Original Article

Validation of the LATCH breastfeeding

assessment instrument for the
Portuguese language
Validação para língua portuguesa do instrumento de
avaliação do aleitamento materno LATCH
Cristiane Maria da Conceição1
Kelly Pereira Coca2
Maria dos Remédios da Silva Alves3
Fabiane de Amorim Almeida4

Keywords Abstract
Breastfeeding; Maternal-child nursing; Objective: To translate into Portuguese and validate the LATCH breastfeeding assessment scale.
Evaluation; Validation studies Methods: This was a methodological study through translation and validation of the instrument. The following
steps were followed: translation, back-translation, committee of judges, pre-test and validation. The validation
Descritores process includes the analysis of 160 women in breastfeeding in the first postpartum days during hospitalization.
Aleitamento materno; Enfermagem Results: The results indicate that the LATCH instrument translated into Portuguese can be used by nurses for
materno-infantil; Avaliação; Estudos de breastfeeding assessment, enabling the early detection of possible problems presented by the mother-baby
validação binomial during breastfeeding.
Conclusion: The study fulfilled the objective of adapting the LATCH breastfeeding assessment instrument to
the Portuguese language and verifying its psychometric properties. The LATCH instrument validity measures
Submitted what it was designed to do and is applicable in clinical practice.
March 5, 2017
Accepted Resumo
March 23, 2017 Objetivo: Traduzir para a língua portuguesa e validar a escala de avaliação da amamentação LATCH.
Métodos: Tratou-se de um estudo do tipo metodológico, por meio da tradução e validação de instrumento.
Seguiu-se as etapas estabelecidas: tradução, back-translation, comitê de juízes, pré-teste e validação. O
processo de validação inclui a análise de 160 mamadas de mulheres nos primeiros dias pós-parto, durante
a internação hospitalar.
Resultados: Os resultados obtidos indicam que o instrumento LATCH traduzido para o português pode ser
utilizado na avaliação do aleitamento materno pelo profissional enfermeiro, possibilitando a detecção precoce
de possíveis problemas apresentados pelo binômio mãe-bebê durante a amamentação.
Conclusão: O estudo cumpriu o objetivo de adaptar para a língua portuguesa e verificar as propriedades
Corresponding author psicométricas do instrumento de avaliação de aleitamento materno LATCH. A validade do instrumento LATCH
Kelly Pereira Coca mede o que foi concebido para medir, sendo ele aplicável na prática clínica.
Rua Napoleão de Barros, 754, 04024-
002, São Paulo, SP, Brazil.
kcoca@unifesp.br
1
Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
DOI 2
Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
http://dx.doi.org/10.1590/1982- 3
Hospital Municipal Vila Santa Catarina, São Paulo, SP, Brazil.
0194201700032 4
Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil.
Conflicts of interest: no conflicts of interest to declare. *Extracted from dissertation titled “Cultural adaptation
to Portuguese of the breastfeeding assessment instrument: LATCH” Professional Master Course of the
Faculdade Israelita de Ciências da Saúde Albert Einstein (FICASE).

