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The development of a new breast feeding assessment tool and the
relationship with breast feeding self-efficacy
Jenny Ingram, BSc, PhD (Senior Research Fellow)
a,
n
, Debbie Johnson, RN,
RM, BSc (Research Assistant)
a
, Marion Copeland, RM, ADM,
IBCLC (Infant Feeding Specialist Midwife)
b
, Cathy Churchill, RN, RM,
IBCLC (Breastfeeding Lead Nurse NICU)
b
, Hazel Taylor, BSc, MSc (Medical Statistician)
c
a
Centre for Child &Adolescent Health, School of Social &Community Medicine, University of Bristol, Bristol BS8 2BN, UK
b
Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
c
Research Design Service-South West, Education Centre, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8AE, UK
article info
Article history:
Received 8 February 2014
Received in revised form
27 June 2014
Accepted 3 July 2014
Keywords:
Breast feeding
Self-efficacy
Frenotomy
Bristol Breastfeeding Assessment Tool
abstract
Objective: to develop a breast feeding assessment tool to facilitate improved targeting of optimum
positioning and attachment advice and to describe the changes seen following the release of a tongue-tie.
Design: development and validation of the Bristol Breastfeeding Assessment Tool (BBAT) and correlation
with breast feeding self-efficacy.
Setting: maternity hospital in South West England.
Participants: 218 breast feeds (160 mother–infant dyads); seven midwife assessors.
Findings: thetoolhasmoreexplanationthanothertoolstoremindthosesupportingbreast-feedingwomen
about the components of an efficient breast feed. There was good internal reliability for the final 4-item BBAT
(Cronbach's alpha¼0.668) and the midwives who used it showed a high correlation in the consistency of its
use (ICC¼0.782).
Midwives were able to score a breast feed consistently using the BBAT and felt that it helped them with
advice to mothers about improving positioning and attachment to make breast feeding less painful,
particularly with a tongue-tied infant. The tool showed strong correlation with breast feeding self-efficacy,
indicating that more efficient breast feeding technique is associated with increased confidence in breast
feeding an infant.
Conclusions: the BBAT is a concise breast feeding assessment tool facilitating accurate, rapid breast feeding
appraisal, and targeting breast feeding advice to mothers acquiring early breast feeding skills or for those
experiencing problems with an older infant. Accurate assessment is essential to ensure enhanced breast
feeding efficiency and increased maternal self-confidence.
Implications for practice: the BBAT could be used both clinically and in research to target advice to improve
breast feeding efficacy. Further research is needed to establish its wider usefulness.
&2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/3.0/).
Introduction
Breast feeding rates in the UK remain below World Health
Organisation guidelines and the most recent Infant Feeding Survey
reported that around 55% of mothers were giving breast milk to
their infants at six weeks, with only 34% still partially or exclu-
sively breast feeding by six months (Infant Feeding Survey, 2010).
Exclusive breast feeding rates are even lower at around 23% at six
weeks and only 1% by six months. The drop off in rates is mostly
explained by early feeding difficulties causing introduction of
bottles, with the highest levels of problems being experienced
by those who used a combination of breast feeding and artificial
milk in a bottle. The survey reported the most common reasons for
introducing bottles and stopping breast feeding in the first week
included the infant not latching on properly, mothers having
painful breasts or nipples and feeling that they had ‘insufficient
milk’(Infant Feeding Survey, 2010).
Tongue-tie may be a contributing factor to mothers' experien-
cing breast feeding problems, as difficulties with both breast and
bottle feeding have been reported in 25–44% of infants with this
condition (Messner et al., 2000;Griffiths, 2004;Ricke et al., 2005;
Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/midw
Midwifery
http://dx.doi.org/10.1016/j.midw.2014.07.001
0266-6138/&2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
n
Corresponding author.
E-mail addresses: jenny.ingram@bristol.ac.uk (J. Ingram),
D.johnson@bristol.ac.uk (D. Johnson), Marion.copeland@nbt.nhs.uk (M. Copeland),
Cathy.churchill@nbt.nhs.uk (C. Churchill), Hazel.taylor@uhbristol.nhs.uk (H. Taylor).
Please cite this article as: Ingram, J., et al., The development of a new breast feeding assessment tool and the relationship with breast
feeding self-efficacy. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.07.001i
Midwifery ∎(∎∎∎∎)∎∎∎–∎∎∎
Segal et al., 2007). These studies noted a range of difficulties
including poor latch, nipple trauma and inability to feed continu-
ously, all problems which can contribute to mothers feeling that
they have insufficient milk and consequently shortening the
duration of breast feeding (Marmet et al., 1990; Notestine, 1990).
