Evaluation of a breastfeeding assessment score in a diverse population

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.

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.

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.

Incentive-based Intervention to Maintain Breastfeeding Among Low-income Puerto Rican Mothers

BACKGROUND AND OBJECTIVE

Despite maternal and child health benefits, breastfeeding rates are relatively low among low-income Puerto Rican mothers. This study examined the hypothesis that monthly financial incentives would significantly increase the proportion of breastfeeding mothers at 6 months postpartum compared with Supplemental Nutrition Program for Women, Infants, and Children (WIC) services only among Puerto Rican mothers.

METHODS

A randomized, 2-arm parallel-group design, from February 2015 through February 2016. Half of the randomized participants received monthly financial incentives contingent on observed breastfeeding for 6 months (Incentive), and the other half received usual WIC services only (Control). Thirty-six self-identified Puerto Rican women who initiated breastfeeding were enrolled. Monthly cash incentives were contingent on observed breastfeeding increasing the amount given at each month from $20 to $70 for a total possible of $270.

RESULTS

The intent-to-treat analysis showed significantly higher percentages of breastfeeding mothers in the incentive group at each time point compared with those in the control group (89% vs 44%, P = .01 at 1 month; 89% vs 17%, P < .001 at 3 months; 72% vs 0%, P < .001 at 6 months). No significant differences were detected at any time point between study groups for self-reported exclusive breastfeeding rate and infant outcomes (ie, weight, emergency department visits).

CONCLUSIONS

Contingent cash incentives significantly increased breastfeeding through 6-month postpartum among WIC-enrolled Puerto Rican mothers; however, no significant differences between the study groups were observed on exclusive breastfeeding rate and infant outcomes. Larger-scale studies are warranted to examine efficacy, implementation potential, and cost-effectiveness.

Exclusive Breastfeeding Experiences among Mexican American Women

BACKGROUND

According to the Centers for Disease Control and Prevention, Hispanic breastfeeding mothers begin early formula supplementation at higher rates than other ethnic groups, which can lead to shorter breastfeeding duration and decreased exclusive breastfeeding. Acculturation, the process of adopting beliefs and behaviors of another culture, appears to influence breastfeeding practices of Hispanic women in the United States. Little is known about Mexican American mothers' formula use and exclusive breastfeeding within the context of acculturation.

OBJECTIVE

Our study identified perceived benefits and barriers to exclusive breastfeeding and levels of acculturation among Mexican American women living in a Midwestern city.

METHODS

We used a qualitative descriptive design integrating Pender's Health Promotion Model concepts. Individual interviews were conducted in English or Spanish (N = 21). The revised Acculturation Rating Scale for Mexican Americans was used to examine acculturation levels.

RESULTS

Acculturation scores indicated that the majority (66%) of the sample was "very Mexican oriented." Most women exclusively breastfed, with a few using early supplementation for "insufficient milk production." Three themes emerged: (1) It is natural that a woman give life and also provide the best food for her baby; (2) Breastfeeding is ultimately a woman's decision but is influenced by tradition, guidance, and encouragement; and (3) Breast milk is superior but life circumstances can challenge one's ability to breastfeed.

CONCLUSION

Strong familial/cultural traditions supported and normalized breastfeeding. Barriers to exclusive breastfeeding were similar to breastfeeding women in general, in the United States. Findings support the need for culturally competent and individualized lactation care.

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.

Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months

OBJECTIVE

We characterized breastfeeding concerns from open-text maternal responses and determined their association with stopping breastfeeding by 60 days (stopping breastfeeding) and feeding any formula between 30 and 60 days (formula use).

METHODS

We assessed breastfeeding support, intentions, and concerns in 532 expectant primiparas and conducted follow-up interviews at 0, 3, 7, 14, 30, and 60 days postpartum. We calculated adjusted relative risk (ARR) and adjusted population attributable risk (PAR) for feeding outcomes by concern category and day, adjusted for feeding intentions and education.

