NICU nurses’ knowledge, attitudes, practices, and influencing factors regarding breastfeeding of newborns: a scoping review

Abstract

Background

Improved survival rates of high-risk neonates have been accompanied by persistent challenges in breastfeeding support within Neonatal Intensive Care Unit settings. While the World Health Organization strongly advocates for breastfeeding, global breastfeeding rates in NICUs remains suboptimal. NICU nurses play a key role in breastfeeding support, yet their knowledge, attitudes, and practices (KAP) remain systematically underexplored. This study aims to assess NICU nurses’ current levels of breastfeeding-related KAP and explore influencing factors, thereby identifying key intervention areas and providing evidence for targeted interventions and training programs.

Methods

This scoping review followed the Arksey and O’Malley framework and systematically searched Medline (Ovid), Embase (Ovid), Web of Science, Scopus, and CINAHL for studies published up to 6 April 2025. Studies were screened using predefined inclusion and exclusion criteria. Data were extracted and synthesized, focusing on NICU nurses’ breastfeeding-related knowledge, attitudes, practices, and influencing factors.

Results

Fourteen studies across nine countries were ultimately included. NICU nurses generally acknowledged the benefits of breastfeeding and maintained positive attitudes, particularly those who had received breastfeeding training. However, their professional knowledge was notably insufficient, particularly regarding lactation physiology and contraindications to breastfeeding. Consequently, positive attitudes did not consistently translate into standardized clinical practice, with notable variability in implementation and heavy reliance on personal experience. These knowledge-attitude-practice gaps were influenced by multiple factors operating at individual, institutional, and family levels. Furthermore, the assessment of KAP revealed significant methodological challenges, as the included studies used highly heterogeneous assessment tools, often self-designed or adapted, highlighting a lack of standardized KAP instruments tailored to NICU settings.

Conclusions

This review reveals a critical knowledge-attitude-practice gap in NICU breastfeeding support. While nurses’ attitudes are positive, their knowledge is deficient and practices inconsistent, a discordance driven by individual, institutional, and methodological challenges. Bridging this gap requires a multi-pronged strategy focused on competency-based training, supportive policies, and the development of validated, NICU-specific assessment tools.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-025-00807-4.

Background

Advancements in neonatal care have significantly improved the survival rates of preterm and high-risk infants, many of whom require extended hospitalization in neonatal intensive care units (NICUs). However, the NICU environment, characterized by intensive medical interventions and extended maternal-infant separation, presents substantial challenges to the initiation and maintenance of breastfeeding [1]. These challenges are further compounded by the physiological immaturity of preterm infants, such as poor coordination of sucking and swallowing, low birth weight, and underdeveloped gastrointestinal function [2]. As a result, appropriate feeding becomes a critical component of their survival and recovery [3].

Breastfeeding is universally recognized as the optimal mode of infant nutrition, offering significant health benefits for both mothers and infants [4]. For mothers, breastfeeding helps reduce the risk of postpartum hemorrhage, breast cancer, and ovarian cancer, while also enhancing maternal-infant bonding [5, 6]. For neonates, particularly those admitted to NICUs, breastfeeding is associated with lower rates of necrotizing enterocolitis, bronchopulmonary dysplasia, and late-onset sepsis, in addition to supporting long-term growth and neurodevelopment [7–9].

The World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) advocate for exclusive breastfeeding for the first six months of life [10, 11]. However, global breastfeeding rates remain below targets: in 2019, only 43.5% of infants worldwide were exclusively breastfed, with lower rates of 37% in low- and middle-income countries [12–14]. The situation is more concerning in NICUs, where exclusive breastfeeding rates at discharge among preterm infants vary widely from 16% to 49% in high-income settings [15], with rates as low as 9.3% reported in China [16].

While breastfeeding is well recognized and endorsed at theoretical and policy levels, numerous structural and systemic barriers hinder its implementation in NICUs. These barriers include non-companionable care models, prolonged maternal-infant separation, and inadequate infrastructure [17–19]. Within these constraints, NICU healthcare providers, particularly nurses, remain crucial to supporting breastfeeding during and after hospitalization [18]. Through their direct care and encouragement, nurses significantly influence maternal motivation, confidence, and breastfeeding competence. A large-scale survey involving 2,941 hospitals emphasized the importance of strengthening breastfeeding support systems by increasing the allocation of nursing staff dedicated to lactation guidance and education [20]. However, emerging studies indicate that optimizing this support requires a deeper understanding of NICU staff attitudes, beliefs, and knowledge regarding breastfeeding to inform the design of targeted training interventions [21].

As the frontline implementers and promoters of breastfeeding in NICU practice, nurses’ knowledge, attitudes, and practices (KAP) directly influence breastfeeding outcomes and neonatal health. According to the KAP model, knowledge serves as the cognitive foundation that shapes attitudes and subsequently guides practice behaviors [22]. In the context of breastfeeding support, “knowledge” refers to nurses’ understanding of lactation physiology, breastfeeding benefits, and clinical guidelines; “attitude” reflects their perceptions, beliefs, and motivation to promote breastfeeding; and “practice” represents their actual supportive behaviors and clinical interventions delivered to mothers and infants [23]. Understanding the interrelationships among these elements and their influencing factors is crucial to identifying gaps in NICU nurses’ breastfeeding-related competence and developing targeted educational interventions.

While research on improving breastfeeding rates has increased in recent years, most studies have focused on mothers and infants, with comparatively limited attention to the nursing workforce. Existing evidence suggests that many NICU nurses lack sufficient knowledge of human milk expression, storage, and feeding initiation for preterm infants [24]. Some also perceive breastfeeding very low birth weight infants as risky, which diminishes their confidence and willingness to provide support [25]. Moreover, most existing studies have been conducted in single centers or specific regions, employing heterogeneous methodologist and yielding disparate results. To date, no comprehensive evidence synthesis has examined NICU nurses’ breastfeeding-related KAP across diverse contexts. This knowledge gap hinders the development of evidence-based training and practice interventions. Given the dispersed and heterogeneous nature of the existing literature, a scoping review is particularly suitable for synthesizing such evidence to map the extent and nature of research, identify key themes, and highlight underexplored areas that warrant further investigation. Therefore, this scoping review aims to systematically map and synthesize existing research on NICU nurses’ breastfeeding-related knowledge, attitudes, practices, and influencing factors, ultimately seeking to identify key areas for intervention and provide evidence-based recommendations for clinical practice, nursing education, and policy formulation.

Methods

Design

This scoping review was conducted based on the framework proposed by Arksey and O’Malley [26] and followed the PRISMA extension for Scoping Reviews (PRISMA-ScR) reporting checklist [27]. The protocol was registered on the Open Science Framework Registry under the title, “Knowledge, Attitudes, Practices, and Influencing Factors of NICU Nurses on Newborn Breastfeeding: A Scoping Review” (osf-registrations-w32f5-v1).

Research questions

This scoping review sought to address the following research questions:

1. What is the current state of NICU nurses’ knowledge, attitudes, and practices regarding newborn breastfeeding?

2. What factors influence NICU nurses’ knowledge, attitudes, and practices in supporting breastfeeding in NICUs?

3. What assessment tools have been used to evaluate NICU nurses’ knowledge, attitudes, and practices related to breastfeeding?

Search methods

Two researchers systematically searched Medline (Ovid), Embase (Ovid), Web of Science, Scopus, and CINAHL, from their inception to 6 April 2025. The search strategy combined Medical Subject Headings (MeSH) and free-text terms, using Boolean operators to enhance both sensitivity and specificity. The search strategy included key terms related to NICU nurses (e.g., “NICU nurse”, “neonatal intensive care unit nurse”), breastfeeding (e.g., “breastfeeding”, “breast milk”, “lactation”), and knowledge, attitudes, practices, and influencing factors (e.g., “knowledge”, “attitude”, “practice”, “perception”, “barrier”, “facilitator”). Additionally, the reference lists of all included articles and relevant reviews were manually screened to identify any further eligible studies. Detailed search strategies for each database are provided in Additional file 1 (see Additional file 1).

Study selection

Studies were included if they met all of the following criteria: (1) the study population primarily comprised registered nurses working in NICUs; (2) the study focused on knowledge, attitudes, practices, perceptions, or influencing factors related to breastfeeding or lactation support for newborns; and (3) the study employed original research designs, such as cross-sectional, qualitative, or mixed-methods approaches. Studies were excluded if they: (1) included only non-registered caregivers, nursing students, or medical students as participants; (2) lacked full text availability or contained incomplete relevant data. No language restrictions were applied to the search to ensure comprehensive coverage of relevant literature. Two researchers (HMP, XL) independently screened titles and abstracts against the eligibility criteria. Subsequently, the full texts of potentially eligible studies were retrieved and independently assessed by the same researchers, with reasons for exclusion documented. Disagreements during the screening process were resolved through discussion or consultation with a third reviewer (YL).

Data charting

A standardized data extraction form was developed and pilot-tested prior to implementation. Two reviewers (HMP, XL) independently extracted key information from each included study, including bibliographic details, study characteristics, participant demographics, assessment tools, measured outcomes (knowledge, attitudes, and practices), and influencing factors. The extracted data were subsequently cross-checked by a third reviewer (YL), with any discrepancies resolved through team consensus.