The surgical division of tongue tie (frenotomy) in the early
postnatal period aims to improve breast feeding and has become
increasingly popular in the UK in recent years, however there is
widespread controversy over its effectiveness (Messner and
Lalakea, 2000).
Research addressing this issue is hampered by a lack of
effective tools both to assess breast feeding and the severity of
tongue-tie in sufficient detail. A systematic review (Webb et al.,
2013) identified studies that reported the outcomes of frenotomy
on breast feeding and documented the objective scoring tools that
were used to assess breast feeding. LATCH and IBFAT were the
main tools used. The LATCH tool (Jensen et al., 1994) was modelled
on the Apgar score with five parameters (latch, audible swallow-
ing, nipple type, comfort, hold) each scoring 0–2, and total scores
have been shown to correlate positively with duration of breast
feeding (Riordan et al., 2001). The 4-item Infant Breast Feeding
Assessment Tool (IBFAT) was developed in 1988 to measure an
infant's readiness to feed, rooting, fixing and sucking behaviours
during a breast feed (Matthews, 1988). The LATCH score was used
by four studies (Dollberg et al., 2006; Srinivasan et al., 2006;
Geddes et al., 2008; Berry et al., 2012) in the Webb review to
compare feeding before and after frenotomy and whilst two
studies showed significant improvements post treatment, two
did not. Buryk et al. (2011) used the IBFAT and reported significant
improvement in breast feeding scores. However others have
suggested that these assessment tools are too broad to show
differences in pre- and post-frenotomy breast feeding scores and
that other more subjective assessment should be used (Griffiths,
2004).
In our randomised trial of 107 women comparing breast
feeding scores before and after frenotomy we also used both
LATCH and IBFAT and found no differences in scores between the
intervention (frenotomy performed) and comparison groups
(Emond et al., 2013). We concluded that these tools were not
sensitive enough to record the changes in breast feeding that
might occur following frenotomy, particularly in the details of
optimum positioning and attachment to the breast.
Psychosocial factors have been shown to have positive correla-
tion with the duration of exclusive breast feeding. A review
exploring the psychological correlates of exclusive breast feeding
reported on eight studies (de Jager et al., 2013), several of which
examined the effects of maternal self-efficacy on breast feeding.
Theoretically based on Bandura's (1977) social cognitive theory,
the Breast feeding Self-Efficacy Score (short-form) (BSES-SF) is an
instrument that measures a mother's confidence in her ability to
breast feed her new infant, which can be used clinically to identify
those at high risk of discontinuing breast feeding (Dennis, 2003)
and to assess breast feeding behaviour. The BSES-SF has good
reliability and validity and has been translated into other lan-
guages and used in a range of populations (as reviewed by Ho and
McGrath (2010)). It is important because mothers who feel self-
confident about their ability to breast feed successfully are more
able to overcome barriers to breast feeding (Entwistle et al., 2010).
Studies exploring the ability of the BSES-SF to predict the duration
of breast feeding, independently of other factors (Blyth et al.,
2002; Baghurst et al., 2007) have found a strong association
between high early scores and longer breast feeding duration.
During our trial study period we were able to develop and test
a tool which we felt might more accurately reflect the effective-
ness of a breast feed, the Bristol Breastfeeding Assessment Tool
(BBAT). We used the BBAT alongside the LATCH and IBFAT and
compared the observed efficiency of breast feeding with how
confident mothers' felt with breast feeding using the BSES-SF. This
paper reports on the development of the BBAT and its comparison
with the previous breast feeding assessment tools.
The study was approved by the Central Bristol Research Ethics
Committee (South West).
Methods
Development, analysis and validation of the Bristol Breastfeeding
Assessment Tool (BBAT)
In developing the BBAT, five infant feeding midwives/breast
feeding experts discussed the elements of the existing breast
feeding assessment tools and decided to use some elements that
were similar to two LATCH items (swallowing, comfort) and one
from the IBFAT (sucking) and added two new items to score
positioning and attachment based on research evidence (Ingram
et al., 2002) and WHO Baby Friendly Initiative breast feeding
practice principles (www.unicef.org/BabyFriendly/healthprofes-
sionals/going-baby-friendly/basic knowledge and skills).
