Breastfeeding assessment and management instruments: a scoping review protocol

Abstract

Introduction

Different aspects are involved in the breastfeeding process that may vary according to the target population, postpartum phase and evaluation scenario. The identification of such instruments, their constructs and applicability in health services will contribute to the understanding of the most relevant aspects and dissemination of tools that can be implemented in the necessary spaces to promote breast feeding. This article describes a review protocol to map the assessment and management instruments applied to breast feeding in the puerperal period existing in the literature.

Methods and analysis

This is a protocol of a scoping review that follows the methodological recommendations of the Joanna Briggs Institute (JBI). In March 2024, a search will be carried out in the databases Medical Literature Analysis and Retrieval System Online—Medline (PubMed), Latin American and Caribbean Health Science Literature—Lilacs (BVS), Cochrane Library and Embase (CAPES). Peer-reviewed studies that address instruments for evaluating the breastfeeding process during the puerperium will be included, regardless of year of publication or language. The selection of studies and data extraction will be done by peers and disagreements will be resolved by a third researcher. The selection will be made through the Rayann platform (https://www.rayyan.ai/). Data extraction and synthesis will be performed by pairs, using a semistructured instrument, based on the model available in the JBI manual. The studies will be summarised according to the postpartum period in which the instrument was used (immediate, remote or late postpartum) and their constructs, domains and contexts of utilisation will be identified.

Ethics and dissemination

Ethical approval is not necessary for this scoping review. The results of the review will be shared through publications in peer-reviewed journals, at relevant scientific conferences and seminars and meetings with maternal and child healthcare providers.

Study registration

This study was registered with Open Science Framework registry (osf.io/f4hz8) on 27 April 2023.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This review will examine the multidisciplinary literature in the postpartum period to identify any scale or instrument pertaining to breast feeding.

• Due to the high degree of heterogeneity among studies examining different aspects related to breast feeding, the scoping review methodology is better suited to map and present findings compared with a systematic review.

• Due to the specificity of some comorbidities, some breastfeeding assessment and management instruments may not be included, as they apply to very specific conditions.

• This scoping review will include literature published in four different databases, so some relevant publications indexed in other places may be missed.

Introduction

Breast feeding is an effective way to protect the child’s health and represents a health promotion practice, being recommended exclusively up to 6 months of life and from that period onwards concomitantly with food introduction.^{1 2} It is considered an important health promotion and disease prevention strategy, being essential for maintaining the health of the infant, with a positive impact on the various organic systems—immunological, respiratory, cardiological, gastrointestinal and dental aspects, among others.^{3 4} Breast feeding represents an effective strategy to reduce child mortality from preventable causes, which is one of the Sustainable Development Goals of the United Nations agenda for the period 2016–2030. There are also benefits for maternal health, since it has a potential to reduce the risk of breast cancer and of the development of cardiovascular diseases among women.⁵

In this context, despite global efforts and the implementation of public health policies, a scenario far from ideal and recommended is still observed worldwide.^{2 6 7} Globally, breastfeeding-related rates are below estimated targets for protecting the health of women and children. The latest Global Breastfeeding Scorecard of WHO and UNICEF for the period 2015–2021 shows that only 47% of newborns are breast fed within the first hour of life and that 48% of women exclusively breastfeed until 6 months of life of the infant.⁸ This study highlighted that breast feeding during the postpartum period, up to 42 days after delivery,⁹ is crucial for continuing breast feeding for a long time.⁴ There are several aspects that may contribute to early weaning, low levels of duration and exclusivity of breast feeding, namely, sociocultural, anatomophysiological factors and, especially, the difficulty in managing the breastfeeding process.^{10 11}

To this end, a question arises about the current existence of a grounded and conducted approach in the space of care production of the mother–child dyad, in order to identify the problems presented by the pair, especially in the initial phase. Given this, there is a need to employ specific tools for the evaluation and proper management of the breastfeeding process during this period, which can support professional performance. The mapping of assessment and management instruments can be valuable in systematising professional assessments, enabling the documentation and ensuring the continuity of the assessment in the management of breast feeding.

The aim of this paper is to describe the framework for a scoping review protocol designed to map the assessment and management instruments applied to breast feeding in the puerperal period existing in the literature. It is intended to understand the constructs related to the assessment and management of breast feeding, understand their application scenarios and analyse the need for new instruments. The final objective is to identify the factors that interfere with breast feeding that can inform more effective measures for the management of breast feeding worldwide.

The primary research question of the review is:

• What assessment and management tools are available in the literature for breast feeding during the puerperal period?

The secondary research questions are:

• Are there intervening factors in breast feeding that infer measures for the management and evaluation of breast feeding in the puerperal period?

• Which are the main constructs of the instruments for breastfeeding assessment and management and to which context they have been applied?