Data synthesis and reporting

Data were synthesized using descriptive statistics and narrative summaries. Results were categorized into three primary domains: knowledge, attitudes, and practices. Furthermore, influencing factors were inductively summarized and organized into emerging themes for clarity. Reporting process adhered to the PRISMA-ScR guidelines [27], focusing on identifying gaps in the existing literature and implications for clinical nursing practice. Consistent with established scoping review methodology, no formal quality assessment was undertaken, as the primary aim was to map the extent and nature of available evidence rather than to evaluate study quality. Findings were presented using tables, figures, and narrative descriptions to enhance clarity and comprehension.

Results

Included studies

The systematic search identified 806 records from Medline Ovid (n = 51), Embase Ovid (n = 222), Web of Science Core Collection (n = 96), Scopus (n = 254), and CINAHL (n = 183) databases. After removing 380 duplicates, 426 unique records remained. Title and abstract screening excluded 382 records, leaving 44 for full-text review. Of these, 31 were excluded for not meeting the inclusion criteria. One additional study was identified through reference screening, yielding 14 studies for final inclusion [24, 25, 28–39]. Figure 1 presents the selection process following PRISMA-ScR guidelines [40].

Fig. 1.

The PRISMA-compliant study selection process

Study characteristics

Characteristics and main findings of the included studies are presented in Table 1. The 14 included studies, published between 2000 and 2024, represented nine countries: the United States (n = 4), China (n = 3), Korea, Sweden, Colombia, Jordan, Thailand, Turkey, and Italy (n = 1 each). Study designs comprised qualitative approaches (n = 7); phenomenological, inductive, participatory, ethnographic), cross-sectional surveys (n = 4), descriptive (n = 1), prospective (n = 1), and pre-post designs (n = 1). Eight studies were multicenter and five single-site; one did not specify setting. Participants were predominantly NICU nurses, with some studies including lactation consultants. Sample sizes ranged from 5 to 252 participants (mean age: 28.9–41.5 years). Educational backgrounds spanned vocational training to postgraduate degrees, with clinical experience ranging from novice to senior-level. Notably, over half of participants in several studies had received breastfeeding training, while more than 40% reported personal breastfeeding experience in others.

Table 1.

