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Developing an instrument to assess infant 
breastfeeding behaviour in the early neonatal 
period 
M. Kay Matthews 
This paper describes the development of the Infant Breastfeeding Assessment Tool (the 
IBFAT) to assess and measure infant breastfeeding competence. It was designed for 
use by mothers, midwives and other health professionals. 
The instrument consists of four items which represent the major components of 
infant breastfeeding behaviour. These components, readiness to feed, rooting, fixing 
and sucking are assigned a numerical value based upon the answer chosen by the 
assessor for each item. The range for each of the four items is 0 to 3, giving a total score 
range of 0 to 12, 12 being the score for a vigorous, effective feeding. 
The instrument was used to assess the breastfeeding behaviours of 60 healthy 
newborn babies from birth to 4 days after birth. In total, 920 feeds were assessed by the 
mothers. The investigator also assessed 77 feeds. Inter-rater reliability for this study 
was 91%. 
The instrument did appear to assess the infants' breastfeeding competence and 
identified changes over time. 
INTRODUCTION 
Assessing infant breastfeeding behaviours is an 
important component of the care of mothers and 
babies in the early neonatal period. In order to 
do this, midwives and maternity nurses have 
relied upon their theoretical knowledge, clinical 
skills and experience to evaluate the breastfeed- 
ing behaviours of both mothers and babies in the 
clinical setting. 
Assessing baby breastfeeding behaviours for 
the purposes of research has proved much more 
difficult. Objective measurement of the complex 
M. Kay Matthews, SRN, SCM,BN, MN. Lecturer 
School of Nursing, Memorial University of 
Newfoundland, Canada, A1C 5S7 
(Requests for offprints to MKM) 
Manuscript accepted 7 June 1988 
154 
behaviours which make up the infant's breast- 
feeding activity is problematical because differ- 
ent behaviours, for example, rooting, fixing and 
sucking are involved. 
St. Clair (1978), in a historical review of the 
development of the best known neonatal assess- 
ment instruments, notes that relatively few 
instruments have focused on the neonate and 
that instruments have differed in approach 
depending on the discipline from which they 
have derived. Instruments designed by medical 
researchers tend to be used to assess neurological 
function, while instruments designed by psycho- 
logists are used to assess behaviour. However, as 
she points out, regardless of discipline, collabora- 
tion between different disciplines has played an 
important role in the work of developing useful 
assessment instruments for the newborn period. 
MmWIFERY 155 
What contributions can midwifery and mater- 
nity nursing make to this important area of re- 
search? The midwife is the health professional 
most intimately involved with the mother and 
baby during labour, delivery and the postpartum 
period and is therefore in a unique position to 
make significant contributions to the develop- 
ment of infant assessment instruments. Import- 
ant functions of the midwife in the care of the 
mother and baby are the detailed observation, 
evaluation and recording of their state and re- 
sponse. Upon these observations both clinical 
practice and clinically-based research is depend- 
ent. For example, from a clinical or a research 
point of view, what is it that the midwife observes 
and analyses when assessing a baby's breastfeed- 
ing behavour? The diagnostic devices available 
to our profession are precisely those signs and ob- 
servations which we derive from the long hours 
spent in close association with the mother and 
baby. These observations are important to define 
and describe and should serve as the basis for 
development of assessment instruments which 
can be used for clinical practice and research. 
These instruments or diagnostic devices are the 
product of clinical skills and experience which 
are unique to nursing and midwifery. In this way 
midwifery and nursing can contribute to health 
care knowledge in a way that adds to, or is differ- 
ent from the knowledge contributed by the other 
health disciplines. 
This writer was faced with a problem recently 
while planning a research study about obstetric 
analgesia and baby breastfeeding behaviour. 
How was the breastfeeding behaviour to be 
measured? A review of the literature revealed no 
previously tested instrument which could be used 
or adapted for the study. This led to the following 
question: What are we observing when we, as 
midwives, assess the neonate at feeding? How can 
these observations be used to determine differ- 
ences between babies or groups of babies? Can 
these observations be measured? Can the qualita- 
tive data collected by those most involved with 
the mothers and the babies, namely the mid- 
wives, nurses and the mothers themselves, be 
quantified and used for clinically-based research? 
It was decided to design an instrument to assess 
infant breastfeeding behaviours. This instrument 
would be based upon observations normally 
carried out in clinical practice by mothers, mid- 
wives and maternity nurses. The major com- 
ponents of the babies' feeding behaviours would 
be analysed and a numerical value assigned in an 
attempt to reflect the degree of competence of the 
baby at each breastfeeding behaviour. A total 
score would reflect the overall competence of the 
baby at each feeding. It was hoped that differ- 
ences could be identified between babies and that 
changes in individual babies would be identified 
and recorded over time. 
