IN REVIEW
A Concept Analysis of Effective
Breastfeeding
Pamela J. Mulder
Objective: To provide a concept analysis of
effective breastfeeding.
Data Sources: Medline and CINAHL electronic
databases, reference lists from selected articles, and
7 breastfeeding assessment tools. Search terms in-
cluded the following: breastfeeding and effective,
adequate, successful.
Study Selection: Literature was selected accord-
ing to whether the concept of effective breastfeeding
was defined or described.
Data Extraction: Literature was reviewed and
data organized as definitions or descriptions, with
descriptions grouped into categories sharing similar
characteristics.
Data Synthesis: Four characteristics were cho-
sen as essential attributes of effective breastfeeding:
positioning, latch, sucking, and milk transfer.
Conclusions: The concept of effective breast-
feeding requires further concept development to de-
fine and describe effective positioning, latch, sucking,
and milk transfer. Future research is needed to deter-
mine the relationships between the antecedents, attri-
butes, and consequences of effective breastfeeding.
JOGNN, 35, 332-339; 2006. DOI: 10.1111/
J.1552-6909.2006.00050.x
Keywords: Breastfeeding—Breastfeeding effec-
tiveness—Concept analysis—Effective breastfeeding
Accepted: October 2005
Many authors have identified the need to assess
the quality of breastfeeding, describing a variety of
attributes associated with its effectiveness or success.
The benefits of developing an operational definition
of effective breastfeeding include improved assess-
ment of the breastfeeding session, assessment of
332 JOGNN © 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
maternal breastfeeding knowledge and skills, the
ability to predict breastfeeding problems and provide
follow-up care, providing indicators for quality
assurance, providing a quantified breastfeeding effec-
tiveness variable for research, and reassuring parents
that they are providing the best care for their infant
(Adams & Hewell, 1997; Moran, Dinwoodie,
Bramwell, & Dykes, 2000; Riordan & Koehn, 1997).
Historically, there has been a lack of consistency
in defining breastfeeding that resulted in difficulty
comparing breastfeeding studies, thus limiting their
generalizability (Smith & Tully, 2001).
The cost of an ambiguous definition of effective
breastfeeding is the failure to identify ineffective
breastfeeding behaviors that may result in clinical
problems such as hyperbilirubinemia, kernicterus,
dehydration, and excessive weight loss. Although
approximately half of all term newborns will experi-
ence hyperbilirubinemia (Porter & Dennis, 2002), the
bilirubin level at which kernicterus occurs is unknown,
and anecdotal reports suggest that apparently healthy,
breast-fed newborns develop kernicterus in the
absence of any other discernible cause for jaundice
(American Academy of Pediatrics, Subcommittee on
Hyperbilirubinemia, 2004; Maisels & Newman,
1995). Although the development of kernicterus is ex-
tremely rare, the consequences can be devastating. In-
fants who survive may develop athetoid cerebral palsy,
hearing loss, developmental and motor delays, or mild
mental retardation (American Academy of Pediatrics,
Subcommittee on Neonatal Hyperbilirubinemia,
2004; Porter & Dennis). Currently, there is no reliable
method for identifying infants at risk for kernicterus
early in the neonatal period (Maisels & Newman).
Failing to identify ineffective breastfeeding during
the early postpartum period may also result in hospital
readmission for the treatment of dehydration and exces-
sive weight loss during the 1st days after discharge. Ng
et al. (1999) identified five exclusively breast-fed infants
during a 5-month period readmitted with fever, weight
loss greater than 10%, and moderate to severe hyperna-
tremic dehydration. All the mothers were either attempting
to breastfeed for the 1st time or had previous unsuccessful
breastfeeding experiences. Blood cultures were negative
for all five infants, with the fevers attributed to the infants’
dehydration. The authors suggest implementing antenatal
breastfeeding classes, in-hospital monitoring using a stan-
dardized breastfeeding charting system, and a structured
postnatal follow-up program to identify ineffective breast-
feeding and initiate appropriate intervention.
