High 5 for Mom & Baby Premier Renewal 2025

Kansas Hospitals and Birth Centers: use this streamlined online form to apply for renewal of recognition as a High 5 for Mom & Baby Premier facility. If helpful, you can download an offline sample to gather the information to enter into the official online form below.

If you have questions about High 5 for Mom & Baby or the renewal process, please contact program coordinator Cara Gerhardt coordinator@high5kansas.org. Thank you for your continued commitment to helping ensure successful breastfeeding for Mom & Baby!

Note: upon submission of the below form, an email confirmation will be sent to the address entered in the email field below. If you want to save a partial form for later completion, please use the Save Draft function at the bottom of the form.

High 5 Premier Renewal Application 2025

High 5 Premier Renewal Application 2025

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The following Facility Self-Assessment questions relate to the evidence-based High 5 for Mom & Baby practices supporting successful breastfeeding.

High 5 for Mom & Baby Premier facilities should answer questions relating to all ten High 5 for Mom & Baby practices. Facilities continuing to follow all ten practices will remain eligible for High 5 for Mom & Baby Premier recognition.

The High 5 for Mom & Baby Practices:

  1. Facility will have a written maternity care and infant feeding policy addressing the High 5 for Mom & Baby practices supporting breastfeeding
  2. Facility will maintain staff competency in lactation support
  3. All pregnant women will receive information and instruction on breastfeeding
  4. Assure immediate and sustained skin-to-skin contact between mother and baby after birth
  5. All families will receive individualized infant feeding counseling
  6. Give newborn infants no food or drink other than breastmilk unless medically indicated
  7. Practice “rooming in” – allow mothers and infants to remain together 24 hours a day
  8. Families will be encouraged to feed their babies when the baby exhibits feeding cues, regardless of feeding methods
  9. Give no pacifiers or artificial nipples to breastfeeding infants
  10. Provide mothers options for breastfeeding support in the community (such as a telephone number, walk-in clinic information, support groups, etc.) upon discharge

High 5 Practice 1 – affirmation and updates

High 5 for Mom & Baby Practice 1: Facility will have a written maternity care and infant feeding policy addressing the High 5 for Mom & Baby practices supporting breastfeeding. Please complete the following questions relating to policy support in your facility:
Practice 1: Does facility policy support all 10 High 5 for Mom & Baby practices?
If ‘No’, please comment in the following field.
If you answered ‘No’ in the previous question, please comment/provide additional information here. Note: for High 5 for Mom & Baby Premier, policy should support all ten practices; High 5 for Mom & Baby facility policies should support at least 5 practices.
Do all policies from all departments in the facility support the Maternity Care and Infant Feeding policies?

Maximum file size: 67.11MB

If relevant policies have been added, changed, or updated since your last renewal, please upload current copies here.

