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            <label><input type="checkbox" checked="checked" topic="topic_0-1" onclick="setTopicVis(this)" />0.1: Introduction</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-0" onclick="setTopicVis(this)" />1.0: Case Study A (Joanne)</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-1" onclick="setTopicVis(this)" />1.1: Discussing breastfeeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-2" onclick="setTopicVis(this)" />1.2: What information to give</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-3" onclick="setTopicVis(this)" />1.3: Effects of Breastfeeding alternatives</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-4" onclick="setTopicVis(this)" />1.4: Common breastfeeding concerns</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-5" onclick="setTopicVis(this)" />1.5: Breast examination</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-6" onclick="setTopicVis(this)" />1.6: Contraindications to breastfeeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-7" onclick="setTopicVis(this)" />1.7: Conditions related to lactation outcomes</label>
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            <label><input type="checkbox" checked="checked" topic="topic_2-0" onclick="setTopicVis(this)" />2.0: Case Study B (Joanne)</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-1" onclick="setTopicVis(this)" />2.1: Preparation Before Birth</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-2" onclick="setTopicVis(this)" />2.2: Birthing Factors that Affect Breastfeeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-3" onclick="setTopicVis(this)" />2.3: Management After Birth</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-4" onclick="setTopicVis(this)" />2.4: Poor Attachment</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-5" onclick="setTopicVis(this)" />2.5: Hypoglycaemia</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-6" onclick="setTopicVis(this)" />2.6: Relationship between Jaundice and Breastfeeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-0" onclick="setTopicVis(this)" />3.0: Case Study C (Joanne)</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-1" onclick="setTopicVis(this)" />3.1: Early problems</label>
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            <label><input type="checkbox" checked="checked" topic="topic_3-2" onclick="setTopicVis(this)" />3.2: Risk of SIDS</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-3" onclick="setTopicVis(this)" />3.3: Contraception</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-4" onclick="setTopicVis(this)" />3.4: Milk composition</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-5" onclick="setTopicVis(this)" />3.5: Slowing of growth</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-6" onclick="setTopicVis(this)" />3.6: Introducing solids</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-7" onclick="setTopicVis(this)" />3.7: Weaning</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-0" onclick="setTopicVis(this)" />4.0: Case Study D (Sally)</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-1" onclick="setTopicVis(this)" />4.1: Initial assessment</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-2" onclick="setTopicVis(this)" />4.2: Milk production</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-3" onclick="setTopicVis(this)" />4.3: Causes of inadequate infant growth</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-4" onclick="setTopicVis(this)" />4.4: Increasing milk supply</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-0" onclick="setTopicVis(this)" />5.0: Case Study E (Anna)</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-1" onclick="setTopicVis(this)" />5.1: Sore nipples</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-2" onclick="setTopicVis(this)" />5.2: Factors causing nipple damage</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-3" onclick="setTopicVis(this)" />5.3: General treatment for sore nipples</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-4" onclick="setTopicVis(this)" />5.4: Further causes of nipple pain</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-5" onclick="setTopicVis(this)" />5.5: Mastitis – diagnosis</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-6" onclick="setTopicVis(this)" />5.6: Mastitis – treatment and complications</label>
            <label><input type="checkbox" checked="checked" topic="topic_6-0" onclick="setTopicVis(this)" />6.0: In conclusion</label>
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          <h1 id="top"> Introduction</h1>
          <p>
		This course is based around a number of cases that reflect day-to-day interactions of mothers with their medical practitioners. The clinically relevant, evidence-based information can then easily be applied within the context of a normal medical practice to provide effective, integrated management of women who are pregnant or breastfeeding.
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          <p>
		However, medical practitioners do not support breastfeeding women in isolation and ideally women receive assistance and correct and consistent information from a number of different sources. Following initial assessment and management, referring mothers with breastfeeding difficulties to other health professionals who have more expertise and fewer time constraints, such as lactation consultants (IBCLCs), is often appropriate. In addition, lay breastfeeding support groups such as the Australian Breastfeeding Association (ABA) provide invaluable support and encouragement to breastfeeding women and are also an important referral option.
	</p>
          <p>
		Before beginning this course take time to complete the pretest quiz. This will give you an indication of your breastfeeding knowledge at this point in time. A similar, but different quiz, at the end of the course will enable you to (hopefully) see an improvement in your knowledge base.
	</p>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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          <h1 id="top">1.0 Case Study A (Joanne)</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
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			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
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			Would you discuss breastfeeding at this visit?
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		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
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			What information would you give?
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		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
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			Why do breastfeeding alternatives have different effects?
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		<dl><dt><a href="topic_1-3.html"><cite>Topic 1.3: Effects of Breastfeeding alternatives</cite></a></dt><dd class="topic-paragraph">These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.</dd></dl>
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			What are mothers' common and valid concerns about breastfeeding?
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		<dl><dt><a href="topic_1-4.html"><cite>Topic 1.4: Common breastfeeding concerns</cite></a></dt><dd class="topic-paragraph">Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.</dd></dl>
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			Would you examine her breasts at this visit?
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		<dl><dt><a href="topic_1-5.html"><cite>Topic 1.5: Breast examination</cite></a></dt><dd class="topic-paragraph">Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.</dd></dl>
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			What are the contraindications to breastfeeding?
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		<dl><dt><a href="topic_1-6.html"><cite>Topic 1.6: Contraindications to breastfeeding</cite></a></dt><dd class="topic-paragraph">There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.</dd></dl>
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			What conditions may be related to poorer lactation outcomes?
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		<dl><dt><a href="topic_1-7.html"><cite>Topic 1.7: Conditions related to lactation outcomes</cite></a></dt><dd class="topic-paragraph">Common problems are previous lactation failure, hormonal problems and obesity.</dd></dl>
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			Joanne's sister-in-law developed hyperthyroidism when she had been breastfeeding her last baby and was told that she would have to wean so that she could commence taking medication. Joanne asks you whether it is common for women to have to wean to be treated for medical conditions. What would you tell her about medication use in breastfeeding women?
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		<dl><dt><a href="topic_1-8.html"><cite>Topic 1.8: Medications</cite></a></dt><dd class="topic-paragraph">There are very few medical conditions for which a mother needs to cease breastfeeding so that she can be adequately treated. In nearly all situations a mother can continue to breastfeed while she is on medication.</dd></dl>
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          <h1 id="top">1.1 Discussing breastfeeding</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
		<stage>
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		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
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		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
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			Would you discuss breastfeeding at this visit?
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		Yes. While it is ultimately the mother who makes a decision regarding the method of infant feeding, she should make an informed decision with evidence-based information. Many women decide before or early in their pregnancy how they will feed their infant and the earlier they decide that they will breastfeed, the more likely they are to initiate and continue to breastfeed.<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>
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		<strong>Intention to breastfeed</strong>,<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> and <strong>intended length of breastfeeding</strong> <sup><a href="#note2">2</a>,</sup><sup><a href="#note4">4</a></sup> are the most powerful predictors of duration of breastfeeding. Additionally, there is a link between a doctor providing breastfeeding information, support and encouragement to women during the antenatal period and the rate of breastfeeding initiation <sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup> and duration <sup><a href="#note6">6</a>,</sup><sup><a href="#note8">8</a>,</sup><sup><a href="#note9">9</a></sup>. Therefore, it is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.<sup><a href="#note10">10</a></sup>
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		The positive influence of doctors and other health professionals on breastfeeding initiation and duration is only effective if there is overt support and encouragement. Neutrality is perceived by mothers as simply disguised indifference to how the baby is fed and has a similar effect on breastfeeding initiation and duration as overtly negative views.<sup><a href="#note7">7</a>,</sup><sup><a href="#note11">11</a>,</sup><sup><a href="#note12">12</a></sup>)
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		Attending antenatal breastfeeding education  either as a separate class or as part of an antenatal education course, also increases breastfeeding initiation <sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup> and duration <sup><a href="#note15">15</a>,</sup><sup><a href="#note16">16</a></sup>. The inclusion of specific segments on correct positioning and attachment of the baby at the breast reduces the incidence of nipple pain and trauma.<sup><a href="#note15">15</a></sup> Providing women with a list of classes in their area, and encouraging them to attend, is recommended.
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#hegn03" title="See full details">#</a> Hegney D et al. (2003) The Toowoomba infant feeding support service project: Report on phase1 - A longitudinal needs analysis of breastfeeding behaviours and supports in the Toowoomba region.</li>
              <li id="note2"><a href="references.html#scot01" title="See full details">#</a> Scott JA et al. (2001) Factors associated with breastfeeding at discharge and duration of breastfeeding</li>
              <li id="note3"><a href="references.html#heat02" title="See full details">#</a> Heath A-LM et al. (2002) A longitudinal study of breastfeeding and weaning practices during the first year of life in Dunedin, New Zealand</li>
              <li id="note4"><a href="references.html#digi05" title="See full details">#</a> diGirolamo A et al. (2005) Intentions or experience? Predictors of continued breastfeeding</li>
              <li id="note5"><a href="references.html#lumc01" title="See full details">#</a> Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey</li>
              <li id="note6"><a href="references.html#lilz04" title="See full details">#</a> Li L et al. (2004) Factors associated with the initiation and duration of breastfeeding by Chinese mothers in Perth, Western Australia</li>
              <li id="note7"><a href="references.html#bent99" title="See full details">#</a> Bentley ME et al. (1999) Sources of influence on intention to breastfeed among African-American women at entry to WIC</li>
              <li id="note8"><a href="references.html#tave03" title="See full details">#</a> Taveras EM et al. (2003) Clinician support and psychosocial risk factors associated with breastfeeding discontinuation</li>
              <li id="note9"><a href="references.html#utak05" title="See full details">#</a> Utaka H et al. (2005) Breastfeeding experiences of Japanese women living in Perth, Australia</li>
              <li id="note10"><a href="references.html#brod07" title="See full details">#</a> Brodribb W et al. (2007) Identifying predictors of the reasons women give for choosing to breastfeed.</li>
              <li id="note11"><a href="references.html#digi03" title="See full details">#</a> DiGirolamo AM et al. (2003) Do perceived attitudes of physicians and hospital staff affect breastfeeding decisions?</li>
              <li id="note12"><a href="references.html#coun83" title="See full details">#</a> Counsilmann JJ et al. (1983) Bivariate analyses of attitudes towards breast-feeding</li>
              <li id="note13"><a href="references.html#desh00" title="See full details">#</a> Deshpande AD et al. (2000) Breast-feeding education and support: association with the decision to breast-feed</li>
              <li id="note14"><a href="references.html#giug94" title="See full details">#</a> Giugliani ER et al. (1994) Effect of breastfeeding support from different sources on mothers' decisions to breastfeed</li>
              <li id="note15"><a href="references.html#duff97" title="See full details">#</a> Duffy EP et al. (1997) Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates.</li>
              <li id="note16"><a href="references.html#pugi96" title="See full details">#</a> Pugin E et al. (1996) Does prenatal breastfeeding skills group education increase the effectiveness of a comprehensive breastfeeding promotion program?</li>
            </ol>
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          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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          <h1 id="top">1.2 What information to give</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
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		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
	</stage>
		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
	</stage>
		<p>
			What information would you give?
		</p>
		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
	</stage>
	</td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
                  <img src="design/callout_06.png" width="10" height="80" alt="" />
                </td>
              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			What information would you give?
		</p>
          </strong>
          <p>
		Ask whether she has thought about how she will feed her baby, and her views about breastfeeding. Most women say they will "breastfeed if they can" or think they should breastfeed but feel uncertain and anxious. They may see breastfeeding as a superior product, with formula feeding being seen as an adequate and valid alternative method of infant feeding<sup><a href="#note1">1</a></sup> with little understanding of the differences between the two.
	</p>
          <div class="section display-accordion" id="Disadvantages_of_Breast_Milk_Substitutes"><h2>Disadvantages of Breast Milk Substitutes</h2>
	<p>
		When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding:
	</p>
	<p>
		<em>(Please click on any point for further details.)</em>
	</p>
	<ul class="collapse"><li>
			are more expensive for the family and the community<sup><a href="#note2">2</a></sup>
			<ul><li>costs of formula, bottles, teats/artificial nipples, etc and medical costs</li><li>costs to community calculated to be at least $1-2 million in Australian Capital Territory each year<sup><a href="#note3">3</a></sup> and $U.S. 3.6 billion/ year in the USA<sup><a href="#note4">4</a></sup></li></ul>
		</li><li>
			are usually less convenient
			<ul collapse="yes"><li>preparation and storage of alternative feeding products</li><li>being caught out without sufficient formula</li><li>needing to find places and ways of keeping formula sterile and utensils clean when travelling</li></ul>
		</li><li>
			risk contamination during
				<ul><li>the manufacture phase</li><li>the preparation phase<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup></li></ul>
		</li><li>
			lack the same hormonal responses in the mother
				<ul><li>fertility returns immediately</li><li>Breastfeeding encourages attachment and bonding between the mother and her infant.<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup></li></ul>
		</li><li>
			lack the same levels of nutritional components
				<ul collapse="yes"><li>
						ie. essential amino acids and types of proteins, fatty acids and other nutritional components tailored to suit the developing human infant.<sup><a href="#note9">9</a></sup> <span class="aside">(See Case 3 for further information)</span>
					</li></ul>
		</li><li>
			lack immunological components that provide protection from a number of diseases and adverse outcomes in infants and their mothers<sup><a href="#note10">10</a>,</sup><sup><a href="#note11">11</a></sup> such as ...
				<ul collapse="yes"><li>infection (otitis media, gastrointestinal infection, lower respiratory tract infections)</li><li>allergy (atopic dermatitis, asthma) </li><li>chronic disease (Type 1 and Type 2 diabetes, childhood leukaemia, SIDS, coeliac disease)</li><li>necrotising enterocolitis (NEC)</li><li>poorer cognitive development</li><li>maternal type 2 diabetes</li><li>maternal breast and ovarian cancer</li><li>maternal rheumatoid arthritis</li><li>All these effects are evident in developed as well as developing countries. Two extensive reviews<sup><a href="#note10">10</a>,</sup><sup><a href="#note11">11</a></sup> published in 2007 evaluated the methodological rigour of studies comparing the effect of breastfeeding and formula feeding on a number of outcomes. These reviews and other studies published since their data were collected are able to quantify the risk for formula fed infants and their mothers.</li></ul>


