Mother-Infant Breastfeeding Progress Tool: a guide for education and support of the breastfeeding dyad

Developing the Mansoura Early Feeding Skills Assessment Scale for Preterm Infants

Purpose

This study aimed to develop a new bedside scoring system scale that assesses preterm infants' oral feeding skills (OFS) in the neonatal intensive care unit (NICU).

Methods

A literature review and critical appraisal of available oral feeding assessment tools/scores were performed. Subsequently, we developed the "Mansoura Early Feeding Skills Assessment" (MEFSA) scale, an 85-item observational measure of oral feeding skills with three main sections. Forty-one preterm infants who did not receive oral feeding but were clinically stable enough to initiate oral feeding were included in the study. Next, we applied and interpreted the MEFSA to describe and score their feeding skills.

Results

Applying the MEFSA resulted in a smooth feeding transition, early start of oral feeding, full oral feeding, and discharge with a shorter period of tube feeding in preterm infants.

Conclusion

The MEFSA is a successful bedside scoring system that assesses the OFS of preterm infants in the NICU.

Effects of prenatal professional breastfeeding education for the family

Mastering the correct breastfeeding posture remains a challenge for many new mothers. Generalized pregnancy breastfeeding education plays a role in helping mothers master breastfeeding positions and prevent nipple damage. This study prospectively analyzed the effects of prenatal professional breastfeeding education for the family on mastering the lactation latch and preventing nipple damage. Medical records of pregnant women in the authors' hospital from April 2020 to July 2020 were prospectively analyzed. A total of 342 patients were enrolled and divided into experimental and control groups according to whether or not they had received prenatal professional breastfeeding education for the family by the random number table method. The difference in the mastery rate of the postpartum breastfeeding posture and nipple damage was examined three days postpartum. The mastery rate in the experimental group (88.5%) was significantly higher than that in the control group (63.8%), whereas the rate of nipple damage in the experimental group (23.1%) was significantly lower than that in the control group (46.9%). Prenatal professional breastfeeding education for the family can promote mothers' mastery of breastfeeding latch skills and reduce the risk of nipple damage.

A Review of Quantitative Instruments for Understanding Breastfeeding Dynamics

Breastfeeding, as a unique behavior of the postpartum period and an ideal source of nourishment, is profoundly impacted by the physiology and behavior of both mothers and infants. For more than three-quarters of a century, there has been an ongoing advancement of instruments that permit insight into the complex process of latching during breastfeeding, which includes coordinating sucking, swallowing, and breathing. Despite the available methodologies for understanding latching dynamics, there continues to be a large void in the understanding of infant latching and feeding. The causes for many breastfeeding difficulties remain unclear, and until a clearer understanding of the mechanics involved is achieved, the struggle will continue in the attempts to aid infants and mothers who struggle to breastfeed. In this review, the history of development for the most prominent tools employed to analyze breastfeeding dynamics is presented. Additionally, the importance of the most advanced instruments and systems used to understand latching dynamics is highlighted and how medical practitioners utilize them is reported. Finally, a controversial argument amongst pediatric otolaryngolo gists concerning breastfeeding difficulties is reviewed and the urgent need for quantification of latching dynamics in conjunction with milk removal rate through prospective controlled studies is discussed.

Effects of a theory of planned behavior-based intervention on breastfeeding behaviors after cesarean section: A randomized controlled trial

Objectives

To examine the efficacy of an intervention based on the theory of planned behavior (TPB) in improving breastfeeding behavior among women with cesarean sections (C-sections).

Methods

This research was a randomized controlled trial. Women with planned elective C-sections were recruited to participate in a randomized controlled trial between June and September 2020. One hundred thirty-two women were divided randomly into the intervention (n = 66) and control group (n = 66) by systematic random sampling. In the intervention group, an intervention project was implemented after the C-section to establish positive breastfeeding attitudes, cultivate supportive subjective norms, enhance perceived behavioral control, and strengthen breastfeeding intention to change behaviors. Those in the control group received routine pre-and post-delivery care. Exclusive breastfeeding rate and breast problem were collected at 5 days, 2 weeks, and 1 month after C-section. The modified Breastfeeding Attrition Prediction Tool (BAPT) on the first day in the hospital, two weeks, and one month after C-section and Numerical Rating Scale (NRS) 24 h postoperatively were used to compare the intervention effect between the two groups.