High 5 Premier Practices 2 through 10

For each of the following High 5 Premier practices, please select Yes or No to indicate whether the practice is currently supported by facility policy, and answer any additional per-practice questions.
Practice 2: Facility will maintain staff competency in lactation support
e.g., competency/skills-based training, skills labs, on-the-job training with certified lactation staff, etc.
Does the facility employ at least one person with advanced lactation education (IBCLC, CLC or similar) as part of the staff working directly with families?
e.g., competency/skills-based training, skills labs, on-the-job training with certified lactation staff, etc.
Practice 3: All pregnant women will receive information and instruction on breastfeeding
Examples include:
  • Providing families with information and resources about breastfeeding prior to arrival through their Health Care Provider (HCP), local health department, WIC clinic or local community-based organization.
  • Collaborating with local breastfeeding coalitions or other groups in their community supporting breastfeeding families.
  • Supporting facility employees who breastfeed by providing reasonable break time and a private, safe, free from intrusion place to express milk close to their workplace (NOT a bathroom).
Practice 4: Assure immediate and sustained skin-to-skin contact between mother and baby after birth.
Examples include:
  • Placing babies skin-to-skin immediately after vaginal delivery if medically stable.
  • Placing babies skin-to-skin as soon as both mom and baby are medically stable after a C-section delivery.
  • Allowing babies to breastfeed before any interventions are performed, such as measurements, bath, glucose sticks, footprints and eye treatment.
  • If mother and baby are separated after birth due to a medical condition, placing the baby skin-to-skin as soon as possible after they are stable.
  • In all of the above circumstances, once the baby is placed in skin-to-skin contact, allowing the baby to remain there continuously until after the first feeding.
Practice 5: All families will receive individualized infant feeding counseling.
Examples include:
  • Providing breastfeeding families culturally-sensitive, inclusive instruction on feeding; including but not limited to: hunger cues, satiety cues, positioning and latch, and how to tell if baby is getting enough to eat. Parents’ questions will be answered by trained staff.
  • Ensuring formula-feeding families receive culturally-sensitive, inclusive verbal AND written instructions on proper formula preparation according to the Centers for Disease Control guidelines.
Practice 6: Give newborn infants no food or drink other than breast milk, unless medically indicated.
Examples include:
  • Breastfed babies are given only breast milk unless ordered for a medical condition.
  • When supplement is needed, an alternative feeding method not requiring an artificial nipple is offered first. such as a cup, spoon, SNS/tube feeder, etc.)
  • Prior to discharge, parents are taught how to use alternative feeding methods.
  • When supplement is necessary for a medical condition, parents are instructed on hand expression or other forms of milk expression (such as pumping).
Practice 7: Practice “rooming in” – allow mothers and infants to remain together 24 hours a day.
Examples include:
  • Education regarding the benefits of rooming in is provided to all mothers.
  • Babies stay in the room with mom 23/24 hours per day.
  • Routine infant care is done in the room with mother by all staff, including but not limited to, nurses, doctors and other health care providers.
  • Parents are educated that nighttime feeding and cluster feeding are normal healthy patterns.
  • If mother chooses not to do nighttime feedings, she is educated about the impact on milk production such as low supply or engorgement and provided with information on milk expression including hand expression.
Practice 8: Families will be encouraged to feed their babies when the baby exhibits feeding cues regardless of feeding method.
Note: the following examples apply to all families, regardless of feeding method (e.g., breastfeeding, donor milk, formula) Examples include:
  • Mothers are educated and supported on how to recognize and respond to feeding cues, regardless of feeding method.
  • Babies have documented 8 or more feeds/attempted feeds every 24 hours when baby exhibits feeding cues. There are no restrictions on feeding length or frequency.
  • All families, regardless of feeding method, have documented teaching of feeding practices and recommendations.
  • All mothers who plan to breastfeed are taught hand expression.
  • Mothers who are separated from their infants are assisted and educated to express their milk 8 or more times per 24 hours. Expression should begin at one hour but no later than 6 hours after birth.
Practice 9: Give no pacifiers or artificial nipples to breastfeeding infants.
Examples include:
  • Families and mothers are counseled on the use and risks of feeding bottles, artificial nipples and pacifiers.
  • Pacifiers are not offered for routine care.
  • If a pacifier is needed for a painful procedure, it is removed from parental view – such as placed in a drawer under the bassinet.
  • Mothers are educated on the “supply and demand” principle of milk production and encouraged to feed frequently.
  • All parents are educated to identify early hunger cues.
Practice 10: Provide mothers options for breastfeeding support in the community (such as a telephone number, walk-in clinic information, support groups, etc.) upon discharge.
Examples include:
  • Mothers are routinely referred to a support group, outpatient clinic, local lactation specialist or community resource to call for breastfeeding support after discharge.
  • The facility has a system of follow-up support for breastfeeding mothers after discharge, such as early post-natal or lactation clinic check-ups, home visits, telephone calls.
Any additional comments you’d like to add about any practices.

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