CLE Protocol Development & Review 2 — Questions and Answers
Question 1: When reviewing an existing breastfeeding protocol, which element should be assessed FIRST to determine if it needs revision?
- Staff satisfaction with the protocol
- The date of last review and evidence currency (Correct answer)
- The number of pages in the document
- Whether the protocol is laminated
Correct answer: The date of last review and evidence currency
Protocols should be reviewed regularly (typically every 2-3 years) and updated when new evidence emerges, so checking the last review date and evidence currency is the first step.
Question 2: A CLE is developing a protocol for nipple pain management. Which intervention should be listed as FIRST-LINE?
- Prescribing topical antibiotics
- Assessing and correcting latch technique (Correct answer)
- Recommending nipple shields immediately
- Advising temporary cessation of breastfeeding
Correct answer: Assessing and correcting latch technique
Most nipple pain is caused by poor latch, so assessing and correcting latch is the evidence-based first-line intervention before other measures.
Question 3: In a hospital breastfeeding protocol, which department or role should approve the final document before implementation?
- The unit's most experienced nurse
- A multidisciplinary committee including medical staff (Correct answer)
- Only the lactation department
- The hospital marketing team
Correct answer: A multidisciplinary committee including medical staff
Institutional protocols require approval by a multidisciplinary committee that typically includes physicians, nurses, and lactation specialists to ensure broad clinical validity.
Question 4: A protocol states that all newborns should be offered the breast within 30 minutes of birth. This aligns with which established guideline?
- La Leche League International guidelines
- WHO/UNICEF Baby-Friendly Hospital Initiative (Correct answer)
- AAP Safe Sleep Campaign
- CDC Growth Chart Standards
Correct answer: WHO/UNICEF Baby-Friendly Hospital Initiative
The WHO/UNICEF BFHI recommends initiating breastfeeding within the first hour of birth, and protocols should support early skin-to-skin and early first feed.
Question 5: When writing the 'purpose' section of a lactation protocol, the CLE should focus on:
- Listing all staff members responsible
- Defining the measurable outcomes the protocol aims to achieve (Correct answer)
- Describing the history of breastfeeding research
- Enumerating equipment costs
Correct answer: Defining the measurable outcomes the protocol aims to achieve
The purpose section should clearly state the protocol's goal and measurable outcomes so staff understand what the procedure is designed to accomplish.
Question 6: A CLE notices that a unit's formula supplementation protocol does not include documentation requirements. What is the PRIMARY risk of this omission?
- Staff may order the wrong formula brand
- Supplementation rates cannot be tracked or quality-improved (Correct answer)
- Mothers will not be notified
- The protocol cannot be printed
Correct answer: Supplementation rates cannot be tracked or quality-improved
Without documentation requirements, supplementation rates cannot be audited, making it impossible to identify patterns, improve practices, or report BFHI metrics.
Question 7: Which format best supports clinical staff in following a complex lactation protocol at the bedside?
- A lengthy narrative paragraph
- A color-coded flowchart or decision tree (Correct answer)
- An email attachment
- A verbal briefing only
Correct answer: A color-coded flowchart or decision tree
Flowcharts and decision trees present complex steps visually and sequentially, reducing cognitive load and decision errors at the point of care.
CLE Protocol Development & Review 2
When reviewing an existing breastfeeding protocol, which element should be assessed FIRST to determine if it needs revision?