		</li><li>
			increase the likelihood of acute otitis media
				<ul collapse="yes"><li>
						Formula fed infants are twice as likely to develop acute otitis media as infants exclusively breastfed for 3-6 months (OR 2)<sup><a href="#note10">10</a></sup> and are more likely to suffer from recurrent otitis media<sup><a href="#note12">12</a></sup>. Additionally, infants breastfed for 4-6 months are nearly twice as likely (OR 1.95) to develop otitis media by the time they are two years old as infants breastfed for more than 6 months<sup><a href="#note13">13</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of gastrointestinal infection
				<ul collapse="yes"><li>
						The adjusted odds ratio of formula fed infants developing non-specific gastrointestinal infection is approximately 2.7.<sup><a href="#note10">10</a>,</sup><sup><a href="#note14">14</a></sup> In recent published research from the United Kingdom<sup><a href="#note14">14</a></sup> exclusive breastfeeding could have prevented 53% of hospital admissions for gastrointestinal illness each month in the first eight months of life. The risk of hospital admission doubles for each month after weaning.
					</li></ul>

		</li><li>
			increase the likelihood of lower respiratory tract infections (LRTI)
				<ul collapse="yes"><li>
						In Ips<sup><a href="#note10">10</a></sup> meta-analysis there would have been a reduction of 72% in hospital admissions for LRTI if all infants were exclusively breastfed for 4 months (OR 3.75). The odds ratio for infants contracting pneumonia if breastfed for between four and six months rather than &gt; 6 months was 4.27.<sup><a href="#note13">13</a></sup>
					</li></ul>

		</li><li>
			increase the likelihood of atopic dermatitis
				<ul collapse="yes"><li>
						For children under school age the odds ratio for those formula fed, compared to those exclusively breastfed for 3 months, developing atopic dermatitis was 1.47. This was even more evident for children from atopic families (OR 1.72)<sup><a href="#note10">10</a></sup>. However, the effect does not appear to persist into later childhood or adulthood<sup><a href="#note15">15</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of asthma
				<ul collapse="yes"><li>
						Although studies appear to give conflicting reports and are difficult to evaluate, formula feeding appears to increase the incidence of wheezing within the first four years of life (OR 1.43) especially for those with a family history of atopy (OR 1.66)<sup><a href="#note10">10</a>,</sup><sup><a href="#note16">16</a></sup>. Similar to the findings with atopic dermatitis, it is unlikely that the effect persists into adolescence and adulthood<sup><a href="#note10">10</a>,</sup><sup><a href="#note16">16</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of Type 1 diabetes
				<ul collapse="yes"><li>
						Formula feeding, compared to breastfeeding for at least 3 months appears to increase the risk of developing Type 1 diabetes (OR 1.23-1.43). However, exclusivity of breastfeeding and other confounders were not always addressed<sup><a href="#note10">10</a>,</sup><sup><a href="#note17">17</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of Type 2 diabetes
				<ul collapse="yes"><li>
						Similarly, formula fed infants are more likely to develop Type 2 diabetes than those breastfed (OR 1.64).<sup><a href="#note18">18</a></sup>
					</li></ul>

		</li><li>
			increase the likelihood of childhood leukaemia
				<ul collapse="yes"><li>
						Infants formula fed or breastfed for less than 6 months had a higher incidence of developing Acute Lymphoblastic Leukaemia (ALL) (OR 1.32) and Acute Myeloblastic Leukaemia (AML) (OR 1.18) in childhood<sup><a href="#note10">10</a>,</sup><sup><a href="#note19">19</a></sup>. There is some evidence that other childhood cancers may also be affected<sup><a href="#note20">20</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of obesity
				<ul collapse="yes"><li>
						There appears to be a small increase in obesity and overweight in children and adults who were not breastfed as infants (OR 1.32  1.07). This effect seems to be dose related ie the effect increases with increasing duration of breastfeeding<sup><a href="#note11">11</a></sup> with one study finding a reduction of 4% in the risk of overweight for each month of breastfeeding.<sup><a href="#note21">21</a></sup>
					</li></ul>

		</li><li>
			increase the likelihood of SIDS
				<ul collapse="yes"><li>
						A meta-analysis of studies using a precise definition of SIDS and adjusting for known confounders found that formula fed infants were more likely to die of SIDS than infants who had been breastfed at all (OR 1.56)<sup><a href="#note10">10</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of coeliac disease
				<ul collapse="yes"><li>
						Being breastfed at the time of the introduction of gluten reduced the incidence of coeliac disease by 52%. Additionally, reducing lengths of breastfeeding increase the risk of the infant developing coeliac disease<sup><a href="#note22">22</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of NEC
				<ul collapse="yes"><li>
						The absolute risk difference for developing NEC between premature infants receiving breast milk or formula is 5%. However, any advantage is still clinically important in these fragile infants<sup><a href="#note10">10</a></sup>.
					</li></ul>

		</li><li>
			increase the rate of infant mortality
				<ul collapse="yes"><li>
						The odds ratio of a formula fed infant dying in the first 12 months in the USA compared to an infant who was ever breastfed is 1.27<sup><a href="#note23">23</a></sup>. This equates to approximately 720 post-neonatal deaths in the USA each year.
					</li></ul>

		</li><li>
			affect cognitive development
				<ul collapse="yes"><li>
						Even when many confounding variables have been accounted for, children who had been breastfed as infants have intelligence scores approximately 4.9 points higher than children who had been formula fed<sup><a href="#note11">11</a></sup>. A 2006 paper<sup><a href="#note24">24</a></sup> and subsequent review<sup><a href="#note10">10</a></sup> suggest that this difference is a function of maternal intelligence rather than a function of breast milk or breastfeeding. However, another study, adjusting for maternal cognitive ability and other confounders found a difference of 5.6 and 6.3 points in two different populations. They also found that the association between breastfeeding and cognitive development was modified by a gene involved in fatty-acid metabolism.<sup><a href="#note25">25</a></sup>
					</li></ul>

		</li><li>
			increase the likelihood of maternal Type 2 diabetes
				<ul collapse="yes"><li>
						In women without gestational diabetes a shorter duration of breastfeeding (or no breastfeeding) was related to an increased risk of developing Type 2 diabetes<sup><a href="#note26">26</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of breast and ovarian cancer
				<ul collapse="yes"><li>
						For every year a woman breastfeeds she reduces her risk of developing breast cancer by 4.3%<sup><a href="#note10">10</a></sup>. Additionally, women who have breastfed for at least 12 months reduce their risk of ovarian cancer by 28%<sup><a href="#note10">10</a></sup>.
					</li></ul>

		</li><li>
			increase the likelihood of other diseases where there is some data
				<ul collapse="yes"><li>
						<p>
							septicaemia and meningitis, urinary tract infection<sup><a href="#note27">27</a></sup>
						</p>

					</li></ul>

		</li></ul>
	</div>
          <div class="captionBox">
            <img width="460" height="389" src="images/disease_odds_ratio.gif" alt="Odds ratio of disease incidence with breast or formula-feeding" />
            <p>Odds ratio of disease incidence with breast or formula-feeding</p>
          </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#wies04" title="See full details">#</a> Wiessinger D (2004) Watch your language</li>
              <li id="note2"><a href="references.html#catt06" title="See full details">#</a> Cattaneo A et al. (2006) Infant feeding and cost of health care: a cohort study</li>
              <li id="note3"><a href="references.html#smit02" title="See full details">#</a> Smith JP et al. (2002) Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory</li>
              <li id="note4"><a href="references.html#weim01" title="See full details">#</a> Weimer J (2001) The Economic Benefits of Breastfeeding: A Review and Analysis</li>
              <li id="note5"><a href="references.html#walk93" title="See full details">#</a> Walker M (1993) A fresh look at the risks of artificial infant feeding</li>
              <li id="note6"><a href="references.html#giov08" title="See full details">#</a> Giovannini M et al. (2008) Enterobacter sakazakii: an emerging problem in paediatric nutrition.</li>
              <li id="note7"><a href="references.html#kenn98" title="See full details">#</a> Kennell JH et al. (1998) Bonding: Recent observations that alter perinatal care</li>
              <li id="note8"><a href="references.html#klau98" title="See full details">#</a> Klaus MH (1998) Mother and infant: Early emotional ties</li>
              <li id="note9"><a href="references.html#laws07" title="See full details">#</a> Lawson M (2007) Contemporary aspects of infant feeding</li>
              <li id="note10"><a href="references.html#ipsc07" title="See full details">#</a> Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries</li>
              <li id="note11"><a href="references.html#hort07" title="See full details">#</a> Horta B et al. (2007) Evidence on the long-term effects of breastfeeding</li>
              <li id="note12"><a href="references.html#lubi06" title="See full details">#</a> Lubianca Neto JF et al. (2006) Systematic literature review of modifiable risk factors for recurrent acute otitis media in childhood</li>
              <li id="note13"><a href="references.html#chan06" title="See full details">#</a> Chantry CJ et al. (2006) Full breastfeeding duration and associated decrease in respiratory tract infection in US children</li>
              <li id="note14"><a href="references.html#quig07" title="See full details">#</a> Quigley MA et al. (2007)  Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study</li>
              <li id="note15"><a href="references.html#peso06" title="See full details">#</a> Pesonen M et al. (2006) Prolonged exclusive breastfeeding is associated with increased atopic dermatitis: a prospective follow-up study of unselected healthy newborns from birth to age 20 years</li>
              <li id="note16"><a href="references.html#gree08" title="See full details">#</a> Greer FR et al. (2008) Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas</li>
              <li id="note17"><a href="references.html#rose07" title="See full details">#</a> Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.</li>
              <li id="note18"><a href="references.html#owen06" title="See full details">#</a> Owen CG et al. ( 2006) Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence</li>
              <li id="note19"><a href="references.html#kwan04" title="See full details">#</a> Kwan ML et al. (2004) Breastfeeding and the risk of childhood leukemia: a meta-analysis</li>
              <li id="note20"><a href="references.html#orte08" title="See full details">#</a> Ortega-Garcia JA et al. (2008) Full breastfeeding and paediatric cancer</li>
              <li id="note21"><a href="references.html#hard05" title="See full details">#</a> Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis</li>
              <li id="note22"><a href="references.html#akob06" title="See full details">#</a> Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies</li>
              <li id="note23"><a href="references.html#chen04" title="See full details">#</a> Chen A et al. (2004) Breastfeeding and the risk of postnatal death in the United States</li>
              <li id="note24"><a href="references.html#derg06" title="See full details">#</a> Der G et al. (2006) Effect of breast feeding on intelligence in children: prospective study, sibling pairs analysis, and meta-analysis</li>
              <li id="note25"><a href="references.html#casp07" title="See full details">#</a> Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism</li>
              <li id="note26"><a href="references.html#stue05a" title="See full details">#</a> Stuebe AM et al. (2005) Duration of lactation and incidence of type 2 diabetes</li>
              <li id="note27"><a href="references.html#hans04a" title="See full details">#</a> Hanson LA (2004) Protective effects of breastfeeding against urinary tract infection</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
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        <div id="topic_1-3" class="content">
          <h1 id="top">1.3 Effects of Breastfeeding alternatives</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		
		
		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
	</stage>
		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
	</stage>
		<p>
			What information would you give?
		</p>
		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
	</stage>
		<p>
			Why do breastfeeding alternatives have different effects?
		</p>
		<dl><dt><a href="topic_1-3.html"><cite>Topic 1.3: Effects of Breastfeeding alternatives</cite></a></dt><dd class="topic-paragraph">These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.</dd></dl>
	</stage>
	</td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
                  <img src="design/callout_06.png" width="10" height="80" alt="" />
                </td>
              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			Why do breastfeeding alternatives have different effects?
		</p>
          </strong>
          <p>
		These effects are due in part to the presence in breastmilk of substances and systems that act against infections and inflammation.
	</p>
          <table>
		<thead>
			<th></th>
			<th></th>
		</thead>
		<tbody>
			<tr class="row0">
				<td>
					<strong>Secretory IgA (SIgA)</strong>
				</td>
				<td>
					Secretory IgA is manufactured in the breast and acts against pathogens to which the mother has been exposed. Stimulated lymphocytes migrate from Peyers patches in the mothers gut and similar lymphoid tissue in the bronchial tree to the breast and produce SIgA in reaction to the pathogens present in the infant's environment (entero-mammary and broncho-mammary pathways). There are high concentrations of SIgA in colostrum to provide protection for the infant postpartum; by 4 months the infant consumes 75mg/Kg/day of SIgA. SIgA prevents the adhesion of bacteria and viruses to epithelial cells as well as neutralising viruses and bacterial toxins. Other antibodies (IgG, IgM and IgE) are also present in breast milk.
				</td>
			</tr>
			<tr class="row1">
				<td>
					<strong>Leukocytes</strong>
				</td>
				<td>
					Similar to SIgA, leukocyte numbers are highest in colostrum, and fall to approximately 10<sup>4</sup>  2x10<sup>5</sup> in mature milk<sup><a href="#note1">1</a></sup>. The majority of cells are macrophages (85%) and small lymphocytes and play a role in protecting the breastfed infant and the breast by destroying pathogens by phagocytosis<sup><a href="#note2">2</a></sup>. Macrophages and lymphocytes in breastmilk produce other active agents (SIgA, lactoferrin, complement, prostaglandins). They are also able to enter the infants circulation<sup><a href="#note3">3</a></sup>.
				</td>
			</tr>
			<tr class="row0">
				<td>
					<strong>Lactoferrin</strong>
				</td>
				<td>
					Lactoferrin is an iron binding glycoprotein that has a bactericidal effect on gram +ve and -ve bacteria as well having antiviral and antifungal capacity.
				</td>
			</tr>
			<tr class="row1">
				<td>
					<strong>Carbohydrates</strong>
				</td>
				<td>
					Carbohydrates - in particular oligosaccharides, glycoproteins and glycolipids promote the growth of non-pathogenic bacteria in the infants gut as well as preventing the attachment of bacteria and other pathogens to the epithelial lining of the gut and other mucosal surfaces.
				</td>
			</tr>
			<tr class="row0">
				<td>
					<strong>Fatty Acids</strong>
				</td>
				<td>
					Fatty Acids affect certain bacteria, viruses and parasites. They also enhance the development of the nervous system<sup><a href="#note2">2</a></sup>. It is hypothesised that the fatty acid composition of breastmilk is responsible for the differences in cognitive development between those breastfed and those formula-fed,<sup><a href="#note4">4</a></sup> and may also impact on the development of allergic disease<sup><a href="#note2">2</a></sup>.
				</td>
			</tr>
			<tr class="row1">
				<td>
					<strong>Lysozyme, α lactalbumin, complement, cytokines, growth factor, nucleotides</strong>
				</td>
				<td>
					Lysozyme, α lactalbumin, complement, cytokines, growth factor, nucleotides present in breastmilk have all been shown to have an active role against pathogens<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup>.
				</td>
			</tr>
		</tbody>
	</table>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#xant95" title="See full details">#</a> Xanthou M et al. (1995) Human milk and intestinal host defense in newborns: an update</li>
              <li id="note2"><a href="references.html#hans04" title="See full details">#</a> Hanson L (2004) Immunology of Human Milk: How breastfeeding protects babies</li>
              <li id="note3"><a href="references.html#hans07" title="See full details">#</a> Hanson LA (2007) The role of breastfeeding in the defense of the infant</li>
              <li id="note4"><a href="references.html#casp07" title="See full details">#</a> Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism</li>
            </ol>
          </div>
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        <div id="topic_1-4" class="content">
          <h1 id="top">1.4 Common breastfeeding concerns</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
		