210 Acta Paul Enferm. 2017; 30(2):210-6.

 Conceição CM, Coca KP, Alves MR, Almeida FA

Introduction ing, we highlight the LATCH Scoring System,

which is highly researched, probably because of
Breastfeeding is the most effective way to feed chil- its practicality.(11-18)
dren, since it addresses the nutritional, immunolog- The tool was elaborated in 1994 in the USA
ical and psychological aspects, and protects them by a nurse called Deborah Jensen(12) and her group
from various health risks.(1,2) In addition, breast- with the objective to document the assessment of
feeding potentially reduces child mortality by 13 breastfeeding during individual sessions in a sys-
per cent, especially in children aged under five years tematic manner.
for preventable causes of death.(3) Thus, the World Each letter of the acronym LATCH rep-
Health Organization recommends the exclusive resents a characteristic: L (Latch) refers to the
breastfeeding (EB) of children up to six months of quality of the child’s latch in the breast; A (Au-
life and up to two years old or more, concomitant dible swallowing) refers to the amount of audi-
with the introduction of complete feeding from six ble swallowing noted while nursing the baby; T
months of age.(4) (Type of nipple) evaluates the type of nipple; C
Despite the recommendation and the various (Comfort) refers to the mother’s comfort level in
benefits that breastfeeding offers, EB indices in relation to the breast and nipple; and H (Hold)
Brazil and worldwide are still far from the recom- refers to whether or not the mother needs help in
mended.(5) According to the latest national study, positioning the child.(12) Each of the five compo-
the duration of EB was only 54 days and the mean nents of breastfeeding assessment receives a nu-
time of breastfeeding was 342 days.(6) merical score ranging from 0 to 2, representing
There are several reasons for abandonment the same form of the Apgar Report for a maxi-
of exclusive and prolonged breastfeeding, among mum score of 10 points.(12) The tool was pub-
which the difficulties in management of breastfeed- lished in English(12) and validated in Spain,(16)
ing stand out because women and children need to Italy(17) and Turkey.(18) To date, there is no record
adapt and learn the process.(7,8) of a validation to the Portuguese language, limit-
Among the actions to encourage and support ing its use in Brazil.(11,16)
breastfeeding, the importance of health profes- In view of the above, the aim of the study was to
sionals is key, as they assist mother/children in translate into Portuguese and validate the LATCH
the first breastfeeding soon after delivery and breastfeeding assessment scale.
perform their follow-up in the maternity ward.
Therefore, the strategy of breastfeeding observa-
tion is fundamental in the sense of identifying Methods
problems presented by the pair, especially in this
initial phase.(9) This is a methodological study through translation
Guidance for the adequate breastfeeding tech- and validation of the instrument. The study respect-
nique provided in the maternity ward may reduce ed the stages of cross-cultural adaptation and clini-
incidence of women with difficulties, such as pre- cal validation:
vention of nipple injury(8) and complaints of low Stage 1 followed the phases: translation of the
milk production.(10) Thus, the use of breastfeeding instrument, back-translation, committee of judg-
assessment tools can be useful to systematize profes- es and pre-test by specialists. The original instru-
sionals’ evaluation, document the performed evalu- ment was translated from English to Portuguese by
ation and offer continuity of the care intervention two experienced translators in the health area. The
process in breastfeeding.(9) translation was performed independently, generat-
Among the tools available in the literature ing versions T1 and T2, which were later discussed
that help to evaluate the performance of the among professionals to obtain a single instrument
nursing mother and the baby during breastfeed- in Portuguese identified as T12.

Acta Paul Enferm. 2017; 30(2):210-6. 211

 Validation of the LATCH breastfeeding assessment instrument for the Portuguese language

Version T12 was submitted to the back-transla- All women who gave birth in the maternity
tion process, in which two independent and expe- ward of a private tertiary hospital in the city of São
rienced translators born in English speaking coun- Paulo between August and December 2015 were
tries (official language) translated version T12 again considered for the evaluation of breastfeeding.
into English without receiving information of the Those who felt uncomfortable by the presence of
original instrument. The process generated two ver- two professionals during data collection, who did
sions of the instrument, called B1 and B2, and sub- not express desire to breastfeed and whose children
sequently reaching consensus in version B12. were hospitalized in the Neonatal Intensive Care
Next, was formed a committee of judges by sev- Unit were excluded from the study. All participants
en breastfeeding specialist professionals by the In- received guidance regarding the study and signed
ternational Board Lactation Consultant Examiners the informed consent form. A single breastfeeding
(IBLCE). These professionals also demonstrated at was evaluated in each woman, totaling 160 women
least five years of experience in breastfeeding and/or evaluated.
education and proficiency in English. The following The estimate of 158 breast feeds was made to
participated of the committee: three nurses, three evaluate the reproducibility of the instrument.
neonatologists and a speech therapist. The profes- Sample calculation was estimated with the main
sionals were invited to participate in the study, the objective of obtaining 0.1 (10%) accuracy in a 95%
objective of the study was clarified, and they signed confidence interval for the intraclass correlation co-
the informed consent form. efficient. The calculation of intraclass correlation
Once the committee was formed, the judges coefficient and construction of the Bland-Altman
analyzed the sentences according to established cri- graph were used to evaluate the instrument repro-
teria (0 = undecided, 1 = equivalent, and -1 = not ducibility, and the calculation of Cronbach’s alpha
equivalent) for the technical review and evaluation coefficient was used to evaluate its reliability.
of semantic, idiomatic, conceptual and cultural The study was submitted to the Research Eth-
equivalence of the versions. The evaluation of items ics Committee of the Hospital Israelita Albert Ein-
was performed through the equivalence scale and stein and and approved under number 985.148
calculated by the Content Validity Index (CVI).(19) and CAAE number 40522214.3.0000.007 ac-
Items with equivalence below 0.80 were reviewed cording to resolution number 466 of 12/12/2012
by translators. of the National Health Council. Authorization for
After defining the final version of the instrument translation, cross-cultural adaptation and validation
in Portuguese, came the pre-test phase. The instru- was obtained through electronic contact with the
ment version was presented to 30 specialist nurs- author of the LATCH scale, Deborah Jensen, and
es in the area of breastfeeding to evaluate content version B12 was subsequently revised and approved
comprehension. Professionals were asked to answer by her too.
an adapted verbal-numerical scale using a five-point
Likert score, and express their doubts and observa-
tions. With these results, was reached the final ver- Results
sion of the LATCH instrument in Portuguese.
The analyzes of concordance among judges and After the stage of instrument translation, when
specialist nurses of the pre-test were performed us- comparing the original version with the back trans-
ing the Gwet’s AC2 coefficient, considering ordinal lation version (B12), translators identified some di-
weights and 95% confidence intervals. vergences: eleven words presented the same result in
In Stage 2 of the instrument validation pro- the Portuguese translation and in the retranslation
cess, 160 breast feeds were evaluated simultane- used to translate the English term: ‘reluctant’ (“re-
ously to verify reproducibility and reliability of lutante” (reluctant) and “hesitante” (hesitating)),
the instrument. ‘sustained’ (“manter” (maintain) and “sustentar”(-