Results

After the intervention, the intervention group had significantly higher exclusive breastfeeding rates than the control group at five days (86.4% vs. 60.6%), two weeks (77.3% vs. 57.6%), and one month (74.2% vs. 50.0%) after the C-section. Besides, the intervention group was less likely to have sore nipples at five days (6.1% vs. 18.2% in the control group, P < 0.05) and two weeks (9.1% vs. 12.1% in the control group, P < 0.05). After two weeks of intervention, attitude scores (90.64 ± 8.31 vs. 87.20 ± 8.15, P < 0.05), subjective norm scores (88.07 ± 24.65 vs. 79.42 ± 19.47, P < 0.05）and behavior control scores in the intervention group were significantly higher than those in the control group. After one month of intervention, attitude scores (90.34 ± 10.35 vs. 84.22 ± 10.51, P < 0.05) and behavior control scores (43.13 ± 5.02 vs. 39.15 ± 4.69, P < 0.05）in the intervention group were significantly higher than those in the control group, which resulted in the higher breastfeeding intention in the intervention group.

Conclusion

This study indicated that the TPB-based interventions effectively improved women's breastfeeding behaviors after C-sections.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

Using the Preterm Infant Breastfeeding Behavior Scale With Late Preterm Infants

Background

Feeding effectiveness of late preterm infants may vary between feedings and over time, creating confusion and frustration for parents and clinicians. An assessment tool for late preterm infants may assist mothers to recognize breastfeeding behavior more clearly. Although tools are available, none have been tested specifically with late preterm infants. We sought to determine the inter-rater reliability of the Preterm Infant Breastfeeding Behavior Scale scores for late preterm infants between mothers and a health professional.

Methods

A one-group observational non-experimental design assessed inter-rater reliability (24 hours [n =23] and 48 hours [n =11] after birth).

Results

The scale's six components were scored independently; agreement ranged from 81.8% to 100% for all components.

Conclusions

The tool was reliable and could be used to help clinicians and parents accurately understand feeding patterns and behaviors assisting with feeding decisions.

Neonatal Eating Assessment Tool - Mixed Breastfeeding and Bottle-Feeding (NeoEAT - Mixed Feeding): factor analysis and psychometric properties

Background

Early identification of feeding difficulty in infancy is critical to supporting breastfeeding and ensuring optimal nutrition for brain development. The Neonatal Eating Assessment Tool (NeoEAT) is a parent-report assessment that currently has two versions: NeoEAT – Breastfeeding and NeoEAT – Bottle-feeding for use in breast and bottle-fed infants, respectively. There are currently no valid and reliable parent-report measures to assess feeding through a combination of both breast and bottle delivery. The purpose of this study was to conduct a factor analysis and test the psychometric properties of a new measure, the NeoEAT – Mixed Breastfeeding and Bottle-Feeding (NeoEAT – Mixed Feeding), including internal consistency reliability, test-retest reliability, construct validity and known-groups validity.

Methods

Parents of infants younger than 7 months who had fed by both bottle and breast in the previous 7 days were invited to participate. Internal consistency reliability was tested using Cronbach’s α. Test-retest reliability was tested between scores on the NeoEAT – Mixed Feeding completed 2 weeks apart. Construct validity was tested using correlations between the NeoEAT – Mixed-Feeding, the Infant Gastroesophageal Reflux Questionnaire - Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was tested between healthy infants and infants with feeding problems.

Results

A total of 608 parents participated. Exploratory factor analysis revealed a 68-item scale with 5 sub-scales. Internal consistency reliability (Cronbach’s α = .88) and test-retest reliability (r = 0.91; p < .001) were both acceptable. Construct validity was demonstrated through correlations with the I-GERQ-R (r = 0.57; p < .001) and IGSQ (r = 0.5; p < .001). Infants with feeding problems scored significantly higher on the NeoEAT – Mixed Feeding, indicating more problematic feeding symptoms, than infants without feeding problems (p < .001), supporting known-groups validity.