Oddie, Richmond, and Coulthard (2001) also reported
on eight exclusively breast-fed infants readmitted at 6 to
10 days for hypernatremic dehydration and weight loss
greater than 10%. The authors suggested that the sole ex-
planation for the infants’ hypernatremia was ineffective
breastfeeding. Escobar et al. (2002) examined 101 cases of
readmission for dehydration during the neonatal period,
reporting that exclusive breastfeeding at hospital discharge
was the most important risk factor for dehydration among
vaginally born infants. Though the authors did not indi-
cate if these infants experienced breastfeeding difficulties
during the birth hospitalization, they suggested that ensur-
ing successful initiation and continuation of breastfeeding
is the most important measure to prevent dehydration and
readmission. Tyler and Hellings (2005) suggested that the
problems infants experience, such as dehydration and hy-
perbilirubinemia, that lead to rehospitalization may be
primarily related to poor breastfeeding and that early
breastfeeding assessment and appropriate follow-up care
may prevent the need for rehospitalization.
C oncept analysis improves communication.
Concept Analysis
Concept analysis is a process that identifies unique at-
tributes of a concept, provides a precise operational defini-
tion of the concept, and improves communication regarding
the concept (Walker & Avant, 2005). Walker and Avant
suggested that concept analysis can provide an excellent
beginning for the construction of new clinical or research
tools or the evaluation of existing tools. Existing tools may
be compared to the results of the concept analysis to deter-
mine if the tools accurately reflect the characteristics of the
concept being measured. When concepts are defined
operationally, they may also be used as variables for the
May/June 2006
purposes of research (Walker & Avant). Therefore, the
purpose of this study is to present the results of a concept
analysis of the interactive process effective breastfeeding,
using the strategies proposed by Walker and Avant.
The CINAHL and Medline databases were searched for
English articles using the keywords breastfeeding and ef-
fective, adequate, or successful. Additional literature from
the reference citations included in these articles was re-
viewed. Articles were selected according to whether the
concept of effective breastfeeding was defined or described
and whether characteristics for effective breastfeeding
were suggested.
Review of the Literature
Authors have described breastfeeding as an “interactive
process” (Karl, 2004, p. 293; Leff, Jefferis, & Gagne,
1994, p. 106), a “systematic product” (Matthews, 1991,
p. 49), a “series of steps” (Shrago & Bocar, 1990, p. 214),
and a “process of sequential steps” (Mulford, 1992, p.
79). As part of their Evidence-Based Clinical Practice
Guideline, the Association of Women’s Health, Obstetric
and Neonatal Nurses [AWHONN] (2000) defined breast-
feeding as “the process whereby the infant receives breast
milk” (p. vi).
Nyqvist, Rubertsson, Ewald, and Sjödén (1996) defined
a breastfeeding session as “a period when the infant has
some kind of oral contact with the breast, no matter if he
shows any activity directed towards the breast” (p. 217).
Livingstone (1995) defined breastfeeding as “a technical
process by which milk is transferred from the maternal
breast to the infant” (p. 30), though he also described
breastfeeding as a “dynamic interaction” (p. 31) and a
“symbiotic relationship” (p. 40). Ingram, Johnson, and
Greenwood (2002) stated that successful breastfeeding
meant “pain-free, effective feeding for both mother and
baby” (p. 89). Women completing the Maternal Breast-
feeding Evaluation Scale described successful breastfeeding
as “a complex, interactive process resulting in mutual sat-
isfaction of maternal and infant needs” (Leff et al., 1994,
p. 106). Breastfeeding success has also been defined by the
absence of breastfeeding problems or by 1-item reports of
maternal satisfaction with breastfeeding (Leff et al.).
The concept of effective or successful breastfeeding has
been used to describe the individual breastfeeding session
(Jensen, Wallace, & Kelsay, 1994; Matthews, 1988;
Nyqvist et al., 1996), the characteristics of several breast-
feeding sessions across a short duration, such as 24 hours
(Johnson, Brennan, & Flynn-Tymkow, 1999; Shrago &
Bocar, 1990; Tobin, 1996), or the duration of breastfeed-
ing in weeks or months (Hamelin & McLennan, 2000;
Janke, 1994; Langley, 1998; Leff et al., 1994). For the
purposes of this analysis, the concept of effective breast-
feeding was reviewed in relation only to the interactive
process that occurs during the individual breastfeeding
JOGNN 333
session. Effective breastfeeding was defined as the interac-
tive process between mother and infant, resulting in the
direct transfer of breast milk from the mother’s breast to
the infant in a manner and quantity adequate to meet both
maternal and infant needs.