Characteristics of the included studies

Study (Country)	Study Design	Setting	Sample Characteristics	Assessment Methods/Tools	Main Findings
Bernaix 2000 (USA)	Prospective study	Two metropolitan teaching hospitals	• Total sample: 151 • Mean age (M ± SD, years): 38.9 ± 9.6 • Education level: basic nursing education preparation in a diploma program (69%), associate’s degree program (17%), bachelor’s degree program (15%). Three of the diploma nurses and one of the associate’s degree nurses had later earned bachelor’s degrees. • Working experience: 10.8 ± 7.8 • Training experience: NR • Breastfeeding experience: NR	Nurses’ Support for Breastfeeding Questionnaire (NSBQ, based on theory of reasoned action)	Knowledge: • Scores ranged from 7 to 16, with a mean of 12.3 ± 2.9. Seven of the nurses had a perfect score. Attitudes: • Attitude scores from the 48 nurses who responded ranged from − 2 to + 24, with a mean of 12.9 ± 6.6, indicating a moderately positive attitude toward providing breastfeeding support. Practices: • Scores on the Behavioral Beliefs subscale ranged from 346 to 857, with a mean of 661 ± 121, indicating a moderately positive attitude about the outcomes of providing breastfeeding support. Influencing factors: NR
Chen 2024 (China)	Cross-sectional survey	Nine hospitals with independent neonatal departments and NICUs in Qianxinan Prefecture, Guizhou Province	• Total sample: 193 • Mean age (M ± SD, years): NR • Education level: vocational high school (0.5%), Associate degree (19.2%), Bachelor’s degree (80.3%) • Working experience: 1-5years (22.2%), 6-10years(32.1%), > 11years (45.6%) • Training experience: 33.2% (64/193) received breastfeeding training • Breastfeeding experience: NR	• A self-designed the knowledge, attitudes, and practices related to breastfeeding in NICUs – Cronbach’s alpha coefficient = 0.86	Knowledge: • The participants’ total mean score: 4.45 ± 1.57 points out of 7 points. Attitudes: • The participants’ total mean score: 32.15 ± 4.83 points out of 45 points. Practices: • The participants’ total mean score: 23.49 ± 3.55 points out of 35 points. Influencing factors: • The parents of the infants were uncooperative with breastfeeding • Insufficient medical and nursing staff • Lack of establishment or implementation of breastfeeding • management policies • Inadequate awareness among doctors and nurses about the importance of breastfeeding • Excessive workload in the department
Cricco-Lizza 2016(USA)	Qualitative design	NICU	• Total sample: 18 • Mean age (M ± SD, years): 33 • Education level: Nursing diplomas (11.1%), Associate’s degree (5.5%), Bachelor’s degrees (77.7%), Master’s degree (5.5%) • Working experience: NR • Training experience: About 50% of these key informants had taken the hospital breastfeeding course • Breastfeeding experience: NR	Formal, 1-hour, tape-recorded interview	Themes related to breastfeeding knowledge and attitudes: Three themes emerged: • Theme 1: The nurses identified health benefits of breastfeeding, but spoke in greater detail and with more emotion about day-to-day challenges of breastfeeding in the NICU. • Theme 2: Formula feeding evoked less emotion, and most nurses viewed it as safe and convenient. • Theme 3: Nurses with training or positive breastfeeding experiences highlighted evidence-based benefits and showed stronger commitment to supporting breastfeeding. Influencing factors: NR
Feng 2022(China)	Descriptive phenomenological qualitative approach	Shanghai First Maternity and Infant Hospital	• Total sample: 15 • Mean age (M ± SD, years): NR • Education level: Bachelor’s degrees (80%), Master’s degree (20%) • Working experience: 6–10 years (46.7%), 11–15 years (13.3%), 16–20 years (13.3%), 21–25 years (6.7%) • Training experience: NR • Breastfeeding experience: NR	In-depth, semi-structured interviews	Practices: Four overarching themes: • Theme 1: Extending the education duration(prenatal to postpartum) • Theme 2: Enriching the educational content(mechanism, skills, misconceptions) • Theme 3: Expanding the education subjects (mothers, husbands, family, caregivers) • Theme 4: Perfecting the educational process(standardization, repetition, nurse training) Influencing factors: NR
Jin-Suk 2013(Korea)	Descriptive study	Seven university hospital NICUs in Seoul, Daejeon, and Daegu	• Total sample: 153 • Mean age (M ± SD, years): 28.86 ± 5.84 • Education level: Junior college (29.4%), 4 years university (57.5%), Master’s degree (13.1%) • Working experience: <1 years (20.3%), 1-3years (28.1%), 3–5 years (13.1%), 5–10 years (30.7%), ≥ 10 (7.8%) • Training experience: NR • Breastfeeding experience: Yes (N = 27), No (N = 6)	• Modified 24-item knowledge questionnaire – Kuder-Richardson 20 (KR-20) coefficient = 0.78 • the Iowa Infant Feeding Attitude Scale (IIFAS) – Cronbach’s α = 0.72 • Breastfeeding Knowledge and Nursing Activity Tool – Cronbach’s α = 0.96	Knowledge: • The participants’ total mean score: 14.07 ± 4.21 points out of 24 points. Attitudes: • The participants’ total mean score: 63.00 ± 6.98 points out of 84 points. Practices: • The participants’ total mean score: 97.66 ± 22.14 points out of 150 points. Influencing factors:NR
Mörelius 2022 (Swedish)	Qualitative inductive approach	Three Swedish FC NICUs	• Total sample: 9 • Mean age (M ± SD, years): 41.5 • Education level: Six of the participants were post-graduate specialists in pediatric and neonatal nursing including a one-year Master of Science degree and three were under-graduate nurses with a Bachelor of Science degree • Working experience: NR • Training experience: NR • Breastfeeding experience: Six had their own experience of breastfeeding	Face-to-face interviews	Attitudes and Practices: • Main category: “A complex and long-lasting collaboration.” Nurses viewed feeding extremely preterm infants as a vulnerable process requiring both practical and emotional support for parents. They emphasized empowering families, promoting milk production, and involving all family members in feeding, consistent with FC NICU principles. Influencing factors: NR
Ochoa Marín 2023 (Colombia)	Qualitative action-participatory research	In the NICU of a hospital in the city of Medellín	• Total sample: 5 • Mean age (M ± SD, years): NR • Education level: NR • Working experience: Their experience in breastfeeding counseling ranged from 5 to 16 years, and their professional experience in the healthcare field ranged from 13 to 21 years • Training experience: All five participants were certified in breastfeeding counseling • Breastfeeding experience: NR	Semi-structured interviews	Knowledge: • Breastfeeding culture, which includes institutional breastfeeding policy and process standardization. Practices: • Quality, which includes activity recording and control; • Indicator monitoring and continuous auditing. Influencing factors: NR
