A Concept Analysis of Effective Breastfeeding: in Review

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IN REVIEW

A Concept Analysis of Effective


Breastfeeding
Pamela J. Mulder

Objective: To provide a concept analysis of maternal breastfeeding knowledge and skills, the
effective breastfeeding. ability to predict breastfeeding problems and provide
Data Sources: Medline and CINAHL electronic follow-up care, providing indicators for quality
databases, reference lists from selected articles, and assurance, providing a quantified breastfeeding effec-
7 breastfeeding assessment tools. Search terms in- tiveness variable for research, and reassuring parents
cluded the following: breastfeeding and effective, that they are providing the best care for their infant
adequate, successful. (Adams & Hewell, 1997; Moran, Dinwoodie,
Study Selection: Literature was selected accord- Bramwell, & Dykes, 2000; Riordan & Koehn, 1997).
ing to whether the concept of effective breastfeeding Historically, there has been a lack of consistency
was defined or described. in defining breastfeeding that resulted in difficulty
Data Extraction: Literature was reviewed and comparing breastfeeding studies, thus limiting their
data organized as definitions or descriptions, with generalizability (Smith & Tully, 2001).
descriptions grouped into categories sharing similar The cost of an ambiguous definition of effective
characteristics. breastfeeding is the failure to identify ineffective
Data Synthesis: Four characteristics were cho- breastfeeding behaviors that may result in clinical
sen as essential attributes of effective breastfeeding: problems such as hyperbilirubinemia, kernicterus,
positioning, latch, sucking, and milk transfer. dehydration, and excessive weight loss. Although
Conclusions: The concept of effective breast- approximately half of all term newborns will experi-
feeding requires further concept development to de- ence hyperbilirubinemia (Porter & Dennis, 2002), the
fine and describe effective positioning, latch, sucking, bilirubin level at which kernicterus occurs is unknown,
and milk transfer. Future research is needed to deter- and anecdotal reports suggest that apparently healthy,
mine the relationships between the antecedents, attri- breast-fed newborns develop kernicterus in the
butes, and consequences of effective breastfeeding. absence of any other discernible cause for jaundice
JOGNN, 35, 332-339; 2006. DOI: 10.1111/ (American Academy of Pediatrics, Subcommittee on
J.1552-6909.2006.00050.x Hyperbilirubinemia, 2004; Maisels & Newman,
Keywords: Breastfeeding—Breastfeeding effec- 1995). Although the development of kernicterus is ex-
tiveness—Concept analysis—Effective breastfeeding tremely rare, the consequences can be devastating. In-
fants who survive may develop athetoid cerebral palsy,
Accepted: October 2005
hearing loss, developmental and motor delays, or mild
mental retardation (American Academy of Pediatrics,
Many authors have identified the need to assess Subcommittee on Neonatal Hyperbilirubinemia,
the quality of breastfeeding, describing a variety of 2004; Porter & Dennis). Currently, there is no reliable
attributes associated with its effectiveness or success. method for identifying infants at risk for kernicterus
The benefits of developing an operational definition early in the neonatal period (Maisels & Newman).
of effective breastfeeding include improved assess- Failing to identify ineffective breastfeeding during
ment of the breastfeeding session, assessment of the early postpartum period may also result in hospital

