Samples: Single servings or small quantities of a product provided without cost (Ministry of Health Manatu Hauora New Zealand, 1997). Self-Efficacy: Breastfeeding self-efficacy refers to a mother’s perceived ability to breastfeed her newborn. It is a significant variable in breastfeeding duration as it predicts: whether a mother chooses to breastfeed or not; how much effort she will put forth; whether she will have self-enhancing or self-defeating thought patterns; and how she will respond emotionally to breastfeeding difficulties (Blyth et al., 2002). Stakeholder: A stakeholder is an individual, group, or organization with a vested interest in the decisions and actions of organizations, who may attempt to influence these decisions and actions (Baker, et al., 1999). Stakeholders include all individuals or groups who will be directly or indirectly affected by the change. Stakeholders can be of various types, and can be divided into opponents, supporters, and neutrals (Ontario Public Health Association, 1996). Systematic Review: Application of a rigorous scientific approach to the preparation of a review article (National Health and Medical Research Council, 1998). Systematic reviews establish where the effects of health care are consistent, and where research results can be applied across populations, settings, and differences in treatment (e.g., dose); and where effects may vary significantly. The use of explicit, systematic methods in reviews limits bias (systematic errors) and reduces chance effects, thus providing more reliable results upon which to draw conclusions and make decisions (Clarke & Oxman, 1999). 22 Breastfeeding Best Practice Guidelines for Nurses Background Context The World Health Organization (1998, 2002) has recommended that infants should be exclusively breastfed for the first six months of life. During the past two decades, the breastfeeding initiation rate in Canada has oscillated from 64% (1979) to 73% (1994). The four months exclusive breastfeeding duration rate ranged from 37% (1979) up to 60% (1994), in comparison, the six months exclusive breastfeeding duration rate increased from 27% (1979) to 30% (1994) (Health Canada, 1996; Hogan, 2001). The benefit of breastfeeding for both the mother and the baby is well researched and documented (AWHONN, 2000; CICH, 1996; Health Canada, 2000; Ministry of Health Manatu Hauora New Zealand, 1997; WHO, 1998). Breast-milk contains all the fluid and nutrients required for optimal growth (Heinig, Nommsen, & Peerson, 1993; Humenick, 1987; Tyson, Burchfield, & Sentence, 1992; Woolridge, Ingram, & Baum, 1990). In particular, breast-milk contains the omega-3 fatty acids docosahexaenoic acid (DHA) and alpha-linolenic acid (ALA), which are important for the development of the retina and brain in the last trimester of pregnancy and throughout the first year of life (Jorgensen, Holmer, Lund, Hernell & Michaelsen, 1998). Artificial milk available in Canada is not supplemented with omega-3 fatty acids, and infants receiving this food must synthesize their own DHA and ALA from precursors. Randomized studies have demonstrated that healthy term infants fed breast-milk have better visual acuity than infants fed standard artificial milks at two and four months postpartum (Jorgensen et al., 1998; Makrides, Neumann, Simmer, Pater & Gibson, 1995). 23 Nursing Best Practice Guideline In developed countries, studies have provided evidence that breastfeeding protects against gastrointestinal infections and otitis media (Beaudry, Dufour, Marcoux,1995; Howie et al., 1990). A report by the U.S. Department of Agriculture’s Economic Research Service has estimated that $3.6 billion could be saved in treating otitis media, gastroenteritis and necrotizing enterocolitis alone, if breastfeeding rates in the United States met current recommendations (Weimer, 2001). Breastfeeding may give some protection against Sudden Infant Death Syndrome (SIDS). A meta-analysis of 23 studies suggested that breastfeeding halved the risk of SIDS (McVea, Turner & Peppler, 2000). However, the authors cautioned that there were many problems with these studies, including mis-classifications of SIDS, inaccurate data on the length of breastfeeding (especially partial breastfeeding), and failure to control for a number of known confounders (such as socioeconomic status, maternal education, infant sleep position and exposure to second hand smoke). Thus, a direct protective relationship is unproven (Bernshaw, 1991; Ford, 1993; Kraus, Greenland & Bulterys,1989; McVea et al., 2000). For infants with a family history of allergies, exclusive breastfeeding for four months appears to have a protective effect (Burr et. al., 1993; Chandra, 1997; Lucas, Brooke, Morley & Bamford, 1990; Saarinen & Kajosaari, 1995). Breastfeeding, however, does not appear to decrease incidence of allergies in infants who do not have a positive family history (Lucus, et al., 1990). There are conflicting views about whether breastfeeding is protective of insulin-dependent diabetes mellitus, whether it is a delayed introduction of cows’ milk that may be protective, or whether the onset of insulin dependent diabetes mellitus results from unrelated environmental factors (see Ellis & Atkinson, 1996 and Heinig, 1997 for discussions of the evidence). Dentists note that breastfeeding is important for the proper development of the