INSIGHT

Breastfeeding: The neglected guideline for futureDietitian-Nutritionists?

Jan Payne,1 Barbara Radcliffe,2 Emma Blank,1 Elizabeth Churchill,1 Nadia Hassan,1

Elizabeth Cox3 and Helen Porteous4

1School of Public Health, Queensland University of Technology, Kelvin Grove, 2Queensland Health, Annerley RoadCommunity Health Service, South Brisbane, 3Queensland Health, Ipswich Health Plaza, Ipswich, and 4QueenslandHealth, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia

AbstractThe objective of the present study is to determine the knowledge, attitudes and beliefs regarding breastfeeding offinal-year nutrition and dietetic students. A cross-sectional survey of final-year nutrition and dietetic students at aleading Australian university was conducted using an emailed questionnaire of 50 multiple-choice questions onknowledge, attitudes, beliefs and future intentions to support and promote breastfeeding. The frequency ofresponse to all questions was determined. Twenty-seven of the 38 eligible students completed the survey. Significantdeficits were identified relating to breastfeeding knowledge. Ninety-two per cent of respondents reported a futureintention to breastfeed or support their partner to do so; yet 69% felt bottle feeding was more socially acceptableand 23% believed that using artificial formula was easier for the mother. Although 85% of respondents believed theycould influence breastfeeding initiation and duration rates, no students perceived that their studies had provided asignificant amount of information on this subject, while only 8% of respondents had a strong interest in work relatingto breastfeeding in the future. Improvements in the curriculum in this context may be required to ensure newgraduates have the appropriate knowledge and are motivated to take positive action so that breastfeeding isproperly supported. Further research is needed to determine if this issue applies in other nutrition courses and toassess the need to adopt an industry position paper on breastfeeding and associated competency standards forvocational training.

Key words: breastfeeding, dietetics, nutrition, training.

INTRODUCTION

Breast milk is a complex and natural substance uniquelysuited to the needs of infants.1 Infants who are not breastfedhave a greater incidence of diarrhoeal illnesses, respiratoryinfections, asthma, otitis media, eczema, necrotising entero-colitis, bacteraemia, meningitis, botulism, urinary tractinfection and sudden infant death syndrome and are atincreased risk of some childhood cancers, type 2 diabetes,obesity and risk factors associated with cardiovasculardisease in adulthood.1–3

The Dietary Guidelines for Australian Adults and the DietaryGuidelines for Children and Adolescents in Australia bothinclude ‘Encourage and support breastfeeding’ as one of theirfour key nutrition guidelines, with the further recommenda-tion that breast milk be the only food for about the first sixmonths of life and that breastfeeding continue, with solidsand other drinks, as long as it is appropriate for the motherand infant.1

Dietitians have an important role to play in supportingand promoting breastfeeding as illustrated by the AmericanDietetic Association’s position paper on breastfeeding, whichstates:

Dietetic professionals have a responsibility to supportbreastfeeding through appropriate education and train-ing, advocacy, and legislative action; through collabora-tion with other professional groups; and through researchto eliminate the barriers to breastfeeding.4

Dietitians have been identified as an untapped resource inbreastfeeding management in hospitals,5 and structuredantenatal breastfeeding education has been found effective at

J. Payne, GradDipNutDiet, APD, LecturerB. Radcliffe, GradDipNutDiet, Community NutritionistE. Blank, BHlthSc(Nut&Diet), APD, Former StudentE. Churchill, BHlthSc(Nut&Diet), APD, Former StudentN. Hassan, BHlthSc(Nut&Diet), APD, Former StudentE. Cox, MND, Community DietitianH. Porteous, GradDipNutDiet, APD, DietitianCorrespondence: J. Payne, School of Public Health, QueenslandUniversity of Technology, Victoria Park Road, Kelvin Grove, Qld4059, Australia. Email: j.payne@qut.edu.au

Nutrition & Dietetics 2007; 64: 93–98 DOI: 10.1111/j.1747-0080.2007.00094.x

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improving both initiation and continuation of breastfeedingduring at least the first two months post partum.6 Similarlyin community and public health settings, dietitians have thepotential to dramatically increase their contribution tobreastfeeding promotion and support by providing consis-tent breastfeeding messages and increasing the capacity andcritical mass in terms of human and other resources tocounteract threats to breastfeeding in Australia.7,8

Improving the vocational training of health professionalshas consistently been recommended in the research litera-ture to increase breastfeeding rates worldwide.9–12 The needfor breastfeeding training for dietitians has been noted,9 butmay receive little attention. For dietitians to make breast-feeding promotion and support a work priority, their voca-tional training should emphasise its important role andprovide students with adequate knowledge and skills. Moreimportantly, such training would seek to engender personalattitudes and beliefs that result in graduates who embracebreastfeeding as the biological norm rather than just a ‘betterchoice’ and develop personal and professional commitmentsand passion to promote it and to seek employment in thisarea.

