Abstract

Breastfeeding, particularly Exclusive Breastfeeding, is the Perfect Start in Human Nutrition and, therefore, the Cornerstone of Neonatal Nutrition. The Benefits of Breastfeeding, Nutritional and Epigenetic including Adult Disease Induction, are only assured with Optimal Breastfeeding Practice which is also only guaranteed with the deployment of Appropriate Breastfeeding Assessment Tools. There is reportedly ‘No Gold Standard’ for Breastfeeding Assessment Tools necessitating the continued Search for Improved Breastfeeding Assessment Tools. Tools with ‘Objective Scoring Schemes’ hold the best promise. The Eregie Breastfeeding Assessment Tool Examination Score (EBATES) is recommended as an Improved Breastfeeding Assessment Tool.

Keywords: Adult Disease Induction, Breastfeeding Assessment Domains, Breastfeeding Assessment Tools, Breastfeeding Practice, Epigenetic Mechanisms, Exclusive Breastfeeding, FOAD Hypothesis, Infant and Young Child Feeding, Maternal Phenotype, Neonatal Nutrition, Pre-FOAD Hypothesis

Abbreviations: ADI: Adult Disease Induction; BAS: Breastfeeding Assessment Score, BEET: Breastfeeding Evaluation and Education Tool, BFHI: Baby-Friendly Hospital Initiative, CBF: Continued Breastfeeding; CF: Complementary Feeding; EBATES: Eregie Breastfeeding Assessment Tool Examination Score; EBF: Exclusive Breastfeeding, EBS: Eregie BREAST Score, EIB: Early Initiation of Breastfeeding; FOAD: Foetal Origins of Adult Disease; IBFAT: Infant Breastfeeding Assessment Tool, NOMAS: Neonatal Oral-Motor Assessment Scale, OIYCF: Optimal Infant and Young Child Feeding, SIAB: Systematic Assessment of the Infant at Breast; UNICEF: United Nations Children’s Fund; WHO: World Health Organization.

Introduction

Breastfeeding is the Perfect Start in Human Nutrition and, therefore, disposes a determinant Pillar and Cornerstone in Neonatal Nutrition. Breastmilk is the Ideal Food for the Human Infant [1]. Therefore, ALL strategies MUST be disposed to optimize the intake of Breastmilk by the Newborn Infant. To achieve this Nutritional Goal, the World Health Organization WHO [2] and the United Nations Children’s Fund UNICEF [3]recommend Breastfeeding as an integral component of Optimal Infant and Young Child Feeding (OIYCF) consisting of: Early Initiation of Breastfeeding (EIB) within the First Hour of Birth, Exclusive Breastfeeding (EBF) for the First Six Completed Months of Life, thereafter the Introduction of Age-appropriate Nutritious and Diverse Complementary Feeding (CF) with Continued Breastfeeding (CBF) until Two Years of Age or Beyond if feasible. Unfortunately, the ‘IYCF Ecosystem’ is reportedly ‘Negatively Altered’ with some revealed uncomplimentary data in the ‘2023 Lancet Breastfeeding Series Papers’ [4-6]: ‘Less than 50% of children are fed according to WHO Recommendations’2,3, ‘Less than 50% of babies are breastfed within the 1st Hour of Life’, ‘45% receive formula within the first 6 months of Life’ and ‘One-third of children prematurely stopped Breastfeeding’. The ‘Negatively Altered IYCF Ecosystem’ was previously addressed to optimize Neonatal Nutrition and Infant and Young Child Nutrition to also optimize the Products of Reproductive Intervention [7]. With the OIYCF, the First 1000 Days of Life dispose Optimal Neonatal Nutrition and Infant and Young Child Nutrition for Optimal Growth, Health and Development of the Human Young Child [8]. Taking cognizance of the World Health Assembly (WHA) Resolution 69.9/ ‘WHO Guidance 2016’ [9] on ‘Ending the Inappropriate Promotion of Foods for Children up to 36 Months’, this Author has also disposed the First 1400 Days to optimize Neonatal and Young Child Nutrition [7,10]. Beyond Breastfeeding as an integral component of OIYCF offering the Newborn and Young Child the Perfect Start and the Best and the Most Nutrients Bioavailability, it also presents Non-Nutrition related and Epigenetic Benefits for the Young Human Child which will not be dilated exhaustively on in this terse Presentation but are distilled in some other Communications [11-18]. While the Foetal Origins of Adult Disease Hypothesis (FOAD Hypothesis) [19,20] has its ‘Starting Locus’ as the ‘Maternal Phenotype’, the Pre-FOAD Hypothesis has its ‘Starting Locus’ as Exclusive Breastfeeding [21-23]. Therefore, Breastfeeding, and particularly Exclusive Breastfeeding, beyond contributing to Optimal Neonatal Nutrition and Infant and Young Child Nutrition, also has the POTENTIALITY of modulating Adult Disease Induction (ADI) through various and varied Epigenetic Mechanisms: DNA Methylation, Histone Modification, Chromatin Re-modelling, Non-coding RNA Modulation etc [11,13,24].

