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Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review
Concetta Brugaletta1, Karine Le Roch2, Jennifer Saxton3
1Gastrointestinal Physiology Unit, University College London Hospitals NHS Trust, London, England, NW12BW, UK.
Insights
Identifying effective breastfeeding assessment tools is crucial for malnourished infants. The WHO/UNICEF B-R-E-A-S-T-Feed Observation Form and UNICEF Baby-Friendly Hospital Initiative tools are recommended for resource-poor settings.
Area of Science:
- Infant Nutrition and Health
- Global Public Health
- Lactation Science
Background:
- Effective exclusive breastfeeding is a key treatment goal for small and malnourished infants under six months.
- Current malnutrition guidelines lack specific methods for assessing breastfeeding challenges in these infants.
- This study aimed to identify suitable breastfeeding assessment tools for at-risk and malnourished infants in resource-limited environments.
Observation:
- A systematic search identified 29 breastfeeding assessment tools and 45 validation studies.
- Most tools had low-quality evidence, primarily from high-income countries and hospital settings.
- The Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools, and CARE training package were most comprehensive.
Findings:
- The WHO/UNICEF B-R-E-A-S-T-Feed Observation Form demonstrated the strongest evidence base among the identified tools.
- No single tool is considered a gold standard for all situations.
- For resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the most suitable available options.
Implications:
- Existing tools, particularly for resource-poor settings, can be enhanced by incorporating elements from other assessments.
- Developing context-specific tools for rapid community-based and detailed clinic/hospital assessments is recommended.
- Further research is vital for refining current tools and developing new ones, with rigorous testing against breastfeeding status and growth outcomes.
Abstract:
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.
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