Defining Attributes
Walker and Avant (2005) described defining attributes
as the characteristics of a concept most frequently associ-
ated with it and which help differentiate the occurrence of
a specific concept from a similar or related concept. A re-
view of the literature resulted in the identification of many
characteristics associated with effective breastfeeding,
including maternal and infant anatomy, maternal state,
infant state, rooting, positioning, latch, sucking, swallow-
ing, and milk transfer. However, to be considered essential
attributes of the interactive process of effective breastfeed-
ing, the characteristics must occur during the defined
breastfeeding interaction, be present in all examples of the
concept, and be required to achieve the transfer of milk
between mother and infant adequate to meet both mater-
nal and infant needs. The four essential attributes of the
interactive process of effective breastfeeding described in
the literature are positioning, latch, sucking, and milk
transfer.
T he attributes of effective breastfeeding are
positioning, latch, sucking, and milk transfer.
Positioning refers to the relative physical placement of
mother and infant for the purposes of breastfeeding
(Mulford, 1992). Shrago and Bocar (1990) used the term
“alignment” instead of positioning, while Jensen et al.
(1994) described it as “hold.” Renfrew (1989) stated that
good positioning is “the subtle interaction of mother’s and
baby’s body positions and the baby’s mouth-to-breast po-
sition” (p. 13). Escott (1989) defined correct positioning
as “any of the positions that are comfortable for the baby
and mother and do not interfere with the baby’s being able
to draw adequate breast tissue into the mouth, remove the
milk effectively, swallow and breathe freely” (p. 32).
Several authors have suggested that good positioning at
the breast is crucial for successful breastfeeding (Henderson,
Stamp, & Pincombe, 2001; Livingstone, 1995; Morland-
Schultz & Hill, 2005). Good positioning prevents com-
mon breastfeeding problems, including sore nipples and
ineffective feeding (Ingram et al., 2002; L’Esperance &
Frantz, 1985; Marmet & Shell, 1984; Renfrew, 1989).
Escott (1989) suggested that assistance with positioning
334 JOGNN
may be the only assistance that mothers require for
successful breastfeeding. Good positioning promotes a
good latch by reducing traction on the mother’s nipples
and helping keep the nipple and areola in the infant’s
mouth (Shrago & Bocar, 1990). Poor positioning may re-
sult in nipple pain and trauma, an inhibited let down of
milk, low supply, breast engorgement, and ineffective
feedings (Henderson et al., 2001; Marmet & Shell;
Morland-Schultz & Hill).
Latch was the most frequently described characteristic
associated with effective breastfeeding, also referred to as
“areolar grasp” (Nyqvist et al., 1996, p. 208; Shrago &
Bocar, 1990, p. 212), “attachment” (Escott, 1989, p. 31;
Henderson et al., 2001, p. 237; Livingstone, 1995, p. 41),
and “fixing” (Matthews, 1988, p. 156; Mulford, 1992,
p. 79). Latch describes the placement of the infant’s mouth,
gums, tongue, and lips in relation to the maternal nipple,
areola, and breast, forming a seal between the infant’s
mouth and breast to provide adequate suction during
sucking (Escott; Jenks, 1991; Jensen et al., 1994; Shrago
& Bocar). A good latch is a prerequisite to adequate
sucking and effective breastfeeding (Escott; Livingstone;
Renfrew, 1989; Shrago & Bocar).
Escott (1989) defined optimal attachment as “the
mother and her new baby being positioned in a way that
allows her to facilitate her baby’s reflexes and help him or
her draw in an adequate mouthful of breast tissue”
(p. 31). As with poor positioning, an inadequate latch will
prevent effective sucking and sufficient milk removal
(Escott; Shrago & Bocar, 1990). Sore, abraded nipples
may develop if the infant latches only to the nipple, with-
out the tongue over the lower gum and gums placed over
the lactiferous sinuses (Escott; L’Esperance & Frantz,
1985; Marmet & Shell, 1984).
Effective sucking behavior is a prerequisite for effective
oral feeding (Livingstone, 1995; MacMullen & Dulski,
2000; Palmer & VandenBerg, 1998) as well as a measure
of behavioral organization (Medoff-Cooper & Ray, 1995).