Literature review 
In the 1950's and 1960's considerable work was 
undertaken to develop infant assessment instru- 
ments although few focused specifically on the 
neonate. The Apgar scoring system is the one 
most commonly used in clinical practice to assess 
the condition of the baby at birth. Graham 
(1956), Brazelton (1973) and Scanlon et al 
(1974) devised instruments which assessed neo- 
natal behavioural capabilities. The instrument 
designed by Brazelton has become one of the 
most important developments in neonatal assess- 
ment and was designed to be comprehensive, 
encompassing much of the behavioural reper- 
toire of the newborn. Andre-Thomas et al 
(1960), Yang (1962) and Prechtl and Beintema 
(1964) developed various neurological tests 
which have been used for neonatal assessment. 
However, in the studies to compare effects of 
various pre- and perinatal variables on newborn 
behaviour, the Brazelton Neonatal Assessment 
Scale is the one most widely used. A review of the 
literature revealed no instrument already vali- 
dated and reliable to test newborn breastfeeding 
behaviour. The neonatal neurobehavioural 
assessment scale in common use to assess baby be- 
haviour tests the rooting and sucking reflexes, but 
these are done by the examiner's finger being 
brushed along the baby's cheek and by inserting 
the finger into the baby's mouth (Brazelton, 
1973). However this does not accurately assess 
the complex behaviours which the breastfeeding 
baby must carry out for effective feeding. 
Several important studies have investigated 
the rooting, sucking and swallowing behaviours 
156 MIDWIFERY 
of the newborn baby. Gentry and Aldrich (1948) 
investigated the incidence of rooting in the first 
days of life and the effect of sleepiness in the new- 
born on rooting behaviour. Both rooting and 
sucking were found to be greatly influenced by 
the baby's state of wakefulness and the age of the 
baby. The most effective rooting and sucking be- 
haviours were found in the alert, awake baby 
while the baby who was difficult to rouse dis- 
played no rooting and poor sucking. This early 
study found an increasein rooting and sucking 
competency over the first 6 days post birth. By 
the fourth postpartum day over 90% were root- 
ing and sucking effectively. The investigators did 
not analyse the variables which may have in- 
fluenced the delay in establishing effective be- 
haviours to determine why these babies were 
unresponsive. Several later ontogenic studies 
analysed the sucking of the baby, particularly 
focusing on patterns of sucking bursts and pauses, 
sucking amplitude and frequency and intra-oral 
pressures (Kron et al, 1966; Dubignon & Cam- 
bell, 1969; Ellison, et al, 1979; Pollitt, et al, 1981; 
Koepke & Barnes, 1982). Ardran (1958) con- 
ducted radiographic studies to determine the 
physiology of the sucking and swallowing pro- 
cesses in the baby's mouth. Richards and Bernal 
(1972) studied a group of babies of mothers who 
had received obstetric medication to assess the 
neurological status of the babies. The babies in 
the group were either breast or bottle fed, but 
only non-nutritive sucking was tested for both 
groups with a teat and breastfeeding behaviours 
as such were not assessed. 
More recently, ultrasonographic studies have 
described the anatomy and physiology of sucking 
(Smith et al, 1985; Selley et al, 1986; Weber, 
Woolridge & Baum, 1986). Prior to the ultra- 
sonographic studies, most researchers used 
mechanical devices such as a suckometer de- 
scribed by Kron et al (1966) to obtain objective 
measurements of sucking. This methodology was 
more appropriate for bottle feeding babies and 
indeed the subjects in most of these studies were 
bottle fed. These methods do not accurately 
assess the feeding behaviours of a baby at the 
breast because the breastfeeding behaviours are 
more complex and the baby must be alert and 
able to grasp the nipple. These methodological 
difficulties are probably the reason for the rela- 
tively few studies on the anatomy and physiology 
of infant breastfeeding until the development of 
the ultrasonographic techniques, which today 
are providing valuable descriptions of the 
mechanisms involved. 
Drewitt and Woolridge (1979) used videotap- 
ing to study the behaviours of the baby at the 
breast. The subjects were babies who were 
already effective breastfeeders in whom rooting, 
fixing and sucking were established. Pauses and 
sucking bursts were measured and the sucking 
pattern described. Bowen-Jones et al (1982) used 
the same method to measure milk flow and suck- 
ing rates in breastfeeding babies. 
