Dr Lynette Shotton discusses three studies which all examine how universities contribute to improving breastfeeding outcomes.
Author:
Dr Lynette Shotton EdD, RN, SCPHN (health visitor), is associate professor, Northumbria University.
RESEARCH SUMMARY
- This paper presents findings from three studies examining the contribution of universities to strengthening breastfeeding education.
- A national mixed-methods evaluation of CHINS (a positioning framework), a qualitative study of mothers’ experiences, and a regional pilot of the LATCHES attachment framework.
- CHINS was widely understood and embedded in practice, enhancing practitioner confidence, consistency and communication, while mothers reported increased clarity and reassurance.
- LATCHES demonstrated strong acceptability as a complementary tool, with refinements suggested to enhance clarity and compassion.
- Together, these frameworks strengthen workforce knowledge and practice, informing a digital CPD package and international pilot.
- This work highlights the role of university-practice partnerships in improving breastfeeding outcomes.
Key words
Breastfeeding, positioning, attachment, universities, professional development, cognitive learning theory
INTRODUCTION
Breastfeeding is a global public health priority, recognised as fundamental to child survival and health, providing optimal nutrition and immunological protection (World Health Organization (WHO), 2025). It is associated with significant benefits across the life course for both infants and mothers (Victora et al., 2016; Tschiderer et al., 2022). Despite this, global rates remain suboptimal, with only 38% of infants exclusively breastfed to 6 months (WHO, 2025), and the UK reporting some of the lowest rates internationally, at around 1% (Victora et al., 2016; World Breastfeeding Trends Initiative (WBTi), 2024).
Within the UK, breastfeeding rates show marked regional and socioeconomic inequalities, with lower prevalence consistently observed in more deprived areas (Office for Health Improvement and Disparities, 2024). These disparities have persisted over time, particularly in regions such as the North East of England.
Barriers to breastfeeding are multifactorial, and include social norms, commercial influences, and inconsistent professional and community support (The Food Foundation, 2024; WBTi, 2024). Many mothers who stop breastfeeding earlier than intended report unmet support needs when facing challenges such as attachment difficulties or pain (WBTi, 2024). These gaps in support highlight the critical role of skilled, consistent professional input. In response, the World Breastfeeding Trends Initiative (WBTi, 2024) emphasises the need for strengthened professional education, alongside improved support systems and coordinated policy action, to address persistently low breastfeeding rates.
THE BABY FRIENDLY INITIATIVE AND THE EVOLVING ROLE OF UNIVERSITIES
The Baby Friendly Initiative (BFI), led by the WHO and UNICEF, has evolved from an initial focus on maternity services to include community and university settings, embedding breastfeeding support across the UK care continuum (UNICEF, no date). The introduction of university accreditation marked a significant shift, recognising UK higher education institutions as key partners in preparing a workforce capable of delivering consistent, evidence-based breastfeeding support from the outset.
The NMC Standards of proficiency for midwives (2019) and Specialist Community Public Health Nurses (SCPHN) in health visiting (NMC, 2022) require practitioners to promote, protect and support breastfeeding, and to apply evidence-based, relationship-centred care. Within midwifery standards, this includes competence in practical infant feeding skills, whereas SCPHN standards emphasise the critical application of specialist knowledge related to infant nutrition within a public health context. University standards, aligned with both NMC frameworks and the UNICEF BFI requirements, not only reflect these expectations, but, in the case of SCPHN, extend beyond them by incorporating practical breastfeeding support competencies.
Uptake of accreditation has increased, with around 40% of midwifery and 21% of health visiting programmes accredited (UNICEF, 2025), reflecting growing recognition of the importance of embedding infant feeding education within professional training.
Teesside University was an early adopter of Baby Friendly university accreditation. As part of this process, a programme of curriculum development was led in close collaboration with NHS partners. It was within this context that CHIN was developed by the author (published as Harland, 2011; now Shotton) as a simple, memorable tool to support the teaching of effective breastfeeding positioning.
The intellectual property remains with the author; however, its adoption within UNICEF Baby Friendly education and wider practice contexts has supported its dissemination and adaptation. In practice, the term CHINS has emerged, reflecting the addition of “sustainable” positioning, with further adaptations identified in practice, including an additional “S” for safety, as outlined in the findings. As a result, both CHIN and CHINS appear within the academic literature, and across NHS and wider health-related practice contexts; in this paper, CHINS is used to reflect its contemporary application and evolution from the original CHIN framework (Harland, 2011).
An overview of CHIN (Harland, 2011), presented here in its adapted form as CHINS, is provided in Table 1.
| Table 1 – CHINS | |
| C – close | Baby needs to be close to their mother so they can scoop enough breast into their mouth. Ensure mother and baby’s clothing and hands are not in the way. |
| H – head free | When attaching to the breast, the baby will tilt their head back to allow their chin to lead as they come onto the breast. Even a finger on the back of baby’s head can prevent this important movement. |
| I – in line | The baby’s head and body should be in alignment so they do not have to twist their neck, which would make feeding and swallowing difficult. |
| N – nose to nipple | Nose to nipple is the starting point for effective attachment. With mother’s nipple resting below baby’s nose, they will begin to root. As baby tilts their head back, the nipple will slip under their top lip upwards and backwards to rest between the hard and soft palate. |
| S – sustainable | Ensure both mother and baby’s position are well supported and comfortable, so that the position is sustainable for the duration of the feed. |
CHINS was informed by breastfeeding theory underpinning UNICEF training, professional practice and educational theory, and developed at the intersection of practice and pedagogy to strengthen practitioner competence and confidence.
Although simple in design, it is grounded in cognitive learning theory (Bruner, 1966), functioning as a cognitive scaffold to support memory, recall and application of key positioning principles in real-world practice. This is particularly valuable in clinical contexts where practitioners must integrate anatomical, physiological and relational knowledge while providing sensitive support to mothers.
CHINS also aligns with Kolb’s (1984) experiential learning cycle, offering a structured approach to observation, practice and evaluation in both classroom and placement settings, supporting declarative and procedural knowledge.
By integrating breastfeeding theory with cognitive and experiential learning principles, CHINS translates complex concepts into accessible, transferable knowledge for education and practice. Its integration into university curricula and UNICEF Baby Friendly training, adoption across NHS services, and inclusion in Myles Textbook for Midwives (Marshall and Raynor, 2020) and Pollard’s Evidence-Based Care for Breastfeeding Mothers (Pollard, 2024) highlight its growing recognition as a credible, evidence-informed educational framework with demonstrable impact on practice.
EVIDENCE OF IMPACT AND SIGNIFICANCE
Study 1: National mixed-methods evaluation of CHINS (Shotton et al., 2024a)
METHOD
A national mixed-methods evaluation of CHINS (Shotton et al., 2024), funded by the Burdett Trust for Nursing, was conducted with ethical approval from Northumbria University. A concurrent, convergent design was underpinned by Normalisation Process Theory (NPT) (May et al., 2015), a sociological theory that explains how new interventions are implemented, embedded and sustained in routine practice. NPT informed the study design, survey and focus group development, coding framework, and interpretation of findings. NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) informed data collection and analysis.
Participants and recruitment
Breastfeeding practitioners, NHS infant feeding leads, midwives, health visitors and university educators were recruited through national infant feeding networks, UNICEF Baby Friendly channels and social media. A total of 115 participants completed the online survey and 16 took part in follow-up focus groups.
Data collection and analysis
Data was collected via an online survey and focus groups. The survey captured socio-demographic data, training background, and awareness and use of CHINS, alongside NPT-informed implementation questions. Focus groups (45-60 minutes) explored how CHINS was used, adapted and valued in practice.
Quantitative data was analysed using descriptive and inferential statistics, including logistic regression, while qualitative data was coded using an NPT-informed framework (coherence, cognitive participation, collective action, reflexive monitoring). Findings were integrated at the interpretation stage.
