{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,7]],"date-time":"2026-04-07T00:59:51Z","timestamp":1775523591631,"version":"3.50.1"},"update-to":[{"DOI":"10.12688\/f1000research.24516.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,10,22]],"date-time":"2021-10-22T00:00:00Z","timestamp":1634860800000}}],"reference-count":101,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2021,10,22]],"date-time":"2021-10-22T00:00:00Z","timestamp":1634860800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100019917","name":"Action Contre la Faim","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100019917","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns4:p><ns4:bold>Background:<\/ns4:bold> Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings.<\/ns4:p><ns4:p> <ns4:bold>Methods<\/ns4:bold>: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children\u2019s Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding \u2018domains\u2019 (baby\u2019s behaviour; mother\u2019s behaviour; position; latching; effective feeding; breast health; baby\u2019s health; mother\u2019s view of \u00a0feed; number, timing and length of feeds).<\/ns4:p><ns4:p> <ns4:bold>Results<\/ns4:bold>: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO\/UNICEF B-R-E-A-S-T-Feed Observation Form.<\/ns4:p><ns4:p> <ns4:bold>Conclusions<\/ns4:bold>: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO\/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic\/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.<\/ns4:p>","DOI":"10.12688\/f1000research.24516.2","type":"journal-article","created":{"date-parts":[[2021,10,22]],"date-time":"2021-10-22T10:21:05Z","timestamp":1634898065000},"page":"1310","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":11,"title":["Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review"],"prefix":"10.12688","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3685-0766","authenticated-orcid":false,"given":"Concetta","family":"Brugaletta","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3608-2418","authenticated-orcid":false,"given":"Karine","family":"Le Roch","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jennifer","family":"Saxton","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2455-2198","authenticated-orcid":false,"given":"C\u00e9cile","family":"Bizouerne","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marie","family":"McGrath","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3745-7317","authenticated-orcid":false,"given":"Marko","family":"Kerac","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2021,10,22]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"279-283","DOI":"10.1177\/089033449701300412","article-title":"Maternal and 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Hanson, Jessamyn Ressler-Maerlender, Independent researcher, Paris, France, 01 Dec 2020, version 1, indexed","URL":"https:\/\/f1000research.com\/articles\/9-1310\/v1#referee-response-74628","order":0,"name":"referee-response-74628","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Concetta Brugaletta<\/b>; \n<i>Posted: 25 May 2021<\/i>; Thank you very much for taking the time to read the manuscript and share your comments and constructive advice.  1. Regarding your first comment where you point out that we mentioned the World Health Organization (WHO), United Nations International Children\u2019s Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites as parts of our search but we didn't mentioned these in the database and search terms;&nbsp;we have now clarified this in the methods search under the databases and search terms paragraph as follow: \u201cWe also included hand search papers form grey literature, WHO and ENN websites\u201d.  2. Regarding your second comment for figure n1 where was unclear where the \u201cHand search Papers\u201d fit;&nbsp;we amended figure n1 in the new version of the manuscript. We also add a reference \n<i>Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) diagram of literature search results. Diagram retrieved from: <\/i>\n<i>http:\/\/prisma-statement.org\/PRISMAStatement\/FlowDiagram.aspx<\/i>  3. Regarding your request of clarification for the paragraph \u201cOf the 29 tools identified: 22 (76%) were developed in high-income countries and used in 31 studies carried out in high-income countries and four (14%) tools were developed in low and middle-income countries.&quot;&nbsp; Three tools are missing such designations&quot;; The tools that do not give any information about country of origin (described in the table 1 as not specified) are: - Baby-friendly Hospital Initiative&nbsp;(BFIH) Worldwide (When the Baby-friendly Hospital Initiative was conceived in the early 1990s in response to the 1990 Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding call for action, there were very few countries that had dedicated Authorities or Committees to oversee and regulate infant feeding standards.) - Essential Nutrition Action Message (Guyon &amp; Quinn 2011) Low and middle-income countries - Infant Feeding in Emergency (IFE) (ENN 2007) Low and middle-income countries - Neonatal Eating Assessment tool (NeoEAT) This is a USA based organisation: AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.