Several studies have noted changes in babies 
over the first few days following birth. Selley et al 
(1986) found an ' immature' sucking pattern at 2 
days which later developed into a more mature 
pattern over 5 to 8 days. Weber et al (1986) 
found that the younger the baby the more in- 
frequent the swallows would be and the more 
likely that breathing and sucking would be 
poorly co-ordinated. Pollitt et al (1981) con- 
cluded that nutritive sucking efficiency improves 
and changes in the first month of life. Another 
study found a difference in the rooting activity of 
babies whose mother was medicated in labour, 
but not in sucking pressures (Brock-Utne et al, 
1982). Again, in this study, sucking was 
measured with a pre-calibrated teat. 
Stock et al (1985) have drawn attention to a 
difficulty with the clinical assessment of the new- 
born. They point out the subjectivity of different 
examiners using the standard sucking test on the 
most widely used neurobehavioural assessment 
scale, the Brazelton Neonatal Assessment Scale, 
to assess infant sucking. They have also raised the 
issue of the loss of information which results from 
the use of binary or ordered categorised data in 
lieu of continuous measures, which may contrib- 
ute to the lack of precision evidenced in the clin- 
ical reflex sucking measure. 
Clinical observations, consultations with 
experts in this area of neonatal behaviour and a 
review of the literature identified four key be- 
haviours involved in infant breastfeeding. These 
are rooting, fixing, sucking and swallowing, the 
anatomy of which have recently been well 
MIDWIFERY 15 7 
described by the ultrasonographic studies of 
Woolridge (1986). However, it is not feasible to 
use ultrasonography in everyday clinical practice 
for several practical and financial reasons. Sim- 
ilarly, videotaping can be intrusive and inhibit- 
ing to a mother who is struggling to breastfeed a 
baby. 
Therefore, even after the studies using these 
methodologies appeared in the literature, it was 
evident that a simple easy-to-use instrument was 
needed which could be used to assess the baby at 
every feeding and over time. Such an instrument 
could be used by mothers, midwives and nurses 
to assess and record the baby's feeding be- 
haviours, especially in the early neonatal period 
before these behaviours were well established. 
Changes in the baby's breastfeeding competence 
over time could then be measured. This is im- 
portant for the clinical management of these 
babies. It is standard midwifery and nursing 
practice to use mothers' reports of their baby's 
progress at feeding and to involve the mothers in 
the baby assessments has subtle benefits for the 
mothers. By sharing the responsibility for the 
assessments, they may be more sensitive to their 
baby's feeding cues and behaviours and, because 
the same person is making the assessment, the 
measurements are likely to be more consistent. 
Instrument design 
The main purpose then, was to develop an 
instrument which was accurate, which measured 
the baby's rooting, fixing and sucking behaviours 
and which could be used easily by mothers, mid- 
wives and maternity nurses to assess the infant's 
performance at each feeding. Because swallowing 
is closely associated with sucking and is more dif- 
ficult to assess without more sophisticated equip- 
ment, this component ofbreastfeeding behaviour 
was not included in the development of the 
instrument as a separate entity. The instrument, 
the Infant Breastfeeding Assessment Tool (the 
IBFAT) was developed over several months and 
was modified several times before the first pre- 
test and again following the pre-test. A baseline 
for effective feeding was established by observing 
a number of healthy vigorous newborns who 
were feeding well. These babies, when put to the 
breast, turned their head and rooted for the 
nipple, opened their mouth, grasped and fixed on 
the nipple and started to suck. The pattern of 
sucking was similar to that described by Wool- 
ridge in that there were short bursts with some 
pauses in-between. 
From these observations four key components 
of feeding were determined and were incorpor- 
ated into the final draft of the instrument: 
1. Readiness to feed or arousability. The observer 
was asked to record whether the baby 
started to feed readily without effort (score 
3), needed mild stimulation to start to feed 
(score 2), needed more vigorous stimula- 
tion to rouse and start to feed (score 1) or if 
the baby could not be roused (score 0). 
This item was included to determine the 
baby's state at the start of the feed since 
infant state is considered to be one of the 
most important variables in any study of 
the newborn (Emde et al 1975). 
2. Rooting. This was defined in the standard 
way as 'At the touch of the nipple to the 
baby's cheek, the head turns towards the 
nipple, the mouth opens and baby 
attempts to fix the mouth on the nipple'. 