Conclusions

The NeoEAT – Mixed Feeding is a 68-item parent-reported measure of breast- and bottle-feeding behavior for infants less than 7 months old that now has evidence of validity and reliability for use in clinical practice and research. The NeoEAT – Mixed Feeding can be used to identify infants with problematic feeding, guide referral decisions, and evaluate response to interventions.

The Breast Feeding Adaptation Scale-Short Form: Development and Testing of Its Psychometric Properties and Measurement Invariance

PURPOSE

This study sought to develop the Breastfeeding Adaptation Scale-Short Form(BFAS-SF) for use at 4 weeks postpartum, to test its validity and reliability, and to examine its measurement invariance. The latent mean score of the BFAS-SF across multiple groups was also compared.

METHODS

This methodological research study was conducted to develop a short form of the BFAS and to test its psychometric properties and measurement invariance. Data were collected twice for measurement invariance testing. The sample included 431 and 272 breastfeeding mothers at 2 weeks and 4 weeks postpartum, respectively.

RESULTS

Confirmatory factor analysis supported six dimensions of the BFAS-SF at 4 weeks postpartum. Multi-group confirmatory factor analysis revealed evidence for invariance of the BFAS-SF according to employment status, parity, delivery mode, and the postpartum period. There were statistically significant latent mean differences. Mothers who were unemployed and who had a vaginal delivery showed significantly higher scores for breastfeeding confidence, sufficient breast milk, and baby's satisfaction with breastfeeding.

CONCLUSION

The BFAS-SF is valid, reliable, and an appropriate instrument for assessing mothers' breastfeeding adaptation. It can be used to compare mean scores according to employment status and delivery mode.

Factor Structure and Psychometric Properties of the Neonatal Eating Assessment Tool-Breastfeeding

The purpose of this study was to identify the factor structure of the Neonatal Eating Assessment Tool-Breastfeeding (NeoEAT-Breastfeeding) and to assess its psychometric properties, including internal consistency reliability, test-retest reliability, and construct validity as measured by concurrent and known-groups validity. Exploratory factor analysis conducted on responses from 402 parents of breastfeeding infants younger than 7 months old showed a 62-item measure with seven subscales and acceptable internal consistency reliability (Cronbach's α = .92). Test-retest reliability was also acceptable (r = .91). The NeoEAT-Breastfeeding has evidence of concurrent validity with the Infant Gastroesophageal Reflux Questionnaire (r = .69) and Infant Gastrointestinal Symptoms Questionnaire (r = .62). The NeoEAT-Breastfeeding total score and all subscale scores were higher in infants with feeding problems than in typically feeding infants (p < .001, known-groups validity). The NeoEAT-Breastfeeding is a parent-report assessment of breastfeeding in infants from birth to 7 months old with good initial evidence of reliability and validity.

Breastfeeding assessment instruments and their use in clinical practice

Objectives

To identify breastfeeding assessment tools, their application in clinical practice, and their validation and cross-cultural adaptation.

Method

This is an integrative review of literature obtained from six databases and an online library, conducted from August 2014 to December 2015, without a temporal delimitation.

Results

We identified 19 assessment tools, of which 12 were validated and five were cross-culturally adapted. In terms of adaptation, the tools were used to assess the risk of early weaning (BAPT) and the perception/behaviour of mothers during nursing (BSES-SF and IIFAS).

Conclusions

The identification of the available instruments and their indications for breastfeeding assessments can help health workers choose the ideal instrument, and qualify maternal and child care.

Development of a Breastfeeding Effectiveness Scale (BES)

PURPOSE

The purpose of this study was to develop and evaluate breastfeeding effectiveness scale to measure effectiveness of breastfeeding for mothers in the early postpartum period.

METHODS

A conceptual framework was constructed from properties of effective breastfeeding (Yang and Seo, 2011), and item construction was derived from literature review and analysis of the data along with interviews with breastfeeding mothers. Content validity was tested by experts. Each item was scored on a five-point Likert scale. The preliminary questionnaire was administered to 248 breastfeeding mothers. Data were analyzed using item analysis, factor analysis, Pearson correlation coefficients, and Cronbach's α.