Universities have a responsibility to maintain the qualityof their education provision.13 It was therefore through aquality assurance framework that staff at a major accreditedteaching program, in partnership with staff of the statehealth department and members of the local BreastfeedingPromotion and Training Coalition (Breastfeeding Coalition),committed to addressing the issue of breastfeeding voca-tional training within its nutrition-related courses.

The ongoing project described here aimed to betterdevelop the knowledge, skills, attitudes and beliefs of nutri-tion and dietetics graduates from the university empoweringthem to better support, promote and advocate for breast-feeding in their personal and professional lives. The presentpaper presents the baseline data from a survey of final-yearnutrition and dietetic students on their knowledge, attitudesand beliefs regarding breastfeeding.

METHODS

Initial project planning

To manage the project, a steering committee was formed ofrepresentatives from the local breastfeeding coalition, theDietitians Association of Australia’s representative for theBaby Friendly Hospital Initiative, two health departmentcommunity nutritionists working in breastfeeding promo-tion and a university representative. Three final-year nutri-tion and dietetic students were actively involved with theproject planning, implementation and evaluation as part oftheir community nutrition placements.

Sample

Although students from all years of training were surveyed,only the results of the final-year student cohort enrolled inundergraduate degrees in nutrition and dietetics at the

university are presented as their results describe the charac-teristics of students who had completed the majority offormal lectures prior to graduation.

Survey development

As no previously validated questionnaire applicable to thistarget group was identified, a questionnaire was developedfollowing recommended principles for questionnairedesign.14,15 As there were no industry standards for learningoutcomes relating to breastfeeding, question developmentwas overseen by a panel of experts and based on a set ofoutcomes considered desirable in graduate dietitians. Thedraft survey was piloted and a final survey comprising 50multiple choice questions produced. This included:• Seven questions profiling students• Twenty knowledge-based questions related to breastfeed-

ing as the biological norm (e.g. common myths, the physi-ology of breastfeeding) and current public health issues,policies and strategies

• Fifteen questions on attitudes and beliefs (to breast-feeding in a social/practical context and to currentrecommendations)

• Six questions relating to future breastfeeding intentions• Two questions relating to student perceptions of the

quality of breastfeeding training provided by theuniversity

Ethics approval to conduct the survey was granted by theUniversity Human Research Ethics Committee.

Dissemination of survey to students

The surveys were distributed by email in April 2005 as thestudents were attending practical placements off campus.Students were advised of the confidentiality of theirresponses and that the university would not receive data onindividual student’s results. They were asked to complete thesurvey without reference to lecture notes, texts or any otherinformation sources. Two email reminders were sent to stu-dents to encourage participation.

Analysis of survey data

Frequencies of responses were calculated using SPSS (SPSSInc., New Jersey, SPSS Version 11.0 2001). All surveys wereincluded for analysis.

RESULTS

Sample

Of the 41 enrolled final-year students, three were excludedfrom completing the survey because of their involvement inits development and implementation. From the 38 eligiblefinal-year students, 27 surveys were returned, resulting in aresponse rate of 71%. Most respondents (96%) completed allof the survey questions. As seen in Table 1, the respondentgroup characteristics were similar to the total cohort. Most

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participants (82%) were young (17–25 years), female (89%)and enrolled in the Bachelor of Health Science (Nutritionand Dietetic) degree (70%) rather than the double degreethat includes Human Movement Studies. None were parents.The majority responded that they were predominantlybreastfed as an infant (78%) with approximately 15% report-ing predominant feeding with infant formula and 7% beingunsure of how they were fed.