Shattnawi 2017(Jordan)	Ethnographic research design	Two NICUs in Jordan	• Total sample: 15 • Mean age (M ± SD, years): 35 • Education level: Diploma (6.7%), Baccalaureate (53.3%), Master (6.7%), Neonatology (33.3%) • Working experience: 0-5years (40%), 6-10years (13.3%), > 11 (46.7%) • Training experience: NR • Breastfeeding experience: Yes (33.3%), No (26.7%), NA (40%)	Participant observation and semistructured interviews	Attitudes: Three key themes emerged: • Theme 1: The first described the contradiction that exists between the staff beliefs and behaviors in relation to breastfeeding and supporting mothers. • Theme 2: The second theme was related to staff working conditions, which described the lack of institutional support and barriers to supporting breastfeeding. • Theme 3: The final theme of controlling relationships captured the essence of the practitioner to mother association. Influencing factors: • The lack of institutional support and barriers to supporting breastfeeding
Smith 2016 (USA)	Pre-test/post-test study design	A northeastern tertiary children’s hospital NICU	• Total sample: 18 • Mean age (M ± SD, years): 41.4 • Education level: NR • Working experience: Total years in a NICU (mean): 11–15 • Training experience: NR • Breastfeeding experience: NR	Participants completed a 10-question pre-test evaluating their knowledge regarding the early initiation of breastfeeding. Following the pre-test, participants engaged in a 20-min PowerPoint integrated literature review presentation	Knowledge: • The NICU staff was divided regarding the existence of a unit protocol for the initiation of breastfeeding in preterm infants. 44.4% (n = 8) reported that such a policy exists compared to 33.3% (n = 6) who reported that a policy did not exist within the unit. Attitudes: • Most participants 77.8% (n = 7) reported that the educational program changed or reinforced their ideas about the early initiation of breastfeeding in preterm infants. Practices: • However, only 33.3% (n = 3) reported making an actual change to their practice as a result of the program. Influencing factors: • Barriers included lack of awareness of evidence, maternal absence, insufficient/inconsistent kangaroo mother care (KMC) support, and family dysfunction.
Srichalerm 2024(Thailand)	Descriptive phenomenological approach	Three medical centers in the central region of Thailand	• Total sample: 13 • Mean age (M ± SD, years): NR • Education level: NR • Working experience: NR • Training experience: NR • Breastfeeding experience: NR	Semi-structured questions	Themes related to breastfeeding knowledge, attitudes, and Practices: The five main themes presented in the data were as: • Theme 1: Positive attitude toward breastfeeding and human milk; • Theme 2: Facing breastfeeding challenges at work; • Theme 3: Self-confidence rooted in experience; • Theme 4: Professional skill needs; and • Theme 5: Requiring further support. Influencing factors: NR
Suluhan 2023(Turkish)	Cross-sectional descriptive survey design	NR	• Total sample: 252 • Mean age (M ± SD, years): 30.26 ± 6.76 • Education level: High school(27.4%), Graduate(59.9%), Postgraduate(12.7%) • Working experience: ≤1 (62.4%), 2–5 (13%), 6–10 (11.1%), > 10 (13.5%) • Training experience: NR • Breastfeeding experience: NR	• Data collection tools included a data collection form, Survey Questionnaire, and Iowa Infant Feeding Attitude Scale (IIFAS) – Cronbach’s α = 0.86	Attitudes • The IIFAS median score of the participants was 70.0 (IQR = 9.0). – Participants who were age between 26–30 years (n = 76, 30.2%), had post-education degree in nursing (n = 32, 12.7%), and attended to international scientific meetings (n = 47, 18.6) had higher positive attitudes of breastfeeding. The nurses (n = 126, 50%) stated that it was difficult to reach mothers in terms of breastfeeding for newborns, and 61.8% of them (n = 156) stated that they had difficulty initiating the mother-baby attachment process in the NICU.
Vizzari 2020(Italy)	Multicenter cross-sectional survey	Six NICUs in Lombardy, Northern Italy	• Total sample: 10.3% (19/183) • Mean age (M ± SD, years): 36.9 ± 9.3 • Education level: NR • Working experience: 11.1 ± 9.5 • Training experience: Other specific training on breastfeeding in 11.5% of cases • Breastfeeding experience: NR	Questionnaire based on the Breastfeeding Support Tool	Themes related to breastfeeding knowledge, attitudes, and Practices: • Nurses demonstrated awareness of early breast milk expression (start within 12 h; 6–8 times/day) and transition practices from tube feeding to breastfeeding. • Majority supported unrestricted maternal presence (75%), early maternal involvement, importance of breastfeeding training (98%), and feasibility of breast pumping (97.3%). • Reported advising mothers on pumping schedules; 67% cited facility availability as key to feasibility; 53% allowed skin-to-skin contact as soon as parents were present, 47% after stability. Influencing factors:NR
Weddig 2010(USA)	Qualitative study	Eight state hospitals	• Total sample:40 • Mean age (M ± SD, years): NR • Education level: More than one half of the nurses had a bachelor of science degree in nursing (BSN), and three had a master of science degree in nursing (MSN) • Working experience: NR • Training experience: NR • Breastfeeding experience: 8.5years	Focus groups on hospital policies, nurses’ knowledge and attitudes, and breastfeeding practices in the first 72 h; content validated by RN and IBCLC	Knowledge: • Nurses generally reported knowledge of evidence-based breastfeeding initiation, but in non-Baby Friendly settings, knowledge often did not match current best practices. • Hospital policies and actual practices were sometimes inconsistent with evidence-based recommendations. Influencing factors: • Hospital lactation policies (formal and informal), nurses’ limited education in breastfeeding initiation best practices, high rates of surgical delivery, and lack of continuity of care with the transition of responsibility from one nurse to another from labor and delivery to transition care to postpartum care
Yang 2018(China)	Cross-sectional survey	Nine tertiary level neonatal intensive care units	• Total sample: 180 • Mean age (M ± SD, years): 30.48 ± 6.76 • Education level: Junior college (34.4%), Undergraduate (55%), Postgraduate or PhD (10.6%) • Working experience: ≤ 5years (62.8%), 6–10years (25%), > 10years (12.2%) • Training experience: NR • Breastfeeding experience: Personal breastfeeding experience (44.4%)	• The survey included three sections: (1) demographic information, (2) breastfeeding knowledge in the preterm infant population (knowledge questionnaire), (3) training assessment related to breastfeeding preterm infants – Cronbach’s alpha = 0.941	Knowledge: • The average breastfeeding knowledge total score was 24.18 ± 4.17 with the range of scores from 34 to 12, highest to lowest respectively. The mean percentage of healthcare providers who correctly answered questions was 53.73%. The majority of the respondents (79.4%) had a score that was 60% (27/45) or below. Influencing factors: • Profession, professional title and sex