Fig. 1 shows the final version of the Breast feeding Assessment
Tool with full description of the scoring. The tool elements
included were:
(1) Positioning: the infant should be well supported; tucked
against mother's body; lying on his/her side /neck not twisted;
nose opposite the nipple; and the mother confident in hand-
ling the infant. Achieving all of these and no advice being
needed was scored as good (2).
(2) Attachment: the infant showed positive rooting; had a wide
open mouth; achieved a quick latch with a good amount of
breast tissue in the mouth; and stayed attached with a good
latch throughout feed. Achieving all of these points scored 2.
(3) Sucking: able to establish effective sucking pattern on both
breasts (initial rapid sucks then slower sucks with pauses);
infant ends feed. A score of 2 was given if an effective sucking
pattern was achieved.
(4) Swallowing: audible, regular soft swallowing with no clicking
was given a score of 2.
(5) Comfort: mother reports breasts and nipples comfortable; no
visible damage. This combination of mother report with visible
inspection of the nipples was only scored as 2 if she reported
complete comfort with no obvious damage. 1 was scored if the
mother reported some discomfort and there was some
damage or soreness to the nipple visible; 0 was scored if the
mother reported severe discomfort and there was moderate or
severe nipple damage visible.
The main aim was to develop an assessment tool that could be
used effectively and consistently by midwives, lactation consul-
tants, breast feeding counsellors and others assessing breast
feeding as a measure of breast feeding proficiency both for
research studies and in practice more generally. We also wanted
the tool to enable comparison before and after a procedure such as
frenotomy, or to compare a breast feeding dyad at different time
points, whilst keeping it simple and easy to use.
During the BBAT assessments, 218 breast feeds were documen-
ted. One hundred and six breast feeds were observations from 48
mother–infant dyads who were part of the feasibility trial (Emond
et al., 2013) and 112 mother–infant dyads assessed after recruit-
ment to the trial had been completed. Some of the assessments in
the trial were for the same infant at different time points after
frenotomy or several days later. These were considered to be
independent as a subsequent observation was assessed ‘blind’by a
J. Ingram et al. / Midwifery ∎(∎∎∎∎)∎∎∎–∎∎∎2
Please cite this article as: Ingram, J., et al., The development of a new breast feeding assessment tool and the relationship with breast
feeding self-efficacy. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.07.001i
different observer with the previous score not being available for
comparison.
During the trial, infants who were under two weeks old and
experiencing breast feeding difficulties thought to be due to
tongue-tie were referred to the research team midwives (Emond
et al., 2013). Breast feeding was assessed using the LATCH and
IBFAT tools at baseline, five days later and when the infants were
eight weeks old. Mothers also completed the self-efficacy BSES-SF
at the three time points. The BBAT was developed and introduced
part way through recruiting infants into the trial.
Forty-one paired assessments were obtained from seven mid-
wives who had been taught the BBAT. These midwives (who
routinely assessed tongue-tie and performed frenotomy within
the Trust) assessed breast feeds jointly with one of those who
developed the tool (so that each breast feed was assessed by two
midwives giving ‘paired assessments’).
All statistical analysis was carried out in SPSS. Cronbach's alpha, as
a measure of internal consistency, was used to estimate the reliability
of the items within the BBAT. Pearson's correlation coefficient was
used to measure the strength of the association between the BBAT
and BSES-SF. Mann Whitney non-parametric tests were used to test
for differences between the groups in the trial.
An intraclass correlation coefficient was used to assess the
consistency in BBAT scores obtained from pairs of assessors for 41
breast feeds carried out by 34 different mother–infant pairs. Seven
different assessors were involved in these comparisons.
Midwives were interviewed to explore their views of using the
tool in their clinical practice. A short telephone interview was
conducted by the trial manager or senior researcher, recorded and
transcribed. Content analysis methods (Julien, 2008)wereusedto
code the text and the codes were grouped together under the
categories of using the tool, teaching it to others and its use in daily
practice. Two researchers coded the interviews and agreed the
categories emerging from the texts. Comments made by the mid-
wives are reported to illustrate views of the wider group of midwives
and not just those who were involved in developing the tool.
