Running head: CLINICAL QUESTION PAPER 1

Clinical Question Paper: Is breastfeeding duration shortened if an artificial nipple is introduced

to the infant during the first month of life verses mothers who breastfeed exclusively?
Charity McKinnon
Ferris State University












CLINICAL QUESTION PAPER 2

Abstract
This paper will discuss research findings with levels of evidence reported that relate to nipple
confusion in breastfeeding infants and how this phenomenon affects nursing mothers and babies.
This paper will reflect on recommendations to improve quality and safety related to supporting
breastfeeding mothers as well as mothers who wish to supplement their infants by choice or
because it is medically indicated. This paper will also describe how occurrences of nipple
confusion can be avoided and communicated in the post-partum setting.












CLINICAL QUESTION PAPER 3

Clinical Question Paper
The PICOT (population, intervention, comparison intervention, outcome desired, time to
achieve outcome) question: Is breastfeeding duration shortened if an artificial nipple is
introduced to the infant during the first month of life verses mothers who breastfeed
exclusively? This question demonstrates beneficial recommendations of avoiding infant nipple
confusion as evidenced through research studies (Nieswiadomy, 2012). Studies on how
introducing a pacifier or artificial nipple can produce nipple confusion in the breastfeeding infant
is a real problem that mothers who choose to nurse may experience (Sears, 2006).
Communication of these findings to acute care staff working with mothers directly in the post-
partum period will ultimately affect the breastfeeding mothers experience and could determine
the duration of successful breastfeeding. Communication can be relayed through nursing
research and evidence based practice (Nieswiadomy, 2012). Three nursing articles that provide
information through research studies in PICOT format demonstrate ways that the findings should
be applied in the post-partum setting due to the recommendations regarding breastfeeding and
nipple confusion. Levels of evidence support these findings. The findings of the research
studies can improve quality and safety by following the recommendations made to promote
successful breastfeeding in mothers and infants, as well as alternatives to artificial nipples for
women who need to supplement or choose to while breastfeeding.
Communication
Is breastfeeding duration shortened if an artificial nipple is introduced to the infant
during the first month of life verses mothers who breastfeed exclusively? is a research question
that can be communicated to staff using Evidenced-based practice because it is a problem that
CLINICAL QUESTION PAPER 4

post-partum nurses can improve on and provide better patient care if aware of the possible
effects of interfering with exclusive breastfeeding. The population (P) is breastfeeding mothers.
The intervention or area of interest (I) is the use of an artificial nipple or supplement. The
comparison intervention (C) is exclusively breastfeeding. The outcome (O) is the question of
long-term success of breastfeeding being decreased if an artificial nipple is introduced. The time
frame (T) is in the first month of an infants life. This represents the clinical question in the form
of PICOT (Nieswiadomy, 2012).
In order to effectively communicate this study, nursing researchers could publish the
results in nursing journals or reports, present the data in presentations such as Power-Point at
professional conferences and meetings, and presentations in the form of a poster or paper are
options (Nieswiadomy, 2012). These types of communicative strategies will help the nursing
staff of a post-partum unit to create procedures that are in accordance with Evidence-based
practice findings. The procedures that would support the mother who wishes to breastfeed
exclusively include providing emotional support, respecting decisions made by the mother in
regards to supplementation, and teaching effective breastfeeding techniques for successful infant
positioning and ways to achieve a deep latch (World Health Organization, 2014). First time
mothers need the support and care from physicians and nurses caring for their family unit in
order to have the resources to provide quality care to her infant. This includes respecting the
mother by giving encouragement and not introducing an artificial nipple if requested and if they
do, explaining the research findings of why this is discouraged in the first month of life. Those
who need to supplement their infants could be given a Haberman feeder or Foley cup which are
instruments used that either mimic the breastfed infants latch or bypass an artificial nipple
completely (P. Oshaben, personal communication, 2014). Following these procedures in clinical
CLINICAL QUESTION PAPER 5