332 JOGNN © 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
readmission for the treatment of dehydration and exces- purposes of research (Walker & Avant). Therefore, the
sive weight loss during the 1st days after discharge. Ng purpose of this study is to present the results of a concept
et al. (1999) identified five exclusively breast-fed infants analysis of the interactive process effective breastfeeding,
during a 5-month period readmitted with fever, weight using the strategies proposed by Walker and Avant.
loss greater than 10%, and moderate to severe hyperna- The CINAHL and Medline databases were searched for
tremic dehydration. All the mothers were either attempting English articles using the keywords breastfeeding and ef-
to breastfeed for the 1st time or had previous unsuccessful fective, adequate, or successful. Additional literature from
breastfeeding experiences. Blood cultures were negative the reference citations included in these articles was re-
for all five infants, with the fevers attributed to the infants’ viewed. Articles were selected according to whether the
dehydration. The authors suggest implementing antenatal concept of effective breastfeeding was defined or described
breastfeeding classes, in-hospital monitoring using a stan- and whether characteristics for effective breastfeeding
dardized breastfeeding charting system, and a structured were suggested.
postnatal follow-up program to identify ineffective breast-
feeding and initiate appropriate intervention.
Review of the Literature
Oddie, Richmond, and Coulthard (2001) also reported
on eight exclusively breast-fed infants readmitted at 6 to Authors have described breastfeeding as an “interactive
10 days for hypernatremic dehydration and weight loss process” (Karl, 2004, p. 293; Leff, Jefferis, & Gagne,
greater than 10%. The authors suggested that the sole ex- 1994, p. 106), a “systematic product” (Matthews, 1991,
planation for the infants’ hypernatremia was ineffective p. 49), a “series of steps” (Shrago & Bocar, 1990, p. 214),
breastfeeding. Escobar et al. (2002) examined 101 cases of and a “process of sequential steps” (Mulford, 1992, p.
readmission for dehydration during the neonatal period, 79). As part of their Evidence-Based Clinical Practice
reporting that exclusive breastfeeding at hospital discharge Guideline, the Association of Women’s Health, Obstetric
was the most important risk factor for dehydration among and Neonatal Nurses [AWHONN] (2000) defined breast-
vaginally born infants. Though the authors did not indi- feeding as “the process whereby the infant receives breast
cate if these infants experienced breastfeeding difficulties milk” (p. vi).
during the birth hospitalization, they suggested that ensur- Nyqvist, Rubertsson, Ewald, and Sjödén (1996) defined
ing successful initiation and continuation of breastfeeding a breastfeeding session as “a period when the infant has
is the most important measure to prevent dehydration and some kind of oral contact with the breast, no matter if he
readmission. Tyler and Hellings (2005) suggested that the shows any activity directed towards the breast” (p. 217).
problems infants experience, such as dehydration and hy- Livingstone (1995) defined breastfeeding as “a technical
perbilirubinemia, that lead to rehospitalization may be process by which milk is transferred from the maternal
primarily related to poor breastfeeding and that early breast to the infant” (p. 30), though he also described
breastfeeding assessment and appropriate follow-up care breastfeeding as a “dynamic interaction” (p. 31) and a
may prevent the need for rehospitalization. “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-
C oncept analysis improves communication.
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.).
Concept Analysis The concept of effective or successful breastfeeding has
Concept analysis is a process that identifies unique at- been used to describe the individual breastfeeding session
tributes of a concept, provides a precise operational defini- (Jensen, Wallace, & Kelsay, 1994; Matthews, 1988;
tion of the concept, and improves communication regarding Nyqvist et al., 1996), the characteristics of several breast-
the concept (Walker & Avant, 2005). Walker and Avant feeding sessions across a short duration, such as 24 hours
suggested that concept analysis can provide an excellent (Johnson, Brennan, & Flynn-Tymkow, 1999; Shrago &
beginning for the construction of new clinical or research Bocar, 1990; Tobin, 1996), or the duration of breastfeed-
tools or the evaluation of existing tools. Existing tools may ing in weeks or months (Hamelin & McLennan, 2000;
be compared to the results of the concept analysis to deter- Janke, 1994; Langley, 1998; Leff et al., 1994). For the
mine if the tools accurately reflect the characteristics of the purposes of this analysis, the concept of effective breast-
concept being measured. When concepts are defined feeding was reviewed in relation only to the interactive
operationally, they may also be used as variables for the process that occurs during the individual breastfeeding