0 Poor 1 Moderate 2 Good Score
POSITIONING
Baby well
supported; Tucked
against mother’s
body; Lying on side
/neck not twisted;
Nose to nipple;
Mother confident
handling baby
No or few
elements achieved
Needs to be
talked through
positioning
Achieving some
elements
Some
positioning
advice still
needed
Achieving all
elements
No positioning
advice needed
ATTACHMENT
Positive rooting;
Wide open mouth;
Baby achieving
quick latch with a
good amount of
breast tissue in
mouth; Baby stays
attached with a
good latch
throughout feed
Baby unable to
latch onto breast
or achieves poor
latch.
No/few elements
achieved
Needs to be
talked through
attachment
Achieving some
elements
Some advice on
attachment
needed
Achieving all
elements
No advice on
attachment
needed
SUCKING
Able to establish
effective sucking
pattern on both
breasts (initial rapid
sucks then slower
sucks with pauses).
Baby ends feed.
No effective
sucking;
no sucking pattern
Some effective
sucking;
no satisfactory
sucking pattern;
on and off the
breast
Effective
sucking pattern
achieved
SWALLOWING
Audible, regular
soft swallowing- no
clicking
No swallowing
heard; clicking
noises
Occasional
swallowing
heard; some
swallows noisy or
clicking
Regular,
audible, quiet
swallowing
Fig. 1. Bristol Breastfeeding Assessment Tool.
J. Ingram et al. / Midwifery ∎(∎∎∎∎)∎∎∎–∎∎∎ 3
Please cite this article as: Ingram, J., et al., The development of a new breast feeding assessment tool and the relationship with breast
feeding self-efficacy. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.07.001i
Findings
The draft 5-item tool included the mother-reported ‘comfort’
element, but we found that sometimes the mother's report
seemed to be at odds with the midwife scored items in measure-
ments of reliability and consistency. So after checking the internal
consistency using Cronbach's alpha we decided to remove it from
the total score and record it separately linked to an assessment of
pain (Table 1). The final version of the BBAT is shown in Fig. 1.
Mothers in the trial had a mean age of 33 years, 58% of the
infants in the trial were first-born and they were recruited at a
mean age of five days. Non-trial infants (n¼112) had a wider age
range (from one day to 10 weeks old) with a mean age of 17 days,
but other characteristics were similar to those in the trial.
BBAT scores were recorded for 106 assessments within the trial
and a further 112 not in the trial giving a total of 218 assessments.
The internal consistency and correlations are shown in Table 1. All
the mothers in the trial and 78 of the non-trial mothers completed
the Breast feeding Self-efficacy tool (BSES-SF). For 106 of the BBAT
assessments, self-efficacy was also recorded and 41 breast feeds
were assessed by two midwives together.
There was good internal reliability for the final 4-item BBAT
(Cronbach's alpha¼0.668) and the seven midwives who used it
showed a high correlation in the consistency of its use (ICC¼0.782).
These scores were recorded after a short period of discussion
between each midwife and the main assessor during which they
agreed the interpretation of the levels of scoring.
The final BBAT showed a strong and significant correlation
(0.57) with breast feeding self-efficacy (BSES), indicating that the
better the technique the more confident a woman felt about breast
feeding her infant.
In the trial of frenotomy for tongue-tie, we showed that
mothers whose infants were randomised to the intervention group
to have an immediate frenotomy had a significantly greater
increase in self-efficacy (using the BSES-SF) over the following
five days compared to the usual care group who did not have a
frenotomy (Emond et al. (2013) and Table 2;p¼0.002).
There were no differences between the LATCH or IBFAT scores
in the trial or changes in the scores from baseline to five days later
or to eight weeks, but BBAT scores (for those infants scored using
the tool) from five days to eight weeks improved significantly
more for those in intervention group compared to the comparison
group (p¼0.02 Mann Whitney; Table 2) indicating that the BBAT
may be a more sensitive breast feeding assessment tool. In the
trial, self-efficacy at 5-days after the baseline was also correlated
with eight week BBAT (n¼36, p¼0.02). It was not possible to
explore the longer relationships between BBAT and breast feeding
self-efficacy in the non-trial mothers.