212 Acta Paul Enferm. 2017; 30(2):210-6.

 Conceição CM, Coca KP, Alves MR, Almeida FA

sustain)), ‘grasps’ (“pega” (latches) and “agarra” In total, each judge made 84 evaluations, con-
(grabs)), ‘breast’ (“mama” (mamma) and “peito” sidering the 21 sentences according to each of the
(breast)), ‘lips flanged’ (“lábios curvados para fora” four components. In relation to concordance be-
(lips curved out) and “lábios voltados para fora” (lips tween their evaluations, the Gwett’s AC 2 concor-
facing out)), ‘a few’ (“um pouco” (a little) and “al- dance coefficient was 0.93 (95% CI 0.91 - 0.96),
guma” (some)), ‘everted’ (“evertido” (everted) and indicating excellent concordance among judges.
“protruso” (prominent)), ‘blisters’ (“vesículas” (ves- Regarding the comprehension evaluation of
icle) and “bolhas” (blisters)), ‘bruises’ (“equimoses” each instrument item by the 30 specialist nurses,
(bruises) and “ferimentos” (injuries)), ‘non-tender’ were obtained high indexes (CVI), the majority was
(“não doloridas” (non-painful) and “não dolorosas” equal to or greater than 0.93. Professionals report-
(non-painful)) and ‘staff’ (“equipe” (team) and “fun- ed a perfect understanding of items without any
cionário” (employee)). The terms selected in this doubts in the whole instrument. Nurses participat-
consensus were those considered more significant ing in the study were aged between 29 and 52 years,
based on publications about breastfeeding available median of 14 years of profession and 9 years of work
in the literature(20,21) (Chart 1). in the institution where the study was performed.
For the evaluation of the reproducibility and Regarding validity and fidelity, the final version
reliability of the translated LACTH scale from the of the instrument was submitted to concomitant
judges’ committee, the instrument was divided into evaluation of two nurses called A and B.
21 sentences. The content equivalence index (CVI) The sample consisted of 160 women aged 34
of the sentences was higher than 0.90, correspond- years on average, 95.6% had higher education level,
ing to 60% of the judges’ evaluations, as well as the 52.5% were primigravidae, 71.2% had a caesarean
general index (CVI), which was 0.91 and evaluated section, and 81.3% had no history of breast surgery.
the set of evaluation of the 21 sentences. Regarding children’s profile, 55% were males, mean
Four sentences related to the terms “agar- birth weight was 3,297 grams, medians of gesta-
ra a mama” (grabs the breast), “dolorosa” (pain- tional age were 39 weeks and Apgar 9/10; and 45%
ful), “posicionamento” (positioning) and “equipe” of them were on the first day of life.
(team) presented a CVI below 0.80, corresponding Each woman was submitted to a breastfeeding
to 20% of the judges’ evaluations. evaluation, totaling 160 breast feeds observed, and