RESULTS

In 2946 interviews, 4179 breastfeeding concerns were reported, comprising 49 subcategories and 9 main categories. Ninety-two percent of participants reported ≥ 1 concern at day 3, with the most predominant being difficulty with infant feeding at breast (52%), breastfeeding pain (44%), and milk quantity (40%). Concerns at any postpartum interview were significantly associated with increased risk of stopping breastfeeding and formula use, with peak ARR at day 3 (eg, stopping breastfeeding ARR [95% confidence interval] = 9.2 [3.0-infinity]). The concerns yielding the largest adjusted PAR for stopping breastfeeding were day 7 "infant feeding difficulty" (adjusted PAR = 32%) and day 14 "milk quantity" (adjusted PAR = 23%).

CONCLUSIONS

Breastfeeding concerns are highly prevalent and associated with stopping breastfeeding. Priority should be given to developing strategies for lowering the overall occurrence of breastfeeding concerns and resolving, in particular, infant feeding and milk quantity concerns occurring within the first 14 days postpartum.

Revision of the Beginning Breastfeeding Survey: a cumulative assessment of breastfeeding

BACKGROUND AND PURPOSE

Women use their cumulative breastfeeding experiences, in combination with other factors, to make their infant feeding decisions. This pilot study assessed the reliability and predictive validity of the revised Beginning Breastfeeding Survey-Cumulative (BBS-C).

METHODS

25 women were recruited prenatally from a university hospital. The BBS-C was completed before hospital discharge. Infant feeding outcomes were measured at 1 and 3 months postpartum.

RESULTS

Participants were 17-40 years old, mostly married, Whites, and well-educated. Coefficient alpha was .92-.94. The BBS-C predicted an infant not receiving breast milk, not feeding from the breast, and receiving infant formula feedings.

CONCLUSIONS

In this sample, the BBS-C had strong reliability and predictive validity. Further testing should assess reliability and predictive validity in a wider range of populations and settings.

Determinants of 6-month maternal satisfaction with breastfeeding experience in a multicenter prospective cohort study

Although a personally defined experience, successful breastfeeding is usually measured with regard to duration. This study investigated the determinants of maternal satisfaction with breastfeeding experience for 907 mothers enrolled in a prospective cohort study. Despite a median breastfeeding duration (18 weeks) that fell short of recommendations, 822 mothers (90.6%) rated their breastfeeding experience as very or fairly satisfactory. Anticipated breastfeeding duration was a determinant of satisfaction only for women who actually breastfeed < 2 months; in this subgroup of mothers, satisfaction rates ranged from 84.6% for those who anticipated breastfeeding < 2 months to 69.8% for those who anticipated breastfeeding > 4 months (P = .01). Smoking during pregnancy and experiencing breastfeeding difficulties after discharge were independently associated with decreased satisfaction. Eliciting the mother's expectations regarding breastfeeding duration may help the lactation consultant in providing appropriate guidance. Future studies should assess maternal satisfaction using validated instruments.

Relationship of lower breastfeeding score and problems in infancy

BACKGROUND AND METHODS

We undertook a descriptive study in 2-month-old healthy infants to determine the factors that affect breastfeeding score. Mother's breastfeeding was evaluated and scored according to the World Health Organization/UNICEF B-R-E-A-S-T Feeding Observation Form.

RESULTS

The breastfeeding score (BFS) was higher in female than male babies (p=0.005). The babies with regurgitation had lower BFS than the babies without (p=0.016). The BFS was lower in babies who had repeated, without cause, inconsolable crying than in those without such crying (p<0.004). When the crying was problematic for the family, BFS was lower (p=0.028). Babies who had another sibling with a history of colic had a lower BFS (p=0.038). A low BFS was associated with short duration of night sleeping (p=0.032).

CONCLUSIONS

A decreased BFS may be a risk factor or indicator for infant crying, regurgitation, and short sleeping duration. As a result, tracking the BFS and appropriate breastfeeding intervention during the newborn period may assist in decreasing the frequency of regurgitation and infant crying.