Sucking has been described as the raising of the infant’s
jaw, compressing the lactiferous sinuses between the up-
per gum and the tongue, which covers the lower gum, fol-
lowed by an anterior to posterior peristaltic wave of the
tongue that sweeps milk toward the end of the nipple
(Woolridge, 1986). Several authors suggest that the term
stripping more accurately describes this action (Escott,
1989; Woolridge), though Shrago and Bocar (1990) refer
to it as “areolar compression” (p. 213).
Sucking may be described as nutritive and nonnutritive
depending on the rate of sucking and the presence or ab-
sence of fluid (Woolridge, 1986). Nonnutritive sucking,
characterized by short, fast bursts of jaw movement, oc-
curs at the start of a breastfeeding and facilitates the let-
down reflex (Escott, 1989). Nutritive sucking, characterized
by a slower, stronger sucking and accompanied by swal-
lowing, occurs in response to milk flow (Escott). Both
Volume 35, Number 3
types of sucking occur during breastfeeding (Escott),
though the nutritive sucking pattern implies that milk
transfer is occurring (Mulford, 1992; Woolridge). Weak,
dysfunctional, or uncoordinated sucking, resulting from
sleepiness, prematurity, illness, neuromotor dysfunction,
or anatomical variations (MacMullen & Dulski, 2000;
Marmet & Shell, 1984; Palmer & VandenBerg, 1998),
may also result in inadequate milk flow (Marmet & Shell;
Medoff-Cooper & Ray, 1995; Palmer & VandenBerg).
Finally, milk transfer occurs when breast milk is passed
from the mother’s nipple to the infant’s mouth and swal-
lowed by the infant. As mentioned above, milk transfer may
be inferred by the presence of nutritive sucking and also by
the presence of audible swallowing (Shrago & Bocar, 1990).
Livingstone (1995) suggested that milk transfer is the cu-
mulative result of the process of breastfeeding, which in-
cludes positioning, attachment, and suckling. However,
adequate milk transfer is also contingent upon the letdown
reflex occurring (Shrago & Bocar) and the mother having
adequate glandular tissue and hormonal function for milk
production to occur (Smith & Tully, 2001).
Effective Breastfeeding Cases
Walker and Avant (2005) suggested identifying a model
case that demonstrates all the defining attributes of the
concept, a borderline case that contains most, but not all
the attributes, related cases that are instances of concepts
related to the concept being studied, and contrary cases
that are clear examples of instances that are not the con-
cept. Based upon the suggested definition and attributes,
the following would be an invented model case:
The mother brings the infant’s flexed body to face hers,
his head cradled in the bend of her arm at the height of her
nipple. With a hand lifting her breast, she brushes her nip-
ple against his lips, waiting for him to respond with a wide-
open mouth. As his mouth gapes open, she moves the
baby’s head closer to her breast and he latches to her are-
ola, cupping the breast and nipple with his tongue. His lips
are flanged outward and his mouth remains wide as his
tongue moves rhythmically to compress the breast against
the roof of his mouth. His sucking begins with a rapid
tempo, quick bursts followed by brief pauses. Then, his
sucking slows and the bursts are followed by swallows.
A breastfeeding infant requires supplementary feeding
at the breast due to inadequate weight gain and provides
an example of a borderline case. The infant may be posi-
tioned appropriately to obtain a latch, the latch may be
optimal, and the infant may exhibit strong, coordinated
sucking behavior. However, if the mother has a history of
breast surgery or trauma resulting in insufficient mam-
mary tissue, there may be little or no breast milk available
to the infant, preventing sufficient breast-milk transfer
(Barger & Kutner, 1999). Thus, an infant requiring
supplementary feeding for these reasons is not exhibiting
May/June 2006
effective breastfeeding because the milk transfer is lacking
or insufficient.
The concept of effective bottle-feeding is similar to the
concept of effective breastfeeding. The mother must posi-
tion the infant to facilitate feeding, the infant needs to
latch on to the bottle nipple and exhibit sucking behavior,
and there needs to be a transfer of milk to the infant.
However, the infant’s method of latching, the mechanics
of sucking, and the source of the milk are significantly
different from breastfeeding, and therefore bottle-feeding
effectiveness would be a related case. Finally, the breast-
feeding infant who fails to open his mouth to latch, whose
suck is weak or irregular, or who cries and turns away
from the breast when positioned for feeding is clearly not
demonstrating effective breastfeeding and serves as an
example of a contrary case.
