Cognitive Breastfeeding Counseling: A Single Session Helps Improve LATCH Score

Abstract

Antenatal counseling improves the rate of exclusive breastfeeding. But routine antenatal counseling may not be effective in achieving this. Cognitive behavioral therapy derived techniques may be more useful in improving breastfeeding outcomes. We did this study to test the effectiveness of a single session of cognitive counseling compared to routine counseling in the third trimester for improving LATCH score. Fifty mother–baby dyads were enrolled. Twenty-six mothers underwent cognitive counseling and 24 mothers underwent routine counseling. After birth, the LATCH scores were assessed within the first 24 hours in the newborn. A single session of cognitive breastfeeding counseling in the third trimester is effective in significantly improving the LATCH scores in the immediate newborn period.

Background

Out of 26 million babies born in India every year, only about 45% are breast fed within the first hour of life and 65% of children are exclusively breast fed for the first 6 months (World Breastfeeding Trends Initiative, 2015). Lack of confidence in mothers’ ability to breastfeed, problems with the infant latching or suckling, breast pain or soreness, perceptions of insufficient milk supply, and a lack of individualized encouragement from their clinicians in the early postdischarge period are some of the common reasons for early breastfeeding discontinuation which can be overcome if the mother is informed antenatally about the benefits of breastfeeding (Ahmad, Sughra, Kalsoom, Imran, & Hadi, 2012). Deficiency of trained counselors in the obstetric outpatient’s department, low literacy levels in the mother, and misconceptions about breastfeeding may result in routine counseling being unproductive in causing a behavior change in the mother (National Institute of Population Studies and Macro International Inc, 2008). Cognitive behavioral therapy is a talking therapy that helps manage problems by altering the way one thinks and behaves (Hofmann, Asmundson, & Beck, 2013). Using a cognitive approach while breastfeeding counseling would have a better impact compared to routine counseling (Sikander et al., 2015). LATCH score is a tool developed in 1994 to assess breastfeeding and identify mothers that were at risk for failure of exclusive breastfeeding (Jensen, Wallace, & Kelsay, 1994). The purpose of this study was to test the effectiveness of a single session of cognitive counseling compared to routine counseling in the third trimester, for improving LATCH scores in the immediate newborn period.

Out of 26 million babies born in India every year, only about 45% are breast fed within the first hour of life and 65% of children are exclusively breast fed for the first 6 months.

Method

Design

All mothers in the study had a single session of antenatal counseling in the third trimester of pregnancy. These mothers were then followed up with, and after birth, the LATCH scores were assessed within the first 24 hours of the newborn period. A LATCH score of less than or equal to 7 was considered as a poor score. In cognitive counseling, an adaptation of the cognitive behavioral technique was used. The mother was first interviewed in a language she could understand. If she was a primigravida, she was asked to tell us about her ideas on breastfeeding, including whether she thought it was useful to the baby and what she thought were the problems during breastfeeding. If she was a multigravida, details were taken about how the previous babies were breastfed and what were the hindrances in practicing exclusive breastfeeding. After all this information was sought, an intensive counseling session was carried out with the use of images and illustrations, along with detailed information given to the expecting mother regarding the usefulness of early initiation of breastfeeding, the right technique of feeding, and problems due to improper latching. In the routine counseling group, a brief session on breastfeeding was conducted without use of any visual aids. The researcher assessing the LATCH scores was blinded to the type of counseling the mother had received prior to birth. The study was approved by the Institutional Ethics Committee of a medical college in southwest India where the researchers are employed.

LATCH score is a tool developed in 1994 to assess breastfeeding and identify mothers that were at risk for failure of exclusive breastfeeding.

Setting

A single randomized controlled trial took place on the obstetrics and gynecology wards of a medical college in India. Data collection was carried out over a period of 1 month in 2016.

Sample

Fifty-two mothers who were in the third trimester were enrolled in the study. Mothers whose antenatal scans showed presence of congenital anomalies were excluded. By simple randomization using sealed envelopes, 26 mothers underwent cognitive counseling and 24 mothers underwent routine counseling. Two babies from the routine counseling group were admitted in the neonatal intensive care after birth, so they could not be assessed for LATCH score.

Measurement

LATCH score is a breastfeeding tool developed in 1994 to assess breastfeeding. It is a simple tool which assesses how well the infant latches onto the breast (L), the amount of audible swallowing noted (A), the mother’s nipple type (T), the mother’s level of comfort (C), and the amount of help (H) the mother needs to hold her infant to the breast. Each parameter is scored as 0, 1, or 2. The total score ranges from 0 to 10, with higher scores associated with successful breastfeeding.

Data Analyses

Descriptive statistics (percentage of subjects with latch score ≤ 7 and >7 for both the routine group and cognitive group) was calculated in order to summarize data in a meaningful way. Pearson’s χ² test was used to analyze the difference in proportion amongst the subjects with latch score ≤ 7 and >7 between routine group and cognitive group using SPPS (Statistical Package for Social Sciences version 20 Armonk, NY; IBM Corp). A p value of less than .05 was considered significant.

Results

The average age of mothers in the cognitive and routine counseling groups was 28.5 and 27 years, respectively. The average gestational age of babies in both groups was 37.8 and 38.3 weeks. None of the mothers had an educational status beyond the tenth grade. In the cognitive counseling group, 17 mothers were multigravida and 12 were primigravida, whereas in the routine counseling group, 15 were multigravida, and 9 were primigravida. Out of 26 mothers who underwent cognitive counseling, only (3.8%) mother had a LATCH score of less than 7. Among the routine counseling group of 24 mothers, 7 (29.2%) of them had a LATCH score of less than 7. The χ² value was 0.015. This difference was statistically significant (Table 1).