		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
	</stage>
		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
	</stage>
		<p>
			What information would you give?
		</p>
		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
	</stage>
		<p>
			Why do breastfeeding alternatives have different effects?
		</p>
		<dl><dt><a href="topic_1-3.html"><cite>Topic 1.3: Effects of Breastfeeding alternatives</cite></a></dt><dd class="topic-paragraph">These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.</dd></dl>
	</stage>
		<p>
			What are mothers' common and valid concerns about breastfeeding?
		</p>
		<dl><dt><a href="topic_1-4.html"><cite>Topic 1.4: Common breastfeeding concerns</cite></a></dt><dd class="topic-paragraph">Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.</dd></dl>
	</stage>
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          <img width="165" height="250" src="images/Pregnant_woman_eating.jpg" alt="Pregnant woman eating" style="float: right;" />
          <strong>
            <p>
			What are mothers' common and valid concerns about breastfeeding?
		</p>
          </strong>
          <p class="listTitle">Common and valid concerns often held by mothers include:</p>
          <ul>
            <li>uncertainty regarding their chances of success</li>
            <li>how they can return to paid work and continue to breastfeed</li>
            <li>whether their partner will feel left out if they breastfeed</li>
            <li>embarrassment about breastfeeding in public</li>
          </ul>
          <p class="listTitle">Women may think they should not breastfeed</p>
          <ul>
            <li>if they smoke</li>
            <li>have an occasional alcoholic drink</li>
            <li>eat 'junk food'</li>
          </ul>
          <p style="height: 0px; overflow: hidden; clear: right;"></p>
          <div class="section" id="">
		<p>
			<strong>Exploring these and other concerns and providing information, reassurance and other resources is useful in allaying anxiety and preparing the parents for their changing role. For example:</strong>
		</p>
		<div class="section display-accordion" id="">
			<div class="section" id="Encourage_acquiring_knowledge_and_support_networks"><h4>Encourage acquiring knowledge and support networks</h4>
				<div class="section" id="">
					Breastfeeding is a learned art; many women do not find it easy especially in the first few weeks. Having a realistic idea of the needs and behaviours of infants, especially those that are breastfed, enables parents to adjust their expectations and goals for this time of their life accordingly. It will also help them to determine when they need to seek assistance from a trained professional, community resources or family and friends to provide physical, emotional and informational support. Developing support networks such as these prior to the infant's birth is very beneficial.
				</div>
			</div>
			<div class="section" id="Discuss_the_most_appropriate_outcome_depending_on_individual_circumstances"><h4>Discuss the most appropriate outcome depending on individual circumstances</h4>
				<div class="section" id="">
					Many women continue to breastfeed while they are in the paid workforce, however, the longer a return to work is delayed the better established breastfeeding will be. Work options (e.g. part-time, job share, working from home, flexible working hours), child care options (e.g. on-site child care, a child care centre near the work place, individual care that allows for the infant to be brought to the mother for breastfeeding)<sup><a href="#note1">1</a></sup> and feeding options (e.g. expressed breastmilk; formula when separated, breastfeed when together<sup><a href="#note2">2</a></sup>; or complementary foods if baby &gt;6 months) can be explored.
				</div>
			</div>
			<div class="section" id="Encourage_both_parents_to_develop_their_own_unique_roles"><h4>Encourage both parents to develop their own unique roles</h4>
				<div class="section" id="">
					Feeding is only one part of infant care and, while fathers are unable to breastfeed, they can play an important role in the other aspects of caring for their children. While bathing, playing or settling their child a father begins to develop a unique relationship that is not dependent on supplying food. It is often a joyful experience as the infant becomes more interactive and responsive. By being aware of the reasons why breastfeeding is important and providing physical and emotional support for the mother the father also contributes to successful breastfeeding outcomes.
				</div>
			</div>
			<div class="section" id="Support_breastfeeding_with_confidence_anywhere_the_mother_and_baby_may_be"><h4>Support breastfeeding with confidence, anywhere the mother and baby may be</h4>
				<div class="section" id="">
					Learning to breastfeed takes time. Many new mothers feel awkward and uncomfortable, and apprehensive about breastfeeding away from home until their baby is able to attach to the breast and breastfeed easily. If mothers feel more comfortable, breastfeeding can be done very discretely with clothing that lifts from the waist, or a wrap or shawl draped across the breastfeeding infant. Parenting rooms are also becoming more common as are venues designated 'breastfeeding friendly'. Regardless, a woman's right to breastfeed in a public place is protected by law in most parts of the World.
				</div>
			</div>
			<div class="section" id="Assist_women_to_quit_smoking_and_limit_alcohol_intake_while_breastfeeding_but_it_s_better_to_be_breastfed_than_formula_fed_even_if_the_mother_smokes."><h4>Assist women to quit smoking and limit alcohol intake while breastfeeding, but it's better to be breastfed than formula fed even if the mother smokes.</h4>
				<div class="section" id="">
					<p>
						While nicotine and alcohol enter breastmilk, any adverse effects in the infant are much smaller than the adverse effects of alternatives to breastmilk.
					</p>
					<p>
						Women who smoke are less likely to initiate breastfeeding,<sup><a href="#note3">3</a></sup> and breastfeed for a shorter duration<sup><a href="#note4">4</a></sup>. Their infants are exposed to nicotine and other substances through the air they breathe and their skin regardless of the method of infant feeding. Breastfeeding significantly modifies the effect of smoking on the risk of respiratory tract infections in the infant<sup><a href="#note5">5</a></sup>. It is recommended that women stop smoking during pregnancy and lactation. However, it is more detrimental for an infant of a mother who continues to smoke to be formula fed than breastfed.
					</p>
					<p>
						Alcohol passes readily into milk with levels peaking 30-60 minutes after ingestion. As the mother metabolises the alcohol, levels in milk reduce in parallel to maternal plasma levels. By 2 hours following the ingestion of one standard drink there is minimal amounts of alcohol in breastmilk. The effects of alcohol on the breastfed infant are dependent on the amount and frequency of maternal ingestion with social drinking having a minimal impact<sup><a href="#note6">6</a></sup>.
					</p>
				</div>
			</div>
			<div class="section" id="Discuss_healthy_eating_for_maternal_well-being"><h4>Discuss healthy eating for maternal well-being</h4>
				<div class="section" id="">
					Maternal nutrition. For the vast majority of women their diet has little effect on the volume and adequacy of the breast milk they produce, although a well balanced diet is recommended for the woman's health and well being. Women who are poorly nourished, or have a specific deficiency (eg vegan mothers may become Vitamin B<sub>12</sub> deficient and produce milk that is Vitamin B<sub>12</sub> deficient) may need to supplement their diet, or supplement their breastfed infant<sup><a href="#note7">7</a></sup>.
				</div>
			</div>
		</div>
	</div>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_q">
<script type="text/javascript">
/* <![CDATA[ */
var qqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>What changes in disease patterns would you see in your practice if all mothers exclusively breastfed for the first six months postpartum?</strong>\n			</p>\n		', r : '\n			<p>\n				You would expect to notice a reduction in gastroenteritis, respiratory tract infections, including wheezing, and otitis media in infants under 6 months. You may also notice fewer cases of atopic dermatitis in this group.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('q');</script>
	</td>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#hawk07" title="See full details">#</a> Hawkins SS et al. (2007) The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study</li>
              <li id="note2"><a href="references.html#mcve01" title="See full details">#</a> McVeagh P (2001) Breastfeeding - help!</li>
              <li id="note3"><a href="references.html#dona04" title="See full details">#</a> Donath SM et al. (2004) The relationship between maternal smoking and breastfeeding duration after adjustment for maternal infant feeding intention</li>
              <li id="note4"><a href="references.html#gigl06" title="See full details">#</a> Giglia R et al. (2006) Maternal cigarette smoking and breastfeeding duration.</li>
              <li id="note5"><a href="references.html#wood90" title="See full details">#</a> Woodward A et al. (1990) Acute respiratory illness in Adelaide children: breast feeding modifies the effect of passive smoking</li>
              <li id="note6"><a href="references.html#mcaf07" title="See full details">#</a> McAfee G ( 2007) Drugs of abuse and breastfeeding.</li>
              <li id="note7"><a href="references.html#hopk07" title="See full details">#</a> Hopkinson JM (2007) Nutrition in lactation</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_1-5" class="content">
          <h1 id="top">1.5 Breast examination</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
		
		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
	</stage>
		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
	</stage>
		<p>
			What information would you give?
		</p>
		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
	</stage>
		<p>
			Why do breastfeeding alternatives have different effects?
		</p>
		<dl><dt><a href="topic_1-3.html"><cite>Topic 1.3: Effects of Breastfeeding alternatives</cite></a></dt><dd class="topic-paragraph">These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.</dd></dl>
	</stage>
		<p>
			What are mothers' common and valid concerns about breastfeeding?
		</p>
		<dl><dt><a href="topic_1-4.html"><cite>Topic 1.4: Common breastfeeding concerns</cite></a></dt><dd class="topic-paragraph">Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.</dd></dl>
	</stage>
		<p>
			Would you examine her breasts at this visit?
		</p>
		<dl><dt><a href="topic_1-5.html"><cite>Topic 1.5: Breast examination</cite></a></dt><dd class="topic-paragraph">Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.</dd></dl>
	</stage>
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          </table>
          <strong>
            <p>
			Would you examine her breasts at this visit?
		</p>
          </strong>
          <p>
		Yes and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal' and allows the identification of any variations that may require planning of appropriate postpartum help.
	</p>
          <div class="section" id="">
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					<td colspan="2">Breasts are composed of both glandular and adipose tissue supported by a loose connective tissue network. Under hormonal influences during pregnancy (e.g. human placental lactogen, oestrogen, progesterone, prolactin, growth hormone) the glandular component of the breast increases with growth and branching of the ductal system, an increase in lobule formation and alveolar differentiation<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>.</td>
				</tr>
				<tr class="row1">
					<td><div class="captionBox"><img width="157" height="140" src="images/breasts_with_ribs.jpg" alt="" /><p> <br />&copy;  Health e-Learning</p></div></td>
					<td valign="middle">While there are great variations in breast size, breast tissue usually lies from the 2nd to the 6th rib and comprises between 15 and 20 lobes that differ in size and intertwine within the breast. Breast milk is stored in the alveoli of the lobes, ducts from the many alveoli joint to form a mean of 9 ducts (range 4  18) opening onto the nipple<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup>.</td>
				</tr>
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					<td><div class="captionBox"><img width="157" height="165" src="images/1.5_size_variance.jpg" alt="" /><p> <br />&copy;  S.Cox IBCLC</p></div></td>
					<td valign="middle">Nipples also vary greatly in size (from less than 12 mm to more than 23 mm)<sup><a href="#note4">4</a></sup> and shape. Most protrude from the surface of the areola and become erect in response to tactile, thermal and sexual stimulation<sup><a href="#note5">5</a></sup>. The nipple is surrounded by the areola that also varies in size and pigmentation with pigmentation increasing during pregnancy. Modified lactiferous ducts and sebaceous glands on the areola (known as Montgomery's follicles) become more prominent during pregnancy. These follicles produce a secretion containing anti-inflammatory factors that helps lubricate the nipple and prevent infection<sup><a href="#note2">2</a>,</sup><sup><a href="#note5">5</a></sup>.</td>
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					<td><div class="captionBox"><a href="images/1.5_breast_anatomy.jpg" rel="lightbox"><img width="157" height="165" src="images/1.5_breast_anatomy_thumb.jpg" alt="" /></a><p>Click on graphic for a larger image. . <br />&copy;  Ramsay DT, Hartmann RL, Hartmann PE</p></div></td>
					<td valign="middle">Major ducts in the lactating breast are small (mean diameter 2mm), easily compressible and lie superficially. Recent work indicates that milk is not stored in the ducts and the 'lactiferous sinuses' often depicted lying beneath the nipple/areola in schematic diagrams of lactating breasts do not exist<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>.</td>
				</tr>
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					<td colspan="2">The breast is innervated by branches of the 2nd to 6th intercostal nerves that contain sympathetic and sensory fibres<sup><a href="#note5">5</a></sup> with the lateral cutaneous branches of the 3rd  5th intercostal (usually the 4th) nerves being responsible for the sensory innervation of the nipple and areolar area<sup><a href="#note2">2</a></sup>. Milk production, however, is independent of nerve stimulation<sup><a href="#note1">1</a></sup>.</td>
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	</div>
          <div class="section" id="What_anatomical_variations_would_give_rise_to_concerns_"><h2>What anatomical variations would give rise to concerns?</h2>
		<table>
			<thead>
				<th>Picture</th>
				<th>Description</th>
				<th>Advice</th>
			</thead>
			<tbody>
				<tr class="row0">
					<td>
						<img width="157" height="165" src="images/1.5_asymmetrical_breasts.jpg" alt="Asymmetrical Breasts" />
						<p style="margin: 0px; font-size: 10px; font-style: italic;">Image © S.Cox IBCLC</p>
					</td>
					<td>
						<strong>Abnormal appearance</strong>
					</td>
					<td>
						Breasts that are markedly asymmetric, are widely spaced with a narrow base, appear to have a large areola with little breast substance may be an indication of insufficient glandular tissue in the breast. Some women will also note no or minimal increase in breast size during pregnancy. While breast milk production will commence, these women often have difficulty producing sufficient breast milk for their infants to grow at an adequate rate. Careful follow-up postpartum (at least within 72 hours of hospital discharge and at least weekly thereafter until breastfeeding is well established) will enable an accurate assessment of the mothers capacity to produce breast milk.
					</td>
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					<td>
						<img width="157" height="165" src="images/1.5_scarred_breasts.jpg" alt="Scarred Breasts" />
						<p style="margin: 0px; font-size: 10px; font-style: italic;">Image © B.Ingle IBCLC</p>
					</td>
					<td>
						<strong>Scars indicating a history of breast surgery</strong>
					</td>
					<td>
						Identifying the reasons for breast surgery, the type of surgery performed and the position of any scars will enable an assessment of the impact the surgery may have on future breastfeeding. Breast reduction surgery often causes difficulties with breastfeeding due to a reduction in glandular tissue, interruption of the ductal system, and damage to the nerve supply to the nipple. While breast augmentation is less likely to cause problems, note needs to be taken of the reasons for the augmentation in the first place (eg hypoplastic breasts). Periareolar incisions may damage the sensory nerve supply to the nipple/areola complex and interrupt the afferent arm of the let down or milk-ejection reflex.
					</td>
				</tr>
				<tr class="row0">
					<td>
						<img width="157" height="165" src="images/inverted_nipple.jpg" alt="Inverted Nipple" />
						<p style="margin: 0px; font-size: 10px; font-style: italic;">Image © Goldfarb Breastfeeding Clinic</p>
					</td>
					<td>
						<strong>Flat or inverted nipples</strong>
					</td>
					<td>
						Occasionally nipples do not protrude but appear to be on the same plane, or below the plane of the areola (flat or inverted nipples). Gently compressing the areola will help distinguish between nipples that appear flat or inverted, but protrude with stimulation, and nipples that become more inverted with stimulation. Infants may have difficulty attaching to these nipples, breast drainage may be poor and the nipples may become painful and cracked. Although nipples often increase in size during pregnancy<sup><a href="#note1">1</a></sup> and become more protractile and elastic, by identifying flat and inverted nipples in the antenatal period strategies to increase the likelihood of successful breastfeeding can be instituted immediately postpartum. (See Case 4 for further information).
					</td>
				</tr>

