infant’s oral cavity (Palmer, 1998). 24 Breastfeeding Best Practice Guidelines for Nurses For mothers, there is mixed evidence from case-control and cohort studies of an inverse relationship between breastfeeding and the risk of breast cancer. Some studies have suggested that this protective effect may only be for women with premenopausal cancer, that the age at which a woman first lactates may be important, and that parity and the duration of breastfeeding are relevant. A case-control study from China, where breastfeeding is typically of a longer duration than in North America, suggests that women who breastfed their children for 2 years had half the risk of breast cancer of women who breastfed for only 1 – 6 months (Zheng et al., 2000). Further, the lifetime duration of breastfeeding was also associated with a much lower risk of breast cancer. A New York case-control study found a weaker relationship between breastfeeding and breast cancer risk (Freudenheim et al., 1997). Among postmenopausal women, breastfeeding was protective if the woman first lactated before 25 years of age (although this is highly correlated with age at first birth, and it is not clear which is more important). In contrast, among premenopausal women with breast cancer, the age at first lactation was not important. Two cohort studies found no association between lactation and risk of breast cancer, while the most recently published cohort study found that the risk of breast cancer was significantly lower for women who had ever lactated (Tryggvadottir, Tulinius, Eyfjord & Sigurvinsson, 2001). There is some suggestion in the literature that possible health benefits for mothers may also include fewer hip fractures after menopause, less risk of ovarian cancer and less bleeding after delivery (Weimer, 2001). Further, there is a large body of research that suggests breastfeeding has mental health benefits for mothers, such as feelings of bonding with their newborns, as well as economic benefits (Montgomery & Splett, 1997). There may be other impacts of breastfeeding on the health of the baby and/or mother, but these issues are not well supported in the research literature, and are not included in this discussion. The importance of breastfeeding worldwide has translated into major world initiatives, such as the joint action between the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) and, appropriately named, “The Baby-Friendly™ Hospital Initiative” (BFHI). Some of the other known breastfeeding initiatives and actions include the WHO/UNICEF “Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding” (1990), the International Code of Marketing of Breastmilk Substitutes, the WHO Working Group on Infant Growth (1994), the WHO/UNICEF “Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services” (1989) and promotional campaigns during World Breastfeeding Week. Refer to Appendix A for a list of breastfeeding position statements reviewed by the guideline development panel. 25 Nursing Best Practice Guideline In addressing breastfeeding recommendations for nurses, the health care team and health care practice settings, the development panel used the framework presented in the Ottawa Charter for health promotion (WHO, 1986) as one tool to structure the development of this document. The Charter addresses five key areas: public policy, supportive environment, community action, development of personal skills, and reorientation of health services. Health professionals must advocate for healthy public policy through legislative changes, economic measures and changes to organizational beliefs and practices. In order to achieve these changes, health professionals must be cognizant of facilitators and inhibitors to policy development and implementation. Health is dependent on the interaction that exists between people and the environment. Consequently, to promote health, we need to continuously examine all factors that impact the working and living environment of people. Community action is a fundamental strategy in health promotion that involves the active participation of the community in identifying their health priorities, deciding on appropriate strategies to deal with the identified priorities and implementing these strategies. Health professionals can enhance the life skills of the community by providing relevant and current health information and education, which people can use to make informed decisions and choices about their health. All health sectors have a shared responsibility in the promotion of the health of the community at large through the use of various channels (e.g., economic, political, social, environmental). Individuals, community groups, health institutions, health professionals and the various levels of government must collaborate to develop a health care system which contributes to and satisfies the health needs of the community (WHO, 1986). Health professionals are utilizing various strategies to increase the number of women who breastfeed. Breastfeeding is dependent upon multiple factors that are related to the mother, the infant, and the environment. Studies have found that most women make their decision about breastfeeding either before or during pregnancy (Caulfield et al., 1998;