A study was conducted to assess the variation in breastfeeding knowledge and practices of registered nurses in hospital women and family-care units. It found that the majority of nurses were knowledgeable of evidence-based best practices related to breastfeeding initiation. However, in non-Baby Friendly/Baby Friendly Intent (non-BF/BFI) settings, nurses' knowledge was often not in accordance with current best practices, and hospital policies were not based upon evidence-based practices.
A noteworthy disparity between nurses' intention to support breastfeeding and their knowledge suggests a need for education based on the World Health Organization Baby Friendly standards for nurses at non-BF/BFI hospitals. A significant barrier to supporting breastfeeding is lack of hospital policy and inappropriate or outdated policy. The study pointed to a varying knowledge between Baby-Friendly Hospital Initiative (BFHI) nurses and non-BFHI nurses which varied across the spectrum.
In the BF/BFI hospitals, breastfeeding initiation policies had recently been updated, enabling the nurses to follow evidence-based best practices. The BFHI promotes the following nine evidence-based practices that relate to specific education:
- Care of breastfeeding mother with a healthy newborn
- Promote breastfeeding in the first hour of life
- Immediate and uninterrupted skin-to-skin
- Unrestricted breastfeeding
- Breast milk only supplementation with human donor milk (HDM)
- Rooming in
- Teach feeding cues
- Provide appropriate discharge education
- Discourage pacifier use for term infants
The Pregnancy Risk Assessment Monitoring System (PRAMS) data indicate that breastfeeding duration rates increased due to five specific BFHI practices:
- Breastfeeding initiation within one hour of birth
- Baby fed breast milk only
- Mother and baby staying together by rooming-in
- No pacifier use
- Parents being given a follow-up phone number upon discharge
However, only 20% of Colorado mothers surveyed experienced these five BFHI practices.
1. Skin-to-Skin and Initiation of Breastfeeding Within the First Hour of Life Policy
The BF/BFI hospitals' policies supported current evidence-based best practices and promoted immediate and uninterrupted skin-to-skin contact at birth and until first breastfeeding occurs. At non-BF/BFI hospitals, many of the nurses reported that they “try” to encourage breastfeeding after delivery, but that the infants are usually removed from their mothers.
Nurses at the BF/BFI hospitals were aware of the physiological properties of breastmilk and that skin-to-skin improves an infant's temperature and blood sugar regulation. At non-BF/BFI hospitals, most nurses put the baby skin-to-skin for less than five minutes, then take the baby away for transition, which includes physical assessment, vitamin K administration, eye antibiotic ointment, and cleaning, prior to being swaddled in a blanket and given to the mother for breastfeeding. This separation of mother and child may result in delayed onset of milk production, which makes the infant more likely to experience excess weight loss during the first 3 days of life.
2. Breast milk only
The nurses at the BF/BFI hospitals reported primarily using human milk, either mother's own pumped milk, or HDM in the neonatal intensive care unit (NICU). Nurses were aware of the research that supports exclusively using expressed breast milk (fortified or unfortified) with NICU babies to decrease the risk for necrotizing enterocolitis (NEC) and other diseases. At non-BF/BFI hospitals, discussions about breastmilk and formula seemed to refer to the two as equal, and even though the nurses stated that breastfeeding was the “gold standard,” they allowed frequent supplementation with formula, regardless of medical need.
3. Rooming in
The BF/BFI hospitals had policies that encouraged rooming-in. In contrast, several of the nurses in the non-BF/BFI group reported that they encourage rooming-in, unless the mom is tired – and then they encourage sending the baby to the nursery. Nurses at BF/BFI hospitals reported that they educate their patients about an infant's nocturnal feeding schedule, where they view nights as an excellent, quiet opportunity to help a patient with latch and assess milk transfer. Nurses in postpartum care understand the reasons for encouraging rooming-in and that mothers do not have improved sleep quality if their infants are removed from the room.
4. Pacifier use
At the BF/BFI hospitals the nurses provided education about avoiding early pacifier use and supported the American Academy of Pediatrics (AAP) recommendations. This education is important in light of recent findings supporting pacifier use to decrease the risk of sudden infant death syndrome (SIDS). AAP guidelines recommend delaying pacifier use in breastfed infants until one month of age when breastfeeding is well established. The use of pacifiers in the hospital setting has been shown to negatively influence breastfeeding success and may delay the onset of milk production. The nurses at non-BF/BFI hospitals were not well informed about pacifier use and its effect on successful breastfeeding, suggesting pacifiers are optional depending on the baby’s suck.
5. Patient education
The policies on patient education at the BF/BFI hospitals encouraged continual education throughout the hospital stay on topics including infant hunger cues, unrestricted breastfeeding, how to know if a newborn baby is getting enough to eat, delaying pacifier use and normal infant feeding patterns. Consistent educational efforts were reported to be conducted within the first 24 to 72 hours so that parents can recognize their newborn’s feeding cues, and so they will know how to tell that their baby is getting an adequate volume of colostrum/breast milk. Patients were provided with a discharge education packet that covered all of these topics as well.
At the non-BF/BFI hospitals, many nurses referred to assessing adequate breastfeeding by how many minutes the infant fed on each breast, rather than physiological cues in the infant and mother that indicate milk transfer. The nurses at the non-BF/BFI hospitals did not discuss any policy on discharge education. However, they indicated that a discharge patient education packet was provided to all patients, but that they did not discuss the topics covered in the discharge education packet.
Encouraging breastfeeding best practices at your hospital
The lack of knowledge of hospital-based nurses and inadequate evidence-based hospital policies concerning best practices are critical barriers to successful breastfeeding initiation and duration. It is essential that all hospital personnel are provided adequate education on breastfeeding best practices.
The process of applying to become a Baby Friendly Hospital requires that the hospital supports breastfeeding best practices, revises policies, creates new evidence-based policy when necessary, and documents formula cost and use within the hospital. The process also calls for adequate education of all hospital personnel on breastfeeding best practices.
Directors of women and family care units should implement policies to support breastfeeding initiation best practices and to ensure adequate documentation of these evidence-based practices. Regardless of a hospital's intent to acquire Baby Friendly status, adopting the Baby Friendly Hospital Initiative's gold standards of competencies, policies and documentation would lead to better evidenced-based care for mothers and infants.
There is a need for consistency in education and management to teach on evidence-based practices in regards to breastfeeding. Evidence-based practices are essential for nurses to know when educating mothers on breastfeeding, and evidence-based practices are more likely to be taught in a consistent manner when obtaining an advanced nursing degree such as a BSN or MSN.
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Adapted from: Weddig, J., Baker, S.S. & Auld, G. (2011) Perspectives of Hospital-Based Nurses on Breastfeeding Initiation Best Practices. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40: 166–178. [WWW document] http://onlinelibrary.wiley.com/doi/10.1111/j.1552-6909.2011.01232.x/abstract [accessed July 4 2014].
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