Note from the National Guideline Clearinghouse (NGC): In March 2007, the Registered Nurses Association of Ontario amended the current practice recommendations for this topic. Through the review process, no recommendations were deleted. These have been noted below as "changed" or "unchanged" or "new."
The levels of evidence supporting the recommendations (Level I, II-1, II-2, II-3, III) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Recommendation 1 (Changed March 2007)
Nurses in all practice settings, endorse the Baby-Friendly™ Hospital Initiative (BFHI), which was jointly launched in 1992 by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) and the Baby-Friendly Initiative in Community Health Services (Breastfeeding Committee for Canada). The BFHI directs health care facilities to meet the "Ten Steps to Successful Breastfeeding". (Level of Evidence II-3)
Recommendation 1.1 (Level of Evidence III) (Unchanged)
Nurses have a role in advocating for "breastfeeding friendly" environments by:
- Advocating for supportive facilities and systems such as day-care facilities, "mother and baby" areas for breastfeeding, public breastfeeding areas, 24-hour help for families having difficulties in breastfeeding
- Promoting community action in breastfeeding
Recommendation 2 (Unchanged)
Nurses and health care practice settings endorse the World Health Organization (WHO) recommendation for exclusive breastfeeding for the first six months, with introduction of complementary foods and continued breastfeeding up to two years and beyond thereafter. (Level of Evidence I)
Recommendation 3 (Changed March 2007)
Nurses should perform a comprehensive breastfeeding assessment of mother/baby/family, both prenatally and postnatally, to facilitate intervention and the development of a breastfeeding plan. (Level of Evidence II-3)
Recommendation 3.1 (Level of Evidence III) (Unchanged)
Key components of the prenatal assessment should include:
- Personal and demographic variables that may influence breastfeeding rates
- Intent to breastfeed
- Access to support for breastfeeding, including significant others and peers
- Attitude about breastfeeding among health care providers, significant others and peers
- Physical factors, including breasts and nipples, that may affect a woman's ability to breastfeed
Recommendation 3.2 (Level of Evidence III except where noted) (Changed March 2007)
Key components of the postnatal assessment should include:
- Intrapartum practices and interventions including medications
- Level of maternal physical discomfort
- Observation of positioning, latching, and sucking
- Signs of milk transfer
- Parental ability to identify infant feeding cues
- Mother-infant interaction and maternal response to feeding cues
- Maternal perception of infant satisfaction/satiety cues
- Woman's ability to identify significant others who are available and supportive of the decision to breastfeed
- Delivery experience
- Infant physical assessment
- Maternal breastfeeding self-efficacy (Level of Evidence I)
Recommendation 4 (Changed March 2007)
Nurses should provide informational support to couples during the childbearing age, as well as to expectant mothers/couples/families and assist them in making informed decisions regarding breastfeeding. Education should include, as a minimum, the following:
- Benefits of breastfeeding (Level I)
- Lifestyle issues (Level III)
- Milk production (Level I)
- Breastfeeding positions (Level I)
- Latching/milk transfer (Level I)
- Prevention and management of problems (Level III)
- Medical interventions (Level III)
- When to seek help (Level III)
- Where to get additional information and resources (Level III)
- Benefits of skin to skin contact (Level III)
- Recognizing feeding cues (Level III)
Recommendation 4.1 (New March 2007)
Women's partners should be encouraged to attend breastfeeding education classes (Level of Evidence I)
Recommendation 5 (Changed March 2007)
Nurses should perform a comprehensive breastfeeding assessment of mother/baby prior to hospital discharge (Level of III)
Recommendation 5.1 (Unchanged)
If mother and baby are discharged within 48 hours of birth, there must be a face-to-face follow up assessment conducted within 48 hours of discharge by a qualified health care professional, such as a Public Health Nurse or Community Nurse specializing in maternal/newborn care. (Level of Evidence III)
Recommendation 5.2 (Changed March 2007)
Discharge of low-risk mothers and infants after 48 hours may be followed by a telephone call within 48 hours of discharge, rather than a home visit. (Level of Evidence I)
Recommendation 6 (Changed March 2007)
Nurses should provide information, emotional and physical support to breastfeeding mothers with an attitude that conveys support for breastfeeding. (Level of Evidence II-3)
Recommendation 7 (Changed March 2007)
Nurses should support local peer support breastfeeding programs, ensuring that women are provided with peer support resources. (Level of Evidence I)
Recommendation 8 (New March 2007)
Nurses should initiate skin to skin contact between mother and infant immediately after birth as part of ongoing, routine care. (Level of Evidence II-2)
Education Recommendations
Recommendation 9 (Changed March 2007)
Organizations must ensure that nurses providing breastfeeding support receive education appropriate to their role in breastfeeding in order to develop the knowledge, skill and attitudes to implement breastfeeding policy and to support breastfeeding mothers. (Level of Evidence III)
Organization and Policy Recommendations
Recommendation 10 (Changed March 2007)
Practice settings/organizations should work towards Baby Friendly Initiative designation as part of a comprehensive plan towards improving breastfeeding outcomes. (Level of Evidence I)
Recommendation 11 (Changed March 2007)
Practice settings should evaluate the effectiveness of their breastfeeding support on rates of initiation, duration and exclusivity of breastfeeding. (Level of Evidence III)
Recommendation 12 (Changed March 2007)
Organizations should establish and support peer support programs. (Level of Evidence I)
Recommendation 13 (Unchanged)
Nursing best practice guidelines can be successfully implemented only when there are adequate planning, resources, organizational, and administrative support, and appropriate facilitation.
Organizations may develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Dedication of a qualified individual to provide the support needed for the education and implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Opportunities for reflection on personal and organizational experience in implementing guidelines
(Level of Evidence III)
Refer to the "Description of the Implementation Strategy" field for more information.
Definitions:
Level I: Evidence obtained from at least one properly designed randomized controlled trial, plus consensus of panel
Level II-1: Evidence obtained from well-designed controlled trials without randomization, plus consensus of panel
Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably for more than one centre or research group, plus consensus of panel
Level II-3: Evidence from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence, plus consensus of panel
Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees, plus consensus of panel