practice and also answering the PICOT question will help the breastfeeding mother have a
positive post-partum experience with feeding her infant, therefore improving quality and safety
of nursing care provided to the patients.
Nursing Research
Three articles that support nipple confusion shortening breastfeeding duration in infants
who are supplemented with formula or pacifier verses exclusively breastfed were found using the
research data bases CINAHL, PUBMED, and Cochrane Review. Levels of evidence were
reviewed and applied to these articles to provide the most relevant and best evidence to answer
the clinical question (Ford, 2014, p. 2). Nursing research from these articles validates the
studies reviewed that breastfeeding duration was shortened when an artificial nipple or form of
supplementation was given to the infant due to less breastfeeding sessions that are needed to
stimulate milk production and mechanical differences of a human nipple verses a bottle nipple
(Jaafar, Jahanfar, Angolkar, & Ho, 2012).
Article One
The article Pacifier use in the first month of life by Ran D. Goldman, MD, FRCPC,
discusses whether it is safe to use a pacifier during the neonates first month to calm them and
improve sleeping (2013). This article was obtained from the CINAHL research database. The
results that he discovered were that overall for breastfeeding mothers the recommendations state
to avoid pacifier use in the first month of life for healthy, breastfeeding newborns (Goldman,
2013, p. 500). The research studies that Goldman reviewed specified that introducing a pacifier
prolonged periods in between breast feedings (2013). This supports nursing research because
studying safety and applying Evidence-based practice care was applied in the studies that this
CLINICAL QUESTION PAPER 6

physician reviewed (Nieswiadomy, 2012). The first article researched is a level seven
measurement because Pacifier use in the first month of life is an article written by a physician.
The level seven measurement indicates that the research study is an expert opinion (Melnyk, &
Fineout-Overholt, 2011).
Article Two
The second article was found using the PUBMED research database. This research study
titled Which method of breastfeeding supplementation is best? The beliefs and practices of
paediatricians and nurses by Al-Sahab, Feldman, Macpherson, Ohlsson, and Tamim, (2010)
discusses the experiences of post-partum nurses and pediatricians working with breastfeeding
mothers. The study supports nursing research by concentrating on a clinical problem in a post-
partum setting (Nieswiadomy, 2012). The results found that following guidelines recommended
by the World Health Organization are what health care providers in these settings can do in their
standard of practice to support breastfeeding mothers, although this particular research study
described data that was inconclusive to nipple confusion (Sahab, Feldman, Macpherson,
Ohlsson, & Tamim, 2010). The level of measurement on this research study is a level two. The
study is considered a cross sectional: qualitative randomized control study (Melnyk, & Fineout-
Overholt, 2011).
Article Three
The third and final article reviewed for the PICOT question Is breastfeeding duration
shortened if an artificial nipple is introduced to the infant during the first month of life verses
mothers who breastfeed exclusively? is a research article called Effects of restricted pacifier
use in breastfeeding term infants for increasing duration of breastfeeding by Jaafar, Jahanfar,
CLINICAL QUESTION PAPER 7

Angolkar, & Ho (2012) retrieved from the Cochrane Review database. This article discusses
studies conducted with restricting pacifier use in the first month of life in one group and allowing
infants to receive pacifiers in another (Jaafar, et al, 2012). This article remarked on how this
specific study is flawed in concluding that breastfeeding cessation does not occur in the first
month of life or after because of pacifier introduction to the infant (Jaafar, 2012). Nurses can
apply this advice in the work setting by following recommendations from breastfeeding support
organizations like the La Leche League and the World Health Organization because there is
minimal to none Evidence-based practice information on nipple confusion not causing early
cessation of breastfeeding (Jaafar, et al, 2012). These findings will assist the nurse in educating
patients and assisting them with the decision on whether a pacifier or other forms of supplement
will be appropriate for their specific case. This article is considered a level 1 because this was a
systematic review and critique of a study that recommends clinical guidelines (Melnyk, &
Fineout-Overholt, 2011).
Quality & Safety
The evidence of the findings of these research articles can improve quality and safety for
the patients that are involved include decreasing infant mortality and improving maternal-infant
bonding. Teaching is integrated into the post-partum nurses standard of practice and it can
improve breastfeeding rates by informing the mother on breastfeeding benefits. These benefits
include increased infant immunity, better feeding tolerance, and many more health related
advantages for mother and baby (World Health Organization, 2014). Benefits of reducing infant
mortality will reduce health care costs overall, which is one of three goals of Campaign Zero, a
patient centered care resource of the QSEN (quality and safety education for nurses) Institute
(QSEN, 2014). The article reviewed for this PICOT question discusses following the guidelines
CLINICAL QUESTION PAPER 8

and recommendations of supportive breastfeeding organizations and nurseries around the country
and nurses on post-partum units will be able to do so because the resources are easily attainable.
By following the ethics and collaboration criteria of the American Nurses Association
Nursing Scope and Standards of Practice guidelines, nurses can implement this research criteria
reviewed by the article critique in the PICOT format into their practice setting (American Nurses
Association (ANA), 2004). Ethics can be put forth into practice for this topic by not introducing
a pacifier or bottle if specified by the parents not too, acting as a patient advocate (ANA, 2004).
If supplementation of the infant has been agreed upon and discussed for the breastfeeding
mother, using appropriate supplementation devices as not to cause nipple confusion should be
used. Collaboration can be practiced in this setting by the nurse discussing a plan of care for the
mother and her infant regarding a feeding regimen (ANA, 2004).
In conclusion, the PICOT question research discusses some inconclusive results on the
topic of nipple confusion and the shortening of breastfeeding duration, but the recommendations
remain the same to promote and lengthen breastfeeding duration by not introducing a pacifier
overall to breastfeeding infants in the first month of life. By consulting QSEN and the ANA
scope and standards of practice, delivery of care will remain of the highest quality and safety for
mothers and infants in the post-partum period. By utilizing the information provided and
continuing to discover changes in evidence by researching, nursing practice will remain
professional and current (Nieswiadomy, 2012). This concept will continue to help patients in the
healthcare setting and upon discharge.


CLINICAL QUESTION PAPER 9

References
Al-Sahab, B., Ferlman, M., Macpherson, A., Ohlsson, A., & Tamim, H. (2010). Which method of
breastfeeding supplementation is best? The beliefs and practices of paediatricians and
nurses. Paediatrics and Child Health. 15(7): 427-431.
American Nurses Association. (2004). Nursing scope and standards of practice. Silver Springs,
MD. Nursebooks.org
Ford, L. (2014). Structure and function of the research process. NURS 350: Research in Nursing
Power-Point. Retrieved from:
https://fsulearn.ferris.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2F
webapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_9157
_1%26url%3D
Goldman, R. (2013). Pacifier use in the first month of life. Canadian Family Physician. (59)5:
499-500.
Jaafer, S., Shayesteh, J., Angolkar, M., Ho, J. (2012). Effects of restricted pacifier use in
breastfeeding term infants for increasing duration of breastfeeding. Cochrane Pregnancy
and Childbirth Group. Doi: 10.1002/14651858.CD007202. pub3.
Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and
healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.
QSEN Institute. (2014). Patient-centered care resources. Retrieved from: http://qsen.org/faculty-
resources/patient-centered-care-resources/
CLINICAL QUESTION PAPER 10

Sears, W., & Sears, M. (2006). Re: Breastfeeding nipple confusion. Retrieved from:
http://www.askdrsears.com/html/2/to22400.asp
World Health Organization. (2014). 10 Facts on Breastfeeding. Retrieved from:
http://www.who.int/features/factfiles/breastfeeding/en/