Conceptual and operational definition of nursing outcomes regarding the breastfeeding establishment*

Objective: to construct conceptual and operational definitions of Nursing Outcomes “Breastfeeding establishment: infant (1000)” and “Breastfeeding establishment: maternal (1001)”. Method: integrative literature review in the following databases: PUBMED (United States National Library of Medicine); LILACS (Latin American and Caribbean Health Sciences Literature); CINAHL (Cumulative Index to Nursing and Allied Health Literature); SciVerse SCOPUS; Web of Science; BDENF (Brazilian Nursing Database) and EMBASE (Excerpta Medica Database). The gray literature was explored to elucidate topics not covered by the articles. Of 3242 articles, 96 were selected to be read in full, and 43 were used for constructing the definitions. Five theses, three dissertations, three books and two manuals were selected. Results: all the results were reviewed. The definitions facilitated the improvement of the content proposed by the Nursing Outcomes Classification, favoring its application in clinical practice and supporting the development of research and teaching. Conclusion: it was proposed to change the definition of the two outcomes, as well as to change the title of one of them to “Breastfeeding establishment: newborn & infant” (1000), modifying seven of its indicators and excluding one. For the outcome related to the mother, it was proposed to modify two indicators and exclude one.

The studies were located using Medical Subject Headings Terms and Health Sciences Descriptors.
Furthermore, the keywords were chosen based on the title of the NO studied, by combining the terms "breastfeeding" or "weaning" with "infant" or "newborn" or "mother" and "establishment" or "success" or "failure" or "obstacle" or "barrier" or "challenge". These terms were searched independently at first, and then in combination, with the help of a librarian (Table 1).
The search in the databases reached a total of 3242 publications and, of these, 43 had content deemed relevant for the construction of the conceptual and operational definitions of the NO under study ( Figure 1).

Supports breast using "C" hold (cupping)"(100102)
-Conceptual definition: The mother supports the breast by positioning her index, middle, ring and little fingers underneath it, and her thumb on top of it, forming the letter "C"; Operational definition: The mother supports the lower part of the breast with her index, middle, ring and little fingers, and positions her thumb on top of it, forming the letter "C", without stretching or compressing the skin, as well as without preventing the baby from approaching and latching onto it. She simulates a scissor with her hand, supporting the breast between the middle and index fingers (27)(28)(29)(30)39,55,60) .

Breast fullness prior to feeding (100103) -
Conceptual definition: The breast contains milk before the baby is positioned to start sucking. Operational definition: Upon inspection or palpation, observe whether the breasts contain milk before the baby is positioned to start sucking (27,(45)(46)53,55,57,59,74) .

Milk ejection (let-down) reflex (100104) -
Conceptual definition: A reflex in which the milk contained in the breast is ejected out of it through the mammary ducts, as a result of the action of oxytocin, which causes the myoepithelial cells of the mammary gland's smooth muscle to contract, upon stimulus triggered by the baby. Operational definition: Observe the spontaneous ejection of milk through one or both nipples, when the mother smells or thinks of the baby, or when the baby cries or is breastfed and milk leaks from the contralateral breast. The woman may describe small shocks or a tingling or pricking sensation in the breasts, before and during breastfeeding (21,(28)(29)33,49,60,63,65) . the baby from the breast properly, so as not to cause pain or discomfort in the nipple. Operational definition:

Recognition of infant swallowing (100106) -
Observe if, when interrupting the breastfeeding process, the mother places her index or little finger in the baby's mouth through the lip commissure, removing the nipple, so that the suction is interrupted before the child is removed from the breast (28,30) .

Techniques to prevent nipple tenderness (100121)
-Conceptual definition: The mother is knowledgeable about techniques that help prevent nipple sensitivity.  Fluid intake of mother (100120) -Conceptual definition: Adequate intake of fluids by the mother during breastfeeding. Operational definition: verify if the mother ingests at least two liters of fluids daily during the period when the baby is being breastfed (44,52,(64)(65)68,71) .

Pumping of breast (100123) -Conceptual
definition: Removal of milk from the breast, manually or using a breast pump, to provide relief from discomfort when the breast is full or turgid, to increase milk production, or to store it. Operational definition: Verify if the mother is able to perform and/or describe the extraction of milk, either manually or using a breast pump, reporting its usefulness and frequency, as well as the appropriate technique, which involves hygiene measures along with proper positioning and use of the pump, to provide relief from discomfort, to increase milk production, or to store it (25,29,44,51,55,57,59,72) .

Discussion
The breastfeeding establishment is a complex process that involves biological, social, cultural and after it, and that each period has its own specific aspects, changing the NO's title to "Breastfeeding establishment: newborn & infant" is suggested. This proposal is made to increase the accuracy of the terms used in the title of this NO, according to definitions proposed by WHO (77)(78) , as well as to highlight the specificity of each period. it is suggested that its definition is changed to "adequate maternal establishment of latch and suction of the nipple-areola complex for the nutrition of newborns or infants during the first weeks of breastfeeding." Regarding the indicators of NO "Breastfeeding establishment: maternal(1001)," it is suggested that seven of them are reviewed, which will be specified below.
"Full breast before breastfeeding (100103)" could be changed to "Presence of colostrum/milk in the breast before breastfeeding," since "full breast" is subject to variations in interpretation. In addition, considering the period when the evaluation is performed, there may be presence of colostrum or milk; thus, this change would make the indicator more specific (19)(20)53,57) .
"Avoids giving water to the infant (100110)" could be changed to "Avoids offering water and other liquids to the newborn or infant," since not only water, but other liquids, such as teas and juices, can also interfere with the Breastfeeding establishment (52)(53)65) .