Original Research

The LATCH Scoring System and Prediction of Breastfeeding Duration

Savitri P. Kumar, MD, FAAP, Roberta Mooney, RN, MS, Linda J. Wieser, PT, MA, IBCLC,
and Suzanne Havstad, MA

Abstract
This study aimed to determine whether LATCH scores assessed by professional staff
during in-hospital stays are predictive of breastfeeding at 6 weeks. Participants were English-
speaking breastfeeding women, 18 years or older, with healthy singletons. LATCH scores
were obtained once every 8 hours on day 1 and daily subsequently until discharge. Data were
obtained from hospital charts and telephone interviews on day 4 and week 6 postdelivery. At
6 weeks, 188 of 248 (76%) women were contacted and 66.5% were breastfeeding. LATCH
scores were higher among women breastfeeding than those who had weaned. Using receiver
operating characteristic (ROC) curves, a score of 9 or above at 16 to 24 hours was the most
discriminate of the 5 time periods examined (area under the ROC curve = 0.72). Furthermore,
women who met this criterion were 1.7 times more likely to be breastfeeding at 6 weeks than
women with lower scores. The LATCH assessment tool is a modest predictor of breastfeeding
duration. J Hum Lact. 22(4):391-397.
Keywords: breastfeeding, LATCH score, breastfeeding duration

The goals of the US Healthy People 2010 are to
increase the breastfeeding initiation rate to 75%, the 6-
month breastfeeding rate to 50%, and the 12-month
rate to 25%.1 The implementation of this public health
policy requires careful assessment of the breastfeeding
dyad while in the hospital. With the institution of early
hospital discharge in the United States, most hospitals
discharge mothers with vaginal births in less than
48 hours and those with cesarean births in less than
96 hours.2-5 Therefore, health care providers have
a decreased opportunity to assess breastfeeding and
teach the proper techniques. They are challenged to
Received for review May 31, 2005; Revised manuscript accepted for pub-
lication December 19, 2005.
No reported competing interests.
Savitri Kumar is the associate director of the Neonatal Intensive Care Unit
at Henry Ford Hospital, Detroit, MI. Roberta Mooney is a registered nurse
with 10 years clinical experience, including neonatal intensive care unit.
Linda J. Wieser is currently working as a lactation consultant at St Joseph
Mercy Hospital, Ann Arbor, MI. Suzanne Havstad is a Biostatistician III
in the Department of Biostatistics and Research Epidemiology at Henry
Ford Hospital, Detroit, MI.
J Hum Lact 22(4), 2006
DOI: 10.1177/0890334406293161
Copyright 2006 International Lactation Consultant Association
determine whether a baby is breastfeeding well at
hospital discharge. In a 2004 Policy Statement, the
American Academy of Pediatrics recommends that
prior to discharge the infant has completed at least
2 successful feedings, with documentation that the
infant is able to coordinate sucking, swallowing, and
breathing while feeding.2
Risk factors for poor breastfeeding outcomes include
primiparity, cesarean birth, flat/inverted nipples, use
of non-breast-milk fluids, pacifier use, prolonged sec-
ond stage of labor, and delayed onset of lactation.6,7
Consequences of inadequate intake of breast milk are
hyperbilirubinemia, infant hunger, slow weight gain,
failure to thrive, starvation, hypernatremic dehydration,
and death.8
Early hospital discharge underscores the need for a
simple and reliable tool that can assess breastfeeding
efficacy and identify problems needing support and
follow-up. Several assessment tools have been devel-
oped to evaluate the ability of the baby to suck at
the breast. Some of the commonly used tools are
the Infant Breastfeeding Assessment Tool (IBFAT),9 the
Mother-Baby Assessment Tool (MBA),10 and the LATCH
Scoring System.11

391
392 Kumar et al J Hum Lact 22(4), 2006

Table 1. LATCH Scoring System*

0 1 2

L: Latch Too sleepy or reluctant Repeated attempts Grasps breast

No latch achieved Hold nipple in mouth Tongue down
Stimulate suck Lips flanged
Rhythmic sucking
A: Audible swallowing None A few with stimulation Spontaneous and intermittent
< 24 hours. Spontaneous
and frequent > 24 hours old.
T: Type of nipple Inverted Flat Everted (after stimulation)
C: Comfort (Breast/nipple) Engorged Filling Soft
Cracked/bleeding/ large Reddened/small Nontender
blisters or bruises blisters or bruises
Severe discomfort Mild/moderate discomfort