May/June 2006 JOGNN 333


session. Effective breastfeeding was defined as the interac- may be the only assistance that mothers require for
tive process between mother and infant, resulting in the successful breastfeeding. Good positioning promotes a
direct transfer of breast milk from the mother’s breast to good latch by reducing traction on the mother’s nipples
the infant in a manner and quantity adequate to meet both and helping keep the nipple and areola in the infant’s
maternal and infant needs. 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
Defining Attributes
feedings (Henderson et al., 2001; Marmet & Shell;
Walker and Avant (2005) described defining attributes Morland-Schultz & Hill).
as the characteristics of a concept most frequently associ- Latch was the most frequently described characteristic
ated with it and which help differentiate the occurrence of associated with effective breastfeeding, also referred to as
a specific concept from a similar or related concept. A re- “areolar grasp” (Nyqvist et al., 1996, p. 208; Shrago &
view of the literature resulted in the identification of many Bocar, 1990, p. 212), “attachment” (Escott, 1989, p. 31;
characteristics associated with effective breastfeeding, Henderson et al., 2001, p. 237; Livingstone, 1995, p. 41),
including maternal and infant anatomy, maternal state, and “fixing” (Matthews, 1988, p. 156; Mulford, 1992,
infant state, rooting, positioning, latch, sucking, swallow- p. 79). Latch describes the placement of the infant’s mouth,
ing, and milk transfer. However, to be considered essential gums, tongue, and lips in relation to the maternal nipple,
attributes of the interactive process of effective breastfeed- areola, and breast, forming a seal between the infant’s
ing, the characteristics must occur during the defined mouth and breast to provide adequate suction during
breastfeeding interaction, be present in all examples of the sucking (Escott; Jenks, 1991; Jensen et al., 1994; Shrago
concept, and be required to achieve the transfer of milk & Bocar). A good latch is a prerequisite to adequate
between mother and infant adequate to meet both mater- sucking and effective breastfeeding (Escott; Livingstone;
nal and infant needs. The four essential attributes of the Renfrew, 1989; Shrago & Bocar).
interactive process of effective breastfeeding described in Escott (1989) defined optimal attachment as “the
the literature are positioning, latch, sucking, and milk mother and her new baby being positioned in a way that
transfer. 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
T he attributes of effective breastfeeding are (Escott; Shrago & Bocar, 1990). Sore, abraded nipples
may develop if the infant latches only to the nipple, with-
positioning, latch, sucking, and milk transfer. 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
Positioning refers to the relative physical placement of oral feeding (Livingstone, 1995; MacMullen & Dulski,
mother and infant for the purposes of breastfeeding 2000; Palmer & VandenBerg, 1998) as well as a measure
(Mulford, 1992). Shrago and Bocar (1990) used the term of behavioral organization (Medoff-Cooper & Ray, 1995).
“alignment” instead of positioning, while Jensen et al. Sucking has been described as the raising of the infant’s
(1994) described it as “hold.” Renfrew (1989) stated that jaw, compressing the lactiferous sinuses between the up-
good positioning is “the subtle interaction of mother’s and per gum and the tongue, which covers the lower gum, fol-
baby’s body positions and the baby’s mouth-to-breast po- lowed by an anterior to posterior peristaltic wave of the
sition” (p. 13). Escott (1989) defined correct positioning tongue that sweeps milk toward the end of the nipple
as “any of the positions that are comfortable for the baby (Woolridge, 1986). Several authors suggest that the term
and mother and do not interfere with the baby’s being able stripping more accurately describes this action (Escott,
to draw adequate breast tissue into the mouth, remove the 1989; Woolridge), though Shrago and Bocar (1990) refer
milk effectively, swallow and breathe freely” (p. 32). to it as “areolar compression” (p. 213).
Several authors have suggested that good positioning at Sucking may be described as nutritive and nonnutritive
the breast is crucial for successful breastfeeding (Henderson, depending on the rate of sucking and the presence or ab-
Stamp, & Pincombe, 2001; Livingstone, 1995; Morland- sence of fluid (Woolridge, 1986). Nonnutritive sucking,
Schultz & Hill, 2005). Good positioning prevents com- characterized by short, fast bursts of jaw movement, oc-
mon breastfeeding problems, including sore nipples and curs at the start of a breastfeeding and facilitates the let-
ineffective feeding (Ingram et al., 2002; L’Esperance & down reflex (Escott, 1989). Nutritive sucking, characterized
Frantz, 1985; Marmet & Shell, 1984; Renfrew, 1989). by a slower, stronger sucking and accompanied by swal-
Escott (1989) suggested that assistance with positioning lowing, occurs in response to milk flow (Escott). Both