Knowledge relating to breastfeeding asthe biological norm

Results in Table 2 indicate that respondents appeared torecognise and understand the superiority of breast milk toartificial formula and recognise some myths such as the

influence of breast size on the ability to breastfeed. Themajority of respondents had knowledge of the physiology ofand factors influencing milk production, with 63% believingthat breastfeeding on demand allows the infant to self-regulate the right amount of milk for their needs and 72%knowing that a woman can produce more milk by increasingthe frequency of infant suckling. Conversely, there was apoor understanding of the relationship between the mother’sdiet and the quality of her breast milk. Only a small minorityof students could identify the increased health risks associ-ated with the use of artificial formula for the infant, with only19% of respondents identifying ear infections, 44% forinsulin-dependent diabetes mellitus, 19% for sudden infantdeath syndrome and 11% for conjunctivitis. Similarly, therewas poor knowledge of the increased risks for women of notbreastfeeding with only 19% of respondents identifying

Table 1 Profile of respondents compared with all final-year nutrition and dietetic students

CharacteristicRespondents, % (n)

(n = 27)Final-year students, % (n)

(n = 41)

Aged 17–25 years 81.5 (22) 80.5 (33)Aged >26 years 18.5 (5) 19.5 (8)Female 88.9 (24) 85.4 (35)Male 11.1 (3) 14.6 (6)Nutrition and Dietetics 70.4 (19) 80.5 (33)Nutrition and Dietetics and Human Movement (double degree) 29.6 (8) 19.5 (8)

Table 2 Results for true and false questions relating to breastfeeding knowledge

Knowledge question (correct answer)

Percentage of respondents (n = 26)

Correct answer Did not know Incorrect answer

Breast milk contains immunological factors that strengthen theinfant’s immune system (True)

96.2 3.8 0.0

Women with smaller breasts are less likely to be able to feedsuccessfully (False)

88.5 11.5 0.0

The amount of breast milk a woman produces is controlled by anendocrine positive feedback mechanism involving the pituitarygland (True)

57.7 42.3 0.0

If a breastfeeding woman does not consume a well-balanced diet,her breast milk will not be of adequate quality for infant growth(False)

26.9 23.1 50.0

The average duration of breastfeeding is a greater problem than therates of initiation within Australia (True)

76.9 19.2 3.8

The earlier in life a woman makes the decision to breastfeed, thelonger she will breastfeed for (True)

53.8 30.8 15.4

Infant growth charts are predominantly based on infant/artificialformula-fed babies (True)(a)

11.5 53.8 34.6

Infant/artificial formula presents a significant cost for parents (True) 100.0 0.0 0.0Infant/artificial formula use is associated with high cost to the

public health-care system (True)53.8 30.8 15.4

Australia has a National Breastfeeding Strategy (True) 84.6 15.4 0.0(a) The survey was completed before the World Health Organization Child Growth Standards were launched in 2006.

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increased risk of osteoporosis, 26% for ovarian cancer and67% for delayed post-partum weight loss. Only 12% ofrespondents knew that the infant growth charts available atthe time of the survey were predominantly based on datafrom infants who were artificial formula-fed.

Students were asked when breastfeeding should beavoided or ceased. Of respondents, 70% correctly identifiedthat breastfeeding should be ceased by HIV-positive mothersin Australia but 22% and 26%, respectively, incorrectlyselected that breastfeeding should be ceased if the infant hadlactose intolerance or if the mother had cracked nipples.

Knowledge relating to public healthissues, policies and strategies

Table 2 shows that all respondents were aware that usingartificial formula results in a significant cost to individualfamilies, and most knew that breastfeeding duration is agreater problem in Australia than initiation rates and that aNational Breastfeeding Strategy exists. However, only 54% ofrespondents identified that the use of artificial formula rep-resents a significant cost to the public health-care system.Similarly, only 54% knew that the earlier in life a womanmakes the decision to breastfeeding, the longer she will doso. Only 44% of students identified media portrayal ofbreastfeeding and artificial formula feeding as a documentedbarrier to breastfeeding.

Attitudes and beliefsrelating to breastfeeding insocial and practical contexts

Table 3 provides the results of selected questions on atti-tudes to breastfeeding. Seventy-seven per cent of respon-

dents reported that they did not feel embarrassed or uncom-fortable when seeing a woman breastfeeding, with 85%agreeing with public policy to support breastfeeding inpublic places. However, 69% reported that bottle feedingwas more socially acceptable and 40% of respondents didnot disagree with the statement that bottle feeding was easierfor everyone concerned. Little support was found for theinternational Baby Friendly Hospital Initiative’s policy thathospitals should only provide artificial formula to infantswhen medically warranted, as only 31% of respondentsagreed with this.16

Intentions of students regardingfuture practice

Table 4 describes students’ personal and professional inten-tions relating to breastfeeding. Most respondents reported acommitment and a responsibility to breastfeeding both atindividual and professional levels and believed they couldplay a role in influencing breastfeeding by women. However,only 8% of respondents reported that their course hadengendered a strong interest to work in an area involvingbreastfeeding.