Interviews with midwives
All seven midwives who routinely used the BBAT in their daily
practice were interviewed and their comments illustrate that they
all found the elements of the tool self-explanatory, it was easy to
use and helped them with their advice to mothers, particularly
around positioning and attachment:
I would use it for checking breastfeeding, perhaps if a baby was
readmitted for weight loss and I would observe a breastfeed
using the tool –to remind me about all the positioning and
attachment points. (MW#1)
The positioning and attachment elements help me to clarify my
advice, they help to trigger conversations about what to tell
mothers to improve the feed. (MW#2)
We've had mothers come in with feeding problems, and we can
improve the positioning and attachment with this advice. The
mother feels the feed is more comfortable and so feels
better. (MW#3)
It is good for evaluating general breastfeeding –good for Mums
to look at to evaluate the breastfeed to work out what might be
improved (MW#5)
They found it easy to teach to others and to achieve similar
scores to other assessors when watching a breast feed together:
I found the tool easy to use; a fast learning process; my scores
were similar to others using the tool. (MW#1)
I have also taught it to others and they like it –it is something
that they can refer to. It confirms what you are thinking and
seeing to make a confident decision. Feedback from other
midwives about using the tool has been positive. (MW#2)
It's not difficult to follow at all. I have taught it to my student
and that was easy to teach (MW#6)
They found it quite easy to use in their daily practice and it was
reported as being very useful:
It helps to remind multiparous mothers about early breastfeed-
ing. I would go through the points with a mother. (MW#1)
It is easy to incorporate into practice and supports breastfeed-
ing. It makes you check all those things and then feed it back to
the mother. The tool is really useful. (MW#3)
It is particularly useful for babies with tongue-tie to help
document what the problems are for those babies. Also when
Table 1
Internal consistency and correlations for Bristol Breastfeeding Assessment Tool (BBAT) and Breast feeding Self-Efficacy (BSES-SF).
n Cronbach's alpha (95% CI) Correlation (95% CI) pValues
All BBATs for 5-item tool 206 0.558 (0.455, 0.647)
All BBATs for final 4-item tool 206 0.668 (0.587, 0.736)
BBATs for seven assessors 41 ICC: 0.782 (0.627, 0.877) o0.0 01
BBAT with BSES-SF 106 Pearson: 0.573 o0.001
Table 2
Change in scores for Bristol Breastfeeding Assessment Tool for some trial partici-
pants and for Breast feeding Self-Efficacy for all trial participants. (medians and
inter-quartile ranges).
Intervention
group
Comparison
group
pValues (Mann
Whitney tests)
BBAT scores n¼15 n¼16
Five days to eight weeks 3 (2–4) 1.5 (1–2) p¼0.02
BSES self-efficacy scores n¼53 n¼52
0–5 days 9 (1.8–12.3) 1 ( 4to þ7.5) p¼0.002
Five days to eight weeks 3 (0–13) 10 (2–18) p¼0.08
J. Ingram et al. / Midwifery ∎(∎∎∎∎)∎∎∎–∎∎∎4
Please cite this article as: Ingram, J., et al., The development of a new breast feeding assessment tool and the relationship with breast
feeding self-efficacy. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.07.001i
we have readmissions for weight loss the tool helps us with
describing the problems during the assessment that we
do (MW#7)
When asked about the comfort item of the tool they gave
differing responses, which confirmed our decision to remove this
item from the final tool and to recommend that discomfort and
pain should be recorded separately:
The comfort element is slightly difficult as pain levels are
different for different women. (MW#3)
Discussion
A concise breast feeding assessment tool (BBAT) was developed
and validated with a group of midwives. The tool has more
explanation than other tools to remind those supporting breast-
feeding women about the components of an efficient breast feed.
Midwives were able to score a breast feed consistently and felt
that it helped them with their advice to mothers about improving
positioning and attachment to make breast feeding less painful,
particularly with a tongue-tied infant.
The components of the tool are relevant for a wide age range of
infants and are also sensitive to the subtle changes that are
important for improving breast feeding following frenotomy. It is
simple to use whilst giving details of positioning and attachment
skills. The mother-reported comfort aspects of breast feeding are
important, but less consistent results were shown when including
them within the midwife-observed breast feeding assessment
items of the tool, and we concluded that comfort should be
recorded as a separate score linked to pain.
The BBAT showed strong correlation with breast feeding self-
efficacy, indicating that a more efficient breast feeding technique is
associated with increased confidenceinbreastfeedinganinfant.This
suggests that those who get the technique correct when their infant
is small may continue to breast feed exclusively for longer as it
enhances their confidence. Blyth et al. (2002) and Baghurst et al.