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		</table>
	</div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#gedd07" title="See full details">#</a> Geddes DT (2007) Gross anatomy of the lactating breast</li>
              <li id="note2"><a href="references.html#gedd07a" title="See full details">#</a> Geddes DT (2007) Inside the lactating breast: The latest anatomy research</li>
              <li id="note3"><a href="references.html#goin04" title="See full details">#</a> Going JJ et al. (2004) Escaping from Flatland: clinical and biological aspects of human mammary duct anatomy in three dimensions</li>
              <li id="note4"><a href="references.html#wils02" title="See full details">#</a> Wilson-Clay B et al. (2002) The Breastfeeding Atlas</li>
              <li id="note5"><a href="references.html#brod04a" title="See full details">#</a> Brodribb W (2004) Breastfeeding Management</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_1-6" class="content">
          <h1 id="top">1.6 Contraindications to breastfeeding</h1>
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
		
		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
	</stage>
		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
	</stage>
		<p>
			What information would you give?
		</p>
		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
	</stage>
		<p>
			Why do breastfeeding alternatives have different effects?
		</p>
		<dl><dt><a href="topic_1-3.html"><cite>Topic 1.3: Effects of Breastfeeding alternatives</cite></a></dt><dd class="topic-paragraph">These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.</dd></dl>
	</stage>
		<p>
			What are mothers' common and valid concerns about breastfeeding?
		</p>
		<dl><dt><a href="topic_1-4.html"><cite>Topic 1.4: Common breastfeeding concerns</cite></a></dt><dd class="topic-paragraph">Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.</dd></dl>
	</stage>
		<p>
			Would you examine her breasts at this visit?
		</p>
		<dl><dt><a href="topic_1-5.html"><cite>Topic 1.5: Breast examination</cite></a></dt><dd class="topic-paragraph">Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.</dd></dl>
	</stage>
		<p>
			What are the contraindications to breastfeeding?
		</p>
		<dl><dt><a href="topic_1-6.html"><cite>Topic 1.6: Contraindications to breastfeeding</cite></a></dt><dd class="topic-paragraph">There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.</dd></dl>
	</stage>
	</td>
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                  <img src="design/callout_06.png" width="10" height="80" alt="" />
                </td>
              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			What are the contraindications to breastfeeding?
		</p>
          </strong>
          <div class="section display-accordion" id="">
		<p>There are very few conditions when women should be discouraged from breastfeeding</p>
		<div class="section" id="Active_tuberculosis"><h3>Active tuberculosis</h3>
			<div class="section" id="">
				Infants of mothers with active tuberculosis are at increased risk of infection whether they are breastfed or not. When a mother is initially diagnosed with active TB and is thought to be infectious, it is recommended that she be separated from her infant for as short a time as possible - until she is having adequate anti-tuberculous treatment and the infant is receiving prophylaxis. The mother can continue to provide breastmilk for her infant during the period of separation as long as she does not have tuberculous mastitis<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>.
			</div>
		</div>
		<div class="section" id="HIV"><h3>HIV</h3>
			<div class="section" id="">
				<p class="listTitle">Because of the risk of transmission of HIV from mother to infant via breastmilk, WHO recommends that when replacement feeding is</p><ul><li>acceptable,</li><li>feasible,</li><li>affordable,</li><li>sustainable, and</li><li>safe</li></ul><p class="listFoot">it is recommend that HIV-infected mothers avoid all breastfeeding.</p> 
				<p>
					If the available replacement feeding does not meet all of these criteria, exclusive breastfeeding is recommended during the first months of life.<sup><a href="#note3">3</a></sup> This recommendation is supported by the NHMRC in Australia<sup><a href="#note4">4</a></sup>. In Australia most women with HIV would be advised not to breastfeed.
				</p>
			</div>
		</div>
		<div class="section" id="Human_T-cell_Leukaemia_Virus_Type_1"><h3>Human T-cell Leukaemia Virus Type 1</h3>
			<div class="section" id="">
				This retrovirus is endemic in the Caribbean, South America, sub-Saharan Africa and parts of Japan and is associated with the development of adult T cell leukaemia/lymphoma and a progressive neuropathy. As well as being transmitted via sexual contact and with blood and blood products, it is also transmitted via breastmilk  the longer the exposure to breastmilk the greater the risk of transmission<sup><a href="#note1">1</a></sup>.
			</div>
		</div>
		<div class="section" id="Brucellosis"><h3>Brucellosis</h3>
			<div class="section" id="">
				Brucella sp. can probably be transmitted via breastmilk although active infection in the infant has not been demonstrated. Breastmilk can be expressed and discarded until the mother has had 48-72 hours of appropriate treatment<sup><a href="#note1">1</a></sup>.
			</div>
		</div>
		<div class="section" id="Medications"><h3>Medications</h3>
			<div class="section" id="">
				There are very few situations where the need for medications results in an absolute contraindication for breastfeeding. In most instances there are alternative medications that are compatible with breastfeeding. Drugs that are absolutely contraindicated (until not detectable in breastmilk) are antimetabolites and radiopharmaceuticals used in therapeutic doses.
			</div>
		</div>
		<div class="section" id="Illicit_drug_use"><h3>Illicit drug use</h3>
			<div class="section" id="">
				Illicit use of drugs such as cocaine and PCP (angel dust) by a mother are known to have a detrimental effect on her breastfed infant and are absolutely contraindicated during lactation. There is limited or no data on the effect of other illicit drugs on breastfed infants. Considering the frequent concomitant use of illicit drugs, the uncertainty of dose and purity of the drugs and impairment of the mother, there must be concern about women who continue to use illicit drugs while breastfeeding<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>.
			</div>
		</div>
		<div class="section" id="Classic_galactosaemia_and_some_inborn_errors_of_metabolism_in_the_infant"><h3>Classic galactosaemia and some inborn errors of metabolism in the infant</h3><sup><a href="#note7">7</a></sup>
			<div class="section" id="">
				These are very rare and require specialist assessment and treatment.
			</div>
		</div>
	</div>
          <div class="section display-accordion" id="Conditions_that_are_NOT_a_contraindication_to_breastfeeding."><h2>Conditions that are NOT a contraindication to breastfeeding.</h2>
		<div class="section" id="Hepatitis_B"><h3>Hepatitis B</h3>
			<div class="section" id="">
				The rate of vertical transmission of Hepatitis B via breast milk is low, even though viral DNA has been recovered from breastmilk. With passive and active immunization of the infant soon after birth the transmission rate is similar regardless of the infant feeding method. Infection with hepatitis B is not a contraindication for breastfeeding<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a>,</sup><sup><a href="#note8">8</a></sup>.
			</div>
		</div>
		<div class="section" id="Hepatitis_C"><h3>Hepatitis C</h3>
			<div class="section" id="">
				Studies have not demonstrated an increase in vertical transmission in infants who have been breastfed and therefore there is no contraindication for women who are HCV antibody positive to breastfeed<sup><a href="#note7">7</a>,</sup><sup><a href="#note9">9</a></sup>. Because of the theoretical risk of transmission through blood, it is recommended that mothers with cracked or bleeding nipples express and discard milk from the affected breast until the nipples have healed<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a>,</sup><sup><a href="#note9">9</a></sup>.
			</div>
		</div>
		<div class="section" id="Pregnancy"><h3>Pregnancy</h3>
			<div class="section" id="">
				There is no reason for a mother to wean her child if she becomes pregnant again. There is no evidence that continued breastfeeding has adverse effects on a normal pregnancy, the growing foetus or older child. Many women experience nipple tenderness during the first trimester and a gradual reduction in milk supply encourages many children to wean during this time. However, some continue to breastfeed throughout the pregnancy and are tandem fed with the new baby<sup><a href="#note10">10</a></sup>
			</div>
		</div>
	</div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#lawr05" title="See full details">#</a> Lawrence RM (2005) Transmission of infectious diseases through breast milk and breastfeeding</li>
              <li id="note2"><a href="references.html#bues07" title="See full details">#</a> Buescher ES (2007) Human milk and infectious disease</li>
              <li id="note3"><a href="references.html#worl03" title="See full details">#</a> World Health Organization (2003) HIV and infant feeding: guidelines for decision makers</li>
              <li id="note4"><a href="references.html#nati03" title="See full details">#</a> National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers</li>
              <li id="note5"><a href="references.html#mcaf07" title="See full details">#</a> McAfee G ( 2007) Drugs of abuse and breastfeeding.</li>
              <li id="note6"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
              <li id="note7"><a href="references.html#gart05" title="See full details">#</a> Gartner LM et al. (2005) Breastfeeding and the use of human milk</li>
              <li id="note8"><a href="references.html#gart05a" title="See full details">#</a> Gartrell N (2005) Not tonight dear, the kids have earaches. What happens to a lesbian couple post-partum?</li>
              <li id="note9"><a href="references.html#macd03" title="See full details">#</a> MacDonald M et al. (2003) Preventing transmission of hepatitis C</li>
              <li id="note10"><a href="references.html#lawr05b" title="See full details">#</a> Lawrence RA (2005) Reproductive function during lactation</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_1-7" class="content">
          <h1 id="top">1.7 Conditions related to lactation outcomes</h1>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
		
		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
	</stage>
		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
	</stage>
		<p>
			What information would you give?
		</p>
		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
	</stage>
		<p>
			Why do breastfeeding alternatives have different effects?
		</p>
		<dl><dt><a href="topic_1-3.html"><cite>Topic 1.3: Effects of Breastfeeding alternatives</cite></a></dt><dd class="topic-paragraph">These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.</dd></dl>
	</stage>
		<p>
			What are mothers' common and valid concerns about breastfeeding?
		</p>
		<dl><dt><a href="topic_1-4.html"><cite>Topic 1.4: Common breastfeeding concerns</cite></a></dt><dd class="topic-paragraph">Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.</dd></dl>
	</stage>
		<p>
			Would you examine her breasts at this visit?
		</p>
		<dl><dt><a href="topic_1-5.html"><cite>Topic 1.5: Breast examination</cite></a></dt><dd class="topic-paragraph">Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.</dd></dl>
	</stage>
		<p>
			What are the contraindications to breastfeeding?
		</p>
		<dl><dt><a href="topic_1-6.html"><cite>Topic 1.6: Contraindications to breastfeeding</cite></a></dt><dd class="topic-paragraph">There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.</dd></dl>
	</stage>
		<p>
			What conditions may be related to poorer lactation outcomes?
		</p>
		<dl><dt><a href="topic_1-7.html"><cite>Topic 1.7: Conditions related to lactation outcomes</cite></a></dt><dd class="topic-paragraph">Common problems are previous lactation failure, hormonal problems and obesity.</dd></dl>
	</stage>
	</td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
                  <img src="design/callout_06.png" width="10" height="80" alt="" />
                </td>
              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			What conditions may be related to poorer lactation outcomes?
		</p>
          </strong>
          <dl>
            <dt>Previous lactation failure</dt>
            <dd>Only a small proportion of women are physically unable to breastfeed. However, many more initiate breastfeeding but wean before they originally intended due to unexpected and insurmountable problems. There is no reason to suspect similar difficulties occurring in a subsequent lactation unless there are fundamental anatomical or hormonal problems. Identifying the reasons for a previous early weaning enables strategies be instituted to prevent or overcome the problems.</dd>
            <dt>Hormonal problems</dt>
            <dd>An interplay of hormones is necessary to prepare the breasts for lactation and to initiate and maintain lactation after the infant is born. Women with hormonal conditions such as hypothyroidism, diabetes and endocrine disorders that lead to difficulty conceiving may experience difficulty initiating lactation.</dd>
            <dt>Obesity</dt>
            <dd>Women who are obese or overweight are less likely to be breastfeeding at any time postpartum than their normal weight counterparts<sup><a href="#note1">1</a></sup>.</dd>
          </dl>
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                  <img src="design/callout_01.png" width="10" height="10" alt="" />
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                </td>
                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_r">
<script type="text/javascript">
/* <![CDATA[ */
var rqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Felicity, a new patient, comes for her first antenatal visit. What questions would you ask her to obtain a history relevant to future breastfeeding?</strong>\n			</p>\n		', r : '\n			<ul>\n				<li>Have you had children previously, and if so, can you tell me about your breastfeeding experiences?</li>\n				<li>Do you have any medical conditions, in particular diabetes, thyroid disorders or polycystic ovarian syndrome? Are you taking any medications regularly?</li>\n				<li>Have you had breast surgery in the past?</li>\n				<li>Do you have any concerns about your breasts or nipples, for example, inverted nipples?</li>\n			</ul>\n		' }
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/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('r');</script>
	</td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
                  <img src="design/callout_06.png" width="10" height="80" alt="" />
                </td>
              </tr>
            </tbody>
          </table>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#oddy06" title="See full details">#</a> Oddy WH et al. (2006) The association of maternal overweight and obesity with breastfeeding duration</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_1-8" class="content">
          <h1 id="top">1.8 Medications</h1>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_03.png" width="10" height="10" alt="" />
                </td>
              </tr>
            </thead>
            <tfoot>
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                <td class="topleft" style="width: 10px">
                  <img src="design/callout_07.png" width="10" height="10" alt="" />
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                <td class="topcenter" style="background-image: url(design/callout_08.png);">
                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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              </tr>
            </tfoot>
            <tbody>
              <tr>
                <td class="middleleft" style="background: repeat-y url(design/callout_04.png);">
                  <img src="design/callout_04.png" width="10" height="80" alt="" />
                </td>
                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study A</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
		
