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.