LATCH SCORE.pptx

Latch scoring

1. JOURNAL club Presenter:- Dr.preethi By BHARATH SARANG MATTH

2. LATCH Score for Identification and Correction of Breastfeeding Problems- A Prospective Observational Study

3. Authors NEHA MARIYA RAPHEAL,1 BALAKRISHNAN RAJAIAH,1 RAJENDRAN KARUPANAN,2 THANGARAJ ABIRAMALATHA,2 SRINIVAS RAMAKRISHNAN1 1Neonatal Intensive Care Unit, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu. 2Department of Pediatrics and Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu. Correspondence to: Dr Balakrishnan Rajaiah , Consultant, Neonatal Intensive Care Unit, Kovai Medical Center and Hospital (KMCH), Coimbatore 641 014, Tamil Nadu. [email protected].

4. JOURNAL:- INDIAN PEDIATRICS (VOLUME 60__JANUARY 15, 2023) Received: April 29, 2022; Initial review: June 23, 2022; Accepted: Sept 19, 2022 .

5. INTRODUCTION Breastfeeding is considered an important intervention to reduce infant and under-5 mortality. Though breastfeeding is a natural process, some mother-infant dyads may have problems in breastfeeding, particularly during the initial days after childbirth. Improper breastfeeding technique may result in inadequate feeds leading to excessive weight loss, hypernatremic dehydration, jaundice and rehospitalizatioN .

6. Evidence suggests that early initiation of breastfeeding and exclusive breastfeeding at hospital discharge are associated with improved rates of exclusive breastfeeding until six months and increased duration of breastfeeding. As we ardently promote institutional deliveries, the initial hospitalization period is a good opportunity for health care workers to assess breastfeeding, educate mothers on correct breastfeeding techniques, and boost their confidence in breastfeeding before discharge from hospital.

7. There is a need for a systematic way to evaluate the breastfeeding technique, identify problems related to breastfeeding and take appropriate corrective actions in a timely manner. In this study, they aimed to determine the incidence and nature of early breastfeeding problems using LATCH tool, and to analyze the impact of breastfeeding support in improving the LATCH score.

8. Objective : To determine early breastfeeding problems using LATCH tool, and analyze the impact of breastfeeding supportive measures in improving LATCH score. Study Design:- prospective observational study

9. Setting:- This prospective observational study was conducted in a tertiary care neonatal centre from September, 2019 to March, 2020, including all inborn term neonates. Participants:- all inborn term neonates.

10. Exclusion criteria The exclusion criteria were neonates who required neonatal intensive care unit (NICU) admission, multiple births and sick mothers where LATCH score could not be assessed within stipulated time. Ethical committee:- The study was approved by the Institutional Ethics Committee.KMCH Ethics Committee; No. EC/AP/762/08/2019, dated August 24, 2019.

11. Limitations The study has some limitations. They did not follow the mother-infant pairs beyond 48 hours. Hence, several problems related to breastfeeding that appear later were not assessed. They did not include neonates who required NICU admission and late preterm neonates, who may be at greater risk of improper breastfeeding. They did not assess inter-observer agreement in assessment of the LATCH score among the study nurses.

12. Methods LATCH is an acronym that stands for latch, audible swallowing, type of nipple, comfort and hold. Each component is scored from 0-2 and the total score ranges from 0-10. A total score less than 8 is considered low/ unsatisfactory. LATCH score was assessed at 6-12 hour after birth.

13. The scoring was performed by a group of eight senior nurses (two in each postnatal ward), who had been trained in LATCH score assessment and breastfeeding support,before commencing the study. The training was provided in multiple sessions using images and videos, and by handson training under direct observation by the study investigators.

14. Depending on the problem in breastfeeding that was identified during the initial assessment, counselling, education and support were provided to the mothers by the study team. Mothers were trained in cradle or crosscradle hold of the baby while breastfeeding. Mothers who had undergone caesarean delivery were taught breastfeeding in side-lying position.

15. Signs of good attachment were explained to the mothers using visual aids. Mothers were encouraged to evaluate and correct the positioning and attachment of the baby by themselves during subsequent feeding sessions, which was supervised by the study team. Tactile stimulation and/or nipple pullers were prescribed to mothers with flat or inverted nipples.