The observer then recorded whether the 
baby, when placed beside the breast, 
rooted effectively at once (score 3), needed 
some coaxing, prompting, or encourage- 
ment to root (score 2), rooted poorly, even 
with coaxing (score 1) or did not try to root 
(score 0). 
3. Fixing. The observer recorded the length of 
time, from placing the baby at thebreast, 
that it took for the baby to 'latch on' and 
start to feed well. Did he or she start to feed 
at once (score 3), take 3 to 10 minutes 
(score 2), take over 10 minutes (score 1) or 
did not feed (score 0)? It was felt that 
'latching on and starting to feed' was the 
best way to define the fixing behaviour. 
The time element attempts to assess the 
degree of difficulty in getting the baby on 
to the breast. Of the four items, this was the 
one least reflective of baby state, since 
failure to grasp the nipple may be due to 
anatomical problems such as flat or 
158 MIDWIFERY 
inverted nipples or oral anomalies in the 
baby. Nevertheless, this is an important 
aspect of feeding as anatomical problems 
compound a situation in which the baby is 
too sleepy or not interested in feeding and 
contribute to feeding difficulties. 
4. Sucking pattern. The observer was asked to 
choose the phrase which best described the 
baby's feeding pattern at the feed. This 
ranged from 'baby did not suck' (score 0), 
through 'sucked poorly' (i.e., weak suck- 
ing, some sucking efforts for short periods ) 
(score 1), 'sucked fairly well' (sucked offand 
on, but needed encouragement) (score 2), 
or 'sucked well on one or both breasts' 
(score 3). The order of the items for this 
behaviour was reversed to avoid automatic 
scoring of the items. The definitions were 
included in the instrument and in all cases 
the observer was asked to choose the best 
answer. 
These four items, which were items 2 to 5 on 
the IBFAT, were considered from the mothers' 
and researcher's responses to give valuable data 
about each baby's feeding behaviours. There 
were two other items, items 1 and 6. Item 1 
simply recorded the baby's state at the start of 
the feed (deeply asleep, drowsy, quiet alert, or 
crying). Item 6 asked the mother, if the mother 
was the observer, to record whether she was 'very 
pleased', 'pleased', 'fairly pleased', or 'not 
pleased' with the way the baby fed at each feed- 
ing. These two items were not scored in the infant 
breastfeeding scale, although a maternal score 
was later assigned to item 6, which ranged from 1 
(not pleased) to 4 (very pleased). 
The scoring range for the four scored infant 
breastfeeding items was 0 to 12 for each feeding. 
The babies in the study were on a 'demand feed- 
ing' schedule and on average were fed 3 to 4 
hourly, although there were wide individual dif- 
ferences with some mothers reporting that their 
babies 'wanted to nurse all the time' compared 
with those babies who had to be roused because 
they were not interested after 4 to 5 hours. It is a 
policy in the maternity unit where the tool was 
developed that babies who are not yet starting to 
feed well are put to the breast and encouraged to 
feed every 4 hours. 
The pre - tes t 
The instrument was first pre-tested with 10 
mothers and babies in the maternity unit. The 
objectives of the pre-test were to determine 
whether the mothers found the instrument easy 
to use, whether the items represented the key 
feeding behaviours accurately and to identify 
whether there were likely to be problems with 
inter-rater reliability. 
The IBFAT was found to be easy to use and 
could be completed by the mothers in less than 1 
minute. The mothers did not find it dificult or 
anxiety-producing. Their comments at this time 
pointed to a need for more than three choices for 
items 2 to 5. The instrument was then modified 
and the four choices for each item as described 
above were included. The modified version of the 
instrument was then pre-tested with five breast- 
feeding mothers. During the second pre-test the 
mothers of the babies and the researcher inde- 
pendently checked each baby's breastfeeding re- 
sponse at two separate feedings for each baby (10 
feedings) and the responses were compared to 
assess inter-rater reliability. For this small group 
inter-rater reliability was 100% . This was the 
final version of the IBFAT. 
At this point it was decided to weight each be- 
haviour equally on the scale and to re-assess after 
the study was completed when, if necessary, 
adjustments could be made. The scoring range of 
0 to 3 for each item was established to try to 
quantify the spontaneity of the rooting activity 
(item 3), the ease with which the baby 'fixed' on 
the breast (item 4), the level of effort required to 
get the baby starting to feed (Items 2, 3 and 4) 
and the type and pattern of sucking once the 
baby was fixed on the breast (Item 5). 