TABLE 1. Cross Tabs and χ² Test for Comparison of Proportions.

	Number of Subjects With LATCH Score (%)		Pearson’s χ2 Value	P Value
Counselling group	≤7	>7
Method 1 (routine)	7 (14)	12 (34)
Method 2 (cognitive)	1 (2)	25 (5)	5.953	.015

Probability value (p value) <.05 is significant.

Discussion

Most mothers discontinue breastfeeding because of lack of confidence to breastfeed, perception of insufficient milk, improper technique resulting in sore nipples, breast engorgement, and mastitis leading to pain. These problems can be solved if the women are counseled antenatally about breastfeeding (Ahmad et al., 2012). Antenatal counseling helps to motivate mothers in early initiation of breastfeeding after birth and to practice prolonged exclusive breastfeeding. In a study done in India, most of the mothers who were prenatally counseled on breastfeeding initiated breastfeeding immediately after birth as compared to the not-counseled mothers, with a highly significant difference between the two groups (Dhandapany, Bethou, Arunagirinathan, & Ananthakrishnan, 2008).

A routine counseling session would include a lecture given on the advantages of exclusive breastfeeding, correct techniques of feeding, and importance of early initiation and continuation of breastfeeding. Given the low levels of literacy among the mothers and the deep-rooted misconceptions, such type of routine counseling may not have the desired impact (Sikander et al., 2015).

Cognitive behavioral therapy is commonly used to treat anxiety and depression. Modern cognitive behavioral therapy refers to a family of interventions that combine a variety of cognitive, behavioral, and emotion-focused techniques (Hofmann et al., 2013). During cognitive behavioral therapy, current thoughts are analyzed, and the negative concepts are then attempted to be replaced by positive ones with an aim to change the behavior in that aspect. This type of therapy was used in a study done in Pakistan, where a psychoeducational intervention was designed based on cognitive behavioral therapy and used to counsel the antenatal mothers regarding breastfeeding (Sikander et al., 2015). This particular study revealed that using cognitive behavioral therapy-derived intervention was successful in increasing the length of exclusive breastfeeding in poor literacy rural settings of Pakistan (Sikander et al., 2015). Similarly, in our study we first analyzed the misconceptions a mother was having and an attempt was made to provide correct concepts regarding the same topic.

LATCH score is a breastfeeding tool developed in 1994 to assess breastfeeding and identify mother–baby dyads that were at risk for nonexclusive breastfeeding (Jensen et al., 1994). When we did a literature search, LATCH score of <7 was found to have a sensitivity of 42% and specificity of 72% (Tornese et al., 2012). A good LATCH score in the first 24 hours of life is associated with higher rates of exclusive breastfeeding at hospital discharge which increases the chances that the infant will be exclusively breast fed for a longer period (Tornese et al., 2012). Therefore, this tool was used to assess breastfeeding in our study.

In the study done in Pakistan, various sessions of cognitive behavioral counseling were carried out beginning from the antenatal period up until the infant was 6 months of age (Sikander et al., 2015). This significantly increased the length of exclusive breastfeeding and doubled the rate of exclusive breastfeeding at 6 months. But this intervention was carried out at the community level with the counseling being done by Lady Health workers who underwent training sessions for the same. This required a large number of resources in terms of manpower and training of the health workers. Conversely, we did not have similar resources at our disposal. Thus, we conducted the study on a smaller scale in a hospital and utilized lactation counselors and health-care professionals to counsel mothers. The results of our study indicated that all except one mother in the cognitive counseling group had a good LATCH score, whereas seven mothers in the routine counseling group had poor LATCH score and this was statistically significant. Primigravida mothers are at a higher risk of unsuccessful breastfeeding. The findings in the current study indicated that mothers who had cognitive counseling had a higher LATCH score than those who had routine counseling. Multiple sessions of antenatal and postnatal counseling combined will be more effective in improving rates of successful breastfeeding, but if we use cognitive behavioral techniques to counsel mothers in the third trimester, even a single session will help improve the rates of breastfeeding. This information is useful where there is a shortage of personnel to conduct antenatal sessions in outpatient settings. In addition, the employment of trained health-care counselors to meet with mothers on a one-to-one basis will be beneficial.

During cognitive behavioral therapy, current thoughts are analyzed, and the negative concepts are then attempted to be replaced by positive ones with an aim to change the behavior in that aspect.

Compared to routine counseling, a single session of cognitive counseling in the third trimester is effective in significantly improving the LATCH scores in the immediate newborn period.

Limitations

Limitations of this study include small sample size and the lack of follow-ups with the babies during the first 6 months. More studies are needed to confirm the findings of this study and show the long term benefits of a single session even after the first 24 hours of life.

Conclusion

Compared to routine counseling, a single session of cognitive counseling in the third trimester is effective in significantly improving the LATCH scores in the immediate newborn period. This is achieved by a simple intervention using limited resources. An improved LATCH score implies that the mother will have a more successful rate of exclusive breastfeeding for a prolonged period which in turn will help the community to have healthier babies and reduced mortality.

Biographies

KAVITA SREEKUMAR is an Assistant Professor in the Department of Pediatrics, Goa Medical College, India.

ANNELY D’LIMA is a Lecturer, Department of Pediatrics, Goa Medical College, India.

M. P. SILVEIRA is a Professor and Head, Department of Pediatrics, Goa Medical College, India.

RIDDHIMA GAONKAR is a Lecturer, Department of Community Dentistry, Goa Dental College, Goa.