		<p>
			Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.
		</p>
	</stage>
		<p>
			Would you discuss breastfeeding at this visit?
		</p>
		<dl><dt><a href="topic_1-1.html"><cite>Topic 1.1: Discussing breastfeeding</cite></a></dt><dd class="topic-paragraph">It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.</dd></dl>
	</stage>
		<p>
			What information would you give?
		</p>
		<dl><dt><a href="topic_1-2.html"><cite>Topic 1.2: What information to give</cite></a></dt><dd class="topic-paragraph">When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.</dd></dl>
	</stage>
		<p>
			Why do breastfeeding alternatives have different effects?
		</p>
		<dl><dt><a href="topic_1-3.html"><cite>Topic 1.3: Effects of Breastfeeding alternatives</cite></a></dt><dd class="topic-paragraph">These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.</dd></dl>
	</stage>
		<p>
			What are mothers' common and valid concerns about breastfeeding?
		</p>
		<dl><dt><a href="topic_1-4.html"><cite>Topic 1.4: Common breastfeeding concerns</cite></a></dt><dd class="topic-paragraph">Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.</dd></dl>
	</stage>
		<p>
			Would you examine her breasts at this visit?
		</p>
		<dl><dt><a href="topic_1-5.html"><cite>Topic 1.5: Breast examination</cite></a></dt><dd class="topic-paragraph">Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.</dd></dl>
	</stage>
		<p>
			What are the contraindications to breastfeeding?
		</p>
		<dl><dt><a href="topic_1-6.html"><cite>Topic 1.6: Contraindications to breastfeeding</cite></a></dt><dd class="topic-paragraph">There are very few conditions when women should be discouraged from breastfeeding, including active tuberculosis, HIV, human T-cell leukaemia virus Type 1, brucellosis, some medications, illicit drug use and classic galactosaemia and some inborn errors of metabolism in the infant.</dd></dl>
	</stage>
		<p>
			What conditions may be related to poorer lactation outcomes?
		</p>
		<dl><dt><a href="topic_1-7.html"><cite>Topic 1.7: Conditions related to lactation outcomes</cite></a></dt><dd class="topic-paragraph">Common problems are previous lactation failure, hormonal problems and obesity.</dd></dl>
	</stage>
		<p>
			Joanne's sister-in-law developed hyperthyroidism when she had been breastfeeding her last baby and was told that she would have to wean so that she could commence taking medication. Joanne asks you whether it is common for women to have to wean to be treated for medical conditions. What would you tell her about medication use in breastfeeding women?
		</p>
		<dl><dt><a href="topic_1-8.html"><cite>Topic 1.8: Medications</cite></a></dt><dd class="topic-paragraph">There are very few medical conditions for which a mother needs to cease breastfeeding so that she can be adequately treated. In nearly all situations a mother can continue to breastfeed while she is on medication.</dd></dl>
	</stage>
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          <strong>
            <p>
			Joanne's sister-in-law developed hyperthyroidism when she had been breastfeeding her last baby and was told that she would have to wean so that she could commence taking medication. Joanne asks you whether it is common for women to have to wean to be treated for medical conditions. What would you tell her about medication use in breastfeeding women?
		</p>
          </strong>
          <p>
		There are very few medical conditions for which a mother needs to cease breastfeeding so that she can be adequately treated. Within most classes of drugs, or drugs used to treat a specific condition some are better options for breastfeeding women than others. In nearly all situations a mother can continue to breastfeed while she is on medication. Medications that are absolute contraindications to breastfeeding have been mentioned above.
	</p>
          <table title="In assessing which medication is most appropriate for use in lactation it is helpful to consider the following:">
		<thead>
			<th></th>
			<th></th>
		</thead>
		<tbody>
			<tr class="row0">
				<td><strong>Has the infant already been exposed in-utero?</strong></td>
				<td>An infant is exposed to much higher levels of a medication in-utero than through breast milk.</td>
			</tr>
			<tr class="row1">
				<td><strong>Is the medication necessary?</strong></td>
				<td>Can a topical or local preparation be used rather than an oral or parenteral preparation?</td>
			</tr>
			<tr class="row0">
				<td><strong>How much of the drug would the infant receive in a day? What is the relative infant dose?</strong></td>
				<td> As a rough guide a relative infant dose of 10% is deemed to be compatible with breastfeeding.
					<p class="listTitle">Consider the following:</p><ul><li>dose and timing of maternal administration of the medication</li><li>molecular weight  large molecules (eg <span class="term">heparin</span>) are less likely to diffuse into the milk compartment than smaller molecules (eg lithium)</li><li>lipid solubility  drugs that are lipophilic diffuse more readily across cell membranes and into the milk compartment</li><li>pH and pKa Because breast milk has a slightly higher pH than plasma, drugs that are weak bases (such as <span class="term">erythromycin</span>, <span class="term">beta blockers</span>) will tend to accumulate in milk, while drugs that are weak acids (<span class="term">sulphonamides</span>, <span class="term">barbiturates</span>) have minimal transfer into milk</li><li>protein binding  drugs that are heavily protein bound are less likely to transfer into milk</li><li>ctive transport  some drugs are preferentially transported into milk</li></ul>
				</td>
			</tr>
			<tr class="row1">
				<td><strong>Is this medication used in infants?</strong></td>
				<td></td>
			</tr>
			<tr class="row0">
				<td><strong>What is its oral bioavailability?</strong></td>
				<td>Medications given parenterally to the mother are unlikely to be absorbed by the infant no matter how much is present in breast milk.</td>
			</tr>
			<tr class="row1">
				<td><strong>How effective will the infant be excreting what has been absorbed?</strong></td>
				<td>Newborns have 33% of the adult capacity for drug excretion while a 7 month old has a similar capacity to an adult. Infants who are premature or sick have reduced capacity.</td>
			</tr>
			<tr class="row0">
				<td><strong>Are there other drugs that will be just as effective but are potentially a safer option for a breastfeeding woman?</strong></td>
				<td></td>
			</tr>
		</tbody>
	</table>
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                <td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>The amount of drug transferred into milk will depend on the dose, timing and formulation of the medication</h3>
		<ul><li>Medications given <strong>once a day</strong> should be taken around the feed <em>just prior</em> to the infant's longest sleep.</li><li>Medications <strong>taken more frequently</strong> should be taken <em>around the time of a feed</em> <span class="aside">(authorities differ whether just before or just after is most appropriate)</span> to allow for drug peaks to fall prior to the next breast feed.</li><li>Expressing and discarding milk <strong>will not necessarily</strong> reduce the amount of the medication in milk. In most instances the concentration of a drug in milk mirrors that in maternal plasma. As the mother metabolises the drug the milk level will fall.</li></ul>
	</td>
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          <p>
		<strong>Obtaining correct and up-to-date information</strong>
	</p>
          <p>
		Recommendations that a mother should not breastfeed while taking a specific medication are common when limited data is available.
	</p>
          <p>
		Generic sentences such as &ldquo;<q>"Drug A is excreted into breast milk and caution should be used when administered to breastfeeding women"</q>&rdquo; or &ldquo;<q>"Alternative feeding arrangements should be considered"</q>&rdquo; are often encountered in product information sheets although recommendations often vary between different references.
	</p>
          <p>
		A recent survey of 10 frequently used sources of information regarding breastfeeding and medication use found wide disparity in the recommendations between the sources for 14 medications<sup><a href="#note1">1</a></sup>.
	</p>
          <p>
		Using a reference or source with expertise in evaluating the risks of medications in breastfeeding women is essential. The following list is not inclusive, but contains resources that have reputable information and recommendations.
		<ul><li>Click <img alt="External" src="design/external.gif" /><a href="http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT" title="External link" target="_blank">here</a><span class="linkDescription">[link: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT]</span> to go to the Drugs and Lactation Database. The LactMed database in the menu on the left will be selected. Enter the name of drug or condition you wish to treat. This database will provide information on the drug's transfer into breast milk, adverse effects in infants, and other drugs with a similar action that may be more appropriate to use in breastfeeding women.</li><li>Medications and Mothers' Milk (Hale Publishing 2006) </li><li>Dr Thomas Hale's <img alt="External" src="design/external.gif" /><a href="http://neonatal.ama.ttuhsc.edu/lact/medicationforumspage.html" title="External link" target="_blank">Breastfeeding and Medications Forums</a><span class="linkDescription">[link: http://neonatal.ama.ttuhsc.edu/lact/medicationforumspage.html]</span></li><li>
				Drug information centres at the local women's hospital
				<ul><li>Queensland – Queensland Drug Information Centre, 07 3636 7098;</li><li>New South Wales – MotherSafe, 02 9382 6539 (1800 647 848 NSW country);</li><li>Victoria – Drug Information Centre, Royal Women's Hospital, 03 9344 2277;</li><li>South Australia – Women's and Children's Hospital, 08 8161 7222;</li><li>Western Australia – Women's and Children's Health Services, 08 9340 2723;</li><li>ACT – Drug Information Canberra Hospital, 02 0624 4333</li></ul>
			</li></ul>
	</p>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_s">
<script type="text/javascript">
/* <![CDATA[ */
var sqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Annette developed a DVT on day three following a caesarean section. She is being treated with low molecular weight heparin subcutaneously (Clexane) at present. She is breastfeeding well and asks you whether she can continue to breastfeed. What would you say to her? (Think about it from first principles and then check a reputable resource.) The hospital\'s usual policy is to commence warfarin therapy after two days of Clexane. Is she able to continue to breastfeed on warfarin?</strong>\n			</p>\n		', r : '\n			<p>\n				Very small amounts of the Clexane, if any, will get into breastmilk. Breastfeeding continues to be the best way to feed your baby.\n			</p>\n			<p>\n				Lactmed notes that because of their molecular size low molecular weight heparins (2000-8000 daltons) are not detectable in breastmilk and are therefore compatible with breastfeeding.\n			</p>\n			<p>\n				Lactmed notes that warfarin passes into breastmilk in very small quantities with none being detected in breastmilk or in infants breastfed by mothers taking warfarin in the postpartum period. Therefore she can continue breastfeeding while taking warfarin.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('s');</script>
	</td>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#akus07" title="See full details">#</a> Akus M et al. (2007) Lactation safety recommendations and reliability compared in 10 medication resources</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-0" class="content">
          <h1 id="top">2.0 Case Study B (Joanne)</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<p>
			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
		</p>
	</stage>
		<p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<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>
	</stage>
		<p>
			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?
		</p>
		<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>
	</stage>
		<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.
			</dd></dl>
	</stage>
		<p>
			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?
		</p>
		<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.
			</dd></dl>
	</stage>
		<p>
			Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?
		</p>
		<dl><dt><a href="topic_2-5.html"><cite>Topic 2.5: Hypoglycaemia</cite></a></dt><dd class="topic-paragraph">Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.</dd></dl>
	</stage>
		<p>
			On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?
		</p>
		<dl><dt><a href="topic_2-6.html"><cite>Topic 2.6: Relationship between Jaundice and Breastfeeding</cite></a></dt><dd class="topic-paragraph">In the early days jaundice in a breastfed infant may be due to inadequate breastfeeding. Breast milk jaundice usually begins after day five, is associated with increasing milk volumes and is thought to be due to as yet unidentified substance in breast milk. It rarely requires investigation or treatment.</dd></dl>
	</stage>
	</td>
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          </table>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-1" class="content">
          <h1 id="top">2.1 Preparation Before Birth</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
		<stage>
		<stage>
		<p>
			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
		</p>
	</stage>
		<p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<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>
	</stage>
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          <strong>
            <p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
          </strong>
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                <td class="body"><h3></h3>
		<p class="listTitle">Every facility providing maternity services and care for newborn infants should:</p><ol><li>Have a written breastfeeding policy that is routinely communicated to all health care staff.</li><li>Train all health care staff in skills necessary to implement the policy.</li><li>Inform all pregnancy women about the benefits and management of breastfeeding.</li><li>Help mothers initiate breastfeeding within a half-hour of birth.</li><li>Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infant.</li><li>Give newborn infants no food or drink other than breastmilk, unless medically indicated</li><li>Practice rooming-in - allow mothers and infants to remain together  24 hours a day.</li><li>Encourage breastfeeding on demand.</li><li>Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.</li><li>Foster establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.</li></ol>
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          <p>
		<strong>Step 3</strong> &ldquo;<q>Inform all pregnant women about the benefits and management of breastfeeding</q>&rdquo;
	</p>
          <p>
		Joanne should be encouraged to access breastfeeding information and support within her local community. Women who feel they have sufficient knowledge and information about breastfeeding before their babies are born are more likely to continue to breastfeed<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>. Some studies have found no effect of antenatal breastfeeding education on breastfeeding initiation or duration <sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup>especially if breastfeeding initiation rates are already high. Others have found a positive relationship between antenatal breastfeeding education and breastfeeding initiation <sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup> and duration<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup> particularly if breastfeeding skills are also taught<sup><a href="#note9">9</a>,</sup><sup><a href="#note10">10</a></sup>. Individual sessions with a lactation consultant or other qualified person appear more beneficial than a non-individualised instruction<sup><a href="#note8">8</a></sup>. Therefore, it is the breastfeeding information and support received during the antenatal period to prepare mothers that is important rather than attendance at a specific class. McLeod<sup><a href="#note1">1</a></sup> suggests that as well as creating realistic breastfeeding expectations and providing consistent and relevant breastfeeding information, antenatal breastfeeding preparation also needs to include &ldquo;<q>quality ongoing support from partners, family, friends, professionals and the community</q>&rdquo;.
	</p>
          <p>
		There is no evidence that antenatal nipple preparation, including the use of creams or ointments prevents nipple tenderness or damage in the postpartum period and is therefore not necessary<sup><a href="#note11">11</a>,</sup><sup><a href="#note12">12</a></sup> although some women find gentle breast massage during their pregnancy enables them to become more familiar with handling their breasts.
	</p>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#mcle02" title="See full details">#</a> McLeod D et al. (2002) Factors influencing continuation of breastfeeding in a cohort of women</li>
              <li id="note2"><a href="references.html#chez03" title="See full details">#</a> Chezem J et al. (2003) Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices</li>
              <li id="note3"><a href="references.html#lave05" title="See full details">#</a> Lavender T et al. (2005) Breastfeeding expectations versus reality: a cluster randomised controlled trial</li>
              <li id="note4"><a href="references.html#fors04" title="See full details">#</a> Forster D et al. (2004) Two mid-pregnancy interventions to increase the initiation and duration of breastfeeding: a randomized controlled trial</li>
              <li id="note5"><a href="references.html#desh00" title="See full details">#</a> Deshpande AD et al. (2000) Breast-feeding education and support: association with the decision to breast-feed</li>
