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Nursing Fundamentals 2: Critical Appraisal.

Sackett (2003) indicates that research should be carefully and critically appraised in order to assess its validity, trustworthiness and relevance. Nurses should incorporate evidence based practice into their profession, therefore it is vital that such professionals are able to judge the quality of available research. The critical appraisal skills programme (CASP) (2017), enables the analysis of different types of study (see Appendix A), with Aveyard, Sharp and Woolliams (2015) recommending the use of 6 questions for critical thinking when reviewing research (see Appendix B). These questions will form the basis of the critical appraisal of the following two sources from the case study.

Hayatbakhsh, M., O’Callaghan, M., Bor, W., Williams, G and Najman, J. (2012) ‘Association of breastfeeding and adolescents’ psychopathology; a large prospective study’, ​Breastfeeding Medicine, ​7(6), pp.480-486.

This timely qualitative study has been produced by the School of Population Health at the University of Queensland, Australia relatively recently in 2012. It focuses on a prospective cohort study and clearly addresses the effect of breastfeeding on the mental health and behaviours of children at 14 years of age. It is clear that the study attempts to detect the beneficial effect of breastfeeding at 6 months of age, although one major drawback of the approach is selection bias, which may affect the findings, as the participants would have to be compliant with the study (Collier and Mahoney, 1996). This means that the cohort may not be representative of the population as a whole if the subjects are sufficiently different and that the findings can not be generalised (Pannucci and Wilkins, 2010). The study involved a large number of participants, as it was based on 4,502 adolescents, although the authors fail to fully define confounding factors as described by Skelly, Dettori and Bordet (2012), which may alter the results, such as differing parenting techniques, life experiences and levels of wealth and education. Anxiety, depression, social problems, aggression, attention problems and delinquency were measured by the Achenbach Youth Self Report (YSR), however, this method of analysis has limitations in terms of how truthful the participants may be when completing the questionnaire. The measurement methods were standardised for all participants, with breastfeeding being assessed at the 6 month follow up for all adolescents taking part and data was taken from pre-birth and followed up to 14 years of age. The results indicate a statistically significant impact of 1 breastfeeding for at least 4 months on social and attention problems, as well as aggression, with fewer mental health and behavioural issues in these children at 14 years of age; the effect of variables such as maternal mental health, unplanned pregnancy and substance misuse during pregnancy was taken into account in the analysis of these results. It would have been more interesting if these children had been followed up for a further period in order to assess the longer term implications. Due to current limited available evidence on the protective relationship of breastfeeding and long term behavioural and mental health problems, the authors recognise the need for further research in this area before changes to clinical practice and policy can be recommended.

Al-Sahab, B., Laves, A., Feldman, M. and Tammi, H. (2010) ‘Prevalence and predictors of 6-month exclusive breastfeeding among Canadian women: a national survey’, ​BMC Paediatrics, 10(20), pp.1471-2431.

This peer reviewed, qualitative study is slightly more dated than the previous paper and was published in the BMC Paediatrics Journal. The methodology involves a survey and the same techniques can be used to critique this paper as with the previous study (Aveyard, Sharp and Woolliams, 2015). It aims to discover what socioeconomic and demographic predictors may influence 6 month exclusive breastfeeding among Canadian women, in order to assist policy makers in improving infant feeding techniques, as recommended by WHO (2003). The study was sponsored by the Public Health Agency of Canada and undertaken by Statistics Canada in 2006, both being respected professional institutions. The study was clearly focussed on whether women aged 15 years and older with singleton live births between November 2005 and May 2006 were exclusively breastfeeding at 6 months (WHO, 2003), using the Maternity Experience Survey (MES). The sample size was 5,615, being weighted to represent 66,810 women, in both the Canadian provinces and the territories, thereby representing a wide cross section of Canadian society. This means that there is less likelihood of selection bias (CASP, 2017). A regression model was used in order to account for any variables and to accurately measure the outcome in order to minimise bias. The results would seem to suggest that being educated for longer, living in more affluent areas, living with a partner, previous pregnancies, lower pre-pregnancy BMI, and being older was associated with greater chances of 6 month exclusive breastfeeding. In contrast, smoking during pregnancy, Caesarean section birth, admission of the infant to intensive care and maternal employment status appear to be associated with poor rates of exclusive breastfeeding by 6 months. It is clear from this study that exclusive breastfeeding rates by 6 months are poor in Canada (13.8%) and the need for further interventions to promote breastfeeding is implied, in order to meet the World Health Organisation (WHO) recommendation of exclusive breastfeeding for the first 6 months of life (2003). One limitation of this study is that it is cross-sectional and it does not measure the duration of breastfeeding longitudinally (Mann, 2003). A more comprehensive study 2 would include the depth of understanding and opinions on breastfeeding of the women, as well as the available support pre and post natally. However, it is one of the first studies of its kind to assess predictors of 6 month exclusive breastfeeding across Canada and is representative of the population.

Conclusion: ‘So What?’

Both papers apply to the individual in this case study. Potential protective effects of breastfeeding as described by Hayatbakhsh et al., (2012), may influence government policy and subsequent social influences to breastfeed, while Al-Sahab et al., (2010) confirms the effect of affluence, age and post secondary education on the duration of breastfeeding, which is the case with this patient. However, the importance of considering the individual’s unique experience when offering nursing advice and support is clear. Whilst the benefits of breastfeeding are demonstrated by both studies, the significance attributed to this health issue has compromised the overall well being of the individual and her family.

Reference List.

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