Jennifer L. Bailey DeJong, Ph.D., FNP-BC, CLE, CNE
Golden Start Breastfeeding Educational Consultant
Associate Professor of Nursing
Concordia College Nursing Department, Moorhead, MN
Intro
 Objective 1:
why study lactation in the first place?
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The Curriculum was written by Dr. DeJong during the
2011-2012 academic year to assist faculty in teaching
undergraduate nursing students about breastfeeding
and human lactation using a multi-dimensional teambased and interactive approach. Golden Start
Breastfeeding Education acknowledges that much of the
information in the curriculum was designed as teaching
modules for The Golden Start Community Leadership
Team by Lactation Consultant Molly Pessl, BSN, IBCLC,
from Evergreen Perinatal Education, Washington. The
program was funded by a grant by the MN Department
of Health. Photos were used with permission from Jane
Stockton, RN, CLC, Iowa Department of Public Health,
Bureau of Nutrition and Health Promotion. Others are
cited on the slide itself, within the text, or within the
notes section of each slide.
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The writing of this curriculum was a direct
result of the research conducted at the NDSU
Data Center on Nurses’ Perception of the
Need for Lactation Education.
You can find the study and its results here:
http://www.ndsu.edu/sdc/publications/repor
ts/LactationReport_FINAL.pdf
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The overall purpose of this curriculum is to
educate nursing students on breastfeeding
and lactation so that they may become
thoughtful and informed men and women
dedicated to providing evidence-based care
to the clients and communities they serve, in
order to protect, promote, and support
breastfeeding.
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The following assumptions were presumed by Dr.
DeJong while writing this curriculum:
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1. Direct breastfeeding or providing human milk
is the optimal choice for infant nutrition.
2. Almost all mothers have the physiologic
capability to successfully breastfeed.
3. Breast milk is the best feeding option for
most infants, with few exceptions (WHO/UNICEF,
2009).
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4. Artificial formulas should only be used in
circumstances where human milk is not
available or when medically advised.
5. Lactation offers short- and long-term
benefits to the mother and child that
synthetic formula and cow’s milk cannot.
6. The aim of nurses and other health
professionals is to support individuals,
families, and communities in attaining and
sustaining holistic health and wellness.
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7. Patients trust nurses to inform them of
research findings that impact their choices.
8. Nurses, educators, and other stakeholders
can influence the health of society through
instruction, support, and the development of
policies and procedures that change practice.
9. Patients and other consumers expect to
receive care and instruction that is consistent
with best practice recommendations based on
sound science and not anecdotal reports.
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10. Nurses must stay well-informed of
current recommendations in order to
maintain competency in their professional
role as provider, educator, and client
advocate.
11. Nurses have an ethical responsibility to
the individual, family, and group as “client” to
discuss health promotion, risk reduction,
illness management, and disease prevention
based on research.
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Upon completion of
The Golden Start Breastfeeding
Curriculum, nursing students should
be able to:
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1. Analyze why breastfeeding and lactation
research are vital topics to study in an
undergraduate nursing curriculum.
2. Examine at least three biological
advantages of lactation and breastfeeding
for the mother and child.
3. Analyze the composition of human milk.
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4. Examine at least three risks of not
breastfeeding for the mother and child.
5. Analyze at least two contraindications to
breastfeeding.
6. Analyze at least three advantages of
breastfeeding for the
community/environment.
7. Discuss the anatomy and physiology of
lactation.
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8. Discuss the role of the nurse in assessing
and encouraging the breastfeeding dyad.
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9. Compare and contrast various breastfeeding
positions.
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10. Discuss the history and current trends of
breastfeeding in the United States and
internationally.
11. Discuss best practices as well as “The
Code” and “The Ten Steps to Successful
Breastfeeding.”
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12. Analyze the components of The
Breastfeeding Report Card, Healthy People
2020 Objectives, and The 2011 Surgeon
General’s Call to Action to Support
Breastfeeding.
13. Analyze problem-based case studies.
14. Write appropriate nursing diagnoses for
breastfeeding-related issues.
15. Appraise lactation-related information
available on the internet.
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16. Role-play selected scenarios with one
another.
17. Analyze the role of the registered nurse in
providing support to mothers in a variety of
settings.
18. Evaluate how public health programs in
particular impact breastfeeding and education.
19. Examine factors that impact breastfeeding
in communities and discuss ways to support
breastfeeding where you work and live.
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Objective 1
Analyze why breastfeeding and
lactation research are vital topics to
study in an undergraduate nursing
curriculum.
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Why is education about lactation and
breastfeeding important for nursing
students?
What does the evidence say?
