• Registered Nurses Association of Ontario (RNAO). Breastfeeding best practice guidelines for nurses. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2003 Sep. 120 p. [175 references]



• Registered Nurses Association of Ontario (RNAO). Breastfeeding best practice guidelines for nurses: supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2007 Mar. 15 p. [49 references]

This is the current release of the guideline.

Infant health

Management

Family Practice
Nursing
Obstetrics and Gynecology

Advanced Practice Nurses
Nurses

• To improve breastfeeding outcomes for mothers and infants
• To provide nursing interventions that promote initiation, duration, and exclusivity of breastfeeding in term infants (>37 weeks).
• The March 2007 supplement should be used in conjunction with the original guideline as a tool to assist in decision making for individualized client care and to ensure that appropriate structures and supports are in place to provide the best possible care.

Pregnant women and new mothers

1. Breastfeeding assessment of mother and baby
2. Prenatal and postnatal assessment
3. Education regarding breastfeeding
4. Follow-up after discharge

• Duration of breastfeeding
• Incidence of breastfeeding
• Exclusivity of breastfeeding
• Validity and reliability of breastfeeding assessment tools

Searches of Electronic Databases
Searches of Unpublished Data

September 2003 Guideline

Eight guidelines were deemed suitable for critical review.

March 2007 Supplement

The literature search yielded 808 abstracts. Seventy-five studies met inclusion criteria. One guideline was identified to inform the revision process.

Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)

Level of Evidence

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

Review of Published Meta-Analyses
Systematic Review
Systematic Review with Evidence Tables

Not stated

Expert Consensus

In February of 2001, a panel of nurses, researchers, and other health professionals with expertise in the practice and research of breastfeeding support, from institutional, community and academic settings was convened under the auspices of the Registered Nurses Association of Ontario (RNAO). At the outset, the panel discussed and came to consensus on the scope of the best practice guideline. The original scope identified was best practices for breastfeeding support from preconception through the mother´s return (postpartum) to school or work. This scope was later found to be too ambitious. Therefore, the panel narrowed the scope of the guideline to address best practices that were general in nature and addressed the competent to proficient level of practice for nurses encountering families in both the prenatal and postnatal periods.

A critique of systematic review articles and pertinent literature was conducted to update the existing guidelines. Through a process of evidence gathering, synthesis, and consensus, the final draft set of recommendations was established.

Not applicable

Cost-effectiveness

A report by the U.S. Department of Agriculture´s Economic Research Service has estimated that $3.6 billion could be saved in treating otitis media, gastroenteritis, and necrotizing enterocolitis alone, if breastfeeding rates in the United States met current recommendations.

Clinical Validation-Pilot Testing
External Peer Review
Internal Peer Review

This draft document was submitted to a set of external stakeholders for review and feedback. Stakeholders represented various health care professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel; discussion and consensus resulted in revisions to the draft document prior to pilot testing.

A pilot implementation site was identified through a "Request for Proposal" (RFP) process. Practice settings in Ontario were asked to submit a proposal if they were interested in pilot testing the recommendations of the guideline. These proposals were then subjected to a review process, from which successful practice settings were identified. A nine-month pilot implementation was undertaken to test and evaluate the recommendations in both a hospital and public health unit in Sudbury, Ontario. The development panel reconvened after the pilot implementation in order to review the experiences of the pilot site, consider the evaluation results and review any new literature published since the initial development phase. All these sources of information were used to update/revise the document prior to publication.

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

An algorithm is provided in the original guideline document for an immediate postpartum decision tree.

The type of evidence is provided for each recommendation (see "Major Recommendations").

• Improved breastfeeding outcomes for mothers and infants
• Appropriate initiation, duration and exclusivity of breastfeeding in term infants

Not stated

• Guidelines should not be applied in a "cookbook" fashion, but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor a discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• The March 2007 supplement to the nursing best practice guideline Breastfeeding Best Practice Guidelines for Nurses is the result of a three year scheduled revision of the guideline. Additional material has been provided in an attempt to provide the reader with current evidence to support practice. Similar to the original guideline publication, this document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client.

September 2003 Guideline

Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. In this light, the Registered Nurses Association of Ontario (RNAO), through a panel of nurses, researchers, and administrators has developed a Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a healthcare organization.