KMC, Kangaroo Mother Care; NICU, Neonatal Intensive Care Unit; IBCLC, International Board Certified Lactation Consultant; IQR, Interquartile Range; M ± SD, Mean ± Standard Deviation; NR, Not Reported

Knowledge, attitudes, and practices in breastfeeding

Among the included studies, nine assessed knowledge, nine examined attitudes, and eight reported practices related to breastfeeding. Knowledge assessment revealed paradoxical findings. While most NICU nurses demonstrated awareness of breastfeeding’s general benefits for neonatal health [25, 28, 30, 36, 38, 39], this basic understanding masked significant clinical knowledge deficits. Nurses showed partial competence in practical areas such as recognizing feeding cues, timing of milk expression, and appropriate pumping frequency [24, 39]. However, substantial gaps emerged in critical areas including lactation physiology, breastfeeding management strategies [28, 32], and individualized care for preterm infants [35]. Additional deficiencies included inadequate understanding of breastfeeding duration recommendations, contraindications, and feeding-related decision-making [29, 39]. Most concerning was that approximately 49% of nurses incorrectly recommended bottle feeding, reflecting fundamental misconceptions about overfeeding risks and alternative feeding methods [24].

In contrast to knowledge deficits, attitude assessments consistently revealed positive orientations toward breastfeeding. Multiple studies reported favorable attitude scores, with Bernaix et al. documenting a mean score of 12.9 ± 6.6 [28] and Jin-Suk et al. finding 3.70 ± 0.41 [32], both indicating supportive attitudes. Although Shattnawi et al. noted a mismatch between attitudes and practice [25], nurses generally agreed on the importance of initiating breastfeeding in physiologically stable preterm infants [35]. Additionally, studies underscored nurses’ endorsement of maternal presence and their widespread recognition of the need for structured breastfeeding education [24].

Despite positive attitudes, practice assessment revealed the most significant implementation challenges. The included studies demonstrated substantial variability in NICU nurses’ supportive behaviors and clinical implementation. While some nurses engaged in supportive actions such as pre- and post-feeding weight checks [24], skin-to-skin contact facilitation, and emotional support provision [24, 33], these practices were not universal. Multiple studies highlighted critical gaps, including the absence of standardized protocols, inconsistent guideline implementation, and limited structured training [29, 31, 34, 35]. Of particular concern, clinical decisions were often experience-based rather than evidence-based [36], while current education efforts were deemed insufficient in scope and depth [31].

Factors influencing knowledge, attitudes, and practices

The factors influencing NICU nurses’ KAP operate operated across three interconnected levels (see Fig. 2). At the institutional level, systemic barriers emerged as primary impediments to effective breastfeeding-related practices. These included insufficient staffing, heavy workload, absent or poorly implemented breastfeeding-related policies, and limited organizational support [25, 29, 38]. These institutional constraints limited nurses’ ability to apply their knowledge and positive attitudes in consistent clinical practice. At the individual level, multiple personal and professional factors shaped nurses’ KAP outcomes. Key determinants included inadequate systematic training, limited understanding of evidence-based practices, over-reliance on personal experience, and variations in professional characteristics such as job category, title, and gender [29, 35, 39]. In particular, nurses with prior breastfeeding training or personal breastfeeding experience were more likely to express positive attitudes toward breastfeeding [30]. The interaction between these individual factors and institutional constraints resulted in practice variations that compromised care standardization. At the family level, limited maternal bedside presence, insufficient family support, and poor communication patterns emerged as significant barriers [35]. These factors often intersected with institutional policies regarding visitation and parental involvement, further complicating family-centered care implementation.