H: Hold (positioning) Full assist (staff holds Minimal assist No assist from staff
infant at breast) Teach 1 side; mother Mother able to
does other position/hold infant
Staff holds and then
mother takes over

*Reprinted with permission from Jensen D, Wallace S, Kelsay P. LATCH: a breastfeeding charting system and documentation tool. JOGNN. 1994;23:27-32;
Blackwell Publishing.

The LATCH Scoring System was designed by
Jensen, Wallace, and Kelsay in 1994 to assist the
health care provider in evaluating the breastfeeding
techniques of mother/infant dyads. The LATCH tool
provides for systematic documentation and standard-
ized communication. The tool was modeled on the
Apgar scoring system with a possible composite score
of 0 to 10. Each letter of the acronym identifies an area
of breastfeeding assessment (Table 1).
Riordan and Koehn12 compared the IBFAT, MBA, and
LATCH assessment tools using 23 videotaped breast-
feeding sessions rated by 6 observers and concluded that
none of the assessment tools were reliable and thus not
recommended for clinical use. However, the LATCH
tool had the best interrater reliability in their study. In
1997, Adams and Hewell13 established reliability of the
LATCH tool for professional assessment of breastfeed-
ing. They used direct observation rather than videotapes.
A subsequent study of 133 mother-infant pairs by
Riordan et al14 concluded that higher LATCH scores cor-
related with longer duration of breastfeeding. In their
study, the LATCH scores were obtained from a single
random breastfeeding between 24 and 72 hours of age.
Early hospital discharge (with visiting nurse follow-
up) has been a well-established practice in our hospital
for almost 2 decades. There have been no data on the use
of the LATCH score in the first day of life to predict
breastfeeding success and duration. The present study
was undertaken to determine if LATCH scores obtained
during the hospital stay are predictive of breastfeeding
at 6 weeks.
Methods
Study Design
This prospective study was conducted from January
to October 2003 at an urban hospital with a delivery
rate of ~2500/year. On arrival to the labor, delivery, and
recovery suite (LDR), expectant mothers where asked
whether they planned to breastfeed, and their response
was documented in the records. Duration of anticipated
breastfeeding was not asked. After giving birth, mother
and baby stayed for 2 hours in the LDR suite following
a vaginal delivery, or in the postoperative recovery
room following a cesarean delivery. During this 2-hour
period, breastfeeding and skin-to-skin contact were
attempted whenever possible. Mother and baby were
then transferred to the Family Centered Maternity Care
unit, where couplet care is practiced. All mothers dur-
ing that period were invited to participate in the study if
they spoke English; were 18 years of age or older;
delivered a singleton, healthy term newborn; and were
planning to breastfeed. Breastfeeding mothers were
excluded from the study if they received magnesium
sulfate postdelivery, if the newborn was admitted to the
neonatal intensive care unit, or if the newborn was sep-
arated from the mother for observation for longer than
2 hours.
J Hum Lact 22(4), 2006
Table 2. Calculating Sensitivity* and Specificity**
True Breastfeeding
Status at 6 Weeks
LATCH Result Breastfeeding Weaned
At/above threshold a b
Below threshold c d
Total a+c b+d
*Sensitivity = a/(a+c).
**Specificity = d/(b+d).
A small pilot study showed a 75% rate of successful
breastfeeding and a standard deviation of 2.1 in LATCH
scores. Using this pilot data and assuming 2-sided test-
ing, a sample size of 200 was calculated to have at least
80% power of detecting a difference of 1 in the LATCH
scores between those who successfully breastfed and
those who weaned at 6 weeks. However, we enrolled
250 mothers anticipating attrition. Three hundred
eighteen (318) women who had initiated breastfeeding
in LDR were asked to participate, and 68 refused. Two