334 JOGNN Volume 35, Number 3


types of sucking occur during breastfeeding (Escott), effective breastfeeding because the milk transfer is lacking
though the nutritive sucking pattern implies that milk or insufficient.
transfer is occurring (Mulford, 1992; Woolridge). Weak, The concept of effective bottle-feeding is similar to the
dysfunctional, or uncoordinated sucking, resulting from concept of effective breastfeeding. The mother must posi-
sleepiness, prematurity, illness, neuromotor dysfunction, tion the infant to facilitate feeding, the infant needs to
or anatomical variations (MacMullen & Dulski, 2000; latch on to the bottle nipple and exhibit sucking behavior,
Marmet & Shell, 1984; Palmer & VandenBerg, 1998), and there needs to be a transfer of milk to the infant.
may also result in inadequate milk flow (Marmet & Shell; However, the infant’s method of latching, the mechanics
Medoff-Cooper & Ray, 1995; Palmer & VandenBerg). of sucking, and the source of the milk are significantly
Finally, milk transfer occurs when breast milk is passed different from breastfeeding, and therefore bottle-feeding
from the mother’s nipple to the infant’s mouth and swal- effectiveness would be a related case. Finally, the breast-
lowed by the infant. As mentioned above, milk transfer may feeding infant who fails to open his mouth to latch, whose
be inferred by the presence of nutritive sucking and also by suck is weak or irregular, or who cries and turns away
the presence of audible swallowing (Shrago & Bocar, 1990). from the breast when positioned for feeding is clearly not
Livingstone (1995) suggested that milk transfer is the cu- demonstrating effective breastfeeding and serves as an
mulative result of the process of breastfeeding, which in- example of a contrary case.
cludes positioning, attachment, and suckling. However,
adequate milk transfer is also contingent upon the letdown
Antecedents and Consequences
reflex occurring (Shrago & Bocar) and the mother having
adequate glandular tissue and hormonal function for milk Antecedents and consequences are events or incidents
production to occur (Smith & Tully, 2001). 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
Effective Breastfeeding Cases literature may be antecedents to the interactive process of
Walker and Avant (2005) suggested identifying a model effective breastfeeding: infant state receptive to feeding, root-
case that demonstrates all the defining attributes of the ing, maternal breastfeeding knowledge, a comfortable and
concept, a borderline case that contains most, but not all relaxed maternal state, functional breast anatomy and phys-
the attributes, related cases that are instances of concepts iology, and functional infant physiology and oral anatomy.
related to the concept being studied, and contrary cases An infant state receptive to breastfeeding is a necessary
that are clear examples of instances that are not the con- antecedent to effective breastfeeding (Karl, 2004; Mulford,
cept. Based upon the suggested definition and attributes, 1992; Shrago & Bocar, 1990). Infant state is typically
the following would be an invented model case: described as a continuum of alertness, ranging from deep
The mother brings the infant’s flexed body to face hers, sleep to crying. Infants who are underaroused, or in a sleep
his head cradled in the bend of her arm at the height of her state, may be hungry but not awake enough to eat, and
nipple. With a hand lifting her breast, she brushes her nip- mothers may need to stimulate their sleepy infants to
ple against his lips, waiting for him to respond with a wide- transition them to wakefulness (Barger & Kutner, 1999;
open mouth. As his mouth gapes open, she moves the Karl). Infants who are overaroused, or are irritable or cry-
baby’s head closer to her breast and he latches to her are- ing, may also be responding to hunger but too disorga-
ola, cupping the breast and nipple with his tongue. His lips nized to breastfeed effectively, and mothers may need to
are flanged outward and his mouth remains wide as his reduce stimulation to calm them (Karl).
tongue moves rhythmically to compress the breast against Shrago and Bocar (1990) stated “ideally, before the
the roof of his mouth. His sucking begins with a rapid mother initiates breastfeeding, the infant should be in a
tempo, quick bursts followed by brief pauses. Then, his relaxed, responsive state.” Karl (2003) also suggested that
sucking slows and the bursts are followed by swallows. the “quiet alert” state is the ideal state for latching and
A breastfeeding infant requires supplementary feeding breastfeeding, although he admitted that newborn infants
at the breast due to inadequate weight gain and provides are seldom in the quiet alert state. Recognition of the rela-
an example of a borderline case. The infant may be posi- tionship between infant state and effective breastfeeding is
tioned appropriately to obtain a latch, the latch may be most important during the 1st several days after birth
optimal, and the infant may exhibit strong, coordinated when the infant is in long, sleep states and may need to be
sucking behavior. However, if the mother has a history of awakened to breastfeed (Neifert, 1999; Walker, 1997).
breast surgery or trauma resulting in insufficient mam- Authors have described rooting as an infant behavior
mary tissue, there may be little or no breast milk available influenced by infant state, occurring prior to the initiation
to the infant, preventing sufficient breast-milk transfer of breastfeeding, indicative of infant hunger, and as an
(Barger & Kutner, 1999). Thus, an infant requiring antecedent to achieving an effective latch (Escott, 1989;
supplementary feeding for these reasons is not exhibiting Gentry & Aldrich, 1948; L’Esperance & Frantz, 1985;

