the strongest risk factors for early termination of breastfeeding were late breastfeeding initiation and supplementation. Lvoff, Lvoff & Klaus (2000) studied the effect of the Baby-Friendly™ Initiative and infant abandonment in Russia. The results of this study indicated that for the six years following implementation of BFHI, there was a marked decrease in infant abandonment. Another study done by Kramer et al. (2001) found that by providing health care workers in Belarus with the 18-hour BFHI lactation management training course, there was an increase in breastfeeding duration. They also found a significant reduction in the risk of gastrointestional infections and atopic eczema. 30 Breastfeeding Best Practice Guidelines for Nurses A report prepared for UNICEF by Relucio-Clavano (1981) documents the impact of a ‘no formula’ {artificial baby milk} policy (before BFHI was implemented) in one Philippine hospital. After 4 years, the hospital’s breastfeeding initiation rate rose from 26 to 87 percent, infant deaths dropped by 47 percent, diseases were reduced by 58 percent, and diarrhea by 79 percent. As detailed in the description of the benefits of breastfeeding to mother and child, this may translate into potential cost savings for the institution. There is limited evidence described in the literature that indicates cost savings for hospitals that adopt BFHI practices. However in one report reviewed (Relucio-Clavano, 1981), a hospital in the Philippines reportedly saved over $100,000 US or 8% of their budget after one year of BFHI accreditation. Recommendation • 1.1 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; and promoting community action in breastfeeding. (Level of Evidence III) Discussion of Evidence Nurses have a role in advocating for “breastfeeding friendly” environments by: 1) 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, etc. 2) Promoting community action in breastfeeding by activities such as: “Providing information about community resources and breastfeeding support groups such as La Leche League and community support groups” (AWHONN, 2000, p.14). “Promoting a discussion of breastfeeding in school health curricula starting at the primary level. Replace bottle-feeding images in texts with breastfeeding pictures” (CICH, 1996, p.23). “Educating employers about the benefits of breastfeeding and how to provide a work environment conducive to the continuation of breastfeeding” (CICH, 1996, p. 23). As many mothers returning to work wish to continue breastfeeding their children, work environments should accommodate breastfeeding. As mothers return to work 31 Nursing Best Practice Guideline at various times postpartum (depending on individual circumstances and wishes), modifications to the workplace will provide supportive facilities for all breastfeeding mothers. “Educating professionals and the public about their responsibilities under the WHO Code and the unethical marketing practices of the formula {artificial baby milk} industry” (CICH, 1996, p. 24). “Encouraging parents to find a supportive breastfeeding network” (CICH, 1996, p.58). Encouraging use of peer counsellors, as they can have a significantly positive effect on breastfeeding initiation rates and duration (Fairbank et al., 2000). “Considering incorporating trained lay counsellors in breastfeeding education programs” (AWHONN, 2000, p. 5). Offering classes, information and education outside traditional health care settings in places such as homes, places of worship, school, local neighbourhoods, etc. (AWHONN, 2000). Ensuring nursing mothers are aware of their rights. Breastfeeding women “have the right to breastfeed a child in a public area. No one should prevent you from nursing your child in a public area or to ask you to move to another area that is more ‘discreet’”(Ontario Human Rights Commission, 1999). Refer to Appendix C for more information about promoting community action. Recommendation • 2 Nurses and health care practice settings endorse the 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) Discussion of Evidence The World Health Organization (2000) systematic review on the optimal duration of exclusive breastfeeding compared exclusive breastfeeding for four to six months versus six months. The review included 3000 references but found only two small controlled trials and seventeen observational studies. It is worthwhile to note that the evidence is limited and the recommendation is made using inferences, other noted results from studies not included in the sample, as well as the weighing of risks against the benefits of exclusive breastfeeding, especially the potential reduction in morbidity and mortality. 32 Breastfeeding Best Practice Guidelines for Nurses A more recent Cochrane review (Kramer & Kakuma, 2002) was conducted with a primary