Methods and analysis

Protocol and registration

This is the framework for a scoping review with registration of the research protocol in the Open Science Framework (osf.io/f4hz8), guided by the recommendations of the Joanna Briggs Institute (JBI),¹² which follows five steps: (1) identification of the research question; (2) identification of relevant studies; (3) selection of studies; (4) data analysis; and (5) data grouping, synthesis and presentation.

The methodological strategy adopted to guide the elaboration of the research question was population; concept; and context,¹² elements that also served as a reference for formulating the inclusion/exclusion criteria.

Population

The review will consider sources of evidence reporting on women in the postpartum period (42 days postnatal)⁹ who underwent evaluation on the breastfeeding process through an instrument. No limitations will be applied based on individual health conditions of the women.

Concept

It encompasses the results of applying instruments to the breastfeeding process, considering that its dimensions can be related to aspects of both the evaluation and management of breast feeding. These aspects may include exclusive breast feeding, anatomy and positioning during breast feeding, duration of breast feeding, breast care, difficulties, women’s knowledge of breast feeding and family support, among other factors.

Context

Any application where the breastfeeding assessment tool was implemented with women during the puerperal period, such as maternity hospital, primary healthcare centres or home. Thus, the location, publication period and research development environment will not be limited.

Source of evidence

Articles published in the databases until February 2024 will be included and the search will be carried out in March 2024. The search will be conducted in the following databases: Medical Literature Analysis and Retrieval System Online—Medline (PubMed), Latin American and Caribbean Health Science Literature—Lilacs (BVS), Cochrane Library and Embase (CAPES). A manual search will also be carried out in the bibliographic references of the selected articles. An adequate search strategy will be developed for each database or electronic repository.

Search strategy

A search strategy was built in PubMed, using Medical Subject Headings and keywords related to the theme were added, which were adapted to other databases. The descriptor related to breast feeding will be combined with descriptors for the different types of instruments, that is, questionnaires, surveys and scales. The full search strategy is presented in the online supplemental file. Hand searching of citations and reference lists of included documents will also be conducted.

Eligibility criteria

Studies that used instruments to assess breast feeding throughout the postpartum (42 days postpartum),⁹ period in which the breastfeeding process is still in consolidation, will be selected. Studies should be indexed in peer-reviewed journals, regardless of year, country of publication and language, in order to expand as much as possible the possibility of identifying feasible instruments for analysis.

Studies with an application instrument for difficult conditions that require specific management, such as the presence of comorbidities in infants or extreme prematurity, will be excluded. No maternal conditions will be considered as an exclusion criterion.

Selection of studies

Initially, a researcher will carry out the search applying the search strategy in the databases and the selected articles will be migrated to the Rayann platform (https://www.rayyan.ai/). After the identification and exclusion of duplicate articles, two independent researchers will select the studies based on reading the titles and abstracts. The articles selected in this first stage will be submitted to full-text reading. If there are discrepancies in the selected articles, a third researcher will be responsible for resolving them.

Data extraction

The procedure for extracting and synthesising data from this research will be carried out in pairs, using a semistructured instrument, made specifically for this research in Microsoft Excel and based on the model available in the JBI manual.¹² Data information related to the following aspects of the studies will be collected: authors; study title; main goal; year; country; journal of publication and its impact factor; instrument name; original language; evaluated outcome; type of health service in which the instrument was used; mean age and age range of the study sample; postpartum period in which the instrument was used; form of application of the instrument; number of instrument items; construct and evaluated domains; and information on tool validation (sensitivity, specificity and reliability data).

Data synthesis

The extracted data will be summarised in tables, with one study presented per line, containing information identifying authors, year, language, country of application, type of application and information on validation. The studies will also be summarised according to the postpartum period in which the instrument was used (immediate, remote or late postpartum). The constructs and domains evaluated in each context will also be identified. Likewise, they will be summarised according to the types of health service in which they were used, to identify the most frequent constructs and domains in each scenario.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Discussion

This scoping review will map the existing body of evidence on instruments for evaluating and managing breast feeding during the postpartum period, whether they are questionnaires, scales or checklists, self-administered or not, regardless of the scenario of application.

This review report will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews, which will ensure that the review objectives are met and that the review steps can be replicated.¹³ However, it should be noted that even with rigorous reporting, it is still possible that the search strategy is not sensitive enough or that some keywords/terms may be missing, which would lead to an incomplete map of evidence.

To minimise the possibility of bias in the process of research, grouping, analysis and synthesis of data, peer review will be employed to achieve a concordance index. This will involve the independent assessment by two researchers.

The results will contribute to assessing the current state of scientific evidence regarding the provision and dissemination of tools that can be useful for identifying barriers to breast feeding in various settings. Ultimately, this review will inform public health strategies aiming at promoting breast feeding. It will also allow the identification of the need for other instruments that may be suitable for specific contexts or scenarios.

Ethics and dissemination

Ethical approval is not necessary for this scoping review. The results of the review will be shared through publications in peer-reviewed journals, at relevant scientific conferences and seminars and meetings with maternal and child healthcare providers.

Ethics statements

Patient consent for publication

Not applicable.