May/June 2006 JOGNN 335


Mulford, 1992; Shrago & Bocar, 1990). Rooting is typi- Finally, both maternal and infant anatomy and physiol-
cally assessed as a neonatal reflex, elicited by touching the ogy are antecedents to effective breastfeeding. A mother
cheek, lip, or mouth with a finger or nipple (May & must have an adequate endocrine response and adequate
Mahlmeister, 1994). Normally, the infant should turn his and functional mammary tissue for milk production to oc-
head toward the stimulus, open his mouth, and begin to cur (Livingstone, 1995). Breast surgery, which cuts milk
suck. However, the rooting reflex may be weak or absent ducts, creates scar tissue, or removes breast tissue, may
with prematurity, neurologic deficit or injury, or central impact both milk gland drainage and milk production
nervous system depression secondary to maternal drug (Smith & Tully, 2001). Endocrine function may be af-
exposure. fected by the failure to remove all placental tissue or by
Gentry and Aldrich (1948) reported that the infant’s insults to the pituitary gland resulting from postpartum
state of wakefulness, prior sucking behavior, age, and time hemorrhage (Livingstone). Externally, a mother’s breast
of last feeding affected the manifestation of the rooting anatomy must match her infant’s anatomy and sucking
reflex. Some of the infants who did not initially exhibit the capabilities. An infant may have difficulty latching to a
rooting reflex in response to tactile stimulation of the breast with flat or inverted nipples, resulting in nipple
cheek would still respond with a sucking reflex when a trauma and pain and little or no milk intake (Escott, 1989;
nipple was placed in their mouths, though these infants Minchin, 1989).
were more likely to exhibit a rooting reflex after sucking Characteristics of infant anatomy that could impact the
(Gentry & Aldrich). Mothers are counseled to initiate ability of the mother and infant to breastfeed include high,
latch once the baby demonstrates rooting behavior, result- steeply domed palates, receding chins (Escott, 1989), an-
ing in a wide-open mouth (Smith & Tully, 2001). How- kyloglossia or tongue-tie, or a short tongue (Barger &
ever, Shrago and Bocar (1990) suggested that the mother Kutner, 1999). Prematurity, illness, or neuromotor dys-
or nurse may pull downward gently on an infant’s chin to function may also affect the infant’s ability to breastfeed
achieve a wide enough mouth for a correct latch. There- effectively (MacMullen & Dulski, 2000; Marmet & Shell,
fore, rooting may not be a necessary antecedent to effec- 1984; Palmer & VandenBerg, 1998).
tive breastfeeding if an adequate latch is achieved with Consequences are the “events that occur as a result of
assistance, and the infant then begins sucking. the occurrence of the concept” (Walker & Avant, 2005,
Maternal breastfeeding knowledge is another anteced- p. 73). As an outcome of effective breastfeeding, Mulford
ent to effective breastfeeding (Jensen et al., 1994; Renfrew, (1992) stated that the infant should demonstrate satiety by
1989; Smith & Tully, 2001). To initiate breastfeeding, a spontaneously releasing the breast, failing to root when
mother must recognize that her infant is exhibiting hunger stimulated, and appearing relaxed. Both Mulford and
cues, such as subtle hand to mouth movements, rooting, Jensen et al. (2004) stated that the mother must report
sucking movements, or crying (Mulford, 1992; White, feeling comfortable and free of breast or nipple pain at the
Simon, & Bryan, 2002). The mother must also recognize end of the breastfeeding session. The International Lacta-
when the infant should be awakened to breastfeed, despite tion Consultant Association (1999) suggested that healthy,
the lack of hunger cues, and be prepared to take action to term breastfeeding infants will exclusively feed at the
breastfeed (Barger & Kutner, 1999; Karl, 2004). Mothers breast, lose no more than 7% of their birthweight, regain
need to be taught the elements of good positioning, latch their birthweight by 14 days of age, have at least three
(Ingram et al., 2002), sucking (Escott, 1989; Johnson bowel movements and six wet diapers per 24 hours by
et al., 1999), signs of milk transfer (Mulford), and the Day 4, and gain 4 to 8 ounces per week. Mothers of
expected outcomes of effective breastfeeding in order to healthy, term breastfeeding infants are expected to exclu-
successfully manage breastfeeding once they are discharged sively breastfeed, recognize and respond appropriately to
from the hospital (AWHONN, 2000). early infant feeding cues, recognize signs of effective
Maternal state impacts the mother’s and infant’s breastfeeding, and have breast and nipples that are pain
ability to participate in effective breastfeeding. A mother free. Figure 1 is a diagram of the proposed relationships
who is anxious or uncomfortable may have an impaired between the antecedents, essential attributes, and conse-
letdown reflex, resulting in diminished milk transfer and quences for the concept of effective breastfeeding.
inadequate breast milk supply (Hill & Humenick, 1989).
Discomfort may be caused by the pain of an inadequate
Empirical Referents
latch and resulting nipple trauma (Smith & Tully, 2001).
Furthermore, this pain may decrease the mother’s feel- Empirical referents are “classes or categories of actual
ings of competence, thus increasing her anxiety and phenomena that by their existence or presence demon-
impairing her willingness to continue breastfeeding strate the occurrence of the concept itself” (Walker &
(Jensen et al., 1994). Therefore, a comfortable and relaxed Avant, 2005, p. 73). Empirical referents are used to mea-
maternal state may also be an antecedent to effective sure the concept. Because the defining attributes of breast-
breastfeeding. feeding are themselves abstract, empirical referents are