RESULTS

From the factor analysis, 20 items in seven factors were derived. The factors were identified as mother's satisfaction, suckling, assurance of milk quantity, infant's satisfaction, latching on, infant's feeding desire, and breastfeeding positioning. The seven factors explained 65.1% of total variance, Cronbach's α of the total items was .83 and the factors ranged from .44 to .75.

CONCLUSION

Results of this study suggest that breastfeeding effectiveness scale is a reliable and valid instrument to measure breastfeeding effectiveness of mothers in the early postpartum period.

Assessment Tools for Evaluation of Oral Feeding in Infants Younger Than 6 Months

BACKGROUND

Feeding difficulty is common in infants younger than 6 months. Identification of infants in need of specialized treatment is critical to ensure appropriate nutrition and feeding skill development. Valid and reliable assessment tools help clinicians objectively evaluate feeding.

PURPOSE

To identify and evaluate assessment tools available for clinical assessment of bottle- and breastfeeding in infants younger than 6 months.

METHODS/SEARCH STRATEGY

CINAHL, HaPI, PubMed, and Web of Science were searched for "infant feeding" and "assessment tool." The literature (n = 237) was reviewed for relevant assessment tools. A secondary search was conducted in CINAHL and PubMed for additional literature on identified tools.

FINDINGS/RESULTS

Eighteen assessment tools met inclusion criteria. Of these, 7 were excluded because of limited available literature or because they were intended for use with a specific diagnosis or in research only. There are 11 assessment tools available for clinical practice. Only 2 of these were intended for bottle-feeding. All 11 indicated that they were appropriate for use with breastfeeding. None of the available tools have adequate psychometric development and testing.

IMPLICATIONS FOR PRACTICE

All of the tools should be used with caution. The Early Feeding Skills Assessment and Bristol Breastfeeding Assessment Tool had the most supportive psychometric development and testing.

IMPLICATIONS FOR RESEARCH

Feeding assessment tools need to be developed and tested to guide optimal clinical care of infants from birth through 6 months. A tool that assesses both bottle- and breastfeeding would allow for consistent assessment across feeding methods.

Breastfeeding Assessment Score: Systematic Review and Meta-analysis

BACKGROUND

Previous studies have revealed conflicting results for the Breastfeeding Assessment Score (BAS) in predicting early breastfeeding cessation. Our objective was to externally validate the BAS and provide summary accuracy estimates for this clinical prediction model.

METHODS

We used the original data from a prospective cohort study. Additional studies were identified by searching electronic databases (Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane) from 2002 to 2013 and contacting research groups that had derived or validated the BAS. Prospective cohort studies were eligible if the BAS was computed at baseline and mothers were followed up for breastfeeding cessation. Two physicians extracted relevant information and independently assessed the methodological quality for the included studies.

RESULTS

In the external validation cohort, 22 of 424 mothers (5.2%) discontinued breastfeeding within 14 days of infant age. The BAS predicted early breastfeeding cessation with an area under the curve of 0.70 (95% confidence interval [CI]: 0.65 to 0.74) and inadequate calibration. When restricting the meta-analysis to 3169 mother-infant pairs enrolled in 4 higher-quality studies, a BAS value <8 predicted early cessation with 0.80 sensitivity (95% CI: 0.69 to 0.91) and 0.51 specificity (95% CI: 0.32 to 0.70) summary estimates.

CONCLUSIONS

Substantial between-study heterogeneity limited the interpretation of summary accuracy estimates. The BAS predicts early breastfeeding cessation with moderate accuracy, although local recalibration is advised before implementation. Further study is warranted to determine whether the BAS can help pediatricians in identifying mother-infant pairs that may benefit from more extensive breastfeeding assessment and support.

Does the LATCH score assessed in the first 24 hours after delivery predict non-exclusive breastfeeding at hospital discharge?

AIM

The aims of this study were to analyze the relationship between the LATCH score assessed in the first 24 hours after delivery and non-exclusive breastfeeding at discharge and to identify a cutoff for the LATCH score in order to identify women with higher risk of non-exclusive breastfeeding who may need additional breastfeeding support.