hundred fifty (250) were enrolled, resulting in a 79%
agreement to participate rate. Two individuals withdrew
after enrollment. The institutional review board approved
the study, and informed consent was obtained from all
participants at the time of enrollment.
An international board-certified lactation consultant
trained all LDR and postpartum nurses in the use of the
LATCH tool and assessed their competency with this
tool. The LATCH scoring system was incorporated
into the newborn flow sheet for easy documentation.
LATCH scoring was performed at least once per
8-hour shift during the mothers hospital stay.
Mothers and babys charts were reviewed during
the hospital stay, and data were collected on the fol-
lowing variables: maternal age, gravidity, parity, eth-
nicity, level of education, mode of delivery, type of
anesthesia, and LATCH scores. For the newborn, birth
weight, gestational age, and 1-minute and 5-minute
Apgar scores were recorded. Mothers phone number,
address where she would be staying, and an alternate
phone number were confirmed prior to discharge.
Postdischarge phone calls were made on day 4 and at
week 6. Each participant was asked if she was still
breastfeeding at the time of the phone call. If yes, it
was determined whether it was exclusive, partial, or
token breastfeeding. These categories for data collec-
tion were based on definitions developed by Labbok
and Krasovec.15 For data analysis, exclusive and partial
The LATCH Scoring System 393
were combined as breastfeeding, whereas token and
none were combined as not breastfeeding.
Statistical Analysis
Total
Comparisons between those lost to follow-up and
a+b those interviewed at 6 weeks were performed using chi-
c+d
square tests for categorical variables (Fishers exact was
a+b+c+d
used where small cell sizes existed). Continuous vari-
ables such as age and Apgar score were analyzed with
the Students t test. Differences in LATCH scores
between those still breastfeeding at 6 weeks and those
who were not were analyzed using a Wilcoxon rank sum
test due to nonnormality of the data. If more than one
LATCH score was documented for the specified time
period, the maximum LATCH score was used for analy-
sis. Means and standard deviations are presented along
with medians for comparison purposes.
Receiver operating characteristic (ROC) analysis was
used to evaluate the sensitivity and specificity of all pos-
sible LATCH score thresholds for predicting breastfeed-
ing at 6 weeks. Sensitivity is the ability of a LATCH
score at or above the threshold to predict whether a sub-
ject will be breastfeeding at 6 weeks. Specificity, in this
study, is the ability of a low LATCH score to predict
that a participant will no longer be breastfeeding at 6
weeks (Table 2). Each time point (ie, 0 to 8 hours, 8 to
16 hours, etc) was considered separately; however, due
to early discharge and some missing data, the sample
size decreased to 23 for the final time period of 48 to
72 hours.
This last time period is presented for descriptive
purposes only. The overall accuracy of each LATCH
score time period in detecting breastfeeding at 6 weeks
was summarized using the area under the ROC curve
(AUC). The AUC is a measure of model discrimina-
tion, where an AUC of 0.5 is completely random and
an AUC of 1.0 indicates perfect discrimination.
In addition to the ROC curves, we calculated the
Youdens J,16(pp434-435) which is the sum of the sensitivity
plus the specificity. Using the highest AUC among the
5 different time periods and then the highest Youdens J
within that time period, we selected the best cutoff
point for our data set. The relative risk (RR) of LATCH
score cutoffs to breastfeeding at 6 weeks, along with
accompanying 95% confidence intervals, was then com-
puted for that cutoff point.
All statistical analyses were performed using SAS
(9.1) software. P values of .05 or less were considered
statistically significant.
394 Kumar et al J Hum Lact 22(4), 2006

