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Original Articles: Nutrition

LATCH Score at Discharge: A Predictor of Weight Gain and Exclusive Breastfeeding at 6 Weeks in Term Healthy Babies

Shah, Mubashir Hassan; Roshan, Reashma; Parikh, Tushar; Sathe, Sayali; Vaidya, Umesh; Pandit, Anand

Author Information
Journal of Pediatric Gastroenterology and Nutrition: February 2021 - Volume 72 - Issue 2 - p e48-e52
doi: 10.1097/MPG.0000000000002927

Abstract

What Is Known

  • LATCH score is a breastfeeding assessment tool that has been used to assess the breastfeeding practices.
  • Babies with low LATCH score at discharge are at risk of early breastfeeding cessation.

What Is New

  • LATCH score >6 at discharge is a good predictor of exclusive breastfeeding and adequate weight gain.
  • Prior breastfeeding experience and initiation of first feed within 2 hours of birth are significant factors for favorable discharge LATCH score of >6.
  • In-hospital breastfeeding counselling significantly improves the discharge LATCH score among healthy term infants.

Exclusive breastfeeding (EBF) for 6 months is recommended by the World Health Organization (WHO) (1). Epidemiological evidence indicates that EBF has a protective role against various communicable, noncommunicable, and malignant diseases (2–7). Despite these benefits, EBF for 6 months, as recommended by WHO, is still not widely practiced. Odds of all-cause death worldwide, among children aged 0–5 months who were not breastfed, was 14.4 times higher than those who were exclusively breastfed (8). In India, around 20 million infants are not exclusively breastfed during the first 6 months (9). During a decade from 2005 to 2015, the EBF rate in India had marginally increased from 46.4% to 54.9%, while at the same time the median duration of EBF had been as brief as 2 months (9).

Studies have shown that the breastfeeding cessation rates are highest during the first month postpartum, and so the early postnatal period is a critical window to identify breastfeeding problems (10–13). Cochrane reviews suggest that professional support in the early postpartum period helps mothers to successfully establish breastfeeding (14). Lactation screening tools developed during the last decades include behavioral, observational, and psychosocial factors connected to breastfeeding (15,16). Five lactation tools have been identified based on the assessment of maternal behavior/attitude and infant sucking skills in breastfeeding (15): BREAST Feed Observation Form, Lactation Assessment Tool, LATCH Scoring System, Mother-Baby Assessment Tool, and Mother-Infant Breastfeeding Progress Tool. The tools have primarily been evaluated for construct and content validity and psychometric properties, and, to a lesser extent, for their predictive validity (16–19). Consensus has not yet been reached on which indicators or indexes are the most reliable. The main characteristics that make a breastfeeding assessment tool useful in clinical settings are reliability, validity, and responsiveness (20). Some tools are comprehensive and contain a large number of variables, making them less useful in practice (16–19). In practice, the screening tools should be simple to use and reliable to identify at-risk mothers. In the present health care system in which breastfeeding is being strongly promoted and at the same time early hospital discharge is advocated, an urgent need of a simple tool is required to identify mother-infant dyad at risk of early breastfeeding cessation.

We choose the LATCH scoring system for this study because of ease of applicability, fewer components, and the similarity with the Apgar score format, which makes it easier to apply in practice. The LATCH scoring assessment tool was designed by Jensen et al (22) in 1994 with a composite score of 0–10, similar to the Apgar scoring system (Table 1). For the LATCH system, the training of staff involved is important as homogeneity in the assessment of the LATCH score is essential to increase the reliability of the tool (22). LATCH score assessment tool has been used in developed countries to identify mothers who need breastfeeding support to sustain lactation (23,24). To our knowledge, only a single study is available on this simple tool from developing countries in which EBF rates are particularly low (25). Moreover, to our knowledge, no study has seen the relation between LATCH score at discharge and weight gain at 6 weeks. The challenge is to identify the mothers at risk of early breastfeeding cessation and thus in need of early support. The primary aim of this study was to examine whether the LATCH score at discharge predicts EBF and weight gain at 6 weeks postpartum: specifically (i) to define a cutoff LATCH score and to compare the 6-week outcomes in those more or less than that score. The secondary objectives were: to see if mothers with a low first LATCH score show improvement after receiving breastfeeding support and to examine whether other factors predict the LATCH score.