Throughout the pre-tests, and through the 
study, there was a wide range of variations in 
baby feeding competence and in the different 
components of the feeding behaviour. 
The subjects 
The main study included 60 healthy, full-term 
newborn babies whose mother intended to 
breastfeed. To be eligible for the study, babies 
had to meet the following criteria. They had to 
be: 
1. Appropriate weight for gestational age. 
MIDWIFERY 159 
2. Assessed at birth to have had Apgar scores 
of equal to or greater than 8 at 5 minutes 
after birth. 
3. Delivered spontaneously following an 
uncomplicated pregnancy and labour 
(babies born to mothers whose labour was 
induced or accelerated were included if 
there were no other complications). 
Because a main purpose was to investigate the re- 
lationship between maternal labour analgesia 
and delay in the initiation of breastfeeding, 
sampling was carefully controlled to exclude 
other possibly competing variables. 
Sampl ing 
Sampling was non-random. When the babies 
were admitted to the nursery following birth, the 
nursery staff identified and recorded the names of 
all babies who fitted the criteria for admission to 
the study. Out of approximately 250 babies de- 
livered at the hospital during the period of data 
collection, 116 (46%) started to breastfeed. Of 
these 116, 69 (59%) were eligible for admission 
to the study. The final sample was 60 out of 69 
babies (86.9%). 
Of the babies, 31 were female and 29 were 
male. The mothers of the babies ranged in age 
from 17 to 40 years; 58 were married, 2 were 
single. Of the mothers, 21 were primiparous, 39 
were multiparous and 32 of the multiparous 
mothers had breastfed previously. All the 
mothers could read and write English and gave 
permission for their baby to be included in the 
study. 
Infant assessments were started as soon as pos- 
sible after a 12 hour rest period for the mother 
following the birth. I f the baby had been put to 
the breast during this rest period, these feeds were 
assessed retroactively from the mother's report 
and a nurse's report, if one was available. This 12 
hour rest period was stipulated by the Human 
Subjects Review Committee at the School of 
Nursing. After the mother signed her consent 
form, full explanations were given to the mother 
about the use of the instrument and the mothers 
were encouraged to complete it as soon as pos- 
sible after each feed. Each morning the mothers 
were given a supply of IBFAT sheets to complete 
throughout the day and night whenever the baby 
fed. At the same time, the IBFAT sheets which 
had been completed in the previous 24 hours 
were collected, the scores were assigned accord- 
ing to the mothers' responses, and the total scores 
calculated and plotted on graph for each indi- 
vidual baby. 
Findings 
Infant feeding assessments 
Total scores in the 10 to 12 range for a particular 
baby indicated an effective vigorous feeding. In 
fact most babies who were effective vigorous 
feeders scored 12. This meant that when put to 
the breast the baby would spontaneously turn his 
or her head towards the nipple and readily start 
sucking. However, some babies who sucked 
effectively once started would lose points by not 
rooting, the mother would have to guide the 
nipple into the baby'smouth (item 3) or by 
taking pauses throughout the feeding (item 5). 
The latter had more to do with the individual 
baby's feeding pattern and this was allowed for in 
the decision to establish the effective feeding 
score range as 10 to 12. Some babies scored 12 
within a couple of hours after birth and main- 
tained these scores throughout the hospital stay 
(Fig. 1), but most babies in the group started 
more slowly and achieved the optimum score by 
36 to 48 hours (Fig. 2). However, six babies took 
59, 56, 64, 79, 76 and 80 hours respectively from 
birth to achieve scores in the effective feeding 
range (Fig. 3). The mothers of'all five babies had 
received analgesia within 1 to 4 hours prior to de- 
livery. Four were babies of primiparous mothers. 
The mother whose baby took 64 hours to start 
feeding gave up breastfeeding on the fourth post- 
partum day. Although the baby had begun to 
feed well, her breasts became engorged and the 
baby started to have difficulty again. At this 
point she wrote on the IBFAT 'Today I decided 
that breastfeeding was not for me'. 