Table 3. Demographics of Study Population (N = 248) Table 4. LATCH Scores and Breastfeeding Status at 6 Weeks*
Entire Six-Week Lost to Maximum
Cohort Follow-up Follow-up LATCH Score Breastfeeding Not Breastfeeding
N = 248 N = 188 N = 60 During the N = 125 N=6
Time Period Mean (SD) Mean (SD) P Value
Maternal characteristics
Age, y, x SD 27.7 6.1 27.8 6.2 27.5 6.1 0-8 hours 8.1 (2.1) 6.8 (2.9) .012
Ethnicity, no (%) Median = 9 Median = 8
African American 157 (63.3%) 112 (59.6%) 45 (75.0%) N = 83 N = 43
Caucasian* 52 (21.0%) 40 (21.3%) 12 (20.0%) 8-16 hours 8.2 (1.9) 6.8 (2.9) .006
Other 39 (15.7%) 36 (19.1%) 3 (5.0%) Median = 9 Median = 8
Educational level N = 73 N = 32
completed, no. (%) 16-24 hours 9.0 (1.1) 7.3 (2.6) .005
< High school 21 (8.5%) 15 (8.0%) 6 (10.0%) Median = 9 Median = 8
High school 118 (47.8%) 90 (48.2%) 28 (46.7%) N = 44 N = 19
College 81 (32.8%) 61 (32.6%) 20 (33.3%) 24-48 hours 8.4 (1.8) 7.4 (2.5) .026
Graduate school 27 (10.9%) 21 (11.2%) 6 (10.0%) Median = 9 Median = 8
Primigravidas, no. (%) 58 (23.4%) 47 (25.0%) 11 (18.3%) N = 60 N = 28
Delivery method, no. (%) 48-72 hours 8.9 (1.3) 7.9 (2.4) .25
Spontaneous vaginal 184 (74.2%) 138 (73.4%) 46 (76.6%) Median = 9 Median = 9
Vaginal assisted 3 (0.1%) 3 (1.6%) 0 (0%) N = 13 N = 10
Scheduled cesarean 31 (12.5%) 23 (12.2%) 7 (11.7%)
Emergent cesarean 30 (12.2%) 24 (12.8%) 7 (11.7%) *Sample sizes for the time periods are less than the 188 total because the
Type of anesthesia/ LATCH score was not documented for every mother each shift, and many
analgesia used, no (%)** mothers were discharged at 24 hours postdelivery.
None 52 (21.0%) 36 (19.2%) 16 (27.1%)
Local 40 (16.2%) 35 (18.6%) 5 (8.5%)
Narcotic/Nubain 56 (22.7%) 45 (23.9%) 11 (8.6%)
Epidural 92 (37.2%) 68 (36.2%) 24 (40.7%) African Americans in the lost to follow-up group. No
Spinal 44 (17.8%) 34 (18.1%) 10 (17.0%)
General 5 (2.0%) 3 (1.6%) 2 (3.4%)
other statistically significant differences were found.
Newborn characteristics, no. (%) Comparison of exclusive, partial, token, or no breast-
Males 134 (54.0%) 104 (55.3%) 30 (50.0%) feeding on day 2 between the 6-week follow-up cohort
Females 114 (46.0%) 84 (44.7%) 30 (50.0%)
Birth weight, g, x SD 3433 502 3429 514 3446 469
and those lost to follow-up also showed no statistical
Gestational age, wk, x SD 39.0 1.3 39.1 1.2 38.8 1.4 differences. However, as early as postpartum day 4, the
1-minute Apgar score, x SD 8.2 0.9 8.2 1.0 8.1 0.8 lost to follow-up group had significantly fewer women
5-minute Apgar score, x SD 9.0 0.2 9.0 0.2 9.0 0.2 breastfeeding when compared with the 6-week follow-up
*Comparison of those with 6-week follow-up to those lost to follow-up sig- group. At 6 weeks, 50% of the original cohort were still
nificant (P < .05). breastfeeding, 26% were not breastfeeding, and 24%
**Some mothers received more than one type of anesthesia/analgesia.
(n = 60) were lost to follow-up.
We compared the LATCH scores obtained at 8-hour
Results
intervals on day 1 and 24-hour intervals on days 2 and
3 with breastfeeding status at 6 weeks. The average
Telephone interviews could be conducted for 182 LATCH scores were significantly higher for the breast-
(73%) participants on day 4 and 188 (76%) at 6 weeks. feeding group at all time periods except 48 to 72 hours
Failure to collect data via telephone interviews was due (P = .25) (Table 4). For 48 to 72 hours, the sample size
to wrong or disconnected phone numbers, the inability to (N = 23) was low because of early hospital discharge
find participants at home, or participants having moved (< 48 hours). Therefore, the power to detect differ-
to another location. This occurred despite having demo- ences even if they truly exist is considerably lower than
graphic data confirmed prior to discharge and obtaining it is for the earlier time periods. Statistically significant
alternate phone numbers. differences were found at the 0- to 48-hour period time
Demographics of the entire study cohort, along with points, but not at the 48- to 72-hour time points, per-
comparison of the demographics of those followed for haps due to this smaller sample size.
6 weeks and those lost to follow-up, are presented in
Table 3. Although 25% of the original cohort was lost to ROC Results
follow-up at 6 weeks, the only difference in demo- The 16- to 24-hour LATCH score had the highest AUC
graphics between the groups was a higher proportion of (0.72) of all 5 time periods examined (Figures 1-5). The
J Hum Lact 22(4), 2006 The LATCH Scoring System 395