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Several national and international health organizations have
developed position statements and practice guidelines
supporting the importance of breastfeeding, including:
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the American Academy of Family Physicians (AAFP);
the American Academy of Pediatrics (AAP);
the American College of Nurse-Midwives (ACNW);
the American College of Obstetricians and Gynecologists (ACOG);
the National Medical Association (NMA);
the Association of Women’s Health, Obstetric, and Neonatal Nurses
(AWHONN);
the American Public Health Association (APHA);
the American Dietetic Association (ADA);
the National Association of Pediatric Nurse Practitioners (NAPNP);
the World Health Organization (WHO);
the United Nations Children’s Fund (UNICEF); and,
the United States Department of Health and Human Services
(USDHHS).
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Nurses play an important role in educating
the public and other healthcare
professionals about the significance of
breastfeeding, and can empower mothers
and their support systems in maintaining
lactation according to the evidence-based
recommendations of HP, the WHO, the
Centers for Disease Control and Prevention
(CDC), the Academy of Breastfeeding
Medicine (ABM), and other leading experts
in the field of lactation.
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Evidence-based practice means the nurse
bases their practice of professional nursing
on:
◦ A. What the unit they work on deems satisfactory
based on patient feedback and confidential surveys.
◦ B. What the hospital or agency they work for gets
reimbursed for by insurance companies.
◦ C. What they have time for in their practice; it
depends on the shift and how demanding it is.
◦ D. Research-based recommendations and best
practices of leading authorities.
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Nurses are in a position to use research
findings from robust investigations to
influence and change practice, to be a
voice for underrepresented populations,
and to educate society about the role that
breastfeeding has in sustaining health and
preventing unnecessary morbidity and
mortality.
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Then why is breastfeeding promotion,
protection, and support so difficult?
 Why are some mothers choosing
formula?
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Brainstorm the factors that you think may
impact breastfeeding initiation and duration.
◦ Who chooses to breastfeed? Imagine a picture of
this mother. Who is she? What does she look like?
◦ Who chooses to feed formula? Imagine a picture of
this mother. Where does she live? What job does
she have?
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For some answers to this
question, let us turn to The
Bailey DeJong Adaptation of
Bronfenbrenner’s Social
Ecological Systems
Framework for Breastfeeding
Mothers Conceptual
Framework (May 2011)
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Microsystem
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Mesosystem
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Exosystem
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Macrosystem
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The Social-Ecological Framework can be
readily applied within the context of health to
explain the levels of bidirectional influence
that affect or could potentially impact
personal behavior.
Numerous variables, besides microsystemrelated influences, exist that may improve or
impair the physical, emotional, or spiritual
well-being of a patient (McLeroy, Bibeau,
Steckler, & Glanz, 1988).
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Support from the father is
associated with increased
breastfeeding rates nationally
and abroad (Alikasifoglu,
Erginoz, Gur, Beker, & Arvas,
2001; Bar-Yam & Darby,
1997; Humphreys et al.,
1998; Isabella & Isabella,
1994; Khoury, Mitra, Hinton,
Carothers, & Sheil, 2002;
Littman, Medendorp, &
Goldfarb, 1994; Mahoney &
James, 2000; Matich & Sims,
1992; Scott & Binns, 1999).
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According to
Morse and
Harrison (1987),
the attitudes of
others toward the
breastfeeding
mother and the
support she
received are
among the most
important
determinants of
breastfeeding
duration.
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Image used with permission from
http://wicworks.nal.usda.gov/wicworks/resources/images.html
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Image used with permission from
http://wicworks.nal.usda.gov/wic
works/resources/images.html
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Research
suggests that
the opinions of
others
significantly
affect the
breastfeeding
decisions of
mothers.
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According to Humphreys, Thompson, and
Miner (1998); Roe et al. (1999); Smith (1985);
Starbird (1991); Winikoff (1980); and Wright
(1988), women in the U.S. who have graduated
from college are more likely to breastfeed than
their less-educated counterparts.
Studies report that more highly educated
women in the U.S. recognize the benefits of
breastfeeding and are more likely to choose
breastfeeding as opposed to bottle feeding.
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Buxton and colleagues (1991)
found that, among mothers
who initiated breastfeeding,
significant predictors of failure
to breastfeed for more than
seven days included lower
confidence in the ability to
breastfeed, delayed first
breastfeeding experience, and
lack of rooming-in with the
baby after delivery.
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How is the
bottle
inconvenient?
How is the
breast
inconvenient?
Discuss both
now.
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Currently in the U.S., 3 of 4 (75%) of all
mothers breastfeed their infants in the
early postpartum period and 29% report
feeding any human milk to their infants
at six months.
However, racial disparities exist with
Black women breastfeeding at a rate
much lower than that of White women.
According to the USDHHS (2010), only
45% of Black women initiate lactation
postpartum. At six months, the
breastfeeding rate is 31% for White
women compared with 19% for Black
women and 28% for Hispanic women.