Chart 1. Description of the LACTH final version in Portuguese

0 1 2 Totais
L
Pega Muito sonolento ou relutante Tentativas repetidas para sustentar a pega ou sucção Agarra a mama
Não consegue sustentar a pega ou Segura o mamilo na boca Língua abaixada
sucção Estimular para sugar Lábios curvados para fora
Sucção rítmica
A
Deglutição audível Nenhuma Um pouco, com estímulo Espontânea e intermitente
(<24 horas de vi da)
Espontânea e frequente
(>24 horas de vida)
T
Tipo de mamilo Invertido Plano Protruso (Após estimulação)
C
Conforto (Mama/mamilo) Ingurgitada Cheia Macias
Com fissura, sangrando, grandes Avermelhado/ pequenas vesículas ou equimoses Não dolorosas
vesículas ou equimoses Desconforto suave/moderado
Desconforto Severo
H
Colo (Posicionamento) Ajuda completa Ajuda mínima (por exemplo, elevar a cabeça na cabeceira Sem ajuda da equipe
(Equipe segura o bebê à mama) da cama, colocar travesseiros para apoio) Mãe capaz de posicionar e segurar o bebê
Ensinar a mãe em uma mama, depois ela faz no outro lado
Equipe segura o bebê, depois a mãe assume

Acta Paul Enferm. 2017; 30(2):210-6. 213

 Validation of the LATCH breastfeeding assessment instrument for the Portuguese language

Table 1. Concordance coefficients (AC2) between the evaluators

average duration of 25 minutes per evaluation. For for each item of the LATCH scale (n = 160)
observer A, the Cronbach’s alpha coefficient was Concordance coefficients AC2 LL UL
0.25, and for observer B it was 0.32. These values Pega (latch) 1.00 0.99 1.00
Deglutição audível (audible swallowing) 0.95 0.93 0.98
are considered low, and show the use of a global Tipo de mamilo (type of nipple) 1.00 1.00 1.00
score is not the most appropriate to evaluate this Conforto (comfort) 0.99 0.98 1.00
information. Therefore, the importance of the par- Posicionamento (hold) 0.99 0.97 1.00

ticularity of each instrument item is evident. LL= lower limit; UL= upper limit; *95% confidence interval

The heterogeneity of this sample could lead to

less reliability hence the choice to analyze the group Discussion
of women submitted to cesarean delivery, and in
which the breastfeeding evaluation was done on the The LATCH scale has been used worldwide as a
first day of life. The overall Cronbach’s alpha had a tool to assist mothers and guide health profession-
slight increase for this group; for evaluator A it was als about breastfeeding. The use of a breastfeeding
0.35, and for evaluator B it was 0.40. assessment instrument enables to record and track
Regarding the concordance between evaluations the evolution of identified difficulties, facilitating
and considering LATCH total scores, was found a the evaluation process of health professionals work-
0.96 intraclass correlation coefficient between ob- ing in the area.
servers, indicating excellent concordance between The American Academy of Pediatrics recom-
both. The Bland-Altman graph demonstrates no mends that professionals who advise mothers on
trend in the evaluations performed. The bar graph breastfeeding should fully evaluate breastfeeding
illustrates the differences between calculated scores, during hospital stay using the LATCH scale as a
and shows that 89% of differences between each standard for health institutions with the aim to im-
observer assessment of the same breastfeeding were plement breastfeeding recommendations based on
equal to zero. This means the majority of LATCH evidence.(22)
total score values were coincident (Figure 1). Since LATCH is a structured breastfeeding as-
In relation to concordance between observers sessment tool, its systematic use can help with the
in each scale item, all coefficients indicate that identification of mother and child difficulties and
concordance was excellent, with 95% confidence who need additional support or referral to reference
(Table 1). services in breastfeeding.(22)
LATCH total score A - LATCH total score B

140
1.0

Absolute frequency of breastfeedign

120
0.5

100
0.0

80
-0.5

60
-1.0

40
-1.5

20
-2.0

3 4 5 6 7 8 9 10 -2 -1 0 1
Means between LATCH total score from A and B LATCH total score A - LATCH total score B