The "Toolkit" provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment, and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing an evaluation
6. Identifying and securing required resources for implementation and evaluation

Implementing practice guidelines that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

March 2007 Supplement

The Registered Nurses Association of Ontario and the guideline panel have compiled a list of implementation strategies to assist health care organizations or health care professionals who are interested in implementing this guideline. A summary of these strategies follows. Organizations should:

• Have at least one dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support, clinical expertise and leadership. The individual should have good interpersonal, facilitation and project management skills.
• Conduct an organizational needs assessment related to breastfeeding support to identify current knowledge and further educational requirements.
• Create a vision to help direct the change effort and develop strategies for achieving and sustaining the vision.
• Establish a steering committee comprised of key stakeholders and interdisciplinary members committed to leading the change initiative. Identify short-term and long-term goals.
• Identify and support designated best practice champions on each unit to promote and support implementation. Celebrate milestones and achievements, acknowledging work well done.
• Provide organizational support such as having the structures in place to facilitate best practices in breastfeeding. For example, having an organizational philosophy that reflects the value of best practices through policies and procedures.
• Develop new documentation tools.

Staying Healthy

Effectiveness
Patient-centeredness

• Registered Nurses Association of Ontario (RNAO). Breastfeeding best practice guidelines for nurses. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2003 Sep. 120 p. [175 references]



• Registered Nurses Association of Ontario (RNAO). Breastfeeding best practice guidelines for nurses: supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2007 Mar. 15 p. [49 references]

Not applicable: The guideline was not adapted from another source.

2003 Sep (addendum released 2007 Mar)

Registered Nurses' Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Guideline Revision Panel Members

Maureen Kennedy RN, BScN, IBLLC, MScN
Team Leader
Ottawa, Ontario

Monique Stewart RN, MN
Co-Team Leader
Ottawa, Ontario

Barb Bowles RN, BScN, PNC(C)
Staff Nurse, Niagara Health System
Maternal Child Family Centre
St. Catharines, Ontario

Anne-Marie Desjardins RN, MSN
Breastfeeding Consultant
Etobicoke, Ontario

Melissa Dougherty RN, BScN, IBCLC, PNC(C), MScN (cand.)
Coordinator, Nursing Professional Practice
Queensway Carleton Hospital
Ottawa, Ontario

Sandra Dunn RN, BScN, MEd, MScN, PhD (cand.), IBCLC
Perinatal Coordinator, Perinatal Partnership Program of Eastern and Southeastern Ontario
Ottawa, Ontario

Joanne Gilmore RN, BScN, Med
Manager, Healthy Families
Toronto Public Health
Toronto, Ontario

Edith Kernerman IBCLC, RLC
Director, Newman Breastfeeding Clinic and Institute
Toronto, Ontario

Denna Lee Leach RN, BScN, Bed
Program Manager, Health Promotion
Grey Bruce Health Unit
Owen Sound, Ontario

Tammy McBride RN, BScN, IBCLC
NICU Lactation Consultant
Mount Sinai Hospital
Toronto, Ontario

Jack Newman MD, FRCPC
Paediatrician, Newman Breastfeeding Clinic & Institute
Toronto, Ontario

Jan Riordan ARNP, EdD, CS, FAAN, IBCLC
Professor, Maternal-Child Women's Health
Wichita State University
Wichita, Kansas

Laura Samaras RN, IBCLC
Childbirth and Parenting Services
St Joseph's Health Centre
Breastfeeding Clinic
Toronto, Ontario

Judy Sheeshka RD, PhD
Associate Professor, Family Relations & Applied Nutrition
University of Guelph
Guelph, Ontario

Dawn Kingston RN, MScN, PhD (student)
Team Facilitator
Assistant Professor, Faculty of Health Sciences
School of Nursing
McMaster University
Hamilton, Ontario

This guideline was developed by a panel of nurses and other health care professionals convened by the Registered Nurses Association of Ontario (RNAO), conducting its work independent of any bias or influence from the Ministry of Health and Long-Term Care.

This is the current release of the guideline.

This NGC summary was completed by ECRI on September 16, 2004. The information was verified by the guideline developer on October 14, 2004. This NGC summary was updated by ECRI Institute on December 31, 2007. The updated information was verified by the guideline developer on March 4, 2008.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or noncommercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses Association of Ontario (2003). Breastfeeding beast practice guidelines for nurses. Toronto, Canada: Registered Nurses Association of Ontario.