To assure that Breastfeeding optimizes Neonatal Nutrition, and Infant and Young Child Nutrition, strategies must guarantee Optimal Breastfeeding Practice. Only appropriate Breastfeeding Assessment Tools assure that, with attention to identified Specific Breastfeeding Assessment Domains Deficits, Optimal Breastfeeding Practice can be guaranteed and improved on. While there are many reported Breastfeeding Assessment Tools, there is ‘No Gold Standard’ [25] necessitating the continued Search for ‘Improved Breastfeeding Assessment Tools’. This Communication explores some attempts to contribute to ‘Improved Breastfeeding Assessment Tools’ towards assuring optimal Breastfeeding Practice for improved Neonatal and Young Child Nutrition

Breastfeeding Assessment Tools and Improved Breastfeeding practice

Several Breastfeeding Assessment Tools [26-37] have been reported previously. They reportedly include, among others: WHO/UNICEF BFHI Forms [26,27], CARE Training Packages [28] , Breastfeeding Assessment Score (BAS) [29], Breastfeeding Evaluation and Education Tool (BEET) [30], Infant Breastfeeding Assessment Tool (IBFAT) [31], LATCH Score [32], Neonatal Oral-Motor Assessment Scale (NOMAS) [33], Systematic Assessment of the Infant at Breast (SAIB) [34], WHO/ UNICEF B-R-E-A-S-T-Feed Observation Form [35], Eregie BREAST Score (EBS) [36], Eregie Breastfeeding Assessment Tool Examination Score (EBATES) [37] etc. A critical evaluation of the Breastfeeding Assessment Tools revealed their differential strengths and weaknesses [25]. Some were reportedly developed from: ‘Poor Study Designs’, ‘Non-validation of Tools Independently’, ‘No Correlations with Breastfeeding Outcomes’, ‘Limited and Restricted Applicability’, ‘Technical Skills Requirement for Use’, ‘Limited Breastfeeding Assessment Domains Coverage’, ‘Questionnaire-based Parameters’, ‘Non-observation of the Breastfeeding Mother-Child Dyad’, ’Lack of Objective Scoring Schemes’ etc. It is reportedly suggested that by deploying ‘Appropriate Breastfeeding Assessment Tools’, specific ‘Breastfeeding Assessment Domains’ may be identified for further and deeper focus by mothers towards addressing and implementing Prescribed ‘Specific Breastfeeding Assessment Domains-related Interventions’ to improve Breastfeeding Practice. With improved Breastfeeding Practice, Breastfeeding is better able to contribute to Optimal Neonatal and Young Child Nutrition and enhanced realization of the desired Epigenetic Implications and Benefits beyond Growth and Development of the Newborn and Young Child.