FINDINGS
Participants were highly familiar with CHINS, and more than 94% reported that it was valuable in their work and that they intended to continue using it. This reflected strong Coherence, with practitioners describing CHINS as logical, memorable and easy to integrate within everyday practice (Collective Action). As one participant explained:
‘I’m using it [CHINS] so that they understand… Because it’s really important, I think, for midwives to be able to support a mother who’s breastfeeding.’ (R16)
Cognitive participation
Engagement with CHINS was strongly supported by organisational structures, particularly the UNICEF BFI, which participants identified as a major driver of implementation. The majority (>79%) felt that sufficient training was available to enable use of CHINS, indicating strong relational and organisational buy-in. This was reflected in comments such as:
‘But I use CHINS every day. We, sort of, adopted it… It came through UNICEF, obviously, for us as well, as a Trust, as a board. So, all our staff have UNICEF training, you know, as the requirements.’ (R14)
Participants also linked CHINS adoption to wider policy priorities:
‘And I think now there’s such a push, isn’t there, with the NHS Long‐term Plan that all maternity services need to be accredited.’ (R15)
Reflexive monitoring
Practitioners demonstrated active appraisal and adaptation of the tool, with 91.7% reporting that CHINS had positively influenced their work. Some described adaptations made in local training contexts, including explicit additions to emphasise safety:
‘We [university academic] put an extra S on it. So, we had CHINS-S. So, sustainable, and then we had safe in there as well.’ (R10)
This was explained by the participant as a practice-informed educational response to local clinical events, reinforcing the importance of safe positioning and airway protection during breastfeeding and skin-to-skin contact. Participants also judged CHINS to be effective based on mothers’ responses:
‘When I use CHINS with mums, they understand instantly. That’s how I know it works.’
OVERALL IMPACT
Across the evaluation, CHINS was viewed as a flexible, intuitive and highly useful tool that enhanced workforce confidence, improved consistency in language and advice across teams, and strengthened teaching and assessment of positioning within university curricula. Participants also highlighted its suitability for a wide range of clinical scenarios, reinforcing its adaptability and relevance.
A commonly noted limitation, however, was the absence of a complementary framework for attachment. Although CHINS was regarded as highly effective for teaching positioning, practitioners emphasised the need for an equivalent, evidence-informed tool to support consistent teaching and assessment of attachment – directly informing the development of the LATCHES framework.
Study 2: Breastfeeding mothers’ qualitative study (Shotton and Collins, 2024).
METHOD
Design
An exploratory descriptive qualitative design (Hunter et al., 2018) was used to explore breastfeeding mothers’ awareness, perceptions and experiences of CHINS. This approach enabled examination of lived experiences rather than testing an intervention. Ethical approval was obtained from Northumbria University.
Participants and recruitment
Participants were UK-based breastfeeding mothers who had received support from midwives, health visitors or infant feeding teams. Eleven mothers, aged 26-44 years participated, all currently or recently breastfeeding, with variation in parity, feeding history and timing of CHINS introduction. Recruitment was via digital advertisements shared through breastfeeding groups, forums and social media, with interested participants contacting the research team directly.
Data collection
Data was collected through semi-structured individual interviews, conducted via telephone or Microsoft Teams. Interviews, lasting 45-60 minutes, were audio-recorded with consent and transcribed verbatim. All identifiable information was removed during transcription and pseudonyms are used in reporting to protect participant anonymity. The topic guide explored:
- Mothers’ first awareness of CHINS
- How CHINS was explained and by whom
- Experiences of applying CHINS during feeding
- Perceptions of usefulness
- Influence on confidence, decision-making and partner involvement
- Suggestions for improvement.
Interviews were conversational, allowing mothers to describe in their own words how CHINS shaped their feeding experiences.
Data analysis
Thematic analysis (Braun and Clarke, 2021) was used to analyse data, and involved becoming familiar with transcripts and individual coding by two independent researchers before development of key themes. These were further refined before agreeing on final themes. Themes were organised to illustrate individual and collective experiences.
FINDINGS
The findings of this study reflect how mothers viewed CHINS as an accessible and confidence-building tool when introduced at an appropriate time by confident professionals.
Awareness and perception of CHINS
All mothers had awareness of CHINS and were able to cite key principles, particularly nose to nipple. Most first encountered it through a midwife or health visitor, and many described the explanation as ‘clear’, ‘simple’ and ‘straightforward’, and felt that CHINS should be shared widely and routinely with breastfeeding mothers. Some felt it helped in the early days and that explanations of CHINS helped them understand how to get positioning right:
‘So, it’s getting it all in the right order, and it made sense to have a correct order.’ (Jane)
‘It was only after I’d got all of the information [CHINS] that she actually started latching on properly.’ (Jill).
CHINS was also shared with partners, relatives and peer supporters, extending its usefulness beyond professional interactions.
‘It helped my partner as well because it made him remember. I remember him
saying to me a few times, “close”… And it was like he’d really taken that in. So, it
was probably a good visual aid for the person supporting the mum, actually.’ (Rachel)
Timing
Participants felt that timing was important, and while being told about and shown CHINS was important, the timing of this was also key. Sarah described how knowing about CHINS antenatally would have helped her feel more prepared, while Jane described the impact that learning about CHINS had:
‘And I didn’t even pack bottles after that.’
