Miami Dade College Week 2 Clinical Issue Research Question Developed Using PICOT Paper

EVIDENCEBASED CARESHEET
Breastfeeding: Factors That Affect Initiation and
Duration of Breastfeeding
What We Know
› Breastfeeding has physical and psychological benefits for both the infant and
mother(1,3,5,7,8,10,15,18)
• Breastfeeding is associated with health benefits for the newborn, including passive
immunity that helps protect the infant against infections, reducing the prevalence of
diarrhea, otitis media, pneumonia, bacteremia, and meningitis during the first year of
life; reduced risk for atopic diseases (e.g., allergies, asthma, eczema); reduced risk for
sudden infant death syndrome (SIDS); decreased risk for childhood leukemia; decreased
risk cardiovascular disease; improved cognitive and developmental outcomes; and
decreased incidence of diabetes mellitus (DM) and obesity later in life(3,13)
• Benefits of breastfeeding for the mother include increased bonding with the infant,
easier postpartum weight loss, reduced risk for postpartum depression, decreased
postpartum bleeding, convenience, delayed fertility, and reduced risk for breast and
ovarian cancers later in life(3,13)
› The World Health Organization (WHO), the United Nations International Children’s
Emergency Fund (UNICEF), and the American Academy of Pediatrics (AAP) recommend
that infants be breastfed for at least the first year of life and exclusively breastfed (i.e.,
breast milk only) for the first 6 months of life(5)
• Among infants born in the United States in 2015, the rate of breastfeeding initiation was
83%; rates of breastfeeding at 6 and 12 months were 58% and 36%, respectively. These
rates lag behind the targets set by the Healthy People 2020 goals of 82% breastfeeding
Authors
Gillian Levy, BSN, RN
Cinahl Information Systems, Glendale, CA
Tamra J. Ashley, RN, MSN, CFNP, IBCLC
Cinahl Information Systems, Glendale, CA
Reviewers
Obiamaka Oji, DNP, APRN, FNP-BC
Cinahl Information Systems, Glendale, CA
Jennifer Kornusky, RN, MS
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
December 28, 2018
initiation, 61% breastfeeding at 6 months and 34% breastfeeding at 1 year(13)
• In 1991, WHO and UNICEF developed an international strategy known as the
Baby-Friendly Hospital Initiative (BFHI) to assist hospitals in supporting a mother’s
decision to breastfeed. Hospitals participating in the BFHI implement the initiative’s “10
steps to successful breastfeeding” program(5,8)
› Reasons for lower-than-optimal initiation and/or duration of breastfeeding are
numerous(1,3,4,8)
• Hospital practices that have been linked to low initiation and/or duration of
breastfeeding include the use of cesarean section delivery; using medications (e.g., I.M.
opiate or epidural analgesia) during labor that interfere with infants’ suckling abilities;
delayed breastfeeding after birth; separation of mother and infant after delivery; early
use of supplements and pacifiers; provision of gift packs that include infant formula;
lack of help and encouragement to breastfeed by healthcare providers; and lack of or
inaccurate information given to mothers by healthcare clinicians(4,8,12)
• Maternal health problems that can result in premature breastfeeding cessation
include painful breasts, cracked nipples, and mastitis.(3) (For more information, see
Evidence-Based Care Sheet: Breastfeeding: Breast and Nipple Problems )
• Women who return to work early after giving birth are at risk for shorter duration
of breastfeeding.(7,8) (For more information, see Evidence-Based Care Sheet:
Breastfeeding: Working Mothers [United States] )
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2019, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
• The most common reason for breastfeeding discontinuation worldwide is maternal perception of low milk supply, even
though it is rare to have actual low milk supply when breastfeeding on demand(9,11,19)
• Emotional stress in the mother and lack of self-confidence and self-efficacy are also associated with reduced likelihood of
breastfeeding initiation and continuation(8)
• Lack of support from partner and family, embarrassment about breastfeeding, and lack of cultural acceptance of
breastfeeding are associated with low initiation and duration of breastfeeding; pressure from relatives to introduce other
liquids and solid foods decrease duration of breastfeeding(3,4,7,8)
• Advertising that both promotes the use of formula and the idea that breasts are sexual objects influences societal
perceptions of breastfeeding and affects breastfeeding initiation and duration(4)
› A number of interventions associated with increased initiation, duration or both of breastfeeding have been
identified(1,3,4,6,7,9,10,12,14)
• Healthcare facility policies during labor, delivery, and recovery that can increase the likelihood that the mother will
breastfeed her infant include administration of analgesic medications at the lowest medication dose possible to limit the
negative impact on breastfeeding outcomes related to infant sedation; promoting skin-to-skin contact (e.g., kangaroo care)
of mother and infant immediately after birth; encouraging breastfeeding immediately after delivery; providing rooming-in
capability (i.e., mother and infant staying in the same room); providing formal training in breastfeeding to clinical staff;
limiting pacifier use in the neonatal period; supplementation with formula only when medically indicated; and employing
International Board Certified Lactation Consultants (IBCLCs) and Doulas (i.e., labor assistants) to help new mothers with
breastfeeding (4,5,6,9,12)
–Researchers in a study of 1,860 mothers who delivered at 34–41 weeks reported that a high level of
in-hospitalbreastfeeding support was associated with a twofold increase in exclusive breastfeeding. They noted, however,
that just 16.4% of late preterm infants (i.e., delivered at 34–36weeks’ gestation); a population in which breastfeeding
might be particularly beneficial in terms of long-term physical and developmental health; received such support,
compared to 37.9% of early-term infants (i.e., delivered at 37–38 weeks’ gestation) and 30.7% of term infants(6)