TABLE 1 - LATCH scoring system (22)
Score
Component 0 1 2
L – Latch Too sleepyNo latch achieved Repeated attemptsHold nipple in mouthStimulate suck Grasps breastTongue downLips flangedRhythmic sucking
A – AudibleSwallowing None A few with stimulation Spontaneous and frequent
T – Type of nipple Inverted Flat Everted (after stimulation)
C – Comfort (breast/nipple) Severe discomfortEngorgedCracked/bleeding ReddenedMild/moderate discomfort No discomfortSoft
H – Hold (positioning) Full assistStaff holds infant at breast Minimal assistStaff holds on and then mother takes over No assist from staffMother able to position/hold infant

MATERIAL AND METHODS

This prospective observational cohort study was conducted during a period of 1 year from April 2017 to March 2018. It was carried out in maternity wards and labor room of King Edward Memorial Hospital & Research Centre (KEMHRC), a tertiary care hospital situated in Pune city of Maharashtra, India, after getting institutional scientific and ethical committees’ approval (KEMHRC ID: Adhoc 39) and written consent from parents. The hospital mainly caters to high-risk pregnancies with approximately 3000 births per year.

The study population consisted of all singleton pregnant women at term gestation who delivered during the study period. Pregnant women were approached purposively at the time of admission to discuss the benefits of breastfeeding and their willingness to participate in the study. Only healthy term babies weighing 2500 to 4000 grams at birth were included in this study. Exclusion criteria were mothers with hearing/speech impairment, a caesarean section under general anesthesia, mother-infant dyad separated because of medical/social reasons at birth, infant or mother requiring admission for medical/surgical reasons during the first 6 weeks postpartum, or refusal of consent from parents.

A total of 218 pregnant women at term gestation were screened and 210 were found eligible for the study after excluding 8 because of hearing/speech impairment in mothers. Further 75 babies were excluded (in 45 mother-infant dyads, LATCH score could not be assessed within 24 hours of birth due to the nonavailability of the lactation consultant and another 30 neonates were separated from their mothers due to either mother or infant requiring admission for medical reasons soon after birth), leaving 135 to be enrolled in this study. At 6 weeks, 93 babies were followed up for outcomes after further excluding 42 babies (25 babies hospitalized in the first 6 weeks and 17 babies lost to follow-up) (Fig. 1 in Appendix, https://links.lww.com/MPG/B955).

After giving birth, the mother and baby stayed in the labor or recovery room. During this period, breastfeeding and skin-to-skin contact were tried with the support of a lactation nurse. All of the mothers were approached by the lactation consultant within 24 hours of delivery for assessing the score. The time given for the baby to LATCH was 10 minutes; that is, this was the time given before the scoring was done on the LATCH sheet. 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 the type of nipple, “C” is for maternal comfort during feeding, and “H” is for the amount of help the mother needs to hold her infant to the breast. The total score ranges from 0 to 10; the higher the score, the more the chances of successful breastfeeding (Table 1). A LATCH score of 0–3 is regarded as poor, 4–7 as moderate, and 8–10 as good. Two LATCH score assessments were carried out by a single lactation consultant: first within 24 hours of birth and second at discharge. This was done to minimize the interobserver bias and to maintain homogeneity in the assessment of the LATCH score, which is essential to increase the reliability of the tool (21). Lactating mothers with low LATCH score at first assessment were counselled and demonstrated a correct breastfeeding technique by a lactation nurse to improve the score before discharge. Weight and type of feeding were recorded at 6 weeks postpartum because, in our hospital, this is the time when infants return for first scheduled vaccination after discharge from the hospital. Postpartum initial 6 weeks is regarded as a vulnerable period during which the mother-infant dyad is learning the skill of breastfeeding and also the milk supply is being established during this period (23).

Mothers were interviewed for relevant demographic data, which were entered in a predesigned proforma. Data were collected for the following variables: maternal age, gravidity, parity, prior breastfeeding experience, mother's occupation, mode of delivery, and contact number. For the newborn, birth weight, gestational age, timing, and the type of first feed after birth were recorded. As per WHO criteria (21), an infant is said to be exclusively breastfed if she has received only breast milk, including expressed milk. Birth weight, discharge weight, and weight at 6 weeks of all of the enrolled babies were recorded with the help of a digital weighing scale that was calibrated at regular intervals. All of the enrolled babies’ weight was recorded at home on a daily basis starting on day 8 of life by Accredited Social Health Activist. The normal weight gain beyond the first week of life in healthy babies is 20–30 grams per day (26). All the measurements were taken twice and the average of these observations was recorded.