336 JOGNN Volume 35, Number 3


FIGURE 1
Effective breastfeeding concept diagram

needed to provide observable phenomenon. Numerous Summary


empirical referents for the attributes of positioning, latch,
sucking, and milk transfer have been reported in the litera- Most of the breastfeeding literature uses similar lan-
ture, and the following descriptions include those reported guage to describe the process of breastfeeding, often re-
most commonly. ferring to the same seminal references to support their
Empirical referents for positioning include the follow- assertions. The main differences occur in the emphasis,
ing: the infant’s head aligned with the infant’s trunk, the division, and labeling of the essential attributes of the
infant’s mouth facing the breast, and the infant’s head at interactive process of breastfeeding. Additionally, much
the height of the breast and nipple to prevent traction on of the literature is more than 5 years old, with little re-
the mother’s nipples and facilitate swallowing (Renfrew, search to support the proposed relationships between the
1989; Shrago & Bocar, 1990); the maternal report of re- antecedents, attributes, and consequences of effective
laxation and comfort (Jensen et al., 1996); and a flexed breastfeeding.
infant body without muscle rigidity (Shrago & Bocar).
Empirical referents for latch include the following: the

T
maternal report of nipple comfort (Jensen et al., 1994;
Smith & Tully, 2001;); the placement of the infant’s here is little research to support the
tongue over the lower gum and under the nipple, the in-
fant’s gums over the areola and lactiferous sinuses, the proposed relationships between the
infant’s mouth wide, and the infant’s lips flanged (Escott, antecedents, attributes, and consequences
1989; Jenks, 1991; Jensen et al., 1996; Nyqvist et al.,
1996; Shrago & Bocar, 1990; Tobin, 1996). Empirical ref- of effective breastfeeding.
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). Moran et al. (2000) compared and contrasted six
Finally, empirical referents for milk transfer include au- breastfeeding assessment tools to identify common themes,
ditory or visual evidence of swallowing (Jensen et al., 1996; strengths, and weaknesses. They reported that there was
Nyqvist et al., 1996; Shrago & Bocar, 1990), the mother’s little consistency among tools in determining how to mea-
subjective report of uterine cramping, thirst, sleepiness, a sure successful breastfeeding. The eight identified themes
discharge of lochia, or a tingling feeling in the breast were baby’s behavior, mother’s behavior, positioning, at-
(Mulford, 1992; Tobin, 1996), or the observation of breast tachment, effective feeding, health of the mother’s breast(s),
milk in the infant’s mouth or dripping from the opposite health of the baby, and the mother’s experience (Moran
breast (Tobin). A change in the sucking pattern from non- et al.). Only three of the tools included items from all eight
nutritive, characterized by irregular, fast sucking, to nutri- themes, and the tools lacked consistency in determining
tive, characterized by slower, stronger sucking, has also which items were most important (Moran et al.). Addi-
been used an empirical referent for milk transfer (Escott, tionally, the tools did not always link research evidence to
1989). Shrago and Bocar suggest that “audible swallowing their development, and the evidence that was cited was of
is the most reliable indicator of milk intake” (p. 214). mixed quality.