• Providing peer support that includes one-to-one counseling or support groups that include paid counselors or volunteers has
been shown to increase breastfeeding initiation/duration. Services include breastfeeding education classes, prenatal classes,
and referrals and can be provided by telephone, during a home visit, or in a clinical or community setting. Populations that
might benefit the most from peer counseling include disadvantaged and low-incomewomen(9,10,16)
–These methods might be most effective when they are delivered in both the pre- and postnatal periods; the U.S.
Preventive Services Task Force (USPSTF) recommends interventions that promote breastfeeding during pregnancy and
after birth(10,15)
–Authors of a systematic review of randomized trials evaluating interventions to promote exclusive breastfeeding
concluded that the most successful programs are those that are conducted in the postnatal period and extend over a long
period of time(18)
–In a recent study in Canada of 109 pregnant women, researchers reported that peer-led prenatal breastfeeding education is
as effective as nurse-led education(16)
–Researchers in a systematic review report that all forms of support for breastfeeding mothers led to a longer duration of
breastfeeding; face-to-face contact (rather than telephone contact), multiple scheduled contacts, and a high number of
women in the community who begin breastfeeding might contribute to success in exclusive breastfeeding (11)
–An updated systematic review of 83,246 mother-infant pairs in 73 studies found that any kind of extra breastfeeding
support decreased the cessation of breastfeeding at 6 months (moderate-quality evidence), and that the exclusivity/
duration of breastfeeding increased. However, the support that was face-to-face increased likelihood to be exclusively
breast fed(11)
• Education is a key intervention in increasing breastfeeding initiation rates and duration of breastfeeding. Staff members
should be well trained in lactation. Mothers can be counseled individually or in groups during the prenatal and intrapartum
periods and including fathers in breastfeeding education can improve breastfeeding rates. Topics covered should include
the benefits of breastfeeding, contraindications, a brief description of the physiology of lactation, latching-on and
positioning techniques, milk removal, and barriers to breastfeeding. Dolls, videos, or observation can be used to facilitate
learning. Classes can be offered in hospitals, libraries, community centers, churches, schools, or online. Structured,
long-term, and intensive educational courses combined with behavioral interventions might be most effective(3,4,14)
• Breastfeeding intervention should include increasing a mother’s ability to correctly interpret her infant’s behavior around
breastfeeding(19)
• Professional support by physicians, nurses, and IBCLCs can increase breastfeeding initiation rates and duration of
breastfeeding. Professionals can assess a new mother’s individual needs and address concerns, and provide follow-up by
phone or in-personcontact(2,13)
–Investigators who undertook a study of 226 obese mothers found that telephone-based support provided by a lactation
specialist led to significant increases in duration of exclusive breastfeeding (120 days vs. 41 days) and any breastfeeding
(184 days vs. 108 days)(2)
• Researchers in a study of 326,263 mothers in 32 states in the U.S. reported that state laws that support breastfeeding (e.g.,
by mandating the provision of break time and private space for breastfeeding employees) were associated with a 1.7%
higher breastfeeding initiation rate(7)
What We Can Do
› Learn about breastfeeding, including benefits, contraindications, techniques, and lactation. Learn interventions that promote
breastfeeding. Share this knowledge with your colleagues
› Become familiar with the BFHI and, if possible, assist your hospital in becoming a BFHI hospital. Learn about the “10 steps
to successful breastfeeding” at the UNICEF Web site, http://www.unicef.org/nutrition/23964_breastfeeding.html
› Provide emotional support and breastfeeding education before, during, and after labor(17)
› Discuss the potential detrimental effects of I.M. opiate or epidural analgesia on breastfeeding behavior(12)
› Assist the treating clinician in examining mothers and infants, and assess for complications (e.g., suckling or breast/nipple
problems) that can interfere with breastfeeding
› Encourage breastfeeding within 30 minutes of delivery, and promote skin-to-skin contact and rooming-in. If possible, avoid
the use of supplements (unless medically indicated) and pacifiers, and do not provide infant formula with gift packs at
discharge(4)
› Discuss the benefits of breastfeeding. Identify barriers to breastfeeding. Answer questions and address concerns. Be
culturally sensitive. When possible, provide women with newborn infants written information on breastfeeding
› Discuss infant feeding and frequency. Instruct on proper latching-on and positioning techniques. Verify that techniques
are being used correctly and assist mothers in maintaining milk supply. Monitor transfer of milk. Document breastfeeding
education and the mother’s progress with establishing copious milk supply. Monitor infant health (e.g., weight, urine/stool
output) and for maternal complications (e.g., breast/nipple problems)
› Encourage one-to-one counseling or group counseling. Develop peer support groups, if possible; matching breastfeeding
mothers with peers who have similar sociodemographic characteristics can be helpful
› Provide follow-up contact by phone calls or, if possible, home visits(18)
› Refer to a lactation consultant if necessary. The International Board of Lactation Consultant Examiners Web site (http://
iblce.org/) can be helpful
› Provide referrals to organizations such as La Leche League International at http://www.lalecheleague.org, and Women,
Infant, and Children (WIC) at http://www.fns.usda.gov/wic/women-infants-and-children-wic (1)
Coding Matrix
References are rated using the following codes, listed in order of strength:
M Published meta-analysis
RV Published review of the literature
SR Published systematic or integrative literature review
RU Published research utilization report
X Practice exemplars, stories, opinions
RCT Published research (randomized controlled trial)
QI Published quality improvement report
GI General or background information/texts/reports
L Legislation
R Published research (not randomized controlled trial)
PP Policies, procedures, protocols
C Case histories, case studies
PGR Published government report
U Unpublished research, reviews, poster presentations or
other such materials
G Published guidelines
PFR Published funded report
CP Conference proceedings, abstracts, presentation
References
1. American College of Obstetricians and Gynecologists Women’s Health Care Physicians & Committee on Health Care for Underserved Women. (2013). Committee
opinion no. 570: Breastfeeding in underserved women: Increasing initiation and continuation of breastfeeding. Obstetrics and Gynecology, 122(2 Pt 1), 423-428.
doi:10.1097/01.AOG.0000433008.93971.6a (G)
2. Carlsen, E. M., Kyhnaeb, A., Renault, K. M., Cortes, D., Michaelsen, K. F., & Pryds, O. (2013). Telephone-based support prolongs breastfeeding duration in obese women: A
randomized trial. American Journal of Clinical Nutrition, 98(5), 1226-1232. doi:10.3945/ajcn.113.059600 (RCT)
3. Cleminson, J., Oddie, S., Renfrew, M. J., & McGuire, W. (2015). Being baby friendly: Evidence-based breastfeeding support. Archives of Disease in Childhood – Fetal &
Neonatal Edition, 100(2), F173-F178. doi:10.1136/archdischild-2013-304873 (RV)
4. Dickens, V. (2008). Learning on the job: Influences on the initiation and duration of breastfeeding. MIDIRS Midwifery Digest, 18(2), 243-247. (RV)
5. Eidelman, A. K., & Schanler, R. J. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), 598-601. doi:10.1542/peds.2011-3552 (G)
6. Goyal, N. K., Attanasio, L. B., & Kozhimannil, K. B. (2014). Hospital care and early breastfeeding outcomes among late preterm, early-term, and term infants. Birth: Issues in
Perinatal Care, 41(4), 330-338. doi:10.1111/birt.12135 (R)
7. Hawkins, S. S., Stern, A. D., & Gillman, M. W. (2013). Do state breastfeeding laws in the USA promote breast feeding? Journal of Epidemiology & Community Health, 67(3),
250-256. doi:10.1136/jech-2012-201619 (R)
8. Imdad, A., Yakoob, M. Y., & Bhutta, Z. A. (2011). Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC
Public Health, 11(Suppl 3), S24. doi:10.1186/1471-2458-11-S3-S24 (SR)
9. Jefferson, U. T. (2018). Support interventions to address breastfeeding challenges. Western Journal of Nursing Research, 40(8), 1107-1109. doi:10.1177/0193945918770746
(R)
10. Kervin, B. E., Kemp, L., & Pulver, L. J. (2010). Types and timing of breastfeeding support and its impact on mothers’ behaviours. Journal of Paediatrics and Child Health, 46(3),
85-91. doi:10.1111/j.1440-1754.2009.01643.x (R)
11. McFadden, A., Gavine, A., Renfrew, M. J., Wade, A., Buchanan, P., Taylor, J. L., … MacGillivray, S. (2017). Support for healthy breastfeeding mothers with healthy term
babies. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001141. doi:10.1002/14651858.CD001141.pub5 (SR)
12. Montgomery, A., Hale, T. W., & the Academy of Breastfeeding Medicine. (2012). ABM Clinical Protocol #15: Analgesia and anesthesia for the breastfeeding mother, revised
2012. Breastfeeding Medicine, 7(6), 547-553. doi:10.1089/bfm.2012.9977 (G)
13. National Center for Chronic Disease Prevention and Health Promotion. (2017). Breastfeeding report card: Progressing toward national breastfeeding goals United States, 2016.
Centers for Disease Control and Prevention. Retrieved November 27, 2018, from https://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdf (PGR)
14. Pate, B. (2009). A systematic review of the effectiveness of breastfeeding intervention delivery methods. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing,
38(6), 642-653. doi:10.1111/j.1552-6909.2009.01068.x (SR)
15. Patnode, C. D., Henninger, M. L., Senger, C. A., Perdue, L. A., & Whitlock, E. P. (2016). Primary care interventions to support breastfeeding: Updated systematic review for the
U.S. Preventive Services Task Force. Evidence Synthesis, 143. Retrieved December 6, 2018, from https://jamanetwork.com/journals/jama/fullarticle/2571248 (SR)
16. Rempel, L. A., & Moore, K. C. J. (2012). Peer-led prenatal breast-feeding education: A viable alternative to nurse-led education. Midwifery, 28(1), 73-79. doi:10.1016/
j.midw.2010.11.005 (R)
17. Renfrew, M. J., McCormick, F. M., Wade, A., Quinn, B., & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of
Systematic Reviews, (Issue 5), CD001141. doi:10.1002/14651858.CD001141.pub4 (SR)
18. Skouteris, H., Nagle, C., Fowler, M., Kent, B., Sahota, P. Y., & Morris, H. (2014). Interventions designed to promote exclusives breastfeeding in high-income countries: A
systematic review. Breastfeeding Medicine, 9(3), 113-127. doi:10.1089/bfm.2013.0081 (SR)
19. Wood, N. K., Woods, N. F., Blackburn, S. T., & Sanders, E. A. (2016). Interventions that enhance breastfeeding initiation, duration, and exclusivity: A systematic review.
American Journal of Maternal Child Nursing, 41(5), 299-307. doi:10.1097/NMC.0000000000000264 (SR)
Week 2 The Clinical Issue and Research Questions Developed Using PICOT
1 of 3
https://canvas.westcoastuniversity.edu/courses/18148/assignments/421101
Start Assignment
Due Sunday by 11:59pm
Points 150
Submitting a file upload
File Types doc, docx, and pdf
PICOT is an acronym used to help develop clinical research questions and guide you in your search for evidence. Finding the right answers
requires the right questions. The PICOT format will help you construct questions that will likely lead to effective searches, the best available
evidence of interventions, and the meaningfulness of patient experiences.
P = Patient population
I = Intervention or issue of interest
C = Comparison of interventions or comparison of interests
O = Outcome
T = Time frame (this element is not always included)*
For example, you may wish to research the effects of interrupted sleep on cognition of ICU patients 65 or older.