Statistical Methods

Baseline data were recorded in a predesigned proforma and a master chart was prepared in Microsoft Excel sheet. Standard statistical methods were used wherein continuous variables are shown in mean (±SD) or median (IQR) depending on the underlying distribution of the data. A descriptive analysis of the study population was done. A univariate analysis was conducted to study the relation between the infant and maternal characteristics with EBF and weight velocity at 6 weeks postpartum. Chi-square or Fisher exact test was used for comparison between categorical data, while Student ‘t’ test was applied for continuous variables distributed normally. To identify the variables significantly and independently associated with the discharge LATCH score, we performed a multivariate analysis, including all the factors with P < 0.05 on univariate analysis. Sensitivity and specificity for LATCH score cutoffs at discharge were calculated to predict EBF and weight gain velocity. Relative risk (RR) with 95% CI was calculated for the LATCH score cutoffs with the highest sensitivity and specificity. Receiver operating characteristic (ROC) was constructed for LATCH score at discharge to predict exclusive breastfeeding and weight gain velocity at 6 weeks. One-way ANOVA with Tukey Post hoc analysis was carried out to indicate if there were significant differences in weight gain velocity between the different LATCH score points at discharge. We used SPSS for Windows 20.0 for analyzing the data. P value ≤0.05 was considered statistically significant.

RESULTS

The flowchart of enrollment and follow-up of the study participants is shown in figure 1 in appendix, https://links.lww.com/MPG/B955. Most of the mothers enrolled in the present study were housewives (82.8%, n = 77) with a mean age of 29.3 years (±3.8 years) and 78.5% (n = 73) of mothers delivered by caesarean section under spinal anaesthesia (this high rate of operative deliveries is because the hospital is a tertiary care referral hospital and most of the complicated pregnancies are referred and managed here), while 31.2% (n = 29) had prior breastfeeding experience. The mean gestational age and birth weight of the cohort were 38.6 weeks (±1.47 weeks) and 2918.7 grams (±475 grams), respectively, with male babies comprising 57% (n = 53) of the study population. A total of 67.7% (n = 63) of neonates were on exclusive breastfeeding at 6 weeks postpartum. The median time to first feed was 2.5 hours (IQR, 1–4 hours), while 39.9% (n = 38) of enrolled babies received feed within 2 hours of birth. The median time of assessment of first and second LATCH score was 12 hours (IQR, 6–19 hours) and 98 hours (IQR, 56–130 hours), respectively (Table 1 in Appendix, https://links.lww.com/MPG/B955). Out of 42 infants who were excluded from the final analysis, 59.5% (n = 25) were hospitalized within 6 weeks postpartum.

Primary Outcomes

Aim 1: LATCH score at discharge and exclusive breastfeeding at 6 weeks

The highest sensitivity (92.1%) and specificity (66.7%) for predicting breastfeeding at 6 weeks postpartum were observed for a cutoff LATCH score of ≥6 at discharge (RR = 6.82; 95% CI, 3.24–13.23, P = 0.0002). ROC of LATCH score at discharge and EBF at 6 weeks had an area under the curve of 0.785 with a cutoff ≥5.5, showing the highest sensitivity of 93.6% with a false-positive rate of 30.1%.

Only 46.2% babies (n = 12) with LATCH score ≤6 at discharge were on exclusive breastfeeding at 6 weeks as compared to 76.1% babies (n = 51) with LATCH score >6 (RR, 95% CI; 0.61 [0.39–0.94], P = 0.01) (Table 2). As the LATCH score improved above 6, the corresponding breastfeeding rate also increased. Babies with LATCH score of 6, 7, 8, 9, or 10 at discharge had a corresponding exclusive breastfeeding rate of 40%, 75%, 85%, 64%, and 83.4%, respectively (See Fig. 2 in Appendix, https://links.lww.com/MPG/B955).