1 1
LATCH Score of 6 or above
0.8 0.8 LATCH Score of 10 or above

True PositiveRate
True PositiveRate

0.6 0.6

0.4 0.4

0.2 AUC = 0.63 0.2 AUC = 0.64

0 0
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
False Positive Rate False Positive Rate

Figure 1. Receiver operating characteristic (ROC) curve for 0- to Figure 4. Receiver operating characteristic (ROC) curve for 24- to
8-hour LATCH score. AUC = area under the ROC curve. 48-hour LATCH score. AUC = area under the ROC curve.

1 1 LATCH Score of 9 or above

LATCH Score of 7 or above

0.8 0.8
True PositiveRate

0.6 True PositiveRate

0.6

0.4 0.4

0.2 AUC = 0.67 0.2 AUC = 0.64

0 0
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
False Positive Rate False Positive Rate

Figure 2. Receiver operating characteristic (ROC) curve for 8- to Figure 5. Receiver operating characteristic (ROC) curve for 48- to
16-hour LATCH score. AUC = area under the ROC curve. 72-hour LATCH score. AUC = area under the ROC curve.

sensitivity of 75.0% and specificity of 63.2% (Table 5).

1 LATCH Score of 9 or above
The RR of a LATCH score of 9 or more at 16 to 24 hours
0.8
was 1.7 (1.1-2.7), P = .004. This means that women with
True PositiveRate

a maximum LATCH score of 9 or more in the 16- to

0.6 24-hour period were 1.7 times more likely to be still breast-
feeding at 6 weeks, compared to women with lower scores.
0.4 Due to sample size issues even at the 16- to 24-hour
time period, we also evaluated best cutoffs at 0 to 8 and
0.2 AUC = 0.72 8 to 16 hours. The best cutoff for the 0- to 8-hour time
period was a LATCH score of 6 or more. The sensitiv-
0
0 0.2 0.4 0.6 0.8 1 ity of a maximum LATCH score during the 0- to 8-hour
False Positive Rate period of 6 or more was 92.8%, with a specificity of
30.2%. The RR for the score of 6 or more at the 0 to 8
Figure 3. Receiver operating characteristic (ROC) curve for 16- to
24-hour LATCH score. AUC = area under the ROC curve. time period was 2.3 (1.2-4.5), P = .001.
The best cutoff for the 8- to 16-hour time period was
a LATCH score of 7 or more. The sensitivity of a max-
cutoff score, which maximizes the sum of sensitivity imum LATCH score during the 8- to 16-hour period of
plus specificity (Youdens J), is a LATCH score of 9 or 7 or more was 89.0% with a specificity of 34.4%. The
higher during the 16- to 24-hour period. This cutoff has a RR was 1.8 (1.0-3.1), P = .006.
396 Kumar et al J Hum Lact 22(4), 2006