Using this PICOT model,
In __________(P), how does __________ (I) compared to _________ (C) influence _________ (O) over ________ (T)?
In ICU patients who are 65 or older, how does interrupted sleep (awakened one time or more in four hours) as compared to uninterrupted sleep
influence the patient’s cognitive ability over 5 days?
Questions of meaningfulness and effectiveness relate to how people experience an intervention or phenomenon.
What is the effectiveness of using a turn schedule (I) versus an audible public address reminder (C) on the incidence of pressure ulcers (O) in
elderly patients in LTAC who require turning (P)?
*Not all studies will have a time frame. This is optional to include as part of your PICOT.
Assignment Directions
Begin by selecting a topic in nursing that is of interest to you. Next, use PICOT to format a possible research question about that topic. Provide
1 possible PICOT research question. Find 1 quantitative or qualitative peer-reviewed research article related to your nursing topic that was
published within the last 5 years. Reminder: All peer-reviewed research articles have methods, discussion, and results sections. Upload the
article with your paper in PDF or Word format. This source can be used again in the Week 4 article assignment if it meets the criteria.
(https://canvas.westcoastuniversity.edu/courses/18148/files/6444531/download?download_frd=1) or pages
See PICOT Formatting Guide
249-257 in your book for additional help with formatting your PICOT.
Include the following:
Title page
Provide a brief description of the topic and background information (see page 37 of your textbook). You can use your text, your peer-reviewed
journal source, or the EBP care sheets in CINAHL or Nursing Reference Center Database.
Explain the significance of the topic to nursing practice (see chart on page 37 of your textbook). Background information can be found in
6/22/2022, 3:59 PM
Week 2 The Clinical Issue and Research Questions Developed Using PICOT
2 of 3
https://canvas.westcoastuniversity.edu/courses/18148/assignments/421101
journal articles in the introduction section. Results and conclusions will speak to significance of the topic. The EBP care sheets may have
sources for you to choose from.
Provide 1 clearly-stated PICOT question.
Include 1 peer-reviewed journal source related to your topic.
The chosen topic and PICOT will be used for your Week 9 poster assignment. It will also guide your article searches in Week 4 on which you
will complete appraisals in Week 6.
Your paper should:
Be 2–3 pages (not including the title page and reference page)
Use current APA format to style your paper and to cite your source.
There will be a 5 point deduction if peer-reviewed research journal article is not used and a 5 point deduction if the article is not included with
your submission.
Review the rubric for further information on how your assignment will be graded.
Week 2: Clinical Issue and Research Questions Developed Using PICOT Rubric
6/22/2022, 3:59 PM
Week 2 The Clinical Issue and Research Questions Developed Using PICOT
3 of 3
Criteria
Ratings
Topic
50 to >43.0 pts
Meets or Exceeds
Expectations
Topic/
Relevance to
Nursing
PICOT
Research
Questions
This criterion
is linked to a
Learning
Outcome
PICOT
Research
Questions
APA and
Mechanics
https://canvas.westcoastuniversity.edu/courses/18148/assignments/421101
Pts
43 to >35.0 pts
Mostly Meets Expectations
35 to >27.0 pts
Below Expectations
A description of the topic is
presented but may be ambiguous
or confusing. Some background
information is provided, but more is
needed for a full explanation. The
significance of the topic to nursing
practice is somewhat explained
and may not be supported with
examples.
A description of the topic is
presented but is ambiguous or
confusing. Some background
information is provided, but more
is needed for a full explanation.
The significance of the topic to
nursing practice is somewhat
explained but is not supported
with examples.
85 to >73.1 pts
Meets or Exceeds Expectations
73.1 to >59.5 pts
Mostly Meets Expectations
59.5 to >45.9 pts
Below Expectations
All research questions are
accurately framed as complete
PICOT questions. PICOT
questions provide a clear and
specific focus for research within
the topic. One peer-reviewed
journal source related to the topic
is included with assignment
submission.
Only some research questions are
framed as PICOT questions, or some
PICOT questions are incomplete.
PICOT questions provide a vague or
unclear focus for research that may
not be within the topic. One peerreviewed journal source is included
but not related to the topic.
Few questions are framed as
PICOT questions, or are
incomplete. PICOT questions
provide a vague or unclear focus
for research that is not within the
topic. One journal source is
included but it is not peerreviewed.
A clear and succinct
description of the topic is
presented. Background
information is relevant and
specific to the topic. The
significance of the topic to
nursing practice is explained
clearly and is supported with
examples.
15 to >12.9 pts
Meets or Exceeds
Expectations
Follows all the requirements
related to format, length,
source citations, and layout.
Written in a clear, concise,
formal, and organized
manner. Responses are
mostly error free.
Information from sources is
paraphrased appropriately
and accurately cited.
27 to >0 pts
Does Not Meet
Expectations
An unclear description of
the topic is presented or
is missing. No
background information is
provided. The
significance of the topic
to nursing practice is not
explained.
50 pts
45.9 to >0 pts
Does Not Meet
Expectations
Research questions
are missing or are not
framed as PICOT
questions. Peerreviewed journal
source is not included.
12.9 to >10.5 pts
Mostly Meets Expectations
10.5 to >8.1 pts
Below Expectations
8.1 to >0 pts
Does Not Meet Expectations
Follows length requirement and
most of the requirements related to
format, source citations, and layout.
Writing is generally clear and
organized but is not concise or
formal in language. Multiple errors
exist in spelling and grammar with