Improved Breastfeeding Assessment Tools

As previously reported [36,37], most ‘Breastfeeding Assessment Tools’ lack ‘Objective Scoring Schemes’ for Observation and Recording of ‘Easily Defined and Scored Alternatives’ for the Breastfeeding Assessment. This is the ‘Attribute’ which particularly and uniquely reportedly recommends the following three ‘Breastfeeding Assessment Tools’: ‘LATCH Score’ [32], ‘Eregie BREAST Score (EBS)’ [36] and ‘Eregie Breastfeeding Assessment Tool Examination Score (EBATES)’ [37]. The LATCH Score [32] includes the ‘Breastfeeding Assessment Domains’: Latch, Audible swallowing, Type of Nipple, Comfort and Hold while the Eregie BREAST Score (EBS) [36] includes the ‘Breastfeeding Assessment Domains’: Body position, Responses, Emotional bonding, Anatomy, Suckling and Time spent suckling. The Eregie Breastfeeding Assessment Tool Examination Score (EBATES) [37] disposes the ‘Breastfeeding Assessment Domains’: Baby’s behavior, Mother’s behavior, Positioning, Attachment, Effective feeding, Health of the breast, Health of the Baby, Mother’s feel of feed, Mother’s level of comfort and Length of feed. It is also uniquely ‘Breastfeeding Assessment Domains-based’ in its development. For the EBS and EBATES, some of the ‘Breastfeeding Assessment Domains’ are separated for the ‘Mother’ and ‘Baby’ to improve ‘Discriminant Functional Capacity’ [36,37]. Indeed, the EBATES is reportedly suggested to have the widest ‘Breastfeeding Assessment Domains Coverage’ which is an ‘Attribute’ that greatly improves the ‘Value’ of ‘Breastfeeding Assessment Tools’ [28,38]. The EBATES is recommended as an ‘Improved Breastfeeding Assessment Tool’ for assuring better Breastfeeding Practice to optimize the impact and import of Breastfeeding in Neonatal and Young Child Nutrition, Optimizing the Outcomes of Reproductive Interventions and possibly the Epigenetic Implication of Adult Disease Induction (ADI).

Conclusion

The Perfect Start in Human Nutrition is Breastfeeding, particularly Exclusive Breastfeeding. Neonatal Nutrition is hinged on Breastfeeding. Only Optimal Breastfeeding Practice guarantees the plethora of Breastfeeding Benefits: Nutritional and Epigenetic including Adult Disease Induction through the deployment of Breastfeeding Assessment Tools. In the absence of a ‘Gold Standard’ for Breastfeeding Assessment Tools, the Search continues for Improved Breastfeeding Assessment Tools. The Eregie Breastfeeding Assessment Tool Examination Score (EBATES) is recommended as an Improved Breastfeeding Assessment Tool.