(2007) both showed that BSES at one week post partum was a strong
predictor of breast feeding in first-time mothers. This was largely
independent of other factors (intention, maternal education, smok-
ing) which are usually indicative of breast feeding duration. They
recommended that breast feeding self-efficacy should be used to
identify women at risk of early cessation of breast feeding. Entwistle
et al. (2010) also suggested that health professionals should take
psychosocial aspects of breast feeding support that influence self-
efficacy into account when counselling women.
Limitations of our study include the fairly small number of
multiple comparisons between midwives, but these are similar in
number to those reported by others in validating screening tools,
including the LATCH and IBFAT (Riordan and Koehn, 1997). The
relationships between BBAT and breast feeding duration and
exclusivity should be explored in further research studies as our
results were limited to those who had repeated observations
within the frenotomy trial.
Lewallen (2006) reviewed instruments used to assess breast
feeding in the early postpartum period that have been used to
identify women at greatest risk of early breast feeding cessation.
Many of the instruments were long and complicated to score;
some were based on particular theoretical frameworks, on quali-
tative studies or derived from clinical care. She concluded that
none of the questionnaires proved to be easy to use in the
postpartum period to predict accurately which women needed
breast feeding support and follow-up or to predict which women
would stop breast feeding.
We suggest that the Bristol Breastfeeding Assessment Tool
could be used generally by those observing breast feeding to
enable an accurate, rapid appraisal, and help to target breast
feeding advice to those mothers acquiring early breast feeding
skills or for those experiencing problems with an older infant.
Accurate assessment is essential to ensure breast feeding effi-
ciency is enhanced, and mother's self-confidence and exclusive
breast feeding duration increased.
We also suggest that the BBAT could prove to be an effective
tool for use in research studies where objective assessments of
breast feeding may be required, especially when assessments
might be performed by more than one assessor. However, further
research should be done in a wider breast feeding population with
larger numbers of multiple comparisons to establish its general
usefulness.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgements
We thank the mothers who took part in the trial and those
since who also provided data, the midwives and the lactation
support team for their help in recruiting and supporting breast-
feeding mothers.
This independent research was funded by the National Institute
for Health Research (NIHR) under its Research for Patient Benefit
(RfPB) Programme (Grant Reference No. PB-PG-0110-21019).
The views expressed are those of the authors and not necessarily
those of the NHS, the NIHR or the Department of Health.
References
Baghurst, P., Pincombe, J., Peat, B., Henderson, A., Reddin, E., Antoniou, G., 2007.
Breastfeeding self-efficacy and other determinants of the duration of breast-
feeding in a cohort of first-time mothers in Adelaide, Australia. Midwifery 23,
382–391.
Bandura, A., 1977. Self-efficacy: toward a unifying theory of behaviour change.
Psychol. Rev. 84, 191–215.
Berry, J., Griffiths, M., Westcott, C., 2012. A double-blind, randomized, controlled
trial of tongue-tie division and its immediate effect on breastfeeding. Breast-
feed. Med. 7, 189–193.
Blyth, R., Creedy, D.K., Dennis, C.L., Moyle, W., Pratt, J., deVries, S.M., 2002. Effect of
maternal confidence on breastfeeding duration: an application of breastfeeding
self-efficacy theory. Birth 29, 278–284.
Buryk, M., Bloom, D., Shope, T., 2011. Efficacy of neonatal release of ankyloglossia: a
randomized trial. Pediatrics 128, 280–288.
de Jager, E., Skouteris, H., Broadbent, J., Amir, L., Mellor, K., 2013. Psychosocial
correlates of exclusive breastfeeding: a systematic review. Midwifery 29,
506–518.
Dennis, C., 2003. The breastfeeding self-efficacy scale: psychometric assessment of
the short-form. J. Obstet. Gynecol. Neonatal Nurs. 32, 734–74 4, http://dx.doi.
org/10.1177/0884217503258459.
Dollberg, S., Botzer, E., Grunis, E., Mimouni, F.B., 2006. Immediate nipple pain relief
after frenotomy in breast-fed infants with ankyloglossia: a randomized,
prospective study. J. Pediatr. Surg. 41, 1598–160 0.
Emond, A., Ingram, J., Johnson, D., et al., 2013. Randomised controlled trial of early
frenotomy in breastfed infants with mild-moderate tongue-tie. Arch. Dis. Child.
–Fetal Neonatal Ed. 11/2013, http://dx.doi.org/10.1136/archdischild-2013-
305031.
Entwistle, F., Kendall, S., Mead, M., 2010. Breastfeeding support –the importance of
self-efficacy for low-income women. Matern. Child Nutr. 6, 228–242.
