of one study from New Zealand (Ministry of Health Manatu Hauora New Zealand, 1997), these studies have not controlled for infant sleep position and exposure to second hand smoke. Thus, a direct protective relationship is unproven as of yet (Bernshaw, 1991; Canadian Paediatric Society, Dietitians of Canada and Health Canada, 1998; Ford, 1993; Kraus et. al., 1989). For infants with a family history of allergies, exclusive breastfeeding for four months appear to have a protective effect (Burr et. al., 1993; Canadian Paediatric Society, Dietitians of Canada and Health Canada, 1998; Chandra, 1997; Lucas et. al., 1990; Saarinen & Kajosaari, 1995). Breastfeeding, however, does not appear to decrease incidence of allergies in infants who are not predisposed due to family history (Lucus et al., 1990). The development panel, through its literature search and critical review of several clinical practice guidelines, arrived at consensus that there are a few special circumstances that may preclude breastfeeding. Breastfeeding is possible for the vast majority of mothers and their children, however galactosemia in the infant, drug abuse by the mother, untreated active tuberculosis, and a mother with HIV are special situations in which the appropriateness of breastfeeding should be evaluated on an individual basis. However, the benefits of breastfeeding with respect to nutrition, immunology and psychosocial gains generally outweigh the need to discontinue breastfeeding. Readers are referred to the work of Riordan, Lawrence and Motherisk (see reference list) for further discussion on this topic. 38 Breastfeeding Best Practice Guidelines for Nurses Lifestyle Issues (Level of Evidence III) Provide consistent information about the potential effects of the following on breastfeeding: a) Medications related to medical interventions; b) Alcohol; c) Smoking; d) Street drugs; and e) Caffeine. Discussion of Evidence a) Medications related to medical interventions Information about the effects of maternal medication on breastfeeding is constantly changing and is dependent on a variety of factors. However, there is agreement that the concentration of the maternal medication in breast-milk is usually c) Smoking Nicotine can be found in breast-milk of both smoking mothers and mothers exposed to second hand smoke. Excessive exposure to nicotine in breast-milk can cause the infant to experience gastrointestinal problems, increased heart rate, increased irritability, and poor weight gain. The breastfeeding mother can experience reduced milk supply and milk ejection (CICH, 1996; Ministry of Health Manatu Hauora New Zealand, 1997; Scarborough Breastfeeding Network, 1999). However, breastfeeding is still the recommended feeding method. Smoking mothers should be encouraged to quit or reduce smoking. To reduce the harmful effects of smoking if the mother continues to smoke, she should smoke immediately after breastfeeding, which allows for a longer period of time for the nicotine to be metabolized. Also, to limit the baby’s exposure to second hand smoke, people who smoke in the household should smoke outside (CICH, 1996; Ministry of Health Manatu Hauora New Zealand,1997; Scarborough Breastfeeding Network, 1999). d) Street drugs Breastfeeding may not be the recommended infant feeding method with mothers who use street drugs (e.g., heroin, cocaine, and marijuana). The concentration of these drugs in breast-milk, even with the use of very small amounts may result in harmful effects to the infant. Infants should also not be exposed to the smoke fumes from marijuana. However, discussing the benefits of breastfeeding to mothers who use street drugs could encourage them to stop using these drugs (CICH, 1996; Hale, 2000; Lawrence, 1994; Moretti, Lee & Ito, 2000). e) Caffeine The American Academy of Pediatrics (Watson, 1994) approves occasional use of caffeine. 40 Breastfeeding Best Practice Guidelines for Nurses Milk Production (Level of Evidence III) Facilitate the development of breastfeeding knowledge by providing the client with consistent information regarding the anatomy and physiology of the breast including: External structures; Internal structures; Hormonal influences on the breast; and Milk production. Discussion of Evidence Educating breastfeeding families about breast-milk production represents one component of a comprehensive breastfeeding education. Although the literature does not specifically identify the importance of educating breastfeeding families about this topic, one can infer that being knowledgeable about how breast-milk is produced would be an asset in supporting families’ overall understanding and comfort with breastfeeding. Fairbank et al. (2000) discussed the effectiveness of interventions to promote the initiation of breastfeeding and found that “small, informal, group health education classes, delivered in the antenatal period, can be effective intervention to increase initiation rates, and in some cases the duration of breastfeeding, among women from different income or ethnic groups” (pg. vi). Fairbank et al. (2000) also suggested that “there is some evidence to show that oneto-one health education can be effective at increasing initiation rates among women on low incomes, and particularly among women who have expressed a wish to breastfeed” (pg. 48). This evidence would further support