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5.3 Assessing breastfeeding

The five-step process

Wolf and Glass1 suggest a five-step assessment/evaluation process:
  1. Gather information and plan for the visit
  2. Feeding observation
  3. Exploration of strategies for improvement
  4. Develop an action plan
  5. Communication of results

1. Gather information and plan for the visit

Review pertinent information including mother's/infant's chart, notes from telephone conversations, notes from referral source, etc, prior to meeting with the mother and infant.

Planning includes assembling any items and equipment you expect to use during the assessment (eg. comfortable chair for mother, clean gloves in case oral examination required, etc.).

2. Feeding observation

Breastfeeding observation entails three parts:
  • General observation: general interaction between the mother and infant. Health of mother, health of baby, health of the mother's breasts.
  • Naturalistic observation: observation of a portion of a usual breastfeeding. This is best performed without intervention from the assessor.
  • Elicited observation: observation of the outcome of suggested modifications (eg changes to position, attachment, etc.).

Use your communication skills

It can help to put the mother at ease if you explain that you would like to watch the baby feeding, rather than saying you are watching what the mother is doing. And don't forget to praise the mother for something she is doing that is good.

What is involved in a 'naturalistic observation'?

A naturalistic observation implies you observe what naturally happens, prior to any interventions.

Mother's and baby's position

  • Do the mother and baby appear comfortable and relaxed?
  • Is the baby well positioned?
    • Good sensory input: breast wasn't washed prior to feeding; baby in firm contact with mother chest-to-chest, either no clothing or minimal clothing between them.
    • Good positional stability: a stable base; proximal stability; midline symmetry

Latching

  • Did mother position baby, then allow baby to latch himself? If not, why not? eg. breast may have needed to be shaped; is the mother controlling the baby's latching?
  • Where is baby's chin? Is it firmly applied to the breast? Is the baby's nose free to breathe without the need to hold the breast tissue away? Exceptions only with very large, soft pendulous breasts.
  • Is baby's mouth very wide open with both lips flanged outwards? Exceptions to this are in mothers with soft, elastic breast tissue where a baby can achieve a deep latch with lots of breast tissue and not need to continue the wide gape throughout the feed.
  • Can you see more areola visible above the top lip than beneath the bottom lip (or, if areola small, another sign that the baby has a large amount of breast tissue in mouth).

Really important!

One author 2 viewed the positioning and latching procedures adopted by mothers with painful nipples and concluded that the whole process from pre-feeding behaviors to the suck rhythm need to be assessed.

Observe the moment of latching of the baby to the breast and as much of the feed as you can, then be there again to observe the nipple as it leaves baby's mouth.

Sucking pattern

  • When first latched was sucking rapid for up to a minute? This is a stimulation pattern to elicit the milk ejection reflex.
  • After about a minute (or less) did sucking settle into a regular, slower suck/swallow/breathe/suck/swallow/breathe pattern with some short pauses? This is a nutritive sucking pattern. You should also hear baby swallowing milk; milk may leak from the other breast; or mother may report feeling the milk ejection reflex.
  • What are baby's jaw movements like? They should be 'deep' movements visible right up to the temporo-mandibular joint below the ears.
  • How long did the nutritive sucking pattern persist? Milk ejection usually lasts about 2 minutes and therefore the nutritive sucking pattern should last about that long. (Note that prior to the milk 'coming in' the nutritive pattern will be briefer, with swallows less frequent.)
  • What happened after the nutritive sucking pattern stopped? Sucking usually returns to the short, quick stimulation pattern again with smaller jaw movement, fewer swallows and longer resting pauses.
  • Was the nutritive pattern repeated? It may not be as noticeable subsequently, but this cycle is usually repeated as baby stimulates a second or more milk ejections during one breastfeed.

How was the breastfeed completed?

  • Did the baby fall asleep at the breast being completely satiated, or detach himself contented, or wanting more milk from the other breast, or did the mother remove the baby when she felt he'd had enough?

What did the nipple look like as it came out of the baby's mouth?

  • Observe the nipple immediately when it comes out of the baby's mouth. It should look very similar to its pre-feeding state. There should be NO ridging or 'squashed' appearance or white compression lines.

How did it feel?

  • Of course you will ask the mother how it feels at each stage, and also observe her for signs of anxiety or pain.
  • In the first few days for the first minute or less she may describe it as painful, but settles to be pain free quickly. This initial pain is called 'nipple stretch pain' and occurs as the nipple and areola form the teat. Breastfeeding may 'tug' but for the majority of mothers it should not be painful.

Ideal teaching opportunity

Don't keep this knowledge to yourself!
The mother and baby will be leaving your care very soon. It is of profound importance that the mother knows what to look for when baby is breastfeeding so she is reassured that baby is breastfeeding well.

Simplify this checklist, putting emphasis on the position/latch and that she can recognize the nutritive suck (baby swallowing milk).

Workbook Activity 5.6

Complete workbook activity 5.6

Observation skills

Look closely at these photos, noting all the details of positioning and latch.
When you are ready, answer the response activity below.


© D.Fisher IBCLC


© D.Fisher IBCLC


3. Exploration of strategies for improvement

  • The development of hypotheses for improving the feeding interaction based on history and observations.
  • Discussion with mother of hypotheses generated, including pros and cons of various methods for improving the feeding outcome.
  • Testing of agreed strategies.

If the strategy involved a practical skill (eg. change of position, using a feeding aid, etc.) a return demonstration with the mother implementing the change unassisted will give you both the confidence that it is achievable.

4. Develop an action plan

Using all gathered data, hypotheses and strategies, develop an action plan for feeding management that is agreed upon between yourself and the mother.
Record this in the mother's file and give a copy to the mother or write a list for her to refer to at home.
If you are working with a mother with a young baby remember that feeding at this stage is dynamic; be prepared to review and revise your plans frequently - at least daily.

5. Communication of results

  • Discuss findings and action plans with the mother. The language used to describe the situation is extremely important. The assessor should take great care to avoid terminology that blames, negatively characterizes, or labels the mother or infant.
  • Review plans with the mother to assure that the plan is achievable and agreeable to all parties.
  • Document the outcomes of the assessment and evaluation.
  • Communicate findings to key healthcare providers in accordance with their need for further care of the mother and baby if in hospital; or mother's consent to release information in the community. Clearly identify and refer any items that need further medical evaluation.1

Observation skills

Look carefully at this baby breastfeeding and complete the response activity below.


© Photo copyright UNICEF C107-5

Workbook Activity 5.7

Complete Activity 5.7 in your workbook.

Make your work easy!

A thorough assessment of a breastfeeding session with each mother at least every 24 hours while she is in hospital, will ensure potential problems are identified early and prevented. Please make this a priority when you plan your work schedule for your shift.

What should I remember?

  • A logical progression to each breastfeeding assessment.
  • How to conduct the assessment in a manner that supports the mother's self-confidence.
  • The mother is the person who must be able to implement any changes required; the importance of knowing she understands and is willing and able to implement the action plan.
  • How early, careful and thorough breastfeeding assessments result in more capable, self-confident mothers.

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 5 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 5.

Skills Competency #2

Observing, assessing and assisting breastfeeding

When you have successfully completed this Module and applied what you have been learning to your practice with mothers and babies you will be ready to complete your Skills Competency. Click on the title of this box to download Observing, assessing and assisting breastfeeding competency form for you to complete with your Supervisor.

Notes

  1. # Wolf LS et al. (1992) Assessment and Management: Feeding and Swallowing Disorders in Infancy
  2. # Blair A et al. (2003) The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples.