shown a positive association between this indicator and actual breastfeeding initiation and duration. Predictors of breastfeeding intention include women’s belief of breastfeeding outcomes, and referent beliefs and attitudes towards breastfeeding and bottle-feeding (Duckett, 1992). The recommendations made by the development panel are directed towards assisting nurses in health care practice settings to implement evidence-based recommendations. However, several recommendations have been made within the parameters of the Ottawa Charter and the WHO/UNICEF initiative that currently have limited research evidence. These gaps in research include: lack of studies evaluating the impact of public policy changes on the uptake of breastfeeding (e.g., length of hospital stay, maternity leave, human rights legislation); lack of studies evaluating the impact of interventions designed to make environments more conducive to breastfeeding (e.g., restaurants, workplace initiatives) and lack of studies of the impact of increased breastfeeding rates on the health care system (e.g., hospital readmissions during the first year, drug costs related to otitis media). 28 Breastfeeding Best Practice Guidelines for Nurses 29 Nursing Best Practice Guideline Practice Recommendations Recommendation • 1 Nurses 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). The BFHI directs health care facilities to meet the “Ten Steps to Successful Breastfeeding”. (Level of Evidence III) Refer to Appendix B for details on the Breastfeeding Committee for Canada’s documents entitled: “The Breastfeeding Committee for Canada Welcomes You to the Baby-Friendly™ Initiative (BFI)”, and “The Baby-Friendly™ Initiative in Community Health Services: A Canadian Implementation Guide”. The Baby-Friendly™ Hospital Initiative (BFHI) directs health care facilities to meet the following ten steps to successful promotion of breastfeeding: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in the skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers to initiate breastfeeding within a half-hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast-milk, unless medically indicated. 7. Practice rooming-in, allow mothers and infants to remain together 24-hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Discussion of Evidence Fairbank et al. (2000) in a systematic review identified that institutional changes in hospital practices to promote breastfeeding can be effective at increasing both the initiation and duration of breastfeeding. These may include stand-alone interventions, such as roomingin, or a package of interventions such as rooming-in, early contact and education. Each of the ten steps has varying levels of research evidence. These ten steps have been accepted by thousands of hospitals around the world and have been accredited by the BFHI. Details on the evidence available for each of the ten steps can be found in the World Health Organization (1998) document titled “Evidence for the Ten Steps to Successful Breastfeeding.” This report states that the most substantive evidence is for guidance and support for the mother (Step 3, antenatal education, Step 5, showing a mother how to breastfeed, and Step 10, continuing support after discharge). The least substantive evidence is the optimal timing of the first feed in Step 4. What is most important is early contact and breastfeeding when the infant shows readiness to feed in the first two hours. Step 7, rooming-in, and Step 8, demand feeding, are closely intertwined and show evidence of increased breastfeeding rates, greater attachment to babies, earlier production of breast-milk, infants crying less, less breast engorgement, no increase in nipple soreness and increased weight gain. Step 6, use of supplements, and Step 9, use of artificial teats and pacifiers, are also closely related. A causal relationship with cessation of breastfeeding and supplementation or the use of artificial teats has not been substantiated within the research literature. The use of artificial teats, however, may be an indication of difficulties with breastfeeding or lack of confidence and the need for increased support from health care workers. There is substantive evidence to indicate that providing discharge packs of artificial baby milk leads to early cessation of breastfeeding. The impact of the Baby-Friendly™ Hospital Initiative, that is, looking at the entire “Ten Steps to Successful Breastfeeding” and the “International Code of Marketing of Breast-Milk Substitutes” as a whole has not been reported in the literature. One study by DiGirolama & Grummer-Strawn (2001) assessed the impact of Baby-Friendly™ practices and termination of breastfeeding before 6 weeks. This study found that