors, drop-ins, moderated forum etc.)

Interactive Internet (Chats, Blogs)

Facebook - Baby Friendly (a closed group that you can request to join)

Facebook - Breastfeeding NB Allaitement (Bilingual)

La Leche League Canada Blogs:
The Milky Way, Grandma Drama

Useful Staff Resources


Breastfeeding Answers Made Simple: A Guide For Helping Mothers.
Mohrbacher N. Amarillo, Texas: Hale Publishing, L. P., 2010.

Staff Education

Healthy Mothers Healthy Babies Breastfeeding Web Course.
(Free, bilingual, online breastfeeding web course for health and social service providers, volunteers and individuals who work with pregnant women or new families to protect, promote and support breastfeeding). Best Start by Health Nexus.

Websites and Electronic Documents

BFI Integrated 10 Steps Practice Outcome Indicators for Hospitals and Community Health Services.
Breastfeeding Committee for Canada. 2011.

Breastfeeding Practices in Canada: Overview.
Health Canada. 2010.

British Columbia Baby-Friendly Initiative: Resources Developed
Through the BC Breastfeeding Resources Project.
Jones F, Green M. 2002. [A revised edition of The Baby-Friendly Resource Binder, third edition, is in development and will be online]

Creating a Breastfeeding Friendly Workplace
Ontario Public Health Association. Breastfeeding Promotion Workgroup. 2008.

Family-Centred Maternity and Newborn Care: National Guidelines.
Public Health Agency of Canada. 2000.

Linking the Circles of Support for Breastfeeding in CAPC/CPNP. B.C. Association of Pregnancy Outreach Programs (BCAPOP). A Breastfeeding Resources Catalogue. 2007.

Making Breastfeeding Your Business: An Action Support Kit.
Frittenburg, Sarah and the Lunenburg and Queens Baby Friendly Initiative Committee. 2009.

Mother to Mother: Creating a Breastfeeding Support Line in Your Community.
Province of Nova Scotia. 2007.

Mother-to-Mother Support
Infact Canada

Nutrition for Healthy Term Infants: Recommendations From Birth to Six Months.
A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada. Health Canada. 2012.

Nutrition for Healthy Term Infants: Recommendations From Six to 24 Months
A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada. Health Canada. 2014.

Nursing is Normal - Quebec (Video)
Le comité local en allaitement maternel des hôpitaux Pierre-Boucher et Charles LeMoyne, Montréal

Peers Work: Breastfeeding Peer Counsellor Program:
A Planning Guide to Breastfeeding Peer Counsellor Programs.
Romphf L. 2010.

Prenatal Nutrition Guidelines for Health Professionals - Background on Canada's Food Guide.
Health Canada. 2009.

The Baby-Friendly Initiative: Evidence-Informed Key Messages and Resources.
Best Start Resource Centre & Baby-Friendly Initiative Ontario. 2013

The Breastfeeding Guidebook: A Practical Guide to Common Breastfeeding Concerns.
Prenatal and Postnatal Nutrition Projects, Northwest Territories. Yellowknife, 1998.

Aboriginal Specific Resources

Aboriginal Parents - Eyes On Breastfeeding: More Than Loving Contact.
Centre of Excellence for Early Childhood Development. 2010.

A Prenatal Resource for Inuit Women and Their Families (DVD)
(This resource includes a DVD, a booklet for providers and a booklet for participants and can be ordered by calling 1-800-667-0749 or emailing
Pauktuutit Inuit Women of Canada.

A Sense of Belonging: Supporting Healthy Child Development in Aboriginal Families.
Fearn, Terrellyn. Spirit Moon Consulting. Best Start Resource Centre. 2006.

Breastfeeding for the Health of Our Nation.
Best Start Resource Centre. 2013.

Open Hearts, Open Minds: Services that are Inclusive of First Nations, Métis and Inuit Families.
Best Start Resource Centre. 2013.

Pimotisiwin: A Good Path for Pregnant and Parenting Aboriginal Teens.
Best Start Resource Centre. 2013.

Supporting the Sacred Journey: From Preconception to Parenting for First Nations Families in Ontario.
Best Start Resource Centre. 2012.

The Inuit Way: A Guide to Inuit Culture.
Pauktuutit Inuit Women of Canada. 2006.

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