&nbsp;https:\/\/www.awhonn.org\/ We amended the information above in table n1 of the&nbsp;new version of the manuscript. In the text of the new version of the manuscript we clarify the follow information:\n<i>&nbsp;\u201cOf the 29 tools identified: 22 (76%) were developed in high-income countries and used in 31 studies carried out in high-income countries, six (21%) tools were developed in low and middle-income countries and one (3%) was developed worldwide\u201d.<\/i>  4. Regarding your comment on considering&nbsp;complex spectrum of breastfeeding problems including potential underlying causes and contributory factors, including but not limited to maternal wellbeing and social support;&nbsp;It is a great suggestion; the number of words required does not allow us to expand on this very interesting and crucial topic. We have however added a reference of the MAMI website, which is regularly being updated and a note saying \n<i>\u201cThe mother-infant dyad is at the heart of approaches to treat malnutrition, but wider family and community relationship are also important but cannot be treated extensively in this review\u201d. <\/i>(ENN\/LSHTM, 2021)https:\/\/www.ennonline.net\/ourwork\/research\/mami\n<u> <\/u> https:\/\/www.ennonline.net\/mami\/practice  5. Regarding your comment on the discussion section where only one tool, BEET, achieves full coverage of all the key assessment domains. Yet, this tool is not included amongst those listed as potentially useful for immediate use;&nbsp;Thank you for your comments. The justification is in the paragraph on evidence underpinning tools: \u2018\n<i>The extent of tool testing varied substantially; 8 tools had no validation studies: Infant Feeding in Emergencies (IFE) Module 2 <\/i>\n<i>(<\/i>\n<i>ENN et al., 2007<\/i>\n<i>)<\/i>\n<i>, Breastfeeding Evaluation and Education Tool <\/i>\n<i>(<\/i>\n<i>Tobin, 1996<\/i>\n<i>)<\/i>\u2019. This is why we do not include for immediate use.&nbsp; We have added a note in the text \u201conly one tool (BEET) achieves full coverage of all the key assessment domains, but there was no validation study at our knowledge\u201d.  6. Regarding your comment on request of clarification if&nbsp;the Baby Friendly Hospital tools and UNICEF\/WHO Breast Observation Aid are referring to the same tool. We would like to explain their difference and the rational for our subtle considerations:&nbsp; - The Baby Friendly Hospital tools: is a checklist (12 to 14 items) designed with the aim to identify area of problem and give advice. These tools take in consideration health professional background and day of life of the baby and one can also be self-administered. This means there are 4 slightly different tools available: for mother and midwife, for mother and health visitor, for neonatal and for mother alone. The domain covered are:&nbsp; baby\u2019s and mother behaviour, positioning, lactating, effective feeding, breast health, baby health, mothers view (in addition these tools look at urine and stools, formula). (https:\/\/www.unicef.org.uk\/babyfriendly\/baby-friendly-resources\/implementing-standards-resources\/breastfeeding-assessment-tools\/). - The UNICEF\/WHO Breastfeeding Observation Aid is a checklist of identify dichotomous items ( 42 items\/5 scales) list signs that represent that BF is going well versus possible difficulties. It cover similar breastfeeding domains of the BFH tools but is a more simple checklist and doesn\u2019t offer possible solutions. (https:\/\/www.scribd.com\/document\/353627133\/Breastfeed-Observation-Job-Aid) This is why we maintained 2 different names and we advise to use the BFHT for resource-poor, high undernutrition settings where it is useful to have alongside the assessment also some initial advice.  7. Regarding your advice to proofread the paper to improve the overall writing; we have proofread and now we think this looks fine in this last of the manuscript.","URL":"https:\/\/f1000research.com\/articles\/9-1310\/v2#referee-comment-6714","order":1,"name":"referee-comment-6714","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.27043.r78113, Sandra Fucile, School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada, 18 Feb 2021, version 1, indexed","URL":"https:\/\/f1000research.com\/articles\/9-1310\/v1#referee-response-78113","order":2,"name":"referee-response-78113","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Concetta Brugaletta<\/b>; \n<i>Posted: 25 May 2021<\/i>; Thank you for taking the time to read the review and write your suggestion.  Regarding your advice to&nbsp;proofread the manuscript to ensure there are no grammatical and editorial errors; We have proofread and we think this looks fine in the new version of the manuscript.  Regarding your advice to ensure the reference on Figure 1;&nbsp;we added the reference at the base of the figure in the new version of the manuscript.