May/June 2006 JOGNN 337


Furthermore, Riordan and Koehn (1997) report that Gentry, E. F., & Aldrich, C. A. (1948). Rooting reflex in the
three of the currently available breastfeeding assessment newborn infant: Incidence and effect on it of sleep. Ameri-
tools, the Infant Breastfeeding Assessment Tool, the can Journal of Diseases of Children, 75, 528-539.
Mother-Baby Assessment Tool, and the LATCH breast- Hamelin, K., & McLennan, J. (2000). Examination of the use of
an in-hospital breastfeeding assessment tool. Mother Baby
feeding charting system are not sufficiently reliable for
Journal, 5, 29-37.
clinical use. The authors suggest that breastfeeding tool
Henderson, A., Stamp, G., & Pincombe, J. (2001). Postpartum
development is at a beginning stage and that breastfeeding positioning and attachment education for increasing
assessment tools require further revision and reevaluation breastfeeding: A randomized trial. Birth, 28, 236-242.
of their reliability and validity. Hill, P. D., & Humenick, S. S. (1989). Insufficient milk supply.
Position, latch, sucking, and milk transfer were consis- IMAGE: Journal of Nursing Scholarship, 21, 145-148.
tently identified in the literature as attributes of the inter- Ingram, J., Johnson, D., & Greenwood, R. (2002). Breastfeeding
active process of effective breastfeeding (AWHONN, in Bristol: Teaching good positioning, and support from
2000; Escott, 1989; International Lactation Consultant fathers and families. Midwifery, 18, 87-101.
Association, 1999; Jensen et al., 1994; Livingstone, 1995; International Lactation Consultant Association. (1999, April).
Mulford, 1992; Shrago & Bocar, 1990). Yet, each of these Evidence-based guidelines for breastfeeding management
during the first fourteen days. Retrieved March 14, 2004,
terms require further development to determine what con-
from http://ilca.org/pubs/ebg.pdf
stitutes an effective position, an effective latch, effective
Janke, J. R. (1994). Development of the breast-feeding attrition
sucking, and effective milk transfer. Researchers need to prediction tool. Nursing Research, 43, 100-104.
operationally define the attributes that are necessary Jenks, M. (1991). Latch assessment documentation in the hospi-
for effective breastfeeding and empirically evaluate the tal nursery. Journal of Human Lactation, 7, 19-20.
relationships between the attributes and breastfeeding Jensen, D., Wallace, S., & Kelsay, P. (1994). LATCH: A breast-
outcomes. However, researchers must also create broad feeding charting system and documentation tool. Journal of
attribute definitions that allow mothers the greatest Obstetric, Gynecologic, and Neonatal Nursing, 23, 27-32.
freedom in choosing a breastfeeding style. Rigid descrip- Johnson, T. S., Brennan, R. A., & Flynn-Tymkow, C. D. (1999).
tions of how to achieve correct positioning, assessments A home visit program for breastfeeding education and
that rely only on the observer’s external assessments, or support. Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 28, 480-485.
consequences that do not address the wide range of mater-
Karl, D. J. (2004). Using principles of newborn behavioral state
nal and infant behaviors do not acknowledge the personal
organization to facilitate breastfeeding. MCN. American
and cultural diversity in breastfeeding mothers and in- Journal of Maternal Child Nursing, 29, 292-298.
fants. For assessing the effectiveness of the breastfeeding Langley, C. (1998). Successful breastfeeding: What does it mean?
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