Fig. 2.

Factors Influencing NICU Nurses’ Breastfeeding KAP

Assessment methods and instruments for KAP evaluation

Considerable methodological heterogeneity characterized KAP assessment across studies. Qualitative studies employed various approaches including semi-structured interviews, focus groups, and observations, yet lacked standardized protocols for cross-study comparison. Quantitative studies predominantly relied on modified or self-developed instruments with limited validation. Specifically, different tools were utilized for each KAP domain. For overall KAP assessment, Bernaix et al. designed the Nurses’ Support for Breastfeeding Questionnaire (NSBQ) based on the Theory of Reasoned Action [28], while Chen et al. developed a comprehensive questionnaire with good internal consistency (Cronbach’s α = 0.86) [29]. For knowledge assessment, Jin-Suk et al. adapted a 24-item tool originally created by Brodribb et al. and revised by Ahmed et al. (KR-20 = 0.78) [32]. The Iowa Infant Feeding Attitude Scale (IIFAS) emerged as the most frequently used attitude measure (Cronbach’s α = 0.72 to 0.86) [32, 37], while Jung et al.’s 30-item Breastfeeding Nursing Activity Scale evaluated practices (Cronbach’s α = 0.96) [37]. However, no comprehensively validated NICU-specific KAP instrument was identified, constituting a critical barrier to research advancement and quality improvement.

Discussion

This scoping review systematically synthesized current evidence on the knowledge, attitudes, and practices of NICU nurses regarding breastfeeding, revealing a substantial disconnect between positive intentions and actual clinical practice. Unlike previous reviews that focused on mothers’ breastfeeding experiences or physicians’ clinical roles, this review emphasizes nurses as the key bedside providers whose competencies directly influence breastfeeding outcomes. We found that although nurses generally hold favorable attitudes, their knowledge base has significant gaps, and their practices are inconsistent. This knowledge-attitude-practice gap is compounded by a range of multi-level influencing factors and a notable lack of standardized assessment tools. These findings underscore the urgent need for comprehensive, multi-faceted strategies to empower NICU nurses, thereby improving care quality and neonatal health outcomes.

First, a central finding of this review is the paradoxical relationship between nurses’ attitudes and their knowledge. In general, NICU nurses widely recognize the health benefits of breastfeeding for neonates, especially those at high risk or born prematurely, a finding consistent with prior studies [41–43]. This positive disposition, however, is often built on a fragile foundation of incomplete knowledge. This review revealed significant knowledge deficits among nurses, particularly in breastfeeding physiology and individualized clinical management, including feeding plans, breastfeeding duration, and contraindication identification. Some nurses made incorrect judgments when recommending alternative feeding methods, potentially compromising the continuity and scientific basis of breastfeeding support. These knowledge disparities may be attributed to cross-country differences in basic education, in-service training, and clinical experience [36, 39, 44]. For instance, an Australian study reported that medical staff often face limited opportunities to acquire structured breastfeeding knowledge during their professional education [45]. Our review reinforces this, showing that some NICU nurses demonstrated an inaccurate understanding of breastfeeding contraindications [29, 39], despite the WHO’s stance that absolute contraindications are rare [46]. This reality highlights the critical importance of providing NICU nurses with systematic and continuously updated training in breastfeeding knowledge to build a robust knowledge base that can truly support their positive attitudes.

Furthermore, the pronounced attitude-practice gap challenges conventional assumptions about healthcare behavior change. As this review indicates, positive attitudes have not been reliably translated into consistent, standardized clinical practices. This discordance suggests that the traditional linear KAP model may not fully explain nursing behavior in complex NICU settings. Our findings indicate that positive attitudes, while necessary, are insufficient when confronted with systemic barriers such as workload pressures, inadequate resources, and a lack of standardized protocols [25]. The predominance of experience-based over evidence-based practice [36] further highlights the disconnect between theoretical support and practical implementation. This gap is particularly problematic given that NICU mothers urgently require both emotional and practical breastfeeding support [47, 48]. Consequently, nurses’ inability to provide consistent, skilled support may significantly undermine maternal confidence and breastfeeding continuation.

The multi-level influences identified in this review necessitate comprehensive, systems-based interventions rather than isolated educational approaches. At the individual level, the positive correlation between personal breastfeeding experience and professional competence [39, 49] suggests that experiential learning plays a crucial role, yet this should complement rather than replace formal education. Professional characteristics including gender, title, and years of experience also influenced practice patterns [39, 50], potentially reflecting differential exposure to training opportunities and clinical scenarios. These findings have significant implications for nursing education curricula, which should incorporate both theoretical breastfeeding knowledge and hands-on clinical skills training specific to NICU environments. At the institutional level, the identified barriers — understaffing, policy gaps, and limited organizational support [39, 51, 52] — create structural impediments that individual motivation cannot overcome. These findings align with previous research emphasizing institutional preparedness as fundamental to successful breastfeeding support programs.