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African American Breastfeeding Network of
Milwaukee at
http://city.milwaukee.gov/breastfeeding
View advertising campaign at:
http://www.iwantastrongbaby.com/
Reaching Our Sisters Everywhere (ROSE) at
http://www.breastfeedingrose.org/
HHS about to release new campaign called
“It’s Only Natural: Mother’s Love, Mother’s
Milk”
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It’s Only Natural:
Mother’s Love, Mother’s Milk found at:
www.womenshealth.gov/itsonlynatural
What are your impressions?
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Although the decision to breastfeed is a personal one
for every mother, the choice not to breastfeed often
results from a lack of material, informational, or
emotional support (Kong & Lee, 2004; Logsdon, Usui,
Birkimer, & McBride, 1996).
The use of supplemental formula feeding prior to
discharge, or in the first month postpartum when milk
supply is being established, has been associated with
breastfeeding failure and premature weaning (Barber,
Abernathy, Steinmetz, & Charlebois, 1997; Chezem,
Friesen, Montgomery, Fortman, & Clark, 1998; Hill et
al., 1997; Perez-Escamilla et al., 1993; Sheehan et al.,
1999).
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Bartick et al. (2009) reported that, in some
maternity centers, greater than 99% of
breastfed infants receive formula.
To combat this growing trend, certain
progressive hospitals now handle infant
formula the same way as medications:
available only with a provider order.
Formula is locked in a medication machine
and strictly regulated.
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Some hospitals require parents and legal caregivers
to sign a consent form, indicating they understand
the inherent risk to their infant’s health, before
providing formula for non-medical reasons (Bartick
et al., 2009).
When such measures have been undertaken, the
results speak for themselves. For instance, one
hospital-based intervention to reduce formula
supplementation of breastfed newborns found that
breastfeeding at six months’ duration increased
from 66% to 87% when supplementation was
discouraged (Nylander, Lindemann, Helsing, &
Bendvold, 1991).
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Women’s early experiences with
breastfeeding considerably affect whether
and how long they will continue to
breastfeed (Caulfield et al., 1998; Taveras
et al., 2004).
Lack of support from professionals who
report reluctance to “push” mothers to
breastfeed (Bartick et al., 2009) has been
identified as a major barrier to
breastfeeding promotion, especially among
African-American women.
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Satcher (2001), former U.S. Surgeon
General, advised, “To encourage
breastfeeding, the health care system
should support the training of health
care professionals on the basics of
lactation counseling and management,
and establish hospital and maternity
center practices that promote
breastfeeding” (p. 72).
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The current Surgeon General., Dr. Regina
Benjamin, concurs with her predecessors’
remarks on the importance of provider
support, writing, “Hospitals, work sites, and
communities should make it easy for
mothers to initiate and sustain
breastfeeding as this practice has been
shown to prevent childhood obesity”
(USDHHS, Office of the Surgeon General, p.
1).
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Healthcare providers’ advice and support
have a considerable influence on a mother’s
decision to breastfeed and on her ability
and desire to maintain breastfeeding (Arora
et al., 2000; DiGirolamo, Grummer-Strawn,
and Fein, 2003; Perez-Escamilla, Pollitt,
Lonnerdal, & Dewey (1994). Phillipp,
Merewood, & O’Brien, 2001; Register, Eren,
Lowdermilk, Hammond, & Tully, 2000;
Ryan, 1997).
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According to Sikorski, Renfrew, and
Pindoria (2003), a Cochrane review
indicated that a mostly in-person
intervention significantly increased
breastfeeding duration while an
intervention using mainly telephone contact
did not.
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Practicing rooming-in
has been associated
with a longer
duration of
breastfeeding
(Anderson, Moore,
Hepworth, &
Bergman, 2004).
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Immediate skin-to-skin contact between
the mother and infant and practicing
rooming-in has been associated with longer
duration of breastfeeding (Anderson,
Moore, Hepworth, & Bergman, 2004).
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There are concerns about creating
anxiety and guilt.
◦ Nurses may have difficulty thinking
of breastfeeding like they think of
other healthcare issues.
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While it may be beneficial to
share personal
breastfeeding stories,
nurses need not have
personal experience in
order to support or
promote breastfeeding.
This is about the evidence not about your attitude,
story, belief, or opinion.
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Breastfeeding assistance and encouragement
has everything to do with providing
individualized care, of which nurses are
educated to do.
Nurses need to emphasize the 3 P’s in their
individualized CarePlan:
◦ PERFECT, PLENTY, and PREVENTATIVE
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Breastfeeding is one of the best
preventative health practices we
have, and we will talk about this
more in the slides to come.
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Breastfeeding is
“normal”
Breastfeeding is
“do-able”
You can do this!
Image used with permission from William
Burleson, Office of Statewide Health Improvement
Initiatives, Minnesota Department of Health on
2/10/2012.
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What has this child
learned about
breastfeeding?
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End of:
 Intro
 Objective 1: Why study lactation in the
first place?
Next:
 Objective
 Objective
 Objective
 Objective
2:
3:
4:
5:
Advantages
Composition
Risks of not breastfeeding
Contraindications
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