Antecedents and Consequences
Antecedents and consequences are events or incidents
that are not defining attributes but that occur prior to or
following the occurrence of the concept (Walker & Avant,
2005, p. 73). Several of the characteristics identified in the
literature may be antecedents to the interactive process of
effective breastfeeding: infant state receptive to feeding, root-
ing, maternal breastfeeding knowledge, a comfortable and
relaxed maternal state, functional breast anatomy and phys-
iology, and functional infant physiology and oral anatomy.
An infant state receptive to breastfeeding is a necessary
antecedent to effective breastfeeding (Karl, 2004; Mulford,
1992; Shrago & Bocar, 1990). Infant state is typically
described as a continuum of alertness, ranging from deep
sleep to crying. Infants who are underaroused, or in a sleep
state, may be hungry but not awake enough to eat, and
mothers may need to stimulate their sleepy infants to
transition them to wakefulness (Barger & Kutner, 1999;
Karl). Infants who are overaroused, or are irritable or cry-
ing, may also be responding to hunger but too disorga-
nized to breastfeed effectively, and mothers may need to
reduce stimulation to calm them (Karl).
Shrago and Bocar (1990) stated “ideally, before the
mother initiates breastfeeding, the infant should be in a
relaxed, responsive state.” Karl (2003) also suggested that
the “quiet alert” state is the ideal state for latching and
breastfeeding, although he admitted that newborn infants
are seldom in the quiet alert state. Recognition of the rela-
tionship between infant state and effective breastfeeding is
most important during the 1st several days after birth
when the infant is in long, sleep states and may need to be
awakened to breastfeed (Neifert, 1999; Walker, 1997).
Authors have described rooting as an infant behavior
influenced by infant state, occurring prior to the initiation
of breastfeeding, indicative of infant hunger, and as an
antecedent to achieving an effective latch (Escott, 1989;
Gentry & Aldrich, 1948; L’Esperance & Frantz, 1985;
JOGNN 335
Mulford, 1992; Shrago & Bocar, 1990). Rooting is typi-
cally assessed as a neonatal reflex, elicited by touching the
cheek, lip, or mouth with a finger or nipple (May &
Mahlmeister, 1994). Normally, the infant should turn his
head toward the stimulus, open his mouth, and begin to
suck. However, the rooting reflex may be weak or absent
with prematurity, neurologic deficit or injury, or central
nervous system depression secondary to maternal drug
exposure.
Gentry and Aldrich (1948) reported that the infant’s
state of wakefulness, prior sucking behavior, age, and time
of last feeding affected the manifestation of the rooting
reflex. Some of the infants who did not initially exhibit the
rooting reflex in response to tactile stimulation of the
cheek would still respond with a sucking reflex when a
nipple was placed in their mouths, though these infants
were more likely to exhibit a rooting reflex after sucking
(Gentry & Aldrich). Mothers are counseled to initiate
latch once the baby demonstrates rooting behavior, result-
ing in a wide-open mouth (Smith & Tully, 2001). How-
ever, Shrago and Bocar (1990) suggested that the mother
or nurse may pull downward gently on an infant’s chin to
achieve a wide enough mouth for a correct latch. There-
fore, rooting may not be a necessary antecedent to effec-
tive breastfeeding if an adequate latch is achieved with
assistance, and the infant then begins sucking.
Maternal breastfeeding knowledge is another anteced-
ent to effective breastfeeding (Jensen et al., 1994; Renfrew,
1989; Smith & Tully, 2001). To initiate breastfeeding, a
mother must recognize that her infant is exhibiting hunger
cues, such as subtle hand to mouth movements, rooting,
sucking movements, or crying (Mulford, 1992; White,
Simon, & Bryan, 2002). The mother must also recognize
when the infant should be awakened to breastfeed, despite
the lack of hunger cues, and be prepared to take action to
breastfeed (Barger & Kutner, 1999; Karl, 2004). Mothers
need to be taught the elements of good positioning, latch
(Ingram et al., 2002), sucking (Escott, 1989; Johnson
et al., 1999), signs of milk transfer (Mulford), and the
expected outcomes of effective breastfeeding in order to
successfully manage breastfeeding once they are discharged
from the hospital (AWHONN, 2000).
Maternal state impacts the mother’s and infant’s
ability to participate in effective breastfeeding. A mother
who is anxious or uncomfortable may have an impaired
letdown reflex, resulting in diminished milk transfer and
inadequate breast milk supply (Hill & Humenick, 1989).