TABLE 2 - Discharge LATCH score and exclusive breastfeeding at 6 weeks postpartum
Feeding at 6 weeks (N = 93)
LATCH score at discharge Not exclusive breastfeeding n (%) Exclusive breastfeeding n (%) P RR (95% CI)
≤6 14 (53.8) 12 (46.2) 0.01 0.61 (0.39–0.94)
>6 16 (23.9) 51 (76.1)

Aim 2: LATCH score at discharge and weight gain velocity at 6 weeks

The LATCH score cutoff of >6 at discharge had the highest sensitivity (88.2%) and specificity (69.4%) in predicting appropriate weight gain velocity (>20 grams/day) at 6 weeks of age. ROC of LATCH score at discharge and weight gain velocity at 6 weeks had an area under the curve of 0.773 with a cutoff ≥5.5, showing the highest sensitivity of 90.1% with a false-positive rate of 34.6%.

Seventy-nine percent babies (n = 53) with a LATCH score of >6 at discharge had a weight gain of >20 grams/day until 6 weeks of age as compared to 34.6% (n = 9) babies with a LATCH score of <6 (RR, 95% CI; 0.44 [0.25–0.75], P < 0.001) (Table 3). Babies with LATCH score of 6, 7, 8, 9, or 10 at discharge had a corresponding weight gain velocity (>20 grams/day) rate of 30%, 68.7%, 84.5%, 80%, and 83.3%, respectively (see Fig. 3 in Appendix, https://links.lww.com/MPG/B955). There was a statistically significant difference in weight gain (≥20 grams/day) between groups as determined by one-way ANOVA (P = 0.039). A Tukey Post hoc analysis revealed that weight gain velocity (>20 grams/day) was significantly higher in babies with discharge LATCH score of 7 (24.94 grams ± 4.5, P = 0.041) and 8 (28.42 grams ± 6.2, P = 0.035) compared to a LATCH score of 6 (15.25 grams ± 4.6). No statistically significant difference in weight gain velocity was observed between LATCH score 9 and 10 (P = 0.142).

TABLE 3 - Discharge LATCH score and weight gain during first 6 weeks
Weight gain during first 6 weeks (N = 93)
LATCH score at discharge <20 grams/day n (%) ≥20 grams/day n (%) P RR (95% CI)
≤6 17 (65.4) 9 (34.6) 0.001 0.44 (0.25–0.75)
>6 14 (20.9) 53 (79.1)

Secondary Outcomes

Aim 1: Effect of counselling on discharge LATCH score

All of the lactating mothers with low LATCH score (<6) at first assessment (n = 62) were counselled and the correct breastfeeding technique was demonstrated by a lactation consultant. The mean LATCH score at first assessment was 6.2 (±1.45), which, after counselling, improved to 7.6 (±1.42) at discharge, which was statistically significant (P < 0.001; 95% CI: 0.74–0.87). In mothers with initial LATCH score >6 (n = 31) who were not offered breastfeeding support, their LATCH score at discharge decreased but was not statistically significant (8.6 ± 0.8 vs. 8.1 ± 1.1, P = 0.201).

Aim 2: Factors affecting the birth (first assessed) LATCH score

Among other factors, prior breastfeeding experience (RR, 95% CI; 0.67 [0.54–0.83], P = 0.002) and timing of first feed within 2 hours of birth (RR, 95% CI; 0.76 [0.59–0.96], P = 0.04) were significantly associated with higher LATCH score (>6) at first assessment. Maternal age, working mothers, mode of delivery, infant sex, or type of first feed (mother's milk or formula milk) were not statistically related to the higher LATCH score at birth in the present study (Table 4).

TABLE 4 - Factors affecting the birth LATCH score
LATCH score at discharge (N = 93)
Variable ≤6 >6 RR (95% CI) P
Maternal age (y): ≤30, n (%) 18 (32.1) 38 (67.9) 0.87 (0.68–1.11) 0.35
Occupation: housewife, n (%) 22 (28.6) 55 (71.4) 1.1 (0.77–1.44) 1.00
Parity: Primiparous, n (%) 17 (58.6) 12 (41.4) 1.8 (0.84–1.56) 0.64
Mode of delivery: cesarean, n (%) 22 (30.1) 51 (69.9) 0.87 (0.67–1.14) 0.57
Previous breast feeding: yes, n (%) 2 (6.9) 27 (93.1) 0.67 (0.54–0.83) 0.002
Infant sex: female, n (%) 12 (30) 28 (70) 1.1 (0.81–1.36) 0.82
Timing of first feed: ≤2 hours, n (%) 6 (15.8) 32 (84.2) 0.76 (0.59–0.96) 0.04
Type of first feed: mother's milk, n (%) 24 (30) 56 (70) 0.83 (0.63–1.1) 0.34

A multivariate analysis was conducted to predict the effect of the factors (prior breastfeeding experience, the timing of first feed, breastfeeding counselling) on discharge LATCH score and it was observed that prior breastfeeding experience and breastfeeding counselling were statistically significantly associated with higher discharge LATCH scores even after controlling the other variables.