Even experienced mothers returned to CHINS when they hit challenges, such as sore nipples. One mother noted:
‘So, it was just a reminder to make sure that they were tucked in close and head in line and…. nose to nipple – that’s the biggest one, from it.’ (Nina)
Mothers described sharing CHINS with others to make sure they were positioning their babies correctly:
‘Do it this way – get her close to you, get her comfortable, make sure that she’s got, you
know, head free and all that […] She is still breastfeeding her daughter.’ (Jane)
Across participants, the timing, clarity and delivery of CHINS shaped outcomes, and they felt that, if given early, CHINS could influence decisions around breastfeeding, as well as help to establish effective breastfeeding and prevent problems from occurring. It was clear that support from professionals varied, and while Kate was happy with the support she received, she said:
‘I felt like I had to reach out for that help. Like, it didn’t feel like, if I hadn’t pushed. If I hadn’t pushed for the help, I don’t think it would have been given to me.’ (Kate)
Other participants felt it was vital that staff ‘know what they’re talking about. And when to intervene [..] I would much rather somebody come and talk to me about breast and bottle feeding rather than giving me a free pack of condoms’. (Jane).
Importantly, mothers noted that they received advice about breastfeeding but none when they wished to stop breastfeeding. For two of the mothers, Hannah and Jenny, this was a challenging and emotional time, and one where they would have welcomed support, but actually felt less support was offered.
Study 3: Extending the work to include attachment
Building on these two studies, a gap in training and assessment of attachment was identified, highlighting the need for a complementary framework. As positioning and attachment are intrinsically linked, difficulties with either can lead to pain, poor milk transfer or early cessation of breastfeeding (WBTi, 2024).
METHOD
A qualitative pilot evaluation was conducted to assess the clarity, acceptability and usefulness of a framework for the principles of attachment, with the aim of refining it prior to wider dissemination. Ethical approval was obtained from Northumbria University.
Development of the framework
Two prototype memory aids (“CLASP” and “LATCHS”) were developed using UNICEF Baby Friendly principles of effective attachment, and reviewed by NHS and university or academic collaborators. Through consensus, LATCHS was selected for piloting based on clarity, theoretical alignment and coherence with CHINS.
Setting and participants
The pilot was undertaken across the North East of England and North Cumbria between March and August 2023. Participants were recruited during routine breastfeeding education sessions delivered by the collaborating educators. A total of 57 participants took part, representing a range of roles central to breastfeeding education and support:
- Infant feeding leads (midwifery, health visiting, family hubs)
- Midwifery lecturers
- Specialist HV and early years practitioners
- Master’s-level midwifery students
- Other community practitioners supporting infant feeding.
All participants were aged over 18 and able to provide informed consent.
Data collection
During scheduled teaching sessions, participants were:
- Introduced to the LATCHS mnemonic
- Provided with a structured explanation of each component and its underpinning theory
- Given time to review the tool.
Following this, participants took part in audio-recorded focus groups exploring:
- First impressions of LATCHS
- Perceived usefulness and clarity
- Limitations or points of confusion
- Suggestions for improvement.
The focus group guide was intentionally open, but directly aligned with the evaluation goals.
Data analysis
Focus group recordings were transcribed verbatim and analysed using a deductive thematic analysis approach. Analysis was structured around two overarching evaluative categories:
- Acceptability and perceived usefulness
- Limitations and suggested refinements.
Initial coding was conducted by the lead author and reviewed collaboratively to ensure dependability and analytic alignment. Anonymised identifiers (R1–R57) were used to protect confidentiality.
FINDINGS
Theme 1: Acceptability and perceived usefulness
Participants consistently referred to the positive impact of CHINS and felt they needed a complementary memory aide for attachment and that LATCHS made sense:
‘I was a community midwife before I was in this role and CHINS I used all day, every day, and I absolutely loved it and so did my colleagues. So, this one, I’ll remember that now.’ (R10, infant feeding lead)
‘But I think the way it’s laid out and it’s, it’s relevant that title, isn’t it to you know, latching the baby fixing on and things.’ (R11, infant feeding lead)
The participants were focused on providing the best possible support for breastfeeding and highlighted the need to get it right, and felt that there was currently no standard approach for the principles of attachment.