Student perceptions as to the qualityand value of their university studiesregarding breastfeeding

No respondents reported that their university studies hadprovided a significant amount of material concerning breast-feeding, with 37% reporting that very little material wasprovided. The remainder of respondents perceived that theyhad received either only some material on breastfeeding or ageneral overview only.

Table 3 Attitudes and beliefs relating to breastfeeding

Statement

Percentage of respondents

Agree orstrongly agree Neutral

Disagree orstrongly disagree

‘I feel embarrassed or uncomfortable when I see a woman breastfeeding inpublic.’ (n = 26)

3.8 19.2 76.9

‘Bottle feeding is a more socially accepted way to feed an infant.’ (n = 26) 69.2 11.5 19.2‘Artificial/infant formula is an easier feeding method than breastfeeding for

everyone concerned (mother, family and friends).’ (n = 25)20.0 20.0 60.0

‘Using artificial/infant formula is preferable to breastfeeding because thefather can be more involved.’ (n = 26)

7.7 19.2 73.1

‘It is normal for a breastfeeding woman to require support from a range ofhealth professionals in order to breastfeed successfully.’ (n = 26)

57.7 23.1 19.1

‘Public policy should support women’s rights to breastfeed in public places.’(n = 26)

84.6 7.7 7.7

‘If women choose to artificially feed and it is not medically warranted,maternity hospitals should not supply infant/artificial formula to theirbabies.’ (n = 25)

30.8 15.4 53.8

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Limitations

The present study provides data for final-year nutrition anddietetic students attending one university and the generalis-ability of its findings to students of other universities is likelyto be limited. For this reason, it would be instructive toimplement the survey in other Australian universities andother relevant health professional courses. Although ques-tionnaires were developed with peer review and some trial-ling, wording and interpretation of questions by studentsmay have influenced responses. As surveys were distributedvia email, it was possible that some students researched theiranswers to the knowledge questions, even though they wererequested not to do so. Attitude responses may also havebeen influenced by students attempting to provide what theyperceived to be the desired responses to the questions toplease their fellow students and lecturers undertaking theresearch. Although this may have occurred, the potential fora positive bias only strengthens the argument to improve thecurriculum relating to breastfeeding in areas where knowl-edge and attitudes were identified as poor.

DISCUSSION

The identified deficits in students’ breastfeeding knowledge,attitudes and beliefs were noted. The literature also supportsthat there are gaps in the knowledge and practice of healthprofessionals12 and that these can be improved with train-ing.17 In relation to knowledge, the fact that many studentschose the ‘did not know’ option suggests that they may seekout the information in a practice setting, rather than provideincorrect information. Despite this, the fact that they did notknow key breastfeeding information so close to graduation isconcerning because these knowledge gaps have the potentialto reduce the capacity of new graduates to appropriatelyadvise and support mothers regarding breastfeeding andtheir desire to seek employment in this area.

A number of identified knowledge deficits have thepotential to result in the provision of information that mayreduce the duration of breastfeeding. These include deficits

in knowledge of the physiology and factors influencingmilk production and quality, and beliefs that breastfeedingshould cease in cases (such as cracked nipples and lactoseintolerance) where mothers only require sound clinicaladvice and support to maintain breastfeeding. A poorunderstanding of the derivation of infant growth charts, ifcoupled with lack of knowledge of the differences in thegrowth patterns of breastfed and artificial formula-fedinfants, is also likely to lead to recommendations to intro-duce supplementary feeds when breastfed babies encounter‘Catch Down Growth’.18

Respondents demonstrated attitudes supporting publicbreastfeeding policies. This was consistent with findingsfrom a survey of 2209 health professionals in NorthCarolina, where nutritionists and paediatricians were mostlikely to have positive beliefs about breastfeeding comparedwith other health professionals.10 However, graduates wereless sure of breastfeeding’s support by society in general andwere generally unaware of the health risks associated withthe use of artificial formula (when compared with breast-feeding) to mothers and infants and the national health costof artificial formula feeding. These attitudes and knowledgedeficits are likely to reduce the desire and ability of newgraduates to successfully advocate for breastfeeding in publichealth settings.