Babies who scored in the 7 to 9 range were 
considered to be moderately effective feeders. It 
took more effort on the part of the mothers to get 
these babies to feed. They had to be roused and/ 
or they were difficult to fix, but once fixed they 
sucked fairly well. Some did not root; the mother 
would have to put the nipple in the baby's mouth 
160 MIDWIFERY 
12 
11 
10 
9 
8 -o ~= 
,BFAT 7 
SCORES 6 -~ ~- m 
5 "~ 
r r 
4 
3 
2 
1 
i l l l | l 
l i l E I I 
I I E | I I 
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 
BIRTH HOURS FROM BIRTH 
DAY 1 DAY 2 DAY 3 DAY 4 
Last baby slow feeder - gave up after 5 days 
Fig. 1 Graph of I B FAT scores during early neonatal period of a baby who started to feed well at the breast from 6 hours 
post birth. 
to stimulate the baby to suck. The sucking pat- 
tern was sporadic, the mother or the maternity 
nurse having to keep stimulating the baby to con- 
tinue to suck. Any or all of these behaviours were 
present to some degree in babies who scored in 
this range in the first 24 to 36 hours after birth 
after which time the scores improved. 
Babies who scored in the 0 to 6 range were 
babies who either could not be roused for feeding 
(zero), or who did not root and sucked weakly for 
short periods only. An effective sucking rhythm 
was not established for that particular feeding. 
These behaviours when they occurred, usually 
occurred in this group of healthy babies in the 
first 24 to 36 hours after birth. Sometimes im- 
provement was gradual, sometimes it was quite 
dramatic, from a low score at one feed to a high 
score at the next. 
Re l iab i l i ty and va l id i ty 
The mothers reported that the IBFAT was easy 
to use and could be completed quickly. Inter- 
rater reliability was assessed by checking the 
congruence of the rnaternal-rated and investig- 
ator-rated scores. During the period of data col- 
lection, data were collected by the mothers on 
920 feedings. Of these feedings, 77 (8.4%) were 
simultaneously assessed by the investigator. 
These assessments were carried out daily at ran- 
dom throughout the period of the study. To rule 
out the influence of visitors, night time versus day 
time or other environmental factors which might 
have affected the scores, the observations were 
carried out at different times during each 24 hour 
period. The 24 hour day was divided into six 4 
hour observation periods, each represented by a 
number on a dice. The 4 hour periods were ran- 
domly selected weekly in advance by tossing the 
dice. Within this period, the first and second 
babies to feed from the beginning of the time 
period were observed and scored by the investig- 
ator as well as by the mother. 
MIDWIFERY 161 
IBFAT 
SCORES 
12 
11 
10 
9 
8 
7 
6 
5 
4 
3 
2 
1 
0 
BIRTH 
>, 
~u3 
,,o 
,-.,/ 
r 
/ 
~U'3 
-o(.9 
,o 
\ / \ / 
4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 
HOURS FROM BIRTH b 
DAY 1 DAY 2 DAY 3 DAY 4 f 
Fig. 2 Graph of IBFAT scores of baby who started to feed slowly and improved by 24 hours post 
birth 
,2 I 
10 2 ¢~" 
9 e0~ ~i l 
IBFAT 7 
SCORES 6 
.----. \m 
4 ~ ~ 
3 / 
/ 1 
~.--L /i 
/ I 
/ 
.---. j 
/ 
J 
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 
BIRTH HOURS FROM BIRTH 
DAY 1 DAY 2 DAY 3 DAY 4 
Fig. 3 Graph of IBFAT scores during the early neonatal period of a baby who tool~ 76 hours to 
reach the effective feeding range 
162 MIDWTFERY 
Because mothers might feel anxious or in- 
hibited if they thought they were being observed, 
the investigator visited all mothers twice daily to 
see how they were coping, so that when the in- 
vestigator entered the room to observe the baby's 
feeding behaviours, assessment could be done 
unobtrusively without distracting the mother. 
After the first 10 and 20 investigator-rated 
feeds, a check was made for significant disagree- 
ment between the maternal and the investig- 
ator's scores. A significant difference was 
predetermined to be a difference greater than 
one in either direction. At this time significant 
disagreement occurred in less than 10% of eases. 
Where there was disagreement, the mother's 
scores were those used for analysis. The investig- 
ator's scores were recorded separately for com- 
parison with the mothers to assess inter-rater 
reliability. There was agreement between the 
mother and the investigator in 70 of the 77 co- 
assessed feeds, an agreement of 91%. Inter-rater 
reliability was high particularly in the upper and 
lower scoring ranges. Babies who were feeding 
well or who were feeding poorly were easy to 
assess. However, the moderate feeders who 
scored in the middle range were harder to assess 
because more judgement was required. Some- 
times the mother would score one item higher or 
lower than the investigator while the researcher 
would score a different item higher or lower than 
the mother, but the overall score for the feeding 
would be the same and reflected the infant's per- 
formance at the feeding. In only one case was dis- 
agreement greater than two. In this case the 
mother had engorged breasts and was generally 
dissatisfied with the feeding, although the invest- 
igator felt the baby had fed well. It appeared in 
this case that the mother's mood may have 
affected her perception of the feeding. 
