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    <meta name="author" content="Denise Fisher" />
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      <h1 id="top">2.4 Poor Attachment</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
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			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
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			The <cite>Ten Steps to Successful Breastfeeding</cite>, designed by the <img alt="External" src="design/external.gif" /><a href="http://www.who.int/en/" title="External link" target="_blank">WHO</a> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a> summarise the maternity practices needed to support and encourage breastfeeding.
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		<dl><dt><a href="topic_2-1.html"><cite>Topic 2.1: Preparation Before Birth</cite></a></dt><dd class="topic-paragraph">Inform all pregnant women about the benefits and management of breastfeeding</dd></dl>
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			Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?
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		<dl><dt><a href="topic_2-2.html"><cite>Topic 2.2: Birthing Factors that Affect Breastfeeding</cite></a></dt><dd class="topic-paragraph">Labour analgesia and near-term birth</dd></dl>
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		<dl><dt><a href="topic_2-3.html"><cite>Topic 2.3: Management After Birth</cite></a></dt><dd class="topic-paragraph">
				Place Rosie in skin-to-skin contact;
				Encourage breastfeeding on demand;
				Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day;
				Give Rosie no food or drink other than breastmilk, unless medically indicated;
				Give Rosie no artificial teats or dummies;
				Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.
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			Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?
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		<dl><dt><a href="topic_2-4.html"><cite>Topic 2.4: Poor Attachment</cite></a></dt><dd class="topic-paragraph">
				Investigate whether there an underlying reason;
				Maximize breastfeeding opportunities;
				Protect the milk supply;
				Feed the baby;
				Nipple shields may be useful.
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			Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?
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			<strong>Investigate whether there an underlying reason</strong>
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				Investigate whether there an underlying reason why Rosie is having difficulty staying attached to the breast. Infants born to primiparous women, particularly if they have received analgesia during labour, are less likely to breastfeeding effectively than other infants up to day 3, although this difference is not significant by day 7.<sup><a href="#note1">1</a></sup> Other causes of ineffective breastfeeding may have more long lasting effects and need to be addressed as soon as possible.
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				For example flat or inverted nipples (See <a href="topic_1-0.html">Case Study 1</a> and <a href="topic_4-0.html">Case Study 4</a>) or conditions that affect the infants ability to create and maintain intraoral negative pressure such as ankyloglossia (See <a href="topic_4-0.html">Case Study 4</a>), a cleft palate, respiratory dysfunction or neurological or muscular problems require individual and specific treatment to ensure breastfeeding progresses well.
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			<strong>Maximize breastfeeding opportunities</strong>
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				Encourage skin-to-skin contact to capitalize on any innate reflex behaviours. Teach Joanne how to watch for early feeding cues and encourage her to assist Rosie to the breast whenever she displays these cues.
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			<strong>Protect the milk supply</strong>
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				Encourage Joanne to express colostrum at least eight times a day if Rosie is not effectively feeding. Hand expression is often easiest when small amounts of colostrum are being collected, but an electric breast pump may be more effective as milk supply increases.
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			<strong>Feed the baby</strong>.
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				Give Rosie expressed colostrum/milk with cup, spoon, dropper or syringe. By day three infants consume on average 408ml/24 hours <sup><a href="#note2">2</a></sup>(approximately 50ml per feed for 8 feeds a day). If Rosie is still not feeding at the breast by that time and Joanne is unable to express enough to satisfy Rosie she may need to be supplemented with an alternative milk such as banked human milk or infant formula.
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			<strong>Nipple shields may be useful</strong>
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				By providing a firmer surface for non-latching infants, especially if the nipples are flat or inverted.<sup><a href="#note3">3</a></sup> However, it is preferable to wait until at least day 3 by which time the milk supply has increased before suggesting their use.
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			Most infants are interested in attempting to breastfeed by 24 hours postpartum. Therefore, infants who are not interested require further evaluation to exclude other conditions such as sepsis, respiratory distress, hypoglycaemia, hypothermia or continued effects from maternal drug administration. However, the premise of feeding the baby and protecting the milk supply remain.
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      <div id="footnotes">
        <h3>Notes</h3>
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          <li id="note1"><a href="references.html#dewe03b" title="See full details">#</a> Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss</li>
          <li id="note2"><a href="references.html#sain84" title="See full details">#</a> Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum</li>
          <li id="note3"><a href="references.html#wils96" title="See full details">#</a> Wilson-Clay B (1996) Clinical use of silicone nipple shields</li>
        </ol>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li>2.2 <a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li>2.3 <a href="topic_2-3.html">Management After Birth</a></li><li class="current">2.4 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li>2.6 <a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li>3.1 <a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li>3.3 <a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li>4.3 <a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li>5.2 <a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
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