For many of our respondents, their scientific knowledgethat supports breastfeeding as the biological norm and theirconflicting social experience may have resulted in inconsis-tent and pragmatic responses to questions relating to futurepractice. The majority of students reported commitment tobreastfeeding both at individual and professional levels andfelt they could be effective future advocates for breastfeed-ing, yet few believed that their course had provided themwith detailed breastfeeding information and very few iden-tified a desire to work in the area in the future. Thesefindings appear similar to the results of a survey of Canadiannurses and dietitians that suggested a lack of perceivedcontrol or confidence to assist and advise women on breast-feeding is associated with a lower intention to work in thisarea.9 Lingering issues relating to women’s rights to choose

Table 4 Survey results relating to future breastfeeding intentions

Statement

Percentage of respondents

Agree orstrongly agree Neutral

Disagree orstrongly disagree

‘If I have children, I plan to breastfeed or support my partner to exclusivelybreastfeed for at least six months.’ (n = 26)

92.3 7.7 0.0

‘In my professional capacity as a nutritionist, I can directly (or indirectly)influence both a woman’s decision to breastfeed and the duration forwhich she will feed.’ (n = 26)

84.6 11.5 3.8

‘As a health professional, I believe it to be my responsibility to highlight thehealth problems associated with the use of infant/artificial formula whengiving advice about breastfeeding.’ (n = 26)

80.8 15.4 3.8

‘My studies thus far have engendered a strong interest in me to work in anarea that involves breastfeeding.’ (n = 25)

8.0 48.0 44.0

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may also explain why only 31% of respondents were com-mitted to the Baby Friendly Hospital Initiative’s policy toonly provide artificial formula on medical grounds.16 Theissue of the rights of the child to be breastfed was notcanvassed in the present survey; and the introduction of thisethical debate into the course curriculum may result inchanges in attitudes relating to this issue.19

As a result of these findings, university staff will incorpo-rate new strategies throughout the curriculum to improvelearning outcomes relating to breastfeeding. These strategieswill be evaluated over the next three years. The new programwill focus on improving not only the knowledge but also themotivation, passion and commitment required to effectivelyadvocate for breastfeeding. An awareness of potential roles ofgraduates and an interest in working in breastfeeding in thefuture will also be encouraged.

It is anticipated these findings will prompt reflection alsoon the current knowledge, attitudes and beliefs of othernutrition and dietetics students and indeed practitioners.This is particularly important because the intention of nursesand dietitians to support breastfeeding has been associatedwith the perceived professional norm.9 To combat the per-ception that breastfeeding is just the best of two choices,curriculum messages regarding breastfeeding should berevised so that, instead of the ‘Breast is Best’ concept, itshould be stated that artificial formula feeding has limita-tions, disadvantages and health risks.20 This would also beconsistent with the messages provided regarding other infanthealth decisions that have associated risks such as use ofmedications and maternal alcohol consumption. Arguably,these beliefs and interpretations influence dietetic practice interms of the priority given to breastfeeding, the action takenand the modelling provided to nutrition and dietetic stu-dents. To increase the priority of breastfeeding within theprofession, and consequently its importance within voca-tional training, the Dietitians’ Association of Australian coulddevelop a position paper on breastfeeding based on that ofthe American Dietetic Association. Competency standardsfor graduates could then be developed.

CONCLUSION

This project has provided baseline data on the currentbreastfeeding knowledge, attitudes, beliefs and intentions ofstudents undertaking nutrition and dietetic studies. It high-lights the need to incorporate interventions to improve thevocational training of these future health professionals inorder for them to adequately support and promote breast-feeding in their future practice. As with other areas of nutri-tion education, it suggests that addressing both knowledgeand attitudes is essential. Individuals not only need to beaware of the facts, capable of taking appropriate steps butalso be motivated to take positive action. Strategies toaddress these issues will be developed and their effectivenessassessed over the next three years. Further research, thedevelopment of industry standards, and continuing voca-tional and professional development are recommended to

continue to promote the capacity of the nutrition workforceto adequately support and promote breastfeeding.

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16 UNICEF and WHO. The Baby Friendly Hospital Initiative. 1991.(Cited 18 Oct 2005.) Available from URL: http://www.unicef.org/nutrition/index_24806.html

17 Vittoz JP, Labarere J, Castell M, Durand M, Pons JC. Effect of atraining program for maternity ward professionals on durationof breastfeeding. Birth 2004; 31: 302–7.

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