Protocol Development & Review Flashcards

A hospital protocol states that pacifiers should not be offered to breastfeeding newborns during the first 3-4 weeks. This recommendation is based on:

Answer: Concerns about nipple confusion and reduced breastfeeding frequency

Pacifier use in early weeks may reduce breastfeeding frequency and has been associated with shorter breastfeeding duration, which underpins this BFHI-aligned recommendation.

When a protocol includes a medication (such as domperidone for low milk supply), what MUST be specified?

Answer: Indications, contraindications, dosing, monitoring, and prescribing authority

Medication protocols must include clinical indications, contraindications, dosing guidelines, monitoring requirements, and which clinicians are authorized to prescribe.

A CLE is asked to write a protocol for skin-to-skin care after cesarean birth. Which evidence-based outcome should be highlighted in the protocol's rationale?

Answer: Improves breastfeeding initiation rates and maternal-infant bonding

Skin-to-skin care after cesarean birth is associated with improved breastfeeding initiation rates and enhanced maternal-infant bonding, which is the primary evidence-based rationale.

In a protocol for donor human milk (DHM) use in the NICU, which element is MOST critical for patient safety?

Answer: Screening, pasteurization verification, and informed consent procedures

DHM protocols must include rigorous donor screening, verification that milk has been pasteurized, and parental informed consent to ensure safety and ethical compliance.

A protocol is being pilot-tested on one unit before hospital-wide rollout. What is the PRIMARY purpose of piloting?

Answer: To identify practical barriers and refine the protocol before full implementation

Piloting allows identification of workflow gaps, staff confusion, or unintended consequences in a controlled setting before committing to a hospital-wide rollout.

A CLE is updating a protocol on hand expression and notices a step is inconsistently followed. The BEST way to address this within the protocol is to:

Answer: Add a rationale explaining why the step is important

Adding a brief rationale within the protocol helps staff understand the clinical importance of each step, increasing adherence to evidence-based practices.

Which body of evidence should a CLE prioritize when writing the evidence base for a new breastfeeding protocol?

Answer: Systematic reviews, meta-analyses, and clinical practice guidelines from recognized organizations

The highest levels of evidence — systematic reviews, meta-analyses, and guidelines from bodies like WHO, AAP, and ABM — should anchor the evidence base of any clinical protocol.