objective to assess the effects on child health, growth, and development, and on maternal health, of exclusive breastfeeding for six months versus exclusive breastfeeding for three to four months with mixed breastfeeding thereafter through six months. Their conclusions indicate that, with the acknowledgement that individual infants must be managed individually, the available evidence demonstrates no apparent risks in recommending, as a general policy, exclusive breastfeeding for the first six months of life. The WHO and World Health Assembly have, subsequent to this review, included in their global strategy statement that all governments ensure that “the health and other relevant sectors, protect, promote and support exclusive breastfeeding for six months and continued breastfeeding up to two years of age and beyond” (WHO, 2002, p. 10). There are several implications for practice identified by the Public Health Research, Education and Development (PHRED) – Effective Public Health Practice Project (2002) related to these findings, including: the need for appropriate health care and supports for individuals; individualized management of maternal and infant health; support to mothers who do not breastfeed to optimize the health of their infants; and the need for processes to ensure that infant status is monitored on an ongoing basis. Many health professionals have promoted the previous, long-standing recommendation of 4 – 6 months for breastfeeding. It is important to communicate this new evidence and accompanying WHO recommendation for exclusive breastfeeding for six months to all nurses, to ensure consumers receive consistent advice. Refer to Appendix B for details of the Baby-Friendly™ Initiative in Community Health Services: A Canadian Implementation Guide. Recommendation • 3 Nurses will 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 III) 33 Nursing Best Practice Guideline Recommendation • 3.1 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; and physical factors, including breasts and nipples, that may effect a woman’s ability to breastfeed. (Level of Evidence III) Appendix D provides a sample prenatal assessment tool. Please note that this tool has been provided as an example only – it has not been tested for reliability or validity. Discussion of Evidence Nurses who work with prenatal populations should assess women for personal and demographic variables, such as age less than 20 years and low socioeconomic status, that are associated with lower initiation and continuation rates (Hartley & O’Connor, 1996; Humphreys et al., 1998; Kessler, Gielen, Diener-West & Paiger, 1995; Kistin, Benton, Rao & Sullivan, 1990). Intent to breastfeed should also be assessed prenatally. Balcazar, Trier & Cobas (1995) identified an association between prenatal exposure to breastfeeding advice and increased expression of intent to breastfeed among Mexican-American and non-Hispanic white women (AWHONN, 2000). The confidence, or self-efficacy, of the mother in relation to breastfeeding plans has an impact on breastfeeding duration (Chezem, Friesen & Boettcher, 2003; McCarter-Spaulding & Kearney, 2001), and should be considered during the prenatal assessment. Women also should be assessed for physical factors such as inverted nipples or surgical scarring that may hinder or impede their ability to breastfeed (Biancuzzo, 1999; Riordan & Auerbach, 1999). The availability of support by significant others and peer counsellors should be assessed, as both may positively influence a woman’s decision to initiate or continue breastfeeding (Duffy, Percival & Kershaw, 1997; Morrow et al., 1999; Sciacca et al., 1995a). Once risk factors are identified, women can be targeted for individualized and culturally sensitive interventions to promote breastfeeding (Biancuzzo, 1999). For example, nurses working with teenagers might want to stress maternal benefits (such as enhanced weight loss) when trying to motivate their clients to breastfeed. 34 Breastfeeding Best Practice Guidelines for Nurses Recommendation • 3.2 Key components of the postnatal assessment should include: intrapartum 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; and infant physical assessment. (Level of Evidence III) Discussion of Evidence Assessment of infant feedings is a critical component of lactation management during the postnatal period. Areas to observe during a feeding include the infant’s position at the breast, latch, suck and signs of milk transfer. Women need information on how to recognize infant feeding and