professionals and clients, ever mindful of the personal preferences and unique needs of each individual client. 17 Guideline Development Process In February of 2001, a panel of nurses, researchers and other health professionals with expertise in the practice and research of breastfeeding support, from institutional, community and academic settings was convened under the auspices of the RNAO. At the outset, the panel discussed and came to consensus on the scope of the best practice guideline. The original scope identified was best practices for breastfeeding support from preconception through the mother’s return (postpartum) to school or work. This scope was later found to be too ambitious. Therefore, the panel narrowed the scope of the guideline to address best practices that were general in nature and addressed the competent to proficient level of practice for nurses encountering families in both the prenatal and postnatal periods. A search of the literature for systematic reviews, clinical practice guidelines, relevant articles and websites was conducted. See Appendix A for a detailed outline of the search strategy employed. A total of eight clinical practice guidelines related to breastfeeding were identified. An initial screening was conducted using the following inclusion criteria: published in English; developed in 1996 or later; strictly about the topic area; evidence-based (or documentation of evidence); and accessible as a complete document. All eight guidelines met the criteria and were critically appraised by the panel members using the “Appraisal Instrument for Clinical Guidelines”, which is a tool from Cluzeau et al. (1997). This tool allows for evaluation in three key dimensions: rigour, content and context, and application. From this appraisal process, three high quality resources were identified for use as foundation documents in the development of this guideline: Nursing Best Practice Guideline 18 Breastfeeding Best Practice Guidelines for Nurses Association of Women’s Health, Obstetric and Neonatal Nurses (2000). Evidence-based clinical practice guideline – Breastfeeding support: Prenatal care through the first year. Association of Women’s Health, Obstetric and Neonatal Nurses. [Online]. Available: http://www.awhonn.org Canadian Institute of Child Health (1996). National breastfeeding guidelines for health care providers. Ottawa: Canadian Institute of Child Health. World Health Organization (1998). Child health and development – Evidence for ten steps to successful breastfeeding. Geneva: Family and Reproductive Health Division of Child Health and Development - World Health Organization. A critique of systematic review articles and pertinent literature was conducted to update the existing guidelines. Through a process of evidence gathering, synthesis and consensus, the final draft set of recommendations was established. This draft document was submitted to a set of external stakeholders for review and feedback – an acknowledgement of these reviewers is provided at the front of this document. Stakeholders represented various health care professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel – discussion and consensus resulted in revisions to the draft document prior to pilot testing. A pilot implementation site was identified through a “Request for Proposal” (RFP) process. Practice settings in Ontario were asked to submit a proposal if they were interested in pilot testing the recommendations of the guideline. These proposals were then subjected to a review process, from which successful practice settings were identified. A nine-month pilot implementation was undertaken to test and evaluate the recommendations in both a hospital and public health unit in Sudbury, Ontario. An acknowledgement of these organizations is included at the front of this document. The development panel reconvened after the pilot implementation in order to review the experiences of the pilot site, consider the evaluation results and review any new literature published since the initial development phase. All these sources of information were used to update/revise the document prior to publication. 19 Definition of Terms Artificial Baby Milk: A food in liquid or powdered form, intended for use as a substitute for human milk and intended as a sole source of nutrition for an infant (Ministry of Health Manatu Hauora New Zealand, 1997). Any food, manufactured or represented as a partial or total replacement for breast-milk, whether or not suitable for that purpose (WHO/UNICEF, 1981). Baby-Friendly™ Hospital Initiative (BFHI): “The BFHI is a global program, initiated in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), in response to the Innocenti Declaration (1990). This program encourages and recognizes hospitals and maternity facilities that offer an optimal level of care for mothers and infants. A Baby-Friendly™ hospital/maternity facility focuses on the needs of the newborns and empowers mothers to give their infant the best possible start in life. In practical terms, a Baby-Friendly™ hospital/maternity facility