Figure 1. Bland-Altman graph (I) and bar graph (II) for the total score obtained by evaluators A and B (n = 160)

214 Acta Paul Enferm. 2017; 30(2):210-6.

 Conceição CM, Coca KP, Alves MR, Almeida FA

Using the instrument that was studied to eval- excellent concordance between the experts in their
uate the effect of orientation in the breastfeeding instrument evaluations.
process between mothers of low birth weight infants The internal consistency of LATCH presented
during maternity stay allowed to identify that sup- low values of Cronbach’s alpha coefficient for both
port increases levels of maternal efficacy and rates evaluators, demonstrating the use of a global score
of prolonged exclusive breastfeeding.(23) Another is not the most indicated to evaluate this informa-
recent study comparing LATCH with a known tion. However, checking the particularities of each
self-efficacy instrument - short version (BSES-SF) instrument item is crucial. As the instrument is very
demonstrated a positive correlation between instru- objective, individual evaluation of each component
ments in postpartum women.(24) of the acronym is recommended for a more reliable
Therefore, the relevance of the present study is breastfeeding assessment when using the scale in
being the first to perform the scale cultural adapta- Portuguese.
tion in South America, which will impact positively Regarding concordance between the observ-
on its use by the Brazilian population given its ben- er nurses for the other instrument items, the in-
efits, mainly in relation to its practicality. This was dex was excellent. Considering the total LATCH
confirmed during the LATCH scale application in scores, the intraclass correlation coefficient was
clinical practice by nurses of this study. very high between observers, indicating excellent
The concordance between judges regarding the concordance between the two specialists who as-
equivalence between the original and translated in- sessed the breast feeds. This fact demonstrates
strument proved to be excellent. The selection of that completing the LATCH instrument showed
IBCLC professionals considered breastfeeding con- a consistent result with reality without distortions
sultants was important because they have the nec- or dubious interpretations.
essary skills, knowledge and attitudes to intervene The results obtained in this study indicate the
effectively in the breastfeeding process, and are ac- LATCH instrument translated into Portuguese
credited by an international institution.(25) can be used by nurses in assessment of breast-
The relative independence between the various feeding, enabling the early detection of possible
components of LATCH, except for “Pega” (Latch) problems presented by the mother-baby binomial
and “Deglutição audível” (Audible swallowing), sug- during breastfeeding. Thus, it provides important
gests to measure separately the components in this subsidies for individualized orientation about the
tool for breastfeeding assessment. “Pega” (Latch) and breastfeeding protocol, with emphasis on the dif-
“Deglutição Audível” (Audible swallowing) could be ficulties of each binomial, contributing to the suc-
combined in a single variable because they overlap. cessful breastfeeding process.
Another disadvantage was observed with regard to
the “Deglutição audível” (Audible swallowing) item,
because audible swallowing is time dependent and Conclusion
not feasible until the third or fourth postpartum day,
when the breast milk volume is produced in greater The cross-cultural adaptation and validation pro-
quantity compared to colostrum.(14,25) Nonetheless, cess of the Portuguese version of the LATCH scale
concordance was greater than 85% for each of the resulted in an adapted instrument, the LATCH
five components of LATCH, supporting the instru- Scale - Brazilian version. It has proven to be appro-
ment reliability as an effective tool for breastfeeding priate for use in clinical practice by professionals
assessment by practitioners. in the area. As the instrument is easy to visualize,
The general index (CVI) considering all items nurses can quickly identify the items of their inter-
evaluated by specialist nurses in the pre-test stage vention, contributing significantly to the successful
indicated an excellent content validity.(19) The con- breastfeeding practice. The LATCH scale translated
cordance coefficient of Gwet’s AC2 represented and adapted to Portuguese, like the original version,

Acta Paul Enferm. 2017; 30(2):210-6. 215

 Validation of the LATCH breastfeeding assessment instrument for the Portuguese language

9. Carvalhaes MA, Corrêa CR. Identificação de dificuldades no início do

should be used considering individual items for a aleitamento materno mediante aplicação de protocolo. J Pediatr. 2003;
more reliable assessment of the breastfeeding pro- 79(1):13-20.
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good positioning, and support fathers and families. Midwifery. 2002;
Thus, the instrument fulfills its intended purpose of 18(2):87-101.
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