Ho, Y-J, McGrath, M., 2010. A review of the psychometric properties of breastfeed-
ing assessment tools. J. Obstet. Gynecol. Neonatal. Nurs. 39, 386–40 0.
Geddes, D.T., Langton, D.B., Gollow, I., Jacobs, L.A., Hartmann, P.E., Simmer, K., 2008.
Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk
removal and sucking mechanism as imaged by ultrasound. Pediatrics 122,
e188–e194.
Griffiths, D.M., 2004. Do tongue-ties affect breastfeeding? J. Hum. Lact. 20, 409–414.
Infant Feeding Survey, 2010. Copyright
©
2012, Health and Social Care Information
Centre. All Rights Reserved.
Ingram, J.C., Johnson, D.J., Greenwood, R.J., 2002. Breastfeeding in Bristol: teaching
good positioning and the importance of fathers and families. Midwifery 18,
87–101.
J. Ingram et al. / Midwifery ∎(∎∎∎∎)∎∎∎–∎∎∎ 5
Please cite this article as: Ingram, J., et al., The development of a new breast feeding assessment tool and the relationship with breast
feeding self-efficacy. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.07.001i
Jensen, D., Wallace, S., Kelsay, P., 1994. LATCH: a breastfeeding charting system and
documentation tool. J. Obstet. Gynecol. Neonatal Nurs. 23, 27–32.
Julien, H., 2008. Content Analysis. The Sage Encyclopedia of Qualitative Research
Methods (12 April 2010). Sage Publications, http://dx.doi.org/10.4135/
9781412963909,〈http://www.sage-ereference.com/research/Article_n65.html〉.
Lewallen, L.P., 2006. A review of instruments used to predict early breastfeeding
attrition. J. Perinat. Educ. 15, 26–41, http://dx.doi.org/10.1624/105812406
92967.
Marmet, C., Shell, E., Marmet, R., 1990. Neonatal frenotomy may be necessary to
correct breastfeeding problems. J. Hum. Lact. 6, 117–121.
Matthews, M.K., 1988. Developing an instrument to assess infant breastfeeding
behaviour in the early neonatal period. Midwifery 4, 154–165.
Messner, A.H., Lalakea, M.L., Aby, J., Macmahon, J., Bair, E., 2000. Ankyloglossia:
incidence and associated feeding difficulties. Arch. Otolaryngol. Head Neck
Surg. 126, 36–39.
Messner, A.H., Lalakea, M.L., 2000. Ankyloglossia: controversies in management.
Int. J. Pediatr. Otorhinolaryngol. 54, 123–131.
Notestine, G.E., 1990. The importance of the identification of ankyloglossia (short
lingual frenulum) as a cause of breastfeeding problems. J. Hum. Lact. 6, 113–115.
Riordan, J., Koehn, M., 1997. Reliability and validity testing of three breastfeeding
assessment tools. J. Obstet. Gynecol. Neonatal Nurs. 26, 181–187 .
Riordan, J., Bib, D., Miller, M., Rawlins, T., 2001. Predicting breastfeeding duration
using the LATCH breastfeeding assessment tool. J. Hum. Lact. 17, 20–23.
Ricke, L.A., Baker, N.J., Diane, J., Madlon-Kay, D.J., DeFor, T.A., 2005. Newborn tongue-
tie: prevalence and effect on breast-feeding. J. Am. Board Fam. Pract. 18, 1–7.
Segal, L., Stephenson, R., Dawes, M., Feldman, P., 2007. Prevalence, diagnosis and
treatment of ankyloglossia. Methodologic Review. Can. Fam. Physician 53,
1027 –1033.
Srinivasan, A., Dobrich, C., Mitnick, H, Feldman, P., 2006. Ankyloglossia in breast-
feeding infants: the effect of frenotomy on maternal nipple pain and latch.
Breastfeed. Med. 1, 216–224.
Webb, A.N., Hao, W., Hong, P., 2013. The effect of tongue-tie division on breastfeed-
ing and speech articulation: a systematic review. Int. J. Pediatr. Otorhinolar-
yngol. 77, 635–646.
J. Ingram et al. / Midwifery ∎(∎∎∎∎)∎∎∎–∎∎∎6
Please cite this article as: Ingram, J., et al., The development of a new breast feeding assessment tool and the relationship with breast
feeding self-efficacy. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.07.001i