              <li id="note6"><a href="references.html#giug94" title="See full details">#</a> Giugliani ER et al. (1994) Effect of breastfeeding support from different sources on mothers' decisions to breastfeed</li>
              <li id="note7"><a href="references.html#sull07" title="See full details">#</a> Su LL et al. (2007) Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial</li>
              <li id="note8"><a href="references.html#matt07" title="See full details">#</a> Mattar CN et al. (2007) Simple antenatal preparation to improve breastfeeding practice: a randomized controlled trial</li>
              <li id="note9"><a href="references.html#duff97" title="See full details">#</a> Duffy EP et al. (1997) Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates.</li>
              <li id="note10"><a href="references.html#pugi96" title="See full details">#</a> Pugin E et al. (1996) Does prenatal breastfeeding skills group education increase the effectiveness of a comprehensive breastfeeding promotion program?</li>
              <li id="note11"><a href="references.html#more05a" title="See full details">#</a> Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review</li>
              <li id="note12"><a href="references.html#hewa87" title="See full details">#</a> Hewat RJ et al. (1987) A comparison of the effectiveness of two methods of nipple care</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-2" class="content">
          <h1 id="top">2.2 Birthing Factors that Affect Breastfeeding</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
		<stage>
		<stage>
		<stage>
		<p>
			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
		</p>
	</stage>
		<p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<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>
	</stage>
		<p>
			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?
		</p>
		<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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          <strong>
            <p>
			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?
		</p>
          </strong>
          <p style="height: 0px; overflow: hidden; clear: right;"></p>
          <div class="section" id="Labour_Analgesia"><h2>Labour Analgesia</h2>
		<p>
			Infants, whose mothers are given analgesia during labour, are at greater risk of a delay in appropriate breastfeeding behaviours and some studies suggest poorer long-term breastfeeding outcomes<sup><a href="#note1">1</a></sup>. Early and prolonged skin-to-skin contact as well as consistent and skilled assistance throughout the postpartum period facilitates breastfeeding and negates some of these negative effects.
		</p>
		<p>
			Pethidine (meperidine), the opiate most widely used for obstetric analgesia in Australia, and its metabolite norpethidine accumulate and are excreted slowly in the infant. Given during labour, especially 2-3 hours prior to delivery, pethidine is known to cause neonatal sedation and respiratory depression<sup><a href="#note2">2</a></sup>. Additionally, its use has been associated with the infant being unable to effectively root, latch and feed soon after delivery<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup> and to have a lower sucking frequency for as long as three days after birth<sup><a href="#note5">5</a></sup>. Other opiates, such as Morphine, do not have an active metabolite and their effect on breastfeeding behaviours, when used during labour, are not as well documented. However, their impact on maternal and neonatal sedation and respiratory depression remains a concern<sup><a href="#note2">2</a></sup>. Short acting opiates such as Fentanyl may be an effective alternative<sup><a href="#note6">6</a></sup>.
		</p>
		<p>
			Studies investigating the effects of epidural analgesia on breastfeeding do not give a clear cut answer in part because there is a wide variation in the doses and drugs used. Additionally, the effects may be confounded by the addition of other analgesia during labour (such as pethidine), the length of the labour and the reason for the epidural<sup><a href="#note1">1</a></sup>. Some studies indicate that adding opiates, such as high doses of epidural fentanyl, to local anaesthetic agents may affect breastfeeding in the short and long term<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup>, although others found no effect of epidurals on breastfeeding success<sup><a href="#note9">9</a></sup>.
		</p>
	</div>
          <div class="section" id="Near-term_Birth"><h2>Near-term Birth</h2>
		<p>
			Although 37 weeks gestation is classified as term many infants born at this gestational age do not act in the same way as term infants. As well as having greater difficulty maintaining stable respirations, body temperature and blood glucose levels they also have higher metabolic needs and lower energy stores. Immature sucking and rooting reflexes as well as a lack of awake/alert periods may result in poor milk transfer, ineffective breast stimulation and incomplete breast emptying leading to poor weight gain and an insufficient milk supply. These factors may result in hypoglycaemia, jaundice, failure to thrive and readmission to hospital<sup><a href="#note10">10</a>,</sup><sup><a href="#note11">11</a></sup>.
		</p>
		<p>
			Therefore Joanne and Rosie need careful monitoring during their hospital stay to ensure good breast drainage and adequate milk intake (urine and stool output, weight and development of jaundice). Joanne may need to express after feeds, and the colostrum or milk fed to Rosie by syringe, dropper, cup or spoon. They also need early follow-up (48 hours) after hospital discharge to ensure problems have not developed<sup><a href="#note10">10</a>,</sup><sup><a href="#note11">11</a></sup>.
		</p>
	</div>
          <div class="captionBox">
            <img width="610" height="400" src="images/factors-affecting-breastfeeding.gif" alt="Factors affecting breastfeeding in the near-term infant" />
            <p>Factors affecting breastfeeding in the near-term infant</p>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_t">
<script type="text/javascript">
/* <![CDATA[ */
var tqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>James is delivered at term by emergency caesarean section following a long and difficult labour. His mother, Mary, had been given pethidine early in the labour and then an epidural. What factors may affect their early breastfeeding relationship and what steps could be taken to minimise these?</strong>\n			</p>\n		', r : '\n			<p>\n				James may be affected by the analgesia used during his mother\'s labour. He may be less able to effectively root, latch and feed after delivery and may be sleepy during the first postpartum days. Long and difficult labours and emergency caesarean sections have been associated with a delay in the onset of copious milk production. Early and frequent skin-to-skin contact and skilled assistance with breastfeeding in the postpartum period will help minimize these factors.\n			</p>\n		' }
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/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('t');</script>
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                <td class="body"><a href="http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf]</span><h3><a href="http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf" target="_blank">Academy of Breastfeeding Medicine Protocol</a><span class="linkDescription">[link: http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf]</span></h3>
		<p>Click on the icon and read the Academy of Breastfeeding Medicine Protocol: Breastfeeding the Near-term Infant.</p>
	</td>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#mont06" title="See full details">#</a> Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.</li>
              <li id="note2"><a href="references.html#matt03" title="See full details">#</a> Mattingly JE et al. (2003) Effects of obstetric analgesics and anesthetics on the neonate : a review</li>
              <li id="note3"><a href="references.html#righ90" title="See full details">#</a> Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed</li>
              <li id="note4"><a href="references.html#niss95" title="See full details">#</a> Nissen E et al. (1995) Effects of maternal pethidine on infants' developing breast feeding behaviours</li>
              <li id="note5"><a href="references.html#hafs00" title="See full details">#</a> Hafstrom M et al. (2000) Non-nutritive sucking by infants exposed to pethidine in utero</li>
              <li id="note6"><a href="references.html#hale07b" title="See full details">#</a> Hale TW (2007) Anesthetic and analgesic medications: Implications for breastfeeding</li>
              <li id="note7"><a href="references.html#beil05" title="See full details">#</a> Beilin Y et al. (2005) Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study</li>
              <li id="note8"><a href="references.html#jord05" title="See full details">#</a> Jordan S et al. (2005) The Impact of Intrapartum Analgesia on Infant Feeding</li>
              <li id="note9"><a href="references.html#halp99" title="See full details">#</a> Halpern SH et al. (1999) Effect of Labor Analgesia on Breastfeeding Success</li>
              <li id="note10"><a href="references.html#meie07" title="See full details">#</a> Meier PP et al. (2007) Increased lactation risk for late preterm infants and mothers: evidence and management strategies to protect breastfeeding</li>
              <li id="note11"><a href="references.html#wigh03" title="See full details">#</a> Wight NE (2003) Breastfeeding the borderline (near-term) preterm infant</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-3" class="content">
          <h1 id="top">2.3 Management After Birth</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<p>
			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
		</p>
	</stage>
		<p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<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>
	</stage>
		<p>
			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?
		</p>
		<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>
	</stage>
		<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.
			</dd></dl>
	</stage>
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          <a name="steps" id="steps"></a>
          <p class="listTitle">
			Steps 4-9 of the Ten Steps to Successful Breastfeeding outline the optimal management of mothers and their infants from birth to encourage and support breastfeeding.
		</p>
          <ul>
            <li>
              <a href="#step4">Step 4 - Place Rosie in skin-to-skin contact</a>
            </li>
            <li>
              <a href="#step5">Step 5 - Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie</a>
            </li>
            <li>
              <a href="#step6">Step 6 - Give Rosie no food or drink other than breastmilk, unless medically indicated</a>
            </li>
            <li>
              <a href="#step7">Step 7 - Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day</a>
            </li>
            <li>
              <a href="#step8">Step 8 - Encourage breastfeeding on demand</a>
            </li>
            <li>
              <a href="#step9">Step 9 - Give Rosie no artificial teats or dummies</a>
            </li>
          </ul>
          <a name="step4" id="step4"></a>
          <div class="section" id="Step_4_-_Place_Rosie_in_skin-to-skin_contact"><h2>Step 4 - Place Rosie in skin-to-skin contact</h2>
		<p>Although Step 4 states</p>
		<blockquote>
			Help mothers initiate breastfeeding within a half-hour of birth, it is now interpreted as Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed. 
		</blockquote><sup><a href="#note1">1</a></sup>
		<p>
			Ideally Rosie will be placed prone, skin-to-skin on her mothers abdomen or chest immediately following birth and left for at least the first hour or until she has attempted to breastfeed. Rosie can be quickly dried, and a blanket or other covering placed over mother and infant to maintain body temperature. Routine administration of medications (e.g. Vitamin K) and assessment and weighing of the infant can either be postponed until after this time, or performed with the infant undisturbed<sup><a href="#note2">2</a></sup>.
		</p>
		<p>
			Many infants are awake and alert in the first two hours after birth and when left skin-to-skin with their mothers go through an ordered series of innate prefeeding movements with most finding the breast and begin to feed within the first hour or so.<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup> Early suckling has been associated with increased breastfeeding duration and the ability to breastfeed.<sup><a href="#note5">5</a></sup>
		</p>
		<p class="listTitle">A recent Cochrane review<sup><a href="#note6">6</a></sup> has also shown that early skin-to-skin contact of healthy term infants:</p><ul><li>Increases the likelihood of a successful first breastfeed;</li><li>Reduces the time to the first effective breastfeed;</li><li>Increases breastfeeding rates at hospital discharge, at four months and six months;</li><li>Encourages better thermal regulation by the infant;</li><li>Improves cardio-respiratory stability in late pre-term infants;</li><li>Increases blood glucose levels;</li><li>Reduces crying; and</li><li>Reduces maternal pain from engorgement on day 3</li></ul><p class="listFoot">
				Additionally, mothers are less anxious on day 3, are more confident handling their infant by hospital discharge and are more likely to exhibit maternal attachment behaviours.<sup><a href="#note6">6</a></sup>
			</p>
		<p>
			The benefits of skin-to-skin contact and early breastfeeding are of even greater importance for infants who are at risk for breastfeeding difficulties such as those born late preterm or whose mothers were given analgesia (particularly opiates) during labour. Women who give birth by caesarean section under epidural or spinal anaesthetic can also hold their infants skin-to-skin either in the operating theatre or in the recovery room. Extra assistance may be required from maternity staff.
		</p>
		<p>
			<a href="#steps">Δ [return to steps]</a>
		</p>
	</div>
          <a name="step5" id="step5"></a>
          <div class="section" id="Step_5_-_Show_Joanne_how_to_breastfeed_and_how_to_maintain_lactation_even_if_she_should_be_separated_from_Rosie"><h2>Step 5 - Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie</h2>
		<p>
			Breastfeeding is a natural process; however, it is not instinctive behaviour for mothers. Therefore, even when they have attended antenatal classes, mothers benefit from skilled support and assistance when learning how to breastfeed. Consistent and appropriate help in the postpartum period increases breastfeeding initiation and duration and should be a normal part of maternity care.<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup> In particular helping women to ensure good positioning and attachment of the infant to the breast, teaching them about early feeding cues and expected course of breastfeeding in the first few days and weeks is important.
		</p>
		<p>
			When an infant is unable to breastfeed (e.g. due to illness of the infant or mother or prematurity) or the infant and his or her mother are separated, the mother requires assistance to initiate and maintain lactation. The infant can then receive breast milk in the short term, and a normal breastfeeding relationship can be established when conditions permit. Mothers benefit from being shown how to express milk (both by hand and pump) as well as being given information regarding expression routines and the safe collection and storage of breast milk.
		</p>
		<p>
			<a href="#steps">Δ [return to steps]</a>
		</p>
	</div>
          <a name="step6" id="step6"></a>
          <div class="section" id="Step_6_-_Give_Rosie_no_food_or_drink_other_than_breastmilk_unless_medically_indicated"><h2>Step 6 - Give Rosie no food or drink other than breastmilk, unless medically indicated</h2>
		<p>
			Practices that interfere with the natural rhythm of the infants appetite and feeding cues will have a negative effect on the establishment of lactation and on breastfeeding duration. Normal, healthy, term infants allowed unlimited access to the breast do not need water, glucose water or infant formula routinely<sup><a href="#note9">9</a></sup>.
		</p>
		<p>
			Their use affects the infants desire to feed at the breast  reducing prolactin release and breast emptying, adversely affecting milk supply<sup><a href="#note10">10</a></sup>, and breastfeeding rates at four and 16 weeks<sup><a href="#note11">11</a></sup>. Additionally, giving infant formula changes the gut environment and increases the risk of infective and atopic disease<sup><a href="#note5">5</a></sup>. In some situations (eg. a delay in lactogenesis ll and subsequent excessive weight loss) supplemental feeding is medically indicated but steps to protect and increase the mothers milk supply should also be undertaken.
		</p>
		<p>
			<a href="#steps">Δ [return to steps]</a>
		</p>
	</div>
          <a name="step7" id="step7"></a>
          <div class="section" id="Step_7_-_Practice_rooming-in_allow_Joanne_and_Rosie_to_remain_together_24_hours_a_day"><h2>Step 7 - Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day</h2>
		<p>
			Rooming-in 24-hours a day enhances the mothers ability to watch and learn about her infant so that she is aware of these early feeding cues and responds to her infant accordingly. This close contact also conditions the milk-ejection reflex resulting in the release of oxytocin and hence availability of milk, three to ten minutes before a feed- just as the infant begins to stir.<sup><a href="#note12">12</a></sup>
		</p>
		<p>