minor interference with readability or
comprehension. Most information
from sources is paraphrased and
cited correctly.
Follows few requirements
related to format, source
citations, and layout. Writing
may be unclear or informal in
language. Multiple errors exist
in spelling and grammar,
interfering with readability or
comprehension. Some
information from sources is
paraphrased and cited
correctly.
Follows few requirements
related to format, source
citations, and layout. Writing
may be unclear or informal in
language. Multiple errors exist
in spelling and grammar,
interfering with readability or
comprehension. Some
information from sources is
paraphrased and cited
correctly.
85 pts
15 pts
Total Points: 150
6/22/2022, 3:59 PM
EVIDENCEBASED CARE
SHEET
Breastfeeding: Factors That Affect Initiation and
Duration of Breastfeeding
What We Know
› Breastfeeding has physical and psychological benefits for both the infant and
mother(1,3,5,7,8,10,15,18)
• Breastfeeding is associated with health benefits for the newborn, including passive
immunity that helps protect the infant against infections, reducing the prevalence of
diarrhea, otitis media, pneumonia, bacteremia, and meningitis during the first year of
life; reduced risk for atopic diseases (e.g., allergies, asthma, eczema); reduced risk for
sudden infant death syndrome (SIDS); decreased risk for childhood leukemia; decreased
risk cardiovascular disease; improved cognitive and developmental outcomes; and
decreased incidence of diabetes mellitus (DM) and obesity later in life(3,13)
• Benefits of breastfeeding for the mother include increased bonding with the infant,
easier postpartum weight loss, reduced risk for postpartum depression, decreased
postpartum bleeding, convenience, delayed fertility, and reduced risk for breast and
ovarian cancers later in life(3,13)
› The World Health Organization (WHO), the United Nations International Children’s
Emergency Fund (UNICEF), and the American Academy of Pediatrics (AAP) recommend
that infants be breastfed for at least the first year of life and exclusively breastfed (i.e.,
breast milk only) for the first 6 months of life(5)
• Among infants born in the United States in 2015, the rate of breastfeeding initiation was
83%; rates of breastfeeding at 6 and 12 months were 58% and 36%, respectively. These
rates lag behind the targets set by the Healthy People 2020 goals of 82% breastfeeding
Authors
Gillian Levy, BSN, RN
Cinahl Information Systems, Glendale, CA
Tamra J. Ashley, RN, MSN, CFNP, IBCLC
Cinahl Information Systems, Glendale, CA
Reviewers
Obiamaka Oji, DNP, APRN, FNP-BC
Cinahl Information Systems, Glendale, CA
Jennifer Kornusky, RN, MS
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
December 28, 2018
initiation, 61% breastfeeding at 6 months and 34% breastfeeding at 1 year(13)
• In 1991, WHO and UNICEF developed an international strategy known as the
Baby-Friendly Hospital Initiative (BFHI) to assist hospitals in supporting a mother’s
decision to breastfeed. Hospitals participating in the BFHI implement the initiative’s “10
steps to successful breastfeeding” program(5,8)
› Reasons for lower-than-optimal initiation and/or duration of breastfeeding are
numerous(1,3,4,8)
• Hospital practices that have been linked to low initiation and/or duration of
breastfeeding include the use of cesarean section delivery; using medications (e.g., I.M.
opiate or epidural analgesia) during labor that interfere with infants’ suckling abilities;
delayed breastfeeding after birth; separation of mother and infant after delivery; early
use of supplements and pacifiers; provision of gift packs that include infant formula;
lack of help and encouragement to breastfeed by healthcare providers; and lack of or
inaccurate information given to mothers by healthcare clinicians(4,8,12)
• Maternal health problems that can result in premature breastfeeding cessation
include painful breasts, cracked nipples, and mastitis.(3) (For more information, see
Evidence-Based Care Sheet: Breastfeeding: Breast and Nipple Problems )
• Women who return to work early after giving birth are at risk for shorter duration
of breastfeeding.(7,8) (For more information, see Evidence-Based Care Sheet:
Breastfeeding: Working Mothers [United States] )
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2019, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
• The most common reason for breastfeeding discontinuation worldwide is maternal perception of low milk supply, even
though it is rare to have actual low milk supply when breastfeeding on demand(9,11,19)
• Emotional stress in the mother and lack of self-confidence and self-efficacy are also associated with reduced likelihood of
breastfeeding initiation and continuation(8)
• Lack of support from partner and family, embarrassment about breastfeeding, and lack of cultural acceptance of
breastfeeding are associated with low initiation and duration of breastfeeding; pressure from relatives to introduce other
liquids and solid foods decrease duration of breastfeeding(3,4,7,8)
• Advertising that both promotes the use of formula and the idea that breasts are sexual objects influences societal
perceptions of breastfeeding and affects breastfeeding initiation and duration(4)
› A number of interventions associated with increased initiation, duration or both of breastfeeding have been
identified(1,3,4,6,7,9,10,12,14)
• Healthcare facility policies during labor, delivery, and recovery that can increase the likelihood that the mother will
breastfeed her infant include administration of analgesic medications at the lowest medication dose possible to limit the
negative impact on breastfeeding outcomes related to infant sedation; promoting skin-to-skin contact (e.g., kangaroo care)
of mother and infant immediately after birth; encouraging breastfeeding immediately after delivery; providing rooming-in
capability (i.e., mother and infant staying in the same room); providing formal training in breastfeeding to clinical staff;
limiting pacifier use in the neonatal period; supplementation with formula only when medically indicated; and employing