Table 5. Predicting Breastfeeding at 6 Weeks* to breastfeed for only a short period of time. The pre-
LATCH Score dictability of the LATCH score in this study is modest.
at Time Period Cutoff Sensitivity Specificity Youdens J This may be a result of sample size losses and/or other
factors influencing weaning. This study shows that the
0-8 hours 6 92.8% (77/83) 30.2% (13/43) 123.0
7 86.8% (72/83) 34.9% (15/43) 121.7 LATCH score is a predictor of breastfeeding duration,
8 74.7% (62/83) 44.2% (19/43) 118.9 but probably not the only influential factor.
9 50.6% (42/83) 62.8% (27/43) 113.4 In conclusion, the LATCH scoring system is a sim-
8-16 hours 6 90.4% (66/73) 21.9% (7/32) 112.3
7 89.0% (65/73) 34.4% (11/32) 123.4 ple and useful tool, capable of predicting breastfeeding
8 72.6% (53/73) 37.5% (12/32) 110.1 duration as early as the first 24 hours of life. Low
9 54.8% (40/73) 65.6% (21/32) 120.4 LATCH scores indicate the need for active interven-
16-24 hours 7 97.7% (43/44) 26.3% (5/19) 124.0
8 90.9% (40/44) 36.8% (7/19) 127.7
tion, support, and postdischarge follow-up. Frequent
9 75.0% (33/44) 63.2% (12/19) 138.2 evaluations, starting in the delivery room and continu-
24-48 hours 8 80.0% (48/60) 39.3% (11/28) 119.3 ing until discharge, are essential. In the present health
9 58.3% (35/60) 60.7% (17/28) 119.0
care climate, where breastfeeding is being strongly
> 10 26.7% (16/60) 92.9% (26/28) 119.6
promoted but early hospital discharge is the norm, the
*Sample size for the time periods are less than 188 total because the LATCH utility of this tool is underscored. Use of the LATCH
score was not documented for every mother each shift, and many mothers
were discharged at 24 hours postdelivery.
tool will assist caregivers to focus on those women
with low scores, who are at risk for early weaning.

Discussion
The present study demonstrates the utility of LATCH
scores in the first days of life to predict breastfeeding
duration at 6 weeks postdelivery, as previously reported
by Riordan et al.14 Both their study and ours found
higher LATCH scores for those who breastfed to 6
weeks than those who had weaned by that time. In our
study, multiple evaluations of the breastfeeding dyad
were carried out in the first 24 hours, compared to
Riordan et als study in which a single, random evalu-
ation was done at 24 to 72 hours. They noted lower
LATCH scores in women who weaned earlier, based
on a single parameter, breast/nipple comfort. We did
not separate the components of the LATCH scoring
system but evaluated the score as a whole.
We noted that a 16- to 24-hour LATCH score of 9 or
higher was the most discriminate of all the 5 time peri-
ods examined. A woman with a 16- to 24-hour LATCH
score of 9 or greater was 1.7 times more likely to be
breastfeeding at 6 weeks, compared to others with lower
scores. The AUC for 16- to 24-hour LATCH score was
0.72. As seen in Table 5, a cutoff of 9 or greater gives the
best Youdons J (the sum of sensitivity and specificity).
Although a cutoff of 7 at 16 to 24 hours has the highest
sensitivity at 97.7%, the specificity is very low at 26.3%.
Because the specificity increases to 63.2% at the cutoff
of 9, this minimizes the number of false positives. A false
positive means that, despite a high LATCH score, partic-
ipants will wean early because weaning is related to mul-
tiple factors such as returning to work or having intended
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J Hum Lact 22(4), 2006 The LATCH Scoring System
Resumen
Este estudio quiere determinar si los puntajes de
LATCH hecho por personal profesional durante la
estada en el hospital son un medio de pronstico de la
lactancia materna a las 6 semanas. Las mujeres
participantes hablan Ingls, 18 aos o mayores con bebes
nicos saludables. Los puntajes de LATCH se obtuvieron
cada 8 horas en el da 1 y una vez al da consecutivamente
hasta la salida del hospital. Los datos se obtuvieron de las
historias clnicas hospitalarias y entrevistas telefnicas en
el da 4 y semana 6 postparto. En la sexta semana 188 de
397
248 (76%) de las mujeres se contactaron y 66.5%
continuaban la lactancia materna. Los puntajes LATCH
fueron mayores en las mujeres que continuaban lactando
que en las que haban interrumpido la lactancia. Se
utilizaron las curvas ROC, un puntaje de 9 o mayor a las
16-24 horas fue el perodo que mostr mas diferencia de
los 5 periodos examinados (AUC = 0.72). Luego, las
mujeres que cumplan con este criterio lactaron a sus
bebes 1.7 veces mas a las 6 semanas que aquellas mujeres
con puntajes menores. El instrumento de evaluacin
LATCH es un instrumento pronostico modesto de la
duracin de la lactancia materna.