			Rooming-in has been associated with more frequent feeding, greater weight gain,<sup><a href="#note13">13</a></sup> and longer duration of breastfeeding.<sup><a href="#note14">14</a></sup> Additionally, mothers who room-in tend to look at, touch and talk to their infants in more intimate ways.<sup><a href="#note15">15</a></sup> Rooming-in does not affect the amount or quality of a mothers sleep.<sup><a href="#note13">13</a></sup>
		</p>
		<p>
			<a href="#steps">Δ [return to steps]</a>
		</p>
	</div>
          <a name="step8" id="step8"></a>
          <div class="section" id="Step_8_-_Encourage_breastfeeding_on_demand"><h2>Step 8 - Encourage breastfeeding on demand</h2>
		<p>
			During the first breastfeed after birth most infants will take between 0 and 5 mls of colostrum. This volume gradually increases as the milk changes from colostrum to mature milk over the first week or so.<sup><a href="#note16">16</a></sup> The increase in volume is instigated by a drop in progesterone levels following the delivery of the placenta. Subsequently the amount of milk produced is regulated by prolactin release and breast emptying, both dependent on the number and length of breastfeeds  a reflection of the infants appetite.
		</p>
		<p>
			On average, infants will breastfeed between 3-8 times in the first 24 hours, and then between 5 -10 times a day until day 7,<sup><a href="#note16">16</a></sup> however, there is considerable variation in the number and length of  breastfeeds between infants and between days with the same infant. Unrestricted access to the breast in the early days of breastfeeding allows for this variation, assists with the regulation of milk supply, provides milk for the infant according to his or her needs, results in lower weight loss or better weight gains and improved breastfeeding rates.<sup><a href="#note5">5</a>,</sup><sup><a href="#note13">13</a></sup> Breastfed infants require no additional supplements or water, even in hot weather, until they are six months old.
		</p>
		<p>
			Feeding the infant 'on demand', that is when he or she displays early feeding cues such as hand to mouth movements, rooting, mouthing or body movement in light sleep provides unrestricted access to the breast. There is no evidence that breastfeeding 'on demand' increases the extent or duration of nipple tenderness.
		</p>
		<p>
			<a href="#steps">Δ [return to steps]</a>
		</p>
	</div>
          <a name="step9" id="step9"></a>
          <div class="section" id="Step_9_-_Give_Rosie_no_artificial_teats_or_dummies"><h2>Step 9 - Give Rosie no artificial teats or dummies</h2>
		<p>
			Dummy or pacifier use, especially before breastfeeding is well established has also been linked with a shorter breastfeeding duration<sup><a href="#note5">5</a>,</sup><sup><a href="#note10">10</a></sup>. This problem is more pronounced when the dummy or pacifier is used as an alternative to quieten an infant rather than breastfeeding him or her. Infants also use a different sucking action with bottle teats (artificial nipples) or dummies than when breastfeeding. There is concern that some infants are unable to adjust their sucking actions between the different modalities and using teats or dummies may exacerbate sucking difficulties at the breast<sup><a href="#note17">17</a></sup>. Therefore dummies and artificial teats should not routinely be used for infants who are breastfed.
		</p>
		<p>
			Recent studies suggest that the risk of SIDS is reduced in infants who use a dummy while going to sleep, especially if the infant has an unsafe sleep environment (e.g. sleeping prone or with a mother who smokes)<sup><a href="#note18">18</a></sup>. This finding needs to be balanced against evidence that SIDS risk is reduced in breastfed infants<sup><a href="#note19">19</a></sup>, and dummy use has an impact on breastfeeding success. The American Academy of Pediatrics<sup><a href="#note20">20</a></sup> and UNICEF UK Baby Friendly Initiative<sup><a href="#note21">21</a></sup> recommend that parents who wish to use a dummy to settle their infant to sleep not do so until breastfeeding is well established  at around four weeks. Other points to note are: it is preferable that dummies not be used at other times; not all infants will accept a dummy and many will not retain the dummy for the whole of the sleep period<sup><a href="#note21">21</a></sup>. There is no evidence that forcing an infant to take a dummy, or replacing it if it has fallen out of the sleeping infants mouth is beneficial<sup><a href="#note18">18</a>,</sup><sup><a href="#note20">20</a></sup>.
		</p>
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			<a href="#steps">Δ [return to steps]</a>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_u">
<script type="text/javascript">
/* <![CDATA[ */
var uqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>A mother in the antenatal clinic expresses concern that your hospital no longer has a nursery in the maternity ward and that dummies were no longer routinely supplied. What points would you make to explain the rational of these decisions to her?</strong>\n			</p>\n		', r : '\n			<p>\n				This hospital provides an environment that supports and assists women to breastfeed. Rooming-in helps a mother get to know her baby before going home from hospital and helps establish breastfeeding early without reducing the amount of sleep she gets. Dummies may interfere with breastfeeding, especially in the early days. Therefore, they are not recommended, at least until the milk supply is well established and the baby is feeding well.\n			</p>\n		' }
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/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('u');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#worl06" title="See full details">#</a> World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care</li>
              <li id="note2"><a href="references.html#acad03" title="See full details">#</a> Academy Of Breastfeeding Medicine Protocol Committee (2003) ABM clinical protocol #5: Peripartum breastfeeding management for the healthy other and infant at term.</li>
              <li id="note3"><a href="references.html#righ90" title="See full details">#</a> Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed</li>
              <li id="note4"><a href="references.html#matt01a" title="See full details">#</a> Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking</li>
              <li id="note5"><a href="references.html#phil04" title="See full details">#</a> Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.</li>
              <li id="note6"><a href="references.html#moor07" title="See full details">#</a> Moore ER et al. (2007) Early skin-to-skin contact for mothers and their healthy newborn infants</li>
              <li id="note7"><a href="references.html#worl98" title="See full details">#</a> World Health Organization Evidence for the 10 Steps to Successful Breastfeeding</li>
              <li id="note8"><a href="references.html#fors07" title="See full details">#</a> Forster D et al. (2007) Breastfeeding initiation and birth setting practices: A review of the literature</li>
              <li id="note9"><a href="references.html#aapp05" title="See full details">#</a> AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk</li>
              <li id="note10"><a href="references.html#howa03" title="See full details">#</a> Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding</li>
              <li id="note11"><a href="references.html#szaj06" title="See full details">#</a> Szajewska H et al. (2006) Effects of brief exposure to water, breast-milk substitutes or other liquids on the success and duration of breastfeeding: A systematic review</li>
              <li id="note12"><a href="references.html#mcne83" title="See full details">#</a> McNeilly A et al. (1983) Release of oxytocin and prolactin in response to suckling</li>
              <li id="note13"><a href="references.html#chil98" title="See full details">#</a> Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding</li>
              <li id="note14"><a href="references.html#scot01" title="See full details">#</a> Scott JA et al. (2001) Factors associated with breastfeeding at discharge and duration of breastfeeding</li>
              <li id="note15"><a href="references.html#prod95" title="See full details">#</a> Prodromidis M et al. (1995) Mothers touching newborns: a comparison of rooming-in versus minimal contact</li>
              <li id="note16"><a href="references.html#kent07" title="See full details">#</a> Kent JC (2007) How breastfeeding works</li>
              <li id="note17"><a href="references.html#wils96" title="See full details">#</a> Wilson-Clay B (1996) Clinical use of silicone nipple shields</li>
              <li id="note18"><a href="references.html#hauc05" title="See full details">#</a> Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis</li>
              <li id="note19"><a href="references.html#ipsc07" title="See full details">#</a> Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries</li>
              <li id="note20"><a href="references.html#amer05" title="See full details">#</a> American Academy of Pediatrics (2005) The changing concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk</li>
              <li id="note21"><a href="references.html#unic08a" title="See full details">#</a> UNICEF UK Baby Friendly Initiative (Accessed April 28, 2008) UNICEF UK Baby Friendly Initiative statement on dummy use</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-4" class="content">
          <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>
		<stage>
		<stage>
		<stage>
		<stage>
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		<p>
			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
		</p>
	</stage>
		<p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<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>
	</stage>
		<p>
			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?
		</p>
		<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>
	</stage>
		<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.
			</dd></dl>
	</stage>
		<p>
			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?
		</p>
		<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.
			</dd></dl>
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          <strong>
            <p>
			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?
		</p>
          </strong>
          <dl>
            <dt>
			<strong>Investigate whether there an underlying reason</strong>
		</dt>
            <dd>
				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.
			</dd>
            <dd>
				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.
			</dd>
            <dt>
			<strong>Maximize breastfeeding opportunities</strong>
		</dt>
            <dd>
				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.
			</dd>
            <dt>
			<strong>Protect the milk supply</strong>
		</dt>
            <dd>
				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.
			</dd>
            <dt>
			<strong>Feed the baby</strong>.
		</dt>
            <dd>
				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.
			</dd>
            <dt>
			<strong>Nipple shields may be useful</strong>
		</dt>
            <dd>
				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.
			</dd>
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                <td class="body"><img src="design/tip.png" class="icon" alt="" /><h3></h3>
		<p>
			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.
		</p>
	</td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
                  <img src="design/callout_06.png" width="10" height="80" alt="" />
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            </tbody>
          </table>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <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>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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        <div id="topic_2-5" class="content">
          <h1 id="top">2.5 Hypoglycaemia</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<p>
			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
		</p>
	</stage>
		<p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<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>
	</stage>
		<p>
			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?
		</p>
		<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>
	</stage>
		<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.
			</dd></dl>
	</stage>
		<p>
			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?
		</p>
		<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.
			</dd></dl>
	</stage>
		<p>
			Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?
		</p>
		<dl><dt><a href="topic_2-5.html"><cite>Topic 2.5: Hypoglycaemia</cite></a></dt><dd class="topic-paragraph">Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.</dd></dl>
	</stage>
	</td>
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          <strong>
            <p>
			Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?
		</p>
          </strong>
          <blockquote>
		Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.<sup><a href="#note1">1</a></sup> 
	</blockquote>
          <p>
	Healthy full term neonates are able to adapt from an intrauterine environment where their energy needs are supplied, to an extrauterine environment where they regulate their own glucose levels within a short period of time. Blood glucose levels fall within the first hour and begin to rise soon after, becoming stable 2-3 hours after birth whether the infant has been fed or not. Assuming normal glycogen and adipose stores, infants produce energy by <span class="term">gluconeogenesis</span>, <span class="term">glycogenolysis</span> and <span class="term">ketogenesis</span>.
	</p>
          <p>
		Skin-to-skin contact and early and frequent breastfeeding helps protect infants at risk from hypoglycaemia. Feeding breast milk not only provides an exogenous source of energy, but also enhances gluconeogenesis and the production of ketone bodies that can be used by the brain to protect neurological function. However, variables such as gestational age, age since birth, and other energy needs affect the infants ability to provide sufficient energy to maintain normal function.
	</p>
          <div class="section" id="Which_infants_are_at_risk_and_should_be_monitored_"><h2>Which infants are at risk and should be monitored?</h2>
		<ul><li>
				There is no evidence that routinely measuring blood glucose in a healthy, full-term infant is helpful, and it may be potentially harmful for establishing breastfeeding.
			</li><li>
				Any infant who becomes symptomatic should be tested and treated according to the result.
			</li><li>
				Infants at risk for hypoglycaemia such as those who:
					<ul><li>Are premature or small for gestational age;</li><li>Have suspected inborn errors of metabolism or endocrine disorders, infections, hypothermia or respiratory distress; or</li><li>Suffered perinatal stress (including hypoxia or low APGAR score)</li></ul>
				should have their blood glucose checked approximately 2 hours after birth.
			</li><li>
				Infants of mothers who have diabetes or other conditions with hyperinsulinaemia are at greater risk of hypoglycaemia and should have their blood glucose checked within 30-60 minutes of birth.
			</li><li>
				While bedside blood glucose monitors are useful screening tools, plasma glucose levels should be confirmed by the laboratory.
			</li><li>
				Plasma glucose levels are 15% higher than whole blood levels.
			</li><li>
				Monitoring before a feed should continue until the levels are normal and stable.
			</li></ul>
	</div>
          <div class="section" id="About_Hypoglycaemia"><h2>About Hypoglycaemia</h2>
		<p>
			Hypoglycaemia is hard to define in the neonate because of the lack of a significant correlation between blood (or plasma) glucose levels, symptoms of hypoglycaemia, and long term neurological sequelae. Some neonates are asymptomatic but have extremely low plasma glucose levels while symptoms of hypoglycaemia such as irritability, tremor, lethargy, hypotonia, high pitched cry, cyanosis, hypothermia, seizures, vasomotor instability, apnoea, poor or inadequate sucking<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> are often non-specific and may be the result of other pathological conditions.
		</p>
		<p>
			Therefore there is no standard definition of hypoglycaemia that can be applied universally to neonates<sup><a href="#note3">3</a></sup> with therapeutic operational thresholds being more suitable indicators for intervention.
		</p>
		<p class="listTitle">Operational thresholds for plasma glucose levels:</p><ul><li>Asymptomatic infants at risk for hypoglycaemia &gt; 2 hours old - &lt; 2.0 mmol/L (36ml/dL)
				<ul><li>Breastfed infants may have a slightly lower threshold.</li><li>In the first two hours after birth levels may be as low as 1.6mmol/L (28mg/dL)</li></ul>
			</li><li>Symptomatic infants at any age - &lt; 2.5mmol/L (45mg/dL)</li><li>The therapeutic target is to maintain plasma glucose levels above 2.5mmol/L (45mg/dL)</li></ul>
		<div class="section" id="Treatment"><h3>Treatment</h3>
			<p class="listTitle">Asymptomatic infants with plasma glucose &gt; 1.4mmol/L</p><ol><li>Continue breastfeeding every 1-2 hours or feed 3-5 ml/Kg of expressed breast milk or substitute nutrition (not glucose water).</li><li>Monitor plasma levels prior to each feed until levels are stable and above the treatment threshold.</li><li>If plasma glucose levels remain low, the infant is not able to suck or tolerate oral feeds commence IV glucose therapy</li></ol>
			<p class="listTitle">Symptomatic infants or infants with plasma glucose &lt; 1.1 - 1.4mmol/L</p><ol><li>Initiate IV glucose therapy  do not rely on nasogastric or oral feeding.</li><li>Adjust rate of glucose infusion so that plasma glucose levels in symptomatic infants are be maintained &gt; 2.5mmol/L.</li><li>Once the infant is stable encourage frequent breastfeeding.</li><li>Monitor plasma levels prior to each feed until levels are stable and above the treatment threshold.</li></ol>
		</div>
		
