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A Concept Analysis of Effective Breastfeeding: in Review
A Concept Analysis of Effective Breastfeeding: in Review
A Concept Analysis of Effective Breastfeeding: in Review
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
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.