Discomfort may be caused by the pain of an inadequate
latch and resulting nipple trauma (Smith & Tully, 2001).
Furthermore, this pain may decrease the mother’s feel-
ings of competence, thus increasing her anxiety and
impairing her willingness to continue breastfeeding
(Jensen et al., 1994). Therefore, a comfortable and relaxed
maternal state may also be an antecedent to effective
breastfeeding.
336 JOGNN
Finally, both maternal and infant anatomy and physiol-
ogy are antecedents to effective breastfeeding. A mother
must have an adequate endocrine response and adequate
and functional mammary tissue for milk production to oc-
cur (Livingstone, 1995). Breast surgery, which cuts milk
ducts, creates scar tissue, or removes breast tissue, may
impact both milk gland drainage and milk production
(Smith & Tully, 2001). Endocrine function may be af-
fected by the failure to remove all placental tissue or by
insults to the pituitary gland resulting from postpartum
hemorrhage (Livingstone). Externally, a mother’s breast
anatomy must match her infant’s anatomy and sucking
capabilities. An infant may have difficulty latching to a
breast with flat or inverted nipples, resulting in nipple
trauma and pain and little or no milk intake (Escott, 1989;
Minchin, 1989).
Characteristics of infant anatomy that could impact the
ability of the mother and infant to breastfeed include high,
steeply domed palates, receding chins (Escott, 1989), an-
kyloglossia or tongue-tie, or a short tongue (Barger &
Kutner, 1999). Prematurity, illness, or neuromotor dys-
function may also affect the infant’s ability to breastfeed
effectively (MacMullen & Dulski, 2000; Marmet & Shell,
1984; Palmer & VandenBerg, 1998).
Consequences are the “events that occur as a result of
the occurrence of the concept” (Walker & Avant, 2005,
p. 73). As an outcome of effective breastfeeding, Mulford
(1992) stated that the infant should demonstrate satiety by
spontaneously releasing the breast, failing to root when
stimulated, and appearing relaxed. Both Mulford and
Jensen et al. (2004) stated that the mother must report
feeling comfortable and free of breast or nipple pain at the
end of the breastfeeding session. The International Lacta-
tion Consultant Association (1999) suggested that healthy,
term breastfeeding infants will exclusively feed at the
breast, lose no more than 7% of their birthweight, regain
their birthweight by 14 days of age, have at least three
bowel movements and six wet diapers per 24 hours by
Day 4, and gain 4 to 8 ounces per week. Mothers of
healthy, term breastfeeding infants are expected to exclu-
sively breastfeed, recognize and respond appropriately to
early infant feeding cues, recognize signs of effective
breastfeeding, and have breast and nipples that are pain
free. Figure 1 is a diagram of the proposed relationships
between the antecedents, essential attributes, and conse-
quences for the concept of effective breastfeeding.
Empirical Referents
Empirical referents are “classes or categories of actual
phenomena that by their existence or presence demon-
strate the occurrence of the concept itself” (Walker &
Avant, 2005, p. 73). Empirical referents are used to mea-
sure the concept. Because the defining attributes of breast-
feeding are themselves abstract, empirical referents are
Volume 35, Number 3
FIGURE 1
Effective breastfeeding concept diagram
needed to provide observable phenomenon. Numerous
empirical referents for the attributes of positioning, latch,
sucking, and milk transfer have been reported in the litera-
ture, and the following descriptions include those reported
most commonly.
Empirical referents for positioning include the follow-
ing: the infant’s head aligned with the infant’s trunk, the
infant’s mouth facing the breast, and the infant’s head at
the height of the breast and nipple to prevent traction on
the mother’s nipples and facilitate swallowing (Renfrew,
1989; Shrago & Bocar, 1990); the maternal report of re-
laxation and comfort (Jensen et al., 1996); and a flexed
infant body without muscle rigidity (Shrago & Bocar).
Empirical referents for latch include the following: the
maternal report of nipple comfort (Jensen et al., 1994;
Smith & Tully, 2001;); the placement of the infant’s
tongue over the lower gum and under the nipple, the in-
fant’s gums over the areola and lactiferous sinuses, the
infant’s mouth wide, and the infant’s lips flanged (Escott,
1989; Jenks, 1991; Jensen et al., 1996; Nyqvist et al.,
1996; Shrago & Bocar, 1990; Tobin, 1996). Empirical ref-
erents for sucking include the maternal report of a strong
tug on the breast (Smith & Tully) and the initial presence
of a nonnutritive sucking rhythm followed by a nutritive
sucking rhythm (Escott).