		<table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><a href="http://www.bfmed.org/Resources/Download.aspx?filename=hypoglycemia.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.bfmed.org/Resources/Download.aspx?filename=hypoglycemia.pdf]</span><h3><a href="http://www.bfmed.org/Resources/Download.aspx?filename=hypoglycemia.pdf" target="_blank">Academy of Breastfeeding Medicine Protocol</a><span class="linkDescription">[link: http://www.bfmed.org/Resources/Download.aspx?filename=hypoglycemia.pdf]</span></h3>
			<p>Click on the icon and read the protocol for diagnosis and management of hypoglycemia published by the Academy of Breastfeeding Medicine.</p>
		</td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
	</div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#wigh06" title="See full details">#</a> Wight NE et al. (2006) ABM Clinical protocol #1 Guidelines for glucose monitoring and treatment of hypoglycemia in breastfed neonates</li>
              <li id="note2"><a href="references.html#wigh06a" title="See full details">#</a> Wight NE (2006) Hypoglycemia in breastfed neonates</li>
              <li id="note3"><a href="references.html#eide01" title="See full details">#</a> Eidelman AI (2001) Hypoglycemia and the breastfed neonate</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-6" class="content">
          <h1 id="top">2.6 Relationship between Jaundice and Breastfeeding</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<p>
			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
		</p>
	</stage>
		<p>
			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><span class="linkDescription">[link: http://www.who.int/en/]</span> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a><span class="linkDescription">[link: http://www.unicef.org/]</span> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<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>
	</stage>
		<p>
			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?
		</p>
		<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>
	</stage>
		<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.
			</dd></dl>
	</stage>
		<p>
			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?
		</p>
		<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.
			</dd></dl>
	</stage>
		<p>
			Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?
		</p>
		<dl><dt><a href="topic_2-5.html"><cite>Topic 2.5: Hypoglycaemia</cite></a></dt><dd class="topic-paragraph">Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.</dd></dl>
	</stage>
		<p>
			On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?
		</p>
		<dl><dt><a href="topic_2-6.html"><cite>Topic 2.6: Relationship between Jaundice and Breastfeeding</cite></a></dt><dd class="topic-paragraph">In the early days jaundice in a breastfed infant may be due to inadequate breastfeeding. Breast milk jaundice usually begins after day five, is associated with increasing milk volumes and is thought to be due to as yet unidentified substance in breast milk. It rarely requires investigation or treatment.</dd></dl>
	</stage>
	</td>
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                  <img src="design/callout_06.png" width="10" height="80" alt="" />
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              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?
		</p>
          </strong>
          <p>
		Unconjugated or indirect bilirubin, derived from the breakdown of haem (mainly red blood cells), is normally bound to albumin and transported to the liver where it is metabolised to conjugated (or direct) bilirubin. Direct bilirubin is excreted via the biliary tree into the small intestine, where it is broken down by bacteria to form urobilinogen. However, urobilinogen and conjugated bilirubin may be converted back to unconjugated bilirubin and resorbed into the portal circulation. 
	</p>
          <p>
		Unconjugated bilirubin is fat soluble and can enter the skin and brain if not bound to albumin causing the yellow colouration of skin and sclera (jaundice) and bilirubin encephalopathy (kernicterus). Jaundice usually appears on the head and progresses caudally with increasing levels of bilirubin.<sup><a href="#note1">1</a></sup>
	</p>
          <p class="listTitle">
			Infants are at risk for increased bilirubin levels postpartum because of an imbalance in bilirubin production and bilirubin elimination due to:
		</p>
          <ul>
            <li>An increase in red cell destruction</li>
            <li>An increase in enterohepatic circulation of bilirubin because of:
			<ul><li>an increased load in the intestine (meconium)</li><li>a lack of bacteria to breakdown conjugated bilirubin</li><li>higher levels of B-glucuronidase - the enzyme that converts urobilinogen and conjugated bilirubin to unconjugated bilirubin</li></ul>
		</li>
            <li>
			Immaturity of the enzyme systems in the liver to transport bilirubin into the liver and metabolise it to conjugated bilirubin
		</li>
            <li>
			Lower levels of albumin to transport unconjugated bilirubin and less tight binding.
		</li>
          </ul>
          <p>
		Early onset jaundice (within the first 24-48 hours) or raised levels of conjugated bilirubin are nearly always due to a pathologic process and needs investigation and appropriate treatment regardless of the feeding method.
	</p>
          <p>
		Even so, bilirubin levels in most infants begin to rise after birth usually peaking around 95µmol/l (5.5mg/dl) around day 4 (physiological jaundice).<sup><a href="#note2">2</a></sup> These levels drop rapidly by day 5 and then more slowly so that by day 11 bilirubin levels in formula fed infants reach the adult range of less than 25.5µmol/l (1.5mg/dl).<sup><a href="#note1">1</a></sup> Bilirubin levels in normal breastfed infants are reported to be higher than formula fed infants during the first week and can take from three and up to 15 weeks to reach adult levels.<sup><a href="#note1">1</a>,</sup><sup><a href="#note3">3</a></sup> Jaundice is more pronounced in infants with Asian origins as well as those born before term.<sup><a href="#note1">1</a></sup>
	</p>
          <p class="listTitle">Higher than average  levels of bilirubin in breastfed infants arise from increased enterohepatic circulation of bilirubin, although there appears to be different mechanisms for elevated levels within the first week and later.</p>
          <ul>
            <li>
				Before day five, higher bilirubin levels are usually the result of inadequate breastfeeding  enterohepatic circulation is increased because of the delayed passage of meconium, few bacteria are present to break down conjugated bilirubin, and there is a starvation effect. Breastfed infants who feed frequently, have little weight loss and experience early, frequent passage of stools have similar bilirubin levels to formula-fed infants. Conversely, when breastfeeding is less than optimal, infants are at increased risk of developing jaundice and reaching bilirubin levels requiring active treatment. Therefore, how effectively the infant is breastfeeding, the presence (or absence) of jaundice, the age of the infant and the gestational age need to be considered when arranging appropriate follow-up following discharge from hospital.<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup> For example, a 48-hour-old infant who is sleepy, not feeding well and is slightly jaundiced probably needs reassessment within 2448 hours of discharge.
			</li>
            <li>
		With increasing volumes of transitional and mature milk after day 5, a rise in bilirubin levels may be due to breast milk jaundice.<sup><a href="#note3">3</a></sup> An as yet unidentified substance in human milk is thought to increase bilirubin enterohepatic circulation. Bilirubin levels will often plateau around 170200 µmol/l (1012mg/dl) and rarely rise above 300 µmol/l (1718mg/dl).
			</li>
          </ul>
          <p class="listTitle">
			Prolonged mild jaundice in a well and thriving breastfed infant is most likely due to breast milk jaundice. However, rare pathological conditions may also present with prolonged jaundice and appropriate investigations should be undertaken especially if:
		</p>
          <ul>
            <li>the level of jaundice is maintained or increases,</li>
            <li>the bilirubin level is unusually high (&gt;300 µmol/l),</li>
            <li>the infant is unwell in any way, or.</li>
            <li>the stools are pale.</li>
          </ul>
          <p>
		These is no need to withhold breast milk from the infant to confirm the diagnosis of breast milk jaundice. In the rare situation where bilirubin levels due to breast milk jaundice are at a level requiring treatment, supplementing the infant with an elemental formula or substituting elemental formula for breastfeeds for a 24-hour period is usually sufficient to reduce it to a satisfactory level.<sup><a href="#note3">3</a></sup>
	</p>
          <div class="section" id="Would_there_be_any_concern_about_Rosie_developing_jaundice_at_this_time_"><h2>Would there be any concern about Rosie developing jaundice at this time?</h2>
		<p>
			As Rosie was born near-term and did not feed well for at least the first 24 hours she is at increased risk of developing clinically apparent jaundice and may require further monitoring. It would be appropriate to check her bilirubin level before discharge and arrange close follow-up.
		</p>
	</div>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_v">
<script type="text/javascript">
/* <![CDATA[ */
var vqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>While treating Jan\'s 3yr old daughter for otitis media you notice that 3 week old Karl appears jaundiced.</strong>\n			</p>\n			<p style=\"margin-top: 0px;\">\n				<strong>What information would make you suspect that this was breast milk jaundice?</strong>\n			</p>\n			<p style=\"margin-top: 0px;\">\n				<strong>What actions would you take?</strong>\n			</p>\n		', r : '\n			<p>\n				Karl has no other risk factors for hyperbilirubinaemia. He is exclusively breastfed at least 8 times a day, is well and active, is gaining at least 150 g a week and is passing a number of mustardy, curdy stools a day. Jan states that he is not becoming more yellow. There is no need for further action at this time although a baseline bilirubin (indirect and direct) may be appropriate at times.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('v');</script>
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                <td class="body"><a href="http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297]</span><h3><a href="http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297" target="_blank">American Academy of Pediatrics Clinical Practice Guideline</a><span class="linkDescription">[link: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297]</span></h3>
		<p>Click on the icon and read the AAP Guidelines: "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation"</p>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#gart01a" title="See full details">#</a> Gartner LM et al. (2001) Jaundice and breastfeeding</li>
              <li id="note2"><a href="references.html#sari04" title="See full details">#</a> Sarici SU et al. (2004) Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns</li>
              <li id="note3"><a href="references.html#gart07" title="See full details">#</a> Gartner LM (2007) Hyperbilirubinemia and breastfeeding</li>
              <li id="note4"><a href="references.html#aaps04" title="See full details">#</a> AAP Subcommittee on Hyperbilirubinemia (2004) Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation</li>
              <li id="note5"><a href="references.html#bhut04" title="See full details">#</a> Bhutani VK et al. (2004) Diagnosis and management of hyperbilirubinemia in the term neonate: for a safer first week</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
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          <h1 id="top">3.0 Case Study C (Joanne)</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
		<stage>
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	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
	</stage>
		<p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.</dd></dl>
	</stage>
		<p>
			Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
		</p>
		<dl><dt><a href="topic_3-3.html"><cite>Topic 3.3: Contraception</cite></a></dt><dd class="topic-paragraph">Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.</dd></dl>
	</stage>
		<p>
			Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
		</p>
		<dl><dt><a href="topic_3-4.html"><cite>Topic 3.4: Milk composition</cite></a></dt><dd class="topic-paragraph">The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant. </dd></dl>
	</stage>
		<p>
			Is there any concern about a slowing of growth around this time?
		</p>
		<dl><dt><a href="topic_3-5.html"><cite>Topic 3.5: Slowing of growth</cite></a></dt><dd class="topic-paragraph">Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.</dd></dl>
	</stage>
		<p>
			Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?
		</p>
		<dl><dt><a href="topic_3-6.html"><cite>Topic 3.6: Introducing solids</cite></a></dt><dd class="topic-paragraph">Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.</dd></dl>
	</stage>
		<p>
			What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?
		</p>
		<dl><dt><a href="topic_3-7.html"><cite>Topic 3.7: Weaning</cite></a></dt><dd class="topic-paragraph">There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months (NHMRC, AAP) or two years (WHO). Gradual weaning is ideal.</dd></dl>
	</stage