&nbsp;  Regarding your suggestion on the use of a different terminology for Table 3; We hope it is okay to stick with validation studies as it is commonly used in the literature. For reference, see: https:\/\/www.equator-network.org\/reporting-guidelines-keyword\/validation-studies\/  Regarding your recommendation to include a&nbsp; specific definitions for high vs low income countries, define at-risk infants, define malnourished infants either in the introduction or methods section;&nbsp;We added the following references that will help clarifying the definition and the concept as follow: - High and low income countries: as classified by The World Bank \n<i>Fantom, Neil; Serajuddin, Umar. 2016. The World Bank's Classification of Countries by Income. Policy Research Working Paper;No. 7528. World Bank, Washington, DC. &copy; World Bank. https:\/\/openknowledge.worldbank.org\/handle\/10986\/23628 License: CC BY 3.0 IGO.<\/i> - At-risk infants: https:\/\/www.ennonline.net\/ourwork\/research\/mami  Regarding your comment &quot;29 tools were identified, 22 were developed in high-income countries, 4 low income countries. Three tools are missing such designations&quot;; The tools that do not give any information about country of origin (described in the table 1 as not specified) are: - Baby-friendly Hospital Initiative&nbsp;(BFIH)\n<i> <\/i> Worldwide (When the Baby-friendly Hospital Initiative was conceived in the early 1990s in response to the 1990 Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding call for action, there were very few countries that had dedicated Authorities or Committees to oversee and regulate infant feeding standards.) - Essential Nutrition Action Message (Guyon &amp; Quinn 2011)\n<b><i> <\/i><\/b> Low and middle-income countries - Infant Feeding in Emergency (IFE) (ENN 2007) Low and middle-income countries - Neonatal Eating Assessment tool (NeoEAT)\n<b><i> <\/i><\/b> This is a USA based organisation: AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. https:\/\/www.awhonn.org\/ We amended the information above in table n1 of the&nbsp;new version of the manuscript. In the text of the new version of the manuscript we clarify the follow information:\n<i>&nbsp;\u201cOf the 29 tools identified: 22 (76%) were developed in high-income countries and used in 31 studies carried out in high-income countries, six (21%) tools were developed in low and middle-income countries and one (3%) was developed worldwide\u201d.<\/i>","URL":"https:\/\/f1000research.com\/articles\/9-1310\/v2#referee-comment-6713","order":3,"name":"referee-comment-6713","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.27043.r77936, Nurul Husna Mohd Shukri, Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri kembangan, Malaysia, 19 Feb 2021, version 1, indexed","URL":"https:\/\/f1000research.com\/articles\/9-1310\/v1#referee-response-77936","order":4,"name":"referee-response-77936","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Concetta Brugaletta<\/b>; \n<i>Posted: 25 May 2021<\/i>; Thank you very much for taking the time to read the review and for all your comments, which we find it constructive and&nbsp; useful to clarify some concepts as below.&nbsp;  1. Regarding your first comment on describe the key term used or provide a table showing all Medical Subject Heading (MeSH) and keyword used for literature search;&nbsp;The search-strategy is deposited at LSHTM Data Compass as part of the Extended Data. Extended data contains tools excluded from the second stage of the search, full search strategy and PRISMA checklist. This was pointed out in the reference \n<i>\u201c Kerac M, Brugaletta C , Le Roch K: Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review. [Data Collection]. London School of Hygiene &amp; Tropical Medicine, London, United Kingdom.2020. <\/i>\n<i>http:\/\/www.doi.org\/10.17037\/DATA.00001881<\/i>\n<i>\u201d<\/i> We have added the link in the methods to make it easier to access.  \n<b>2. <\/b>Regarding your second comment to clarify or describe the term at-risk and malnourished infants;&nbsp;\u201c\n<i>A group with higher risk of mortality and morbidity are the small and nutritionally at risk infants under six months of age compared to the infant that achieve optimal growth. At a population level, small and nutritionally at-risk children are those identified as wasted, stunted and underweight and a combination of these (ENN\/LSHTM, 2021)<\/i>\n<i>\u201d<\/i>. We added a reference in the text of the larger project that clarify this concept: https:\/\/www.ennonline.net\/ourwork\/research\/mami  \n<b>3. <\/b>Regarding your third comment on differentiate or explain the difference\/similarity between breastfeeding outcomes and performance; We decided to modify the phrasing and replaced by: \u2018\n<i>how to observe and\/or assess the breastfeeding performance with outcomes<\/i>\u2019.  \n<b>4. <\/b>Regarding your suggestion for authors to proofread the paper to improve the overall writing; We have now proofread and think this looks fine in this last version. the major changes are:&nbsp; Table 2: corrected \u2018behaviour\u2019 Table 3: corrected \u2018postnatal\u2019; \u2018paediatric\u2019 Table 4: corrected \u2018analysis\u2019 Text and table 1: corrected \u2018lactating\u2019 (https:\/\/www.macmillandictionary.com\/dictionary\/british\/lactate Text corrected \u2018paediatric\u2019","URL":"https:\/\/f1000research.com\/articles\/9-1310\/v2#referee-comment-6712","order":5,"name":"referee-comment-6712","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"Publication expenses have been provided from Action Contre la Faim, 14-16 boulevard Douaumont, 75854 Paris Cedex 17, Paris, France.","order":6,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}