Finally, empirical referents for milk transfer include au-
ditory or visual evidence of swallowing (Jensen et al., 1996;
Nyqvist et al., 1996; Shrago & Bocar, 1990), the mother’s
subjective report of uterine cramping, thirst, sleepiness, a
discharge of lochia, or a tingling feeling in the breast
(Mulford, 1992; Tobin, 1996), or the observation of breast
milk in the infant’s mouth or dripping from the opposite
breast (Tobin). A change in the sucking pattern from non-
nutritive, characterized by irregular, fast sucking, to nutri-
tive, characterized by slower, stronger sucking, has also
been used an empirical referent for milk transfer (Escott,
1989). Shrago and Bocar suggest that “audible swallowing
is the most reliable indicator of milk intake” (p. 214).
May/June 2006
Summary
Most of the breastfeeding literature uses similar lan-
guage to describe the process of breastfeeding, often re-
ferring to the same seminal references to support their
assertions. The main differences occur in the emphasis,
division, and labeling of the essential attributes of the
interactive process of breastfeeding. Additionally, much
of the literature is more than 5 years old, with little re-
search to support the proposed relationships between the
antecedents, attributes, and consequences of effective
breastfeeding.
T
here is little research to support the
proposed relationships between the
antecedents, attributes, and consequences
of effective breastfeeding.
Moran et al. (2000) compared and contrasted six
breastfeeding assessment tools to identify common themes,
strengths, and weaknesses. They reported that there was
little consistency among tools in determining how to mea-
sure successful breastfeeding. The eight identified themes
were baby’s behavior, mother’s behavior, positioning, at-
tachment, effective feeding, health of the mother’s breast(s),
health of the baby, and the mother’s experience (Moran
et al.). Only three of the tools included items from all eight
themes, and the tools lacked consistency in determining
which items were most important (Moran et al.). Addi-
tionally, the tools did not always link research evidence to
their development, and the evidence that was cited was of
mixed quality.
JOGNN 337
 Furthermore, Riordan and Koehn (1997) report that
three of the currently available breastfeeding assessment
tools, the Infant Breastfeeding Assessment Tool, the
Mother-Baby Assessment Tool, and the LATCH breast-
feeding charting system are not sufficiently reliable for
clinical use. The authors suggest that breastfeeding tool
development is at a beginning stage and that breastfeeding
assessment tools require further revision and reevaluation
of their reliability and validity.
Position, latch, sucking, and milk transfer were consis-
tently identified in the literature as attributes of the inter-
active process of effective breastfeeding (AWHONN,
2000; Escott, 1989; International Lactation Consultant
Association, 1999; Jensen et al., 1994; Livingstone, 1995;
Mulford, 1992; Shrago & Bocar, 1990). Yet, each of these
terms require further development to determine what con-
stitutes an effective position, an effective latch, effective
sucking, and effective milk transfer. Researchers need to
operationally define the attributes that are necessary
for effective breastfeeding and empirically evaluate the
relationships between the attributes and breastfeeding
outcomes. However, researchers must also create broad
attribute definitions that allow mothers the greatest
freedom in choosing a breastfeeding style. Rigid descrip-
tions of how to achieve correct positioning, assessments
that rely only on the observer’s external assessments, or
consequences that do not address the wide range of mater-
nal and infant behaviors do not acknowledge the personal
and cultural diversity in breastfeeding mothers and in-
fants. For assessing the effectiveness of the breastfeeding
session, Renfrew (1989) suggested that “a baby may not
look technically perfect, but if the sucking is strong and
regular and the mother is pain free, chances are that the
positioning is right for that mother and baby” (p. 14).
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Pamela J. Mulder, RN, BSN, is a graduate student at the Univer-
sity of Wisconsin—Milwaukee.
Address for Correspondence: Pamela J. Mulder, RN, BSN,
University of Wisconsin—Milwaukee, P.O. Box 413, CUN 564,
2200 E. Kenwood Boulevard, Milwaukee, WI 53201-0413.
E-mail: pjmulder@uwm.edu.
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