International Board Certified Lactation Consultants (IBCLCs) and Doulas (i.e., labor assistants) to help new mothers with
breastfeeding (4,5,6,9,12)
–Researchers in a study of 1,860 mothers who delivered at 34–41 weeks reported that a high level of
in-hospitalbreastfeeding support was associated with a twofold increase in exclusive breastfeeding. They noted, however,
that just 16.4% of late preterm infants (i.e., delivered at 34–36weeks’ gestation); a population in which breastfeeding
might be particularly beneficial in terms of long-term physical and developmental health; received such support,
compared to 37.9% of early-term infants (i.e., delivered at 37–38 weeks’ gestation) and 30.7% of term infants(6)
• Providing peer support that includes one-to-one counseling or support groups that include paid counselors or volunteers has
been shown to increase breastfeeding initiation/duration. Services include breastfeeding education classes, prenatal classes,
and referrals and can be provided by telephone, during a home visit, or in a clinical or community setting. Populations that
might benefit the most from peer counseling include disadvantaged and low-incomewomen(9,10,16)
–These methods might be most effective when they are delivered in both the pre- and postnatal periods; the U.S.
Preventive Services Task Force (USPSTF) recommends interventions that promote breastfeeding during pregnancy and
after birth(10,15)
–Authors of a systematic review of randomized trials evaluating interventions to promote exclusive breastfeeding
concluded that the most successful programs are those that are conducted in the postnatal period and extend over a long
period of time(18)
–In a recent study in Canada of 109 pregnant women, researchers reported that peer-led prenatal breastfeeding education is
as effective as nurse-led education(16)
–Researchers in a systematic review report that all forms of support for breastfeeding mothers led to a longer duration of
breastfeeding; face-to-face contact (rather than telephone contact), multiple scheduled contacts, and a high number of
women in the community who begin breastfeeding might contribute to success in exclusive breastfeeding (11)
–An updated systematic review of 83,246 mother-infant pairs in 73 studies found that any kind of extra breastfeeding
support decreased the cessation of breastfeeding at 6 months (moderate-quality evidence), and that the exclusivity/
duration of breastfeeding increased. However, the support that was face-to-face increased likelihood to be exclusively
breast fed(11)
• Education is a key intervention in increasing breastfeeding initiation rates and duration of breastfeeding. Staff members
should be well trained in lactation. Mothers can be counseled individually or in groups during the prenatal and intrapartum
periods and including fathers in breastfeeding education can improve breastfeeding rates. Topics covered should include
the benefits of breastfeeding, contraindications, a brief description of the physiology of lactation, latching-on and
positioning techniques, milk removal, and barriers to breastfeeding. Dolls, videos, or observation can be used to facilitate
learning. Classes can be offered in hospitals, libraries, community centers, churches, schools, or online. Structured,
long-term, and intensive educational courses combined with behavioral interventions might be most effective(3,4,14)
• Breastfeeding intervention should include increasing a mother’s ability to correctly interpret her infant’s behavior around
breastfeeding(19)
• Professional support by physicians, nurses, and IBCLCs can increase breastfeeding initiation rates and duration of
breastfeeding. Professionals can assess a new mother’s individual needs and address concerns, and provide follow-up by
phone or in-personcontact(2,13)
–Investigators who undertook a study of 226 obese mothers found that telephone-based support provided by a lactation
specialist led to significant increases in duration of exclusive breastfeeding (120 days vs. 41 days) and any breastfeeding
(184 days vs. 108 days)(2)
• Researchers in a study of 326,263 mothers in 32 states in the U.S. reported that state laws that support breastfeeding (e.g.,
by mandating the provision of break time and private space for breastfeeding employees) were associated with a 1.7%
higher breastfeeding initiation rate(7)
What We Can Do
› Learn about breastfeeding, including benefits, contraindications, techniques, and lactation. Learn interventions that promote
breastfeeding. Share this knowledge with your colleagues
› Become familiar with the BFHI and, if possible, assist your hospital in becoming a BFHI hospital. Learn about the “10 steps
to successful breastfeeding” at the UNICEF Web site, http://www.unicef.org/nutrition/23964_breastfeeding.html
› Provide emotional support and breastfeeding education before, during, and after labor(17)
› Discuss the potential detrimental effects of I.M. opiate or epidural analgesia on breastfeeding behavior(12)
› Assist the treating clinician in examining mothers and infants, and assess for complications (e.g., suckling or breast/nipple
problems) that can interfere with breastfeeding
› Encourage breastfeeding within 30 minutes of delivery, and promote skin-to-skin contact and rooming-in. If possible, avoid
the use of supplements (unless medically indicated) and pacifiers, and do not provide infant formula with gift packs at
discharge(4)
› Discuss the benefits of breastfeeding. Identify barriers to breastfeeding. Answer questions and address concerns. Be
culturally sensitive. When possible, provide women with newborn infants written information on breastfeeding
› Discuss infant feeding and frequency. Instruct on proper latching-on and positioning techniques. Verify that techniques
are being used correctly and assist mothers in maintaining milk supply. Monitor transfer of milk. Document breastfeeding
education and the mother’s progress with establishing copious milk supply. Monitor infant health (e.g., weight, urine/stool
output) and for maternal complications (e.g., breast/nipple problems)
› Encourage one-to-one counseling or group counseling. Develop peer support groups, if possible; matching breastfeeding
mothers with peers who have similar sociodemographic characteristics can be helpful
› Provide follow-up contact by phone calls or, if possible, home visits(18)
› Refer to a lactation consultant if necessary. The International Board of Lactation Consultant Examiners Web site (http://
iblce.org/) can be helpful
› Provide referrals to organizations such as La Leche League International at http://www.lalecheleague.org, and Women,
Infant, and Children (WIC) at http://www.fns.usda.gov/wic/women-infants-and-children-wic (1)
Coding Matrix
References are rated using the following codes, listed in order of strength:
M Published meta-analysis
RV Published review of the literature
SR Published systematic or integrative literature review
RU Published research utilization report
X Practice exemplars, stories, opinions
RCT Published research (randomized controlled trial)
QI Published quality improvement report
GI General or background information/texts/reports
L Legislation
R Published research (not randomized controlled trial)
PP Policies, procedures, protocols
C Case histories, case studies
PGR Published government report
U Unpublished research, reviews, poster presentations or
other such materials
G Published guidelines
PFR Published funded report
CP Conference proceedings, abstracts, presentation
References
1. American College of Obstetricians and Gynecologists Women’s Health Care Physicians & Committee on Health Care for Underserved Women. (2013). Committee
opinion no. 570: Breastfeeding in underserved women: Increasing initiation and continuation of breastfeeding. Obstetrics and Gynecology, 122(2 Pt 1), 423-428.
doi:10.1097/01.AOG.0000433008.93971.6a (G)
2. Carlsen, E. M., Kyhnaeb, A., Renault, K. M., Cortes, D., Michaelsen, K. F., & Pryds, O. (2013). Telephone-based support prolongs breastfeeding duration in obese women: A
randomized trial. American Journal of Clinical Nutrition, 98(5), 1226-1232. doi:10.3945/ajcn.113.059600 (RCT)
3. Cleminson, J., Oddie, S., Renfrew, M. J., & McGuire, W. (2015). Being baby friendly: Evidence-based breastfeeding support. Archives of Disease in Childhood – Fetal &
Neonatal Edition, 100(2), F173-F178. doi:10.1136/archdischild-2013-304873 (RV)
4. Dickens, V. (2008). Learning on the job: Influences on the initiation and duration of breastfeeding. MIDIRS Midwifery Digest, 18(2), 243-247. (RV)
5. Eidelman, A. K., & Schanler, R. J. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), 598-601. doi:10.1542/peds.2011-3552 (G)
6. Goyal, N. K., Attanasio, L. B., & Kozhimannil, K. B. (2014). Hospital care and early breastfeeding outcomes among late preterm, early-term, and term infants. Birth: Issues in
Perinatal Care, 41(4), 330-338. doi:10.1111/birt.12135 (R)
7. Hawkins, S. S., Stern, A. D., & Gillman, M. W. (2013). Do state breastfeeding laws in the USA promote breast feeding? Journal of Epidemiology & Community Health, 67(3),
250-256. doi:10.1136/jech-2012-201619 (R)
8. Imdad, A., Yakoob, M. Y., & Bhutta, Z. A. (2011). Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC
Public Health, 11(Suppl 3), S24. doi:10.1186/1471-2458-11-S3-S24 (SR)
9. Jefferson, U. T. (2018). Support interventions to address breastfeeding challenges. Western Journal of Nursing Research, 40(8), 1107-1109. doi:10.1177/0193945918770746
(R)
10. Kervin, B. E., Kemp, L., & Pulver, L. J. (2010). Types and timing of breastfeeding support and its impact on mothers’ behaviours. Journal of Paediatrics and Child Health, 46(3),
85-91. doi:10.1111/j.1440-1754.2009.01643.x (R)
11. McFadden, A., Gavine, A., Renfrew, M. J., Wade, A., Buchanan, P., Taylor, J. L., … MacGillivray, S. (2017). Support for healthy breastfeeding mothers with healthy term
babies. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001141. doi:10.1002/14651858.CD001141.pub5 (SR)
12. Montgomery, A., Hale, T. W., & the Academy of Breastfeeding Medicine. (2012). ABM Clinical Protocol #15: Analgesia and anesthesia for the breastfeeding mother, revised
2012. Breastfeeding Medicine, 7(6), 547-553. doi:10.1089/bfm.2012.9977 (G)
13. National Center for Chronic Disease Prevention and Health Promotion. (2017). Breastfeeding report card: Progressing toward national breastfeeding goals United States, 2016.
Centers for Disease Control and Prevention. Retrieved November 27, 2018, from https://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdf (PGR)
14. Pate, B. (2009). A systematic review of the effectiveness of breastfeeding intervention delivery methods. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing,
38(6), 642-653. doi:10.1111/j.1552-6909.2009.01068.x (SR)
15. Patnode, C. D., Henninger, M. L., Senger, C. A., Perdue, L. A., & Whitlock, E. P. (2016). Primary care interventions to support breastfeeding: Updated systematic review for the
U.S. Preventive Services Task Force. Evidence Synthesis, 143. Retrieved December 6, 2018, from https://jamanetwork.com/journals/jama/fullarticle/2571248 (SR)
16. Rempel, L. A., & Moore, K. C. J. (2012). Peer-led prenatal breast-feeding education: A viable alternative to nurse-led education. Midwifery, 28(1), 73-79. doi:10.1016/
j.midw.2010.11.005 (R)
17. Renfrew, M. J., McCormick, F. M., Wade, A., Quinn, B., & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of
Systematic Reviews, (Issue 5), CD001141. doi:10.1002/14651858.CD001141.pub4 (SR)
18. Skouteris, H., Nagle, C., Fowler, M., Kent, B., Sahota, P. Y., & Morris, H. (2014). Interventions designed to promote exclusives breastfeeding in high-income countries: A
systematic review. Breastfeeding Medicine, 9(3), 113-127. doi:10.1089/bfm.2013.0081 (SR)
19. Wood, N. K., Woods, N. F., Blackburn, S. T., & Sanders, E. A. (2016). Interventions that enhance breastfeeding initiation, duration, and exclusivity: A systematic review.
American Journal of Maternal Child Nursing, 41(5), 299-307. doi:10.1097/NMC.0000000000000264 (SR)
Template  for  Asking  PICOT  Questions  
INTERVENTION  
In  ____________________(P),  how  does  ____________________  (I)  compared  to  
____________________(C)  affect  _____________________(O)  within  ___________(T)?    
 