Further, the study observed that the discharge LATCH score was significantly higher among infants who were followed up at 6 weeks (n = 93) than those who were excluded from the study (n = 42) (7.8 ± 0.8 vs. 6.4 ± 0.6; P = 0.03). Among the infants excluded from the study, there was statistically no difference in discharge LATCH scores among subgroups of those who were lost to follow up (n = 17) with those who were hospitalized within 6 weeks postpartum (n = 25).

DISCUSSION

Maternal satisfaction regarding breastfeeding increases as LATCH scores improve, which leads to a decrease in breastfeeding problems (27). The present study demonstrates the utility of LATCH score at discharge to predict exclusive breastfeeding and weight gain velocity at 6 weeks of age in term healthy babies. We derived cutoffs for discharge LATCH score along with sensitivity and specificity to predict EBF and weight gain velocity at 6 weeks. Authors observed that the LATCH score >6 at discharge has the highest sensitivity and specificity in predicting EBF as well as weight gain velocity 6 weeks postpartum. Factors such as in-hospital breastfeeding counselling, prior breastfeeding experience of mothers, and first feed within 2 hours of birth were significantly associated with LATCH score of >6 at birth (first assessment). The authors could trace a single study in the literature from the Indian subcontinent on this breastfeeding assessment tool (25). Moreover, the present study is the first to our knowledge to correlate LATCH score with weight gain velocity at 6 weeks postpartum. The present study has also shown exclusive breastfeeding rates and weight gain velocity at individual LATCH scores. No such observation is seen in other studies on this subject. The other important observation from the present study was that the infants with low LATCH scores at discharge were more prone to get hospitalized within the first 6 weeks postpartum, emphasizing regular follow-up post discharge.

Our exclusive breastfeeding rates were similar to other studies (21,23–25). Studies by Tornese et al (21), Riordan et al (23), and Kumar et al (24) have included the mothers who delivered either vaginally or through cesarean section, similar to our study, while the study by Sowjanya et al (25) has included only those mothers who delivered vaginally. Riordan et al (23) and Kumar et al (24) have observed that the women who continued to breastfeed at 6 weeks had higher LATCH scores than those who have stopped. Both these studies were passive observation with no support provided to those mothers with low LATCH scores. Raghavan et al (28) have also observed that babies with good LATCH score had better chances of being exclusively breastfed at 6 weeks. LATCH score predicted mothers who are at risk of early discontinuation of lactation, thus needing interventions to sustain breastfeeding.

The main limitation of the present study is that the LATCH score assessment was made by observing a single feeding session at one point in time and not a composite score of several consecutive feedings. Apart from this, other limitations include small sample size, delayed initiation of breastfeeding, and the possible bias in assessing the discharge LATCH score as the lactation consultant invariably knew about the mothers being counselled. Maternal stress, social support, and prior breastfeeding knowledge were not assessed in the present study. The strengths of the present study were that a single lactation consultant has assessed all the LATCH scores, thus minimizing interobserver bias; also weight gain was recorded during the first 6 weeks of life. The present study was conducted in a hospital setting; however, the LATCH tool can also be used in community-based health care centers in which mothers and infants are seen after discharge from the hospital. Developing countries, in which neonatal and infant mortality rates are high because of infections and malnutrition, may get benefitted by adopting this simple tool to improve EBF rates.

CONCLUSIONS

LATCH score can be used as a simple tool to identify mothers and infants who are at risk of early breastfeeding cessation and inadequate weight gain, respectively. Authors suggest that such an easy to use tool should be adopted and implemented in maternity wards, especially in developing countries like India where EBF rates are low. LATCH assessment tool will help lactation nurses or lactation consultants to identify mothers who need extra breastfeeding support before discharge from the hospital and on follow-up to sustain lactation even after discharge.

Further studies should be carried out to determine the effect of breastfeeding counselling on the LATCH score in specific subgroups of mother-infant dyads. Further, more evidence should be gathered on the reliability of the LATCH score.

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Keywords:

counselling; exclusive breastfeeding; LATCH Score; weight gain

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