Predictability 
An issue which was considered when the instru- 
ment was designed was whether low or high 
scores in the early neonatal period would predict 
breastfeeding success or failure later. A telephone 
call was made to the mothers 4 weeks following 
hospital discharge to find out if they were still 
breastfeeding. Of the 59 mothers still breastfeed- 
ing on discharge from the hospital, 49 could be 
contacted. Of these, 39 (79.6%) were breastfeed- 
ing completely, 6 (12.2%) were breastfeeding 
with a bottle supplement and 4 (8.2%) had 
changed to bottle feeding. In this group there 
was no correlation between low scores and giving 
up breastfeeding although the baby of the 
mother who gave up breastfeeding while in the 
hospital had low scores. 
Some of the mothers whose baby initially had 
low scores while in hospital, reported that their 
baby was now feeding well. Of the 4 mothers who 
gave up, 1 had difficulties throughout the hos- 
pital stay and gave up on leaving the hospital. In 
this case the baby breastfed well throughout the 
hospital period, but the mother seemed unable to 
relax, she had problems with 'let-down', her 
breasts became engorged and the whole experi- 
ence was anxiety-producing in spite of much 
encouragementby the staff. At the telephone 
interview, she admitted there were 'lots of other 
problems in my life' which had contributed to 
her breastfeeding problems. In this case the high 
scores on the IBFAT had suggested the problem 
lay with the mother rather than the baby. 
The other 3 mothers, whose baby had breast- 
fed well in the hospital in that they had all estab- 
lished feeding by 30 hours, gave various reasons 
for changing to bottle feeding. One mother 
developed a breast abscess which had to be 
drained. The third mother cited 'big family, no 
privacy, I found it inconvenient'. The fourth 
mother in the group gave up at 1 week. She said 
'She was starved to death. She drained the bottle. 
Already I 'm giving her cereal twice a day. All of 
the women in my family had to do this'. It is clear 
that many factors contribute to success with 
breastfeeding. 
This group of mothers was in some ways a 
special group in any analysis ofbreastfeeding suc- 
cess at 1 month and this may have affected any 
assessment of the predictive value of the instru- 
ment. The fact that this was a study group and 
the mothers knew that the investigator was going 
to contact them by telephone after 1 month may 
have encouraged some mothers to persist with 
breastfeeding until that time. This may have in- 
fluenced this set of findings. 
One other important aspect of the use of this 
instrument should be considered. On the first 
MIDWIFERY 163 
pre-test, one baby had persistently low scores 
throughout the 5 day hospital stay. The mother 
became very discouraged and the baby was 
switched to the bottle on the day of discharge. A 
baby with this atypical pattern suggests a need 
for close follow up by the health visitor and 
physician since weak sucking can indicate other 
health problems such as neurological damage. 
Signif icance of parity as a variable 
When the study was being planned, a decision 
was made to include babies of multiparous and 
primiparous mothers. Since the baby was the 
subject of the study, and the feeding behaviours 
were the focus, the researcher wanted to find out 
if the feeding competence per se of the babies was 
dependent or independent of the parity of the 
mother. 
When the findings were analysed, it was clear 
that there were significant differences in IBFAT 
scores and in the length of time to establishing 
effective feeding between babies of first-time 
mothers and babies of multiparous mothers, 
babies of first-time mothers taking longer to 
establish feeding according to the pre-deter- 
mined criteria (Mean = 35 hours compared with 
21.2 hours, p = <0.05). Because 83.4% of the 
first-time mothers had received analgesia 1 to 4 
hours prior to delivery compared with 45% of 
multiparous mothers and because timing of ad- 
ministration of medication prior to delivery was 
considered to be a significant variable from the 
results of other analyses, the statistical analysis 
was done on babies ofmultiparous and primipar- 
ous mothers who had received alphaprodine 
(Nisentil, a rapid acting narcotic analgesic with 
short duration of action with pharmacological 
properties similar to those of meperidine or mor- 
phine) within 1 to 4 hours prior to delivery. 
These other analyses included Analysis of Vari- 
ance which identified parity as a significant vari- 
able and a scatter diagram which indicated that 
a longer period to establishing feeding was asso- 
ciated with the timing of drug administration in 
labour. There were only three first-time mothers 
who had not received obstetric medication, so 
comparisons could not be made with babies in 
the non-medicated groups. The findings there- 
fore showed that, even when timing of adminis- 
Table 1 
Means and standard deviations for length of t ime 
in hours from birth to establishing breastfeeding 
for babies of primiparous and multiparous 
mothers who received alphaprodine one to four 
hours prior to delivery 
Group N X S.D. p 
Babies of multiparous 
mothers 9 21.2 17.1 
Babies of primiparous 12 35.0 24.1 <0.05 
tration and dosage of the drug was controlled, 
there was a significant difference in breastfeeding 
competence between babies of first-time and 
multiparous mothers (Table 1). A more compre- 
hensive analysis of the significance of maternal 
labour analgesia on infant breastfeeding will be 
published separately (see Midwifery 5 : 1). 
DISCUSSION 
The Infant Breastfeeding Assessment Tool did 
appear to assess the infants' feeding behaviours 
and to identify changes in breastfeeding com- 
petence over time. 
Although the instrument needs to be re-tested 
and lacks the methodological objectivity of some 
of the other methods used in this type of research, 
it is valuable as a research tool for several 
reasons. The total breastfeeding activity of the 
baby is more complex than any one of the com- 
ponents which have been studied in much of the 
previous research as separate entities. In this type 
of methodology, which is based upon the close 
observations of the mother or midwife, the baby 
is observed in his or her natural state. Because the 
instrument is easy to use, all feeds in the 24-hour- 
period and over several days can be evaluated. 
This provides for a developmental approach to 
assessment since it is clear, particularly in the 
early neonatal period, that changes do occur over 
a period of time. There is no interference by the 
investigator in the breastfeeding process between 
mother and baby. In methodologies where any 
type of mechanical device is involved, the invest- 
igator usually has to interrupt the feeding to posi- 
tion the mother or baby in a certain way or has to 
conduct the studies of the baby in a laboratory- 
type situation. 
164 MIDWIFERY 
There are, of course, l imitations to this 
method and they have to be recognised. The 
Infant Breastfeeding Assessment Tool is a new 
instrument which has not been previously tested 
to establish rel iabil ity and validity. Although 
inter-rater reliabil ity was high between the 
mothers and the investigator in this study, it 
needs to be tested by midwives and other health 
professionals involved with neonates and their 
mothers. The study was confined to one mater- 
nity populat ion and therefore needs to be tested 
in other centres before it can be confirmed as a 
useful instrument for research. Apart from the 
need for further testing, an addit ional l imitation 
relates to the subjectivity of the mothers' evalu- 
ation of the feed if mothers are used as the main 
data collectors. 
The mother's perception of her baby's feeding 
behaviours may be influenced or affected by 
variables relating to her emotional or physical 
state. Anxiety or depression might cause the 
mother to assess the baby negatively which could 
contr ibute to lower scores for the baby, or, if 
there were other problems such as breast en- 
gorgement she might negatively assess the total 
feeding rather than the infant's rooting and suck- 
ing behaviours. In this study, this happened 
rarely, but it was felt to be a factor in an occa- 
sional feed for three mothers. Also, if the mother 
felt that her baby's performance was being evalu- 
ated she might score the baby higher than an in- 
dependent observer. 
Although maternal perception of the baby's 
feeding abil ity is clinically extremely important 
and relevant to the total experience, from a re- 
search point of view, assessment is based upon 
subjective evaluation which may, depending on 
the part icular research question, weaken the 
findings. Nevertheless, in this study mothers were 
found to be generally very reliable in recording 
their baby's behaviours while the scoring scheme 
did differentiate between babies who were feed- 
ing well, moderately well, or poorly. 
The findings support the findings of other 
studieswhich found an improvement in rooting 
and sucking behaviours over the first few days 
after birth (Gentry 1948; Brazelton 1961; Selley 
et al 1986). Improvements in infant scores were 
observed over time. As the baby appeared to re- 
cover from the effects of birth, scores improved 
until each baby was exhibiting the type of be- 
haviours described by Woolr idge (1986). 
A much larger, multi-site study is being 
planned to test the instrument with a larger 
group of babies, including babies with more com- 
plicated obstetrical and perinatal histories. It is 
hoped that such a study will support the useful- 
ness of the Infant Breastfeeding Assessment Tool 
as well as increase our knowledge of breastfeed- 
ing infants and their mother. 
Acknowledgements 
The author would like to acknowledge the advice and guid- 
ance of Dr Caroline White, and Ms Shirley Solberg, in the de- 
velopment of the instrument. 
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