SUBJECTS AND METHODS

We conducted a prospective observational study in the Maternity Ward of the Institute for Maternal and Child Health "Burlo Garofolo" (Trieste, Italy) and collected data from 299 mother-infant dyads.

RESULTS

The rate of nonexclusive breastfeeding was inversely related to the LATCH score (p<0.001) with non-exclusive breastfeeding infants scoring less (6.9) than infants exclusively breastfed at discharge (7.6) (p=0.001). In multivariate analysis, non-exclusive breastfeeding was also associated with cesarean section, primiparity, and infant phototherapy. In order to support maternity staff in providing targeted interventions, we identified four LATCH score cutoffs associated with as many risk groups for non-exclusive breastfeeding at discharge.

CONCLUSIONS

The LATCH score is a useful tool to identify mother-infant pairs who might benefit from additional skilled support in specific subgroups at risk of non-exclusive breastfeeding at discharge. Future research is needed to explore if the LATCH score assessed in the first days of life can also predict the duration of breastfeeding.

Reliability and validity of swallows as a measure of breast milk intake in the first days of life

BACKGROUND

Breastfeeding assessment in the hospital to determine adequacy of feeds remains controversial. Swallow evaluation is integral to current assessment tools, but the literature is not clear about whether the number of swallows is an accurate indicator of breast milk intake in early postpartum.

OBJECTIVES

To determine the reliability and validity of swallows as a measure of breast milk intake in the first days of a newborn's life.

METHODS

Thirty mother-baby dyads were observed at one breastfeeding; pre- and postfeed weights were done, bedside audible swallows were counted, and feeds were videotaped for independent rating. Milk intake was determined from weight change, adjusted for insensible water loss.

RESULTS

Number of swallows was significantly and positively correlated with breast milk intake (r = .71). Number of swallows alone, however, accounted for only 50.8% (R (2) = .508) of the variation in milk intake. Infant age was the best predictor of milk intake (β(age) = .56 vs β(No. swallows) = .36), accounting for 68% of the variation in milk intake when combined with swallows. The majority of infants took in 10 g or less of breast milk (77%); length of feeds was variable. In-room (at bedside) lactation consultant (LC) and video rater LC swallow counts were significantly and positively correlated (r = .93; P < .01). However, the 2 lactation consultant swallow numbers include clinically important discrepancies in a Bland-Altman analysis.

CONCLUSIONS

Number of swallows was not supported as a reliable or valid indicator of milk intake and adequacy of a feed in the first few days of life.

How are effective breastfeeding technique and pacifier use related to breastfeeding problems and breastfeeding duration?

BACKGROUND

Inconsistent findings leave uncertainty about the impact of pacifier use on effective breastfeeding technique. The purpose of this study was to investigate how breastfeeding technique and pacifier use were related to breastfeeding problems and duration of breastfeeding.

METHODS

Data were collected from the intervention group of a randomized trial in which health visitors followed up with mothers for 6 months after childbirth. The health visitors classified the breastfeeding technique at approximately 1 week after birth and repeated the observation if a correction was necessary. Effective technique included positioning, latch, sucking, and milk transfer. Data on breastfeeding problems and pacifier use were obtained from self-reported questionnaires. The study population included 570 mother-baby pairs with complete information on breastfeeding technique and pacifier use. The primary outcome was duration of exclusive breastfeeding.

RESULTS

One-half of the mothers showed ineffective breastfeeding technique at the first\ observation, most frequently ineffective position (61%) and latch (52%). In the unadjusted analysis, only sucking and milk transfer were associated with breastfeeding duration. In the adjusted analysis, ineffective technique was significantly associated with mothers reporting early breastfeeding problems, which thereby influenced the breastfeeding duration. Pacifier use had an independent negative impact on duration of breastfeeding. A single correction of the breastfeeding technique was not associated with duration or occurrence of problems.

CONCLUSIONS

Observation of breastfeeding technique may help mothers in the stage of when they are establishing breastfeeding to avoid early and later problems, but breastfeeding technique is less useful in predicting breastfeeding duration. Use of a pacifier should be avoided in the first weeks after birth.