References

1. Neville MC, Anderson SM, McManaman JL (2012) Lactation and Neonatal Nutrition: Defining and Refining the Critical Questions. J Mammary Gland Biol Neoplasia 17(2): 167-188.
2. (2021) World Health Organization. Infants and young children feeding. World Health Organization. Geneva.
3. (2021) UNICEF. Infants and young children feeding. UNICEF. New York.
4. Perez ER, Tomori C, Hernandez CS (2023) Breastfeeding: crucially important, but increasingly challenged in a market-driven world. Lancet 401(10375): 472-485.
5. Rollins N, Piwoz E, Baker P (2023) Marketing of commercial milk formula: a system to capture parents, communities, science and policy. Lancet 401(10375): 486-502.
6. Baker P, Smith J, Garde A (2023) The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress. Lancet 401(10375): 503-524.
7. Eregie C.O (2023) Addressing the Optimal Infant and Young Child Feeding Ecosystem to improve the Status of the Outcome of Reproductive Interventions; No ‘Breastmilk Substitutes’. Global Journal of Reproductive Medicine 10(2): 555784.
8. (2016) Guidance on ending the inappropriate promotion of foods for infants and young children. World Health Organization. Geneva.
9. Barker DJ (1990) The fetal and infant origins of adult disease. BMJ 301(6761): 1111.
10. Eregie CO (2023) Enabling the ‘Breastfeeding-Work Dyad’ and Understanding the Contextual Pentad of Productive Work, Reproductive Work, Reproductive Health, Reproductive Rights and Reproductive Politics: The Tantalizing Microcosmic Perspectives Encapsulated with Some Imaginatively Innovative Interventions. Gynecol Reprod Health 7(5): 1-16.
11. Verduci E, Barderali G, Barberi S (2014) Epigenetic effects of Human Breast Milk. Nutrients 6(4): 1711-1724.
12. Genna CW (2018) Epigenetics, Methylation, and Breastfeeding. Clinical Lactation 9(3): 144-147.
13. Briollais L, Rustand D, Allard C (2021) DNA methylation mediates the association between breastfeeding and early-life growth trajectories. Clinical Epigenetics 13.
14. Van Esterik P (1989) Beyond the breast-bottle controversy. Rutgers University Press, New Brunswick, NJ.
15. Andrews B (2017) Sucking versus Suckling and Mouth Development.
16. Narbutyte I, Narbutyte A, Linkeviciene L (2013) Relationship between breastfeeding, bottle-feeding and development of malocclusion. Stomatogija 15: 67-72.
17. Peres KG, Cascaes AM, Nascimento GG, Victora CG (2015) Effects of breastfeeding on malocclusion: a systematic review and meta-analysis. Acta Paediatrica 104(s467): 54-61.
18. Abate A, Cavagnetto D, Fama A, Maspero C, Farronato G et al. (2020) Relationship between breastfeeding and malocclusion: A Systematic Review of the Literature. Nutrients; 12(12): 3688.
19. Barker DJP, Osmond C (1986) Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales. Lancet 327(8489): 1077-1081.
20. Barker DJP (2007) The origins of the developmental origins theory. J Intern Med 261(5): 412-417.
21. Eregie CO (2009) Programming the END from before the BEGINNING-: Juxtaposing TECHNOLOGY with the TEA Triad’ University of Benin Press. 106th Inaugural Lecture, University of Benin, Nigeria.
22. Eregie CO (2019) Obesity as a Public Health Emergency: A look at the ‘Pre-FOAD Hypothesis’ as a Panacea for the ‘Interventional Inequity’.
23. Eregie CO (2023) The rise in diabetes burden and the compelling importance of prevention: The imperative to focus on the ‘Pre-FOAD Hypothesis’.
24. Wu YL, Lin ZJ, Li CC (2023) Epigenetic regulation in metabolic diseases: mechanisms and advances in clinical study. Signal Transduction and Targeted Therapy 8: 98.
25. Moran VH, Dinwoodie K, Bramwell R, Dykes F (2000) A critical analysis of the content of the tools that measure breast-feeding interaction. Midwifery 16 (4): 260-268.
26. Hall RT, Mercer AM, Teasley SL (2002) A breast-feeding assessment score to evaluate the risk for cessation of breast-feeding by 7 to 10 days of age. J Pediatr 141(5): 659-664.
27. Tobin DL (1996) A breastfeeding evaluation and education tool. J Hum Lact 12(1): 47-49.
28. Matthews MK (1998) Breastfeeding assessment tools. J Obstet Gynecol Neonatal Nurs 27(3): 236-237.
29. Jensen D, Wallace S, Kelsay P (1994) LATCH a breastfeeding charting system and documentation tool. J Obstet Gynecol Neonatal Nurs 23(1): 27-32.
30. Palmer MM, Crawley K, Blanco IA (1993) Neonatal Oral-Motor Assessment scale: a reliability study. J Perinatol 13(1): 28-35.
31. Shrago L, Bocar D (1990) The infant's contribution to breastfeeding. J Obstet Gynecol Neonatal Nurs 19(3): 209-215.
32. (1994) WHO/UNICEF: Breastfeeding counselling: a training course. World Health Organisation and United Nations International Children’s Education Fund.
33. (2009) WHO/UNICEF: Baby Friendly Hospital Initiative: Revised Updated and Expanded for Integrated Care - Section 3: Breastfeeding promotion and support in a baby-friendly hospital. Library Cataloguing-in-Publication 107.
34. (2010) UNICEF: Baby Friendly Hospital Initiative: Breastfeeding Assessment Form.
35. (2004) CARE: Preparation of a Trainer's Course: Mother to Mother Support Group Methodology and Breastfeeding and Complementary Feeding Basics. United States Agency for International Development (USAID) / The Infant & Young Child Nutrition (IYCN) Project.
36. Eregie CO (2024) Breastfeeding Assessment; Preliminary Report on a New Scoring System as an Assessment Tool: The Eregie BREAST Score (EBS). Am J Biomed Sci & Res 23(2): AJBSR.MS.ID.003069.
37. Eregie CO (2024) Breastfeeding Assessment Tool; Preliminary Report on A Breastfeeding Domains-Based Examination Scoring System: The Eregie Breastfeeding Assessment Tool Examination Score (EBATES). Am J Biomed Sci & Res. 23(5) AJBSR.MS.ID.003111.
38. Raskovalova T, Teasley SL, Gelbert-Baudino N Breastfeeding Assessment Score: Systematic Review and Meta-analysis.