Theme 2: Limitations
LATCHS was more positively received by professional registrants and those with a key role in breastfeeding practice or education. Particular concerns were voiced by Master’s-level midwifery students and early years practitioners:
‘The word hurting is a negative word […] this may make mothers think breastfeeding is always painful.’ (R56, early years practitioner)
‘I would maybe spell it LATCHES [to make it more similar to a word].’ (R51, Master’s midwifery student).
The findings suggest that more experienced staff were more likely to value LATCHS, which may be linked to their established practice. In contrast, for those with less expertise, the framework in its initial form did not support meaningful organisation of the underpinning theory. However, participant feedback informed further refinement of LATCHS.
Specifically, “Hurting” was revised to:
H – How does it feel? This wording encourages exploration of maternal comfort, supports open dialogue, avoids pain-centred framing and reflects contemporary communication approaches.
To further improve clarity and coherence, participant feedback also led to the addition of an “E” for Examine and Explore, emphasising the importance of comprehensive breastfeeding assessment and forward planning, and ensuring the revised memory aide was spelled in the expected way.
These refinements resulted in the final LATCHES framework used in this paper. Table 2 presents this final version, aligned with the pedagogical principles of CHINS and designed to support the observation, assessment and explanation of effective attachment in line with UNICEF Baby Friendly standards.
| Table 2: LATCHES | |
| L – large gape | Look for the baby’s mouth to open widely. Mother should move baby to her breast with the baby’s head tilted back and the chin leading. Baby’s tongue will move down and forward so the baby can scoop a large mouthful of breast with the nipple aimed towards the rear roof of baby’s mouth. |
| A – areola T – top lip | If visible, more areola will be seen above the baby’s top lip. This will result in asymmetric attachment. |
| C – chin and cheeks | Baby’s chin leads and will indent the breast, and baby’s cheeks will be full and rounded. |
| H – how does it feel? | Check how it feels for mother and ensure feeding is comfortable. |
| E – examine and explore | Conduct a thorough examination, which will include a breastfeeding assessment, and then explore future support needs. |
| S – sucking and swallowing | Look and listen for sucking and swallowing, but remember, these will be appropriate to the age of the baby. |
NEXT STEPS: Digital learning, CPD and international collaboration
Findings from the CHINS and LATCHES studies demonstrate that simple, evidence-informed teaching tools can enhance workforce confidence, consistency and the quality of breastfeeding support, while highlighting the need for accessible, scalable training. In response, the next phase focuses on developing a digital training and CPD package centred on CHINS and LATCHES, funded by the Sir Halley Stewart Trust. This aims to strengthen practitioner knowledge and competence in positioning and attachment, improve access to high-quality training, and provide a consistent framework across settings and professional groups. The package will use case-based learning, digital images, animations and guided reflection, informed by cognitive and experiential learning principles to support application in practice.
A further stage will involve an international pilot with global partners to explore transferability across cultural and healthcare contexts, to include a broader range of practitioners involved in infant feeding support, including midwives, nurses, general practitioners, pharmacists, academics and community practitioners across international contexts, such as Hong Kong, Ireland and Australia. This will evaluate the impact of the digital training on practitioner confidence and competence, and inform adaptation for international education and policy.
Overall, this work builds on the principles underpinning CHINS – co-production, evidence-based education and workforce empowerment – extending their reach through accessible digital learning to support consistent, compassionate breastfeeding care globally.
CONCLUSION
The development and evaluation of CHINS and LATCHES demonstrate how innovation at the interface of education and practice can strengthen workforce capability and improve breastfeeding support. Grounded in evidence, learning theory and co-production, these frameworks illustrate the contribution of universities to enhancing practitioner confidence and consistency.
By embedding UNICEF Baby Friendly standards within curricula and aligning with NMC proficiencies, universities act as catalysts for system-wide improvement, preparing graduates with the knowledge and skills required for effective breastfeeding support. Collaboration with NHS partners ensures that education remains authentic, relevant and responsive, while the iterative development of LATCHES highlights the value of partnership in driving continuous improvement.
As the digital training package is developed and piloted internationally, this work demonstrates how academic leadership can contribute to global public health priorities.
While these frameworks demonstrate clear value, they are intended to complement, not replace, clinical judgement and person-centred care. Continued, integrated approaches are essential to addressing persistently low breastfeeding rates, which are shaped by complex and interrelated factors, including social norms, commercial influences and policy contexts. Within this, university–practice partnerships play an important role in strengthening workforce knowledge, confidence and consistency in breastfeeding support.
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