Evidence from the Neo-Baby Friendly Hospital Initiative (Neo-BFHI) demonstrates that structured, hospital-wide implementation of breastfeeding-supportive policies and training can effectively address these barriers [53, 54]. Following Neo-BFHI implementation, healthcare professionals across all NICU staff groups showed significant improvements in breastfeeding-related attitudes, and hospitals achieved notable progress in breastfeeding support practices [55]. Building on these findings, institutional policies must shift from merely encouraging breastfeeding to actively promoting it. First, clear, evidence-based NICU-specific breastfeeding protocols should be established to reduce reliance on experience-based practice. Second, supportive resources should be provided, including the integration of IBCLC specialists and optimized nurse-to-patient ratios to allow dedicated breastfeeding support time. Third, institutional policies should mandate regular competency assessments and continuing education requirements for NICU nurses. Furthermore, consideration should be given to incorporating breastfeeding support into recognized nursing quality indicators to enhance its institutional prioritization. At the family level, limited parental presence and support [56, 57] represent missed opportunities for collaborative care, particularly given evidence that paternal involvement enhances breastfeeding continuity. The failure to achieve true family-integrated care contradicts contemporary family-centered care principles [58] and may undermine post-discharge breastfeeding success.

Finally, a critical finding is the methodological heterogeneity in KAP assessment, which has profound implications for evidence synthesis and quality improvement. The absence of validated, NICU-specific assessment tools not only limits research comparability but also impedes the development and evaluation of targeted interventions. While some studies employed validated general instruments like IIFAS [32, 37], these tools may not capture the unique competencies required in NICU settings. This measurement gap creates a vicious cycle: without standardized assessment, it is impossible to accurately identify competency gaps, design appropriate interventions, or evaluate their effectiveness. The development of psychometrically sound, culturally adaptable, NICU-specific KAP instruments should therefore be a clear research priority to break this cycle and advance evidence-based practice.

Limitations

While this review provides a comprehensive overview, several limitations should be acknowledged. First, the number of included studies was limited and predominantly qualitative, restricting causal inference. Second, there was high heterogeneity in study methods, compounded by a general lack of standardized measurement tools with proven reliability and validity. In particular, the absence of NICU-specific, psychometrically tested KAP instruments, which weakens the comparability and robustness of the synthesized results. Third, potential publication bias cannot be ruled out, which may have influenced the synthesized results. Finally, the geographical distribution of studies was uneven, with a predominance of research from China and the United States, which may affect the generalizability of findings. Therefore, future research should employ rigorous designs including multicenter studies with validated instruments and mixed-methods approaches to strengthen the evidence base.

Conclusions

This scoping review reveals a critical paradox in NICU breastfeeding support: while nurses’ attitudes are overwhelmingly positive, their clinical knowledge and practices remain inconsistent and suboptimal. The identified knowledge-attitude-practice gap is perpetuated by a triad of challenges: foundational knowledge deficits, systemic institutional barriers, and a critical lack of validated assessment tools. These factors collectively undermine the translation of pro-breastfeeding policies into consistent, high-quality clinical care. Bridging this gap requires a multi-pronged strategy. Priority must be given to implementing competency-based training that moves beyond theory to practical skills, establishing supportive institutional policies that alleviate workload pressures, and fostering true family-integrated care. Crucially, future research must prioritize the development and validation of standardized, NICU-specific KAP instruments. Such tools are essential for diagnosing competency gaps, evaluating interventions, and elevating breastfeeding support standards for vulnerable neonates. Strengthening NICU nurses’ breastfeeding competencies is not merely a clinical quality imperative but a critical pathway to achieving WHO/UNICEF’s global target of 50% exclusive breastfeeding rates. As frontline providers who translate policy into practice, empowering nurses is pivotal to realizing these international health goals and improving outcomes for the world’s most vulnerable neonates.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

IBCLC

International Board Certified Lactation Consultant

KAP

Knowledge, Attitudes, and Practices

Neo-BFHI

Neo–Baby-Friendly Hospital Initiative

NICU

Neonatal Intensive Care Unit

UNICEF

United Nations Children’s Fund

WHO

World Health Organization

Author contributions

HMP drafted the manuscript and contributed to its revision. XL, XMG, YXL, and XH were responsible for data acquisition and analysis. LNZ and CML contributed to data interpretation. YL and YLH provided conceptual guidance, supervised the study, and substantially revised the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by the Sichuan Province Nursing Association [grant number H23020]; the Sichuan Medical Association [grant number Q2024011]; the Chengdu Science and Technology Bureau [grant number 2024-YF05-00503-SN]; and the 2025 Hospital Management Research Project of West China Second University Hospital [grant number GLYJ2025-12]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Human ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.