THERAPY  
In  __________________(P),  what  is  the  effect  of  __________________(I)  compared  to  
_____________  (C)  on  ________________(O  within  _____________(T)?  
 
PROGNOSIS/PREDICTION  
In  ______________  (P),  how  does  ___________________  (I)  compared  to  _____________(C)  
influence  __________________  (O)  over  _______________  (T)?  
 
DIAGNOSIS  OR  DIAGNOSTIC  TEST  
In  ___________________(P)  are/is  ____________________(I)    compared  with  
_______________________(C)  more  accurate  in  diagnosing  _________________(O)?  
 
ETIOLOGY  
Are____________________  (P),  who  have  ____________________  (I)  compared  with  those  
without  ____________________(C)  at  ____________  risk  for/of  
____________________(O)  over  ________________(T)?    
 
MEANING  
How  do  _______________________  (P)  with  _______________________  (I)    perceive  
_______________________  (O)  during  ________________(T)?  
 
 
 
 
 
Adapted from the PICOT Questions Template; Ellen Fineout-Overholt, 2006. This form may be used for educational & research purposes without permission.
 
Short  Definitions  of  Different  Types  of  Questions  
 
Intervention/Therapy:  Questions  addressing  the  treatment  of  an  illness  or  disability.  
 
Etiology:  Questions  addressing  the  causes  or  origins  of  disease  (i.e.,  factors  that  produce  or  
predispose  toward  a  certain  disease  or  disorder).  
 
Diagnosis:  Questions  addressing  the  act  or  process  of  identifying  or  determining  the  nature  and  
cause  of  a  disease  or  injury  through  evaluation.  
 
Prognosis/Prediction:  Questions  addressing  the  prediction  of  the  course  of  a  disease.  
 
Meaning:  Questions  addressing  how  one  experiences  a  phenomenon.  
 
Sample  Questions:  
 
Intervention:  In  African-­‐American  female  adolescents  with  hepatitis  B  (P),  how  does  
acetaminophen  (I)  compared  to  ibuprofen  (C)  affect  liver  function  (O)?  
 
Therapy:  In  children  with  spastic  cerebral  palsy  (P),  what  is  the  effect  of  splinting  and  casting(I)  
compared  to  constraint-­‐  induced  therapy  (C)  on  two-­‐handed  skill  development  (O)?  
 
Prognosis/Prediction:    
1)  For  patients  65  years  and  older  (P),  how  does  the  use  of  an  influenza  vaccine  (I)  compared  to  
not  received  the  vaccine  (C)  influence  the  risk  of  developing  pneumonia  (O)  during  flu  season  
(T)?    
2)  In  patients  who  have  experienced  an  acute  myocardial  infarction  (P),  how  does  being  a  
smoker  (I)  compared  to  a  non-­‐smoker  (C)  influence  death  and  infarction  rates  (O)  during  the  
first  5  years  after  the  myocardial  infarction  (T)?  
 
Diagnosis:  In  middle-­‐aged  males  with  suspected  myocardial  infarction  (P),  are  serial  12-­‐lead  
ECGs  (I)  compared  to  one  initial  12-­‐lead  ECG  (C)  more  accurate  in  diagnosing  an  acute  
myocardial  infarction  (O)?  
 
Etiology:  Are  30-­‐  to  50-­‐year-­‐old  women  (P)  who  have  high  blood  pressure  (I)  compared  with  
those  without  high  blood  pressure  (C)  at  increased  risk  for  an  acute  myocardial  infarction  (O)  
during  the  first  year  after  hysterectomy  (T)?  
 
Meaning:  How  do  young  males  (P)  with  a  diagnosis  of  below  the  waist  paralysis  (I)  perceive  
their  interactions  with  their  romantic  significant  others  (O)  during  the  first  year  after  their  
diagnosis  (T)?  
Adapted from the PICOT Questions Template; Ellen Fineout-Overholt, 2006. This form may be used for educational & research purposes without permission.