16. Following the interventions, LATCH scores were reassessed at 24-48 hour from the time of delivery. For most mother-infant dyads, both the initial assessment and Post intervention assessment were performed by the same nurse.

17. Demographic and clinical details of the mother and the baby were collected in a pretested study form. Sample size obtained was 400 mother-infant pairs, assuming a 50% incidence of breastfeeding problems in term neonates, taking precision of 5%.

18. Statistical analysis Descriptive statistics are presented as median and interquartile range (IQR) or number and percentage, as appropriate. Chi-square test was used to compare categorical data between independent samples,McNemar test for categorical data between pairedsamples , and Wilcoxon signed rank test for ordinal data between paired samples. All statistical analyses wereperformed using SPSS 20.0. A P value <0.05 wasconsidered statistically significant.

19. Results Among the 400 study neonates, 217 (54.2%) were boys and 19 (4.8%) had a birth weight <2500 g. Nearly half of the mothers (197, 49.2%) were primiparous , and 252 (63%) had delivery by cesarean section. Maternal age was <20, 20-30 and > 30 years in 4 (1%), 290 (72.5%) and 106 (26.5%), respectively. Of these, 29 (7.2%) mothers had high-school education, 342 (85.6%) were graduates and 29 (7.2%) were professionals.

20. During the initial assessment at 6-12 hour, 399 (99.7%) mothers required support to position the neonate, 190 (47.5%) mother-infant dyads had a poor latch with a score of 0 or 1, and 52 (13%) mothers had a flat or inverted nipple. While 288 (72%) mother-infant dyads had a LATCH score of < 8 at 6-12 hour after delivery, this reduced significantly to 63 (15.8%) at 24-48 hour after the breastfeeding support and training (P< 0.001). The median (IQR) LATCH scores also improved significantly [7 (5,8) vs 8 (8,8); P<0.001].

21. The scores of individual components are given in Table. The ‘latch’ component improved significantly with 95.5% mother-infant pairs having a score of 2 at 24-48 hour. Though there was improvement in ‘audible swallowing’ and ‘hold’ components, the proportion of mother-infant pairs achieving a score of 2 was less even after the training. Most of the mothers had a score of 2 for ‘comfort during breastfeeding.’ Number of mothers who have a flat or an inverted nipple decreased from 13% to 2.7% after the intervention.

22. Analysis of the association between demographic characteristics and LATCH scores showed that caesarean delivery, primiparity and mother’s education were risk factors for a lower LATCH score at 6-12 hours. Though, the scores improved significantly after breastfeeding support in all these subgroups, they had persistently lower scores at 24-48 hours when compared to their fellow groups.

23. Conclusion: LATCH is a comprehensive yet simple tool to identify breastfeeding problems. Given the high incidence of breastfeeding problems during early postpartum period, systematic assessment of breastfeeding related problems using LATCH tool can help timely intervention and improvement in the breastfeeding technique.

24. Discussion Their study showed that almost all the mothers required assistance in positioning the neonate during breastfeeding and almost half of mother-infant dyads had problems related to latching, with 13% mothers having nipple issues soon after delivery. We found a significant reduction in breastfeeding problems with timely support, training and counselling of mothers.

25. LATCH score provides a systematic method to evaluate five key components of the breastfeeding technique. It helps to identify the nature of the problem, so that appropriate corrective measures can be taken by counselling and training the mothers with simple visual aids. Improper latching and positioning of the neonate during breastfeeding may result in the baby sucking only on the nipple, which in turn will lead to inadequate feeds to the neonate and sore/cracked nipples and breast engorgement in the mother.

26. They found a significant improvement in nipple problems such as flat or inverted nipples by 24 hours after delivery with simple interventions such as tactile stimulation or nipple puller. The ‘comfort’ component had good scores at both 6-12 and 24-48 hours post-delivery, probably because problems causing discomfort while breastfeeding, such as breast engorgement or sore/cracked nipples usually develop later during the postpartum period.

27. ‘Audible swallowing’ component scored low at both assessments and this is probably due to the less quantity of milk secreted by mothers on day 1 and 2 after delivery. The frequency of audible swallowing improves after the secondary lactogenesis , when mother starts secreting more milk

28. Primipara mothers who have no previous experience with breastfeeding and mothers who have a caesarean delivery and hence have pain and cannot sit up are more likely to have problems in breastfeeding, as shown by our study and previous studies. These subgroups of mothers would require more support to establish breastfeeding

29. Better LATCH scores in the early postnatal period were shown to correlate positively with exclusive breastfeeding rates at discharge and at 6-8 weeks of life. Hence, we are of the view that systematic assessment of breastfeeding using the LATCH tool and timely initiation of appropriate measures to address the problems that are identified will help to improve exclusive breastfeeding rates at and after hospital discharge.

30. References 1. Sankar MJ, Sinha B, Chowdhury R, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr . 2015; 104:3-13. 2. Azuine RE, Murray J, Alsafi N, Singh GK. Exclusive breastfeeding and under-five mortality, 2006-2014: A crossnational analysis of 57 low- and-middle income countries. Int J MCH AIDS. 2015;4:13-21. 3. Feenstra MM, Jørgine Kirkeby M, Thygesen M, et al. Early breastfeeding problems: A mixed method study of mothers’ experiences. Sex Reprod Healthc . 2018;16:167-74. 4. Suresh S, Sharma KK, Saksena M, et al. Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: Experience in a tertiary care centre in Northern India. Indian J Public Health. 2014;58:270-3.

31. 5. van Dellen SA, Wisse B, Mobach MP, Dijkstra A. The effect of a breastfeeding support programme on breastfeeding duration and exclusivity: a quasi-experiment. BMC Public Health. 2019;19:993. 6. Fadiloglu E, Karatas E, Tez R, et al. Assessment of factors affecting breastfeeding performance and latch score: A prospective cohort study. Z Geburtshilfe Neonatol . 2021; 225:353-60. 7. Hobbs AJ, Mannion CA, McDonald SW, et al. The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum. BMC Pregnancy Childbirth. 2016;16:90. 8. Sowjanya SVNS, Venugopalan L. LATCH Score as a predictor of exclusive breastfeeding at 6 weeks postpartum: A prospective cohort study. Breastfeed Med. 2018;13:444-9. 9. Tornese G, Ronfani L, Pavan C, et al. Does the LATCH score assessed in the first 24 hours after delivery predict non-exclusive breastfeeding at hospital discharge? Breastfeed Med. 2012;7:423-30. 10. Riordan J, Bibb D, Miller M, Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact . 2001;17:20-3.

32. LATCH scoring The LATCH charting system assigns a numerical score (0, 1, or 2) to 5 key. breastfeeding components identified by the letters of the acronym LATCH: ‘‘L’’ is for how well the infant latches onto the breast, ‘‘A’’ is for the amount of audible swallowing noted, ‘‘T’’ is for thetype of nipple,

33. ‘‘C’’ is for maternal comfort during feeding, and
‘‘H’’ is for the amount of help the mother needs to hold her infant tothe breast.
The total score ranges from 0 to 10; the higher the score,the more the chances of successful breastfeeding .
A LATCH score of 0–3 is regarded as poor, 4–7 as moderate, and8–10 as good

34. Breast feeding WHO recommends that infants should be exclusively breastfed for the first 6 months. Thereafter, complementary food should be introduced while continuing breastfeeding for 2 years or beyond. Breastfeeding may contribute towards a lifetime of good health and is also considered to benefit mothers. The milk transfer to the infant precedes the maternal report by nearly 12 to 24 h.

35. The symptoms of “coming in of milk” as reported by the mothers include breast fullness, milk leakage from the nipple, infant cues, and breast tingling.’ On average, mothers perceive “coming in of milk” at 59 to 67 h after delivery, earlier in multiparous compared to primiparous mothers.
The touching of nipple, areola and breast skin and infant’s suckling increase plasma oxytocin level, which mediates let- down of milk (milk ejection reflex).” Acute physical and mental stress reduce the oxytocin release.

36. The key points of good positioning are 1. The head and body of the baby are in a straight line 2. The baby’s whole body (not only the neck and shoulders) are well supported
3. The baby faces the breast with nose being opposite the nipple of the mother 4. Baby’s abdomen touching the mother’s abdomen

37. To teach the mother to hold her breast correctly. The thumb and forefinger should be at the right and left of her breast as opposed to at the top and bottom. The thumbs and fingers should not be close to the nipple and areola.

38. Advise her not to hold the breast between her index and middle finger (scissor hold). The mother should touch. The baby’s lips with her nipple and wait until baby opens her month widely. At this point, the baby be brought to the breast aiming for a good attachment. The mother should not lean on the baby.

39. The four key points of attachment during breastfeeding: 1. Baby’s mouth is wide open.
2. The nipple and the most areola must be in baby’s mouth More areola should be visible above baby’s mouth than below it
3. Baby’s lower lip is turn outward 4. Baby’s chin is touching the mother’s breast

40. The newborn responds by opening eyes and seeking the breast. The baby turns the head back slightly and opens the mouth when ready to breastfeed. The tongue usually moves down andforward ; the neonate tries to lick and the saliva may also drip. An infant who sucks effectively takes several slow deep sucks and then swallows. An infant who sucks for a short time but tires out and is unable to continue long enough is sucking ineffectively.

41. Different breast feeding positions

42. Assessing breastfeeding adequacy Breastfeeding is considered adequate. if there is softening of breast after a feeding session and the neonate sleeps well between the breastfeeding sessions, passes urine at least 6 to 8 times in a day, crosses birth weight by 7 to 10 days and gains at least 25 to 40 g per day thereafter.

43. Common issues in breastfeeding in the first few days Afrantic newborn This baby feeds incessantly and does not get satisfied. The mother gets exhausted thus affecting her ability to breastfeed the baby. This usually happens if the baby is not optimally attached and is sucking only on the nipple. Also, if the baby is feeding for a short duration on one breast and the mother switches the baby to the other the baby may end up gettings only foremilk and hence may not be satisfied.

44. Management Ensure optimal position and latch. Leave the mother and baby together in skin-to-skin position and respond to early feeding cues.
Explain the mother to ensure feeding from one breast in one session so that the baby gets both foremilk and hindmilk .
Reassure the mother that the baby will settle when milk volume increases.

45. A sleepy newborn A sleepy newborn has difficulty in waking up for feeds or not feeding adequately even after appropriate latching and may have inadequate weight gain or even weight loss.
A normal newborn may sleep most of 24 hours and get up only for feeding. However, if the newborn does not ask for feed, one should seek the help. Avoid supplemental feeding unless medically indicated.

46. Management the mother and baby should be put together in skin-to-skin position and the mother should respond to early feeding cues. The mother has to be explained to ensure adequate latch during breast feeding, Once the neonate has surpassed the birth weight, the feeding can be easily given on demand for term, otherwise normal neonates.

47. Flat/inverted nipple The nipple can be pulled out with a nipple everter which is made from a plastic syringe (20 mL syringe). The mother is advised to apply the plunger and gently pull back to apply suction to the nipple. The negative suction pressure on the nipple should be just enough to pull out the nipple without causing pain or discomfort to the mother.

48. Management The mother should do it by herself. The negative suction is continued till a count of 10. This should be carried out prior to each feeding or repeated between feedings as required. Application of a breast pump may be used to apply gentle pressure before feedings. This may assist with nipple eversion and assist latch-on. Note : Nipple shield should not be used for this purpose of breastfeeding.

49. Sore nipples Many mother experience slight discomfort just at start of feeding; however, this subsides soon after feeding”. The good positioning and attachment help pain subside. However, some mothers develop soreness of nipple making breastfeeding painful.
The most common cause of sore nipples is poor attachment and, consequently, the baby is suckling on the nipple rather than areola.

50. As the baby does not get enough milk while sucking on the nipple, he sucks even harder making things worse for the mother.
Rarely, soreness may happen due to excessive washing of nipple or a candida infection.

51. Sore nipple and cracked nipple

52. Treatment includes ensuring proper positioning and attachment. In most cases of sore nipples, the mother is able to feed the baby if proper attachment is ensured. The mother can apply hind milk to the sore nipple after breastfeeding the infant. There is no need for using any medicated ointment for treating sore nipple.

53. If the nipple is too sore, cessation of direct breastfeeding for 24 to 48 hours, pumping the breast and feeding expressed milk to the infant may help.
Mother should avoid frequent washing of the nipple; just routine cleaning during bath suffices.
Candida infection, if present, may require local application of clotrimazole cream

54. Breast engorgement Breast engorgement must be differentiated from the engorged breasts. With engorgement, the breasts are tight and painful. There may be fever and malaise in the mother. The overlying skin is red and hot and nodules can be felt in the breast tissue. These symptoms and signs are absent when breasts are just full. The engorgement can interfere with milk flow.

55. Engorged breast

56. Management The condition is treated by ensuring optimum attachment, increased frequency of feeds and complete emptying of the breast. A warm shower/ fomentation followed by breast massage (like kneading the flour from base to nipple covering all sides) before breastfeeding will also encourage milk flow. Cold fomentation after breastfeeding helps in reducing inflammation.

57. The mother can also pump or hand express milk to soften breasts prior to feeding. Breastfeeding every two hours prevents engorgement in the breast.
Engorgement tends to be less severe if baby is allowed to nurse on the first breast until the baby comes off on its own rather than switching breasts sooner.

58. Mastitis Risk factors for developing mastitis are blocked ducts, cracked nipples and past history of mastitis”. Breastfeeding mothers with mastitis complain of sudden onset with intense localised pain. On examination , redness may appear in a wedge-shaped area on the breast which is red, hot, tender and swollen. Mother has flu-like symptoms and fever.

59. Mastitis

60. Antibiotics should be started and analgesia should be encouraged with an anti-inflammatory agent.
The preferred antibiotics are penicillinase resistant penicillins , ( e.g , flucloxacillin , amoxycyclin with clavulanic acid, or macrolides such as erythromycin or clarithromycin). Help the mother empty out the breast (breastfeeding or hand-expression)

61. The mother can use warmth and massage. With warm breast, milk flow would be easier. This would help thoroughly drain affected area. Frequent breastfeeding also helps. The mother should wear a bra which is a size larger to relieve pressure on the affected area. Proper latch-on is essential to effective breastfeeding.

62. Ultrasound examination should be performed in any patient whose infection does not subside even after antibiotic therapy had been implemented. The traditional management of a breast abscess was a surgical incision and drainage. A modern and less invasive approach is to aspirate the pus under ultrasonic guidance and if required, to irrigate the cavity with normal saline until it collapses.”

63. Inadequate milk supply Primary failure of lactogenesis is a very rare. The common causes include delayed onset of lactation is defined as the “coming in of milk” later than 72 h. This condition is observed more often in primiparous mothers, after a stressful, prolonged or cesarean delivery, in overweight, elerly or diabetic mothers, after delayed initiation of breastfeeding, and with prelacteal or supplemental feeds of the newborn ” .

64. In addition, insufficient milk supply occurs with incomplete emptying of breasts due to inappropriate breastfeeding technique, obesity and large breasts, maternal or infant illness, giving top feeds to the infant or painful latch-on. Conversely, milk production can be increased with frequent feedings including night feeding. Maternal fear of not having enough milk may be an additional stress inhibiting the let-down reflex, the removal of milk, and consequently the milk production.” Conversely, at 2 weeks, a significant factor for the continuation of breastfeeding is the mothers’ feeling that they have enough milk supply

65. Indications for supplementation in the hospital setting Supplemental feedings are NOT necessary in most situations but may be required in cases of maternal infant separation, maternal illness or certain maternal medication. Infant demonstrating clinical signs of dehydration with mother having decreased milk output, with hypoglycemia or at high-risk for hypoglycemia and not feeding effectively are relative indications for supplemental feeding.

66. Recently WHO in 2018 has released updated breast feeding hospital initiative guidelines. The topic of each of 10 steps remains same but each one has been updated as per latest evidence. The steps can be broadly subdivided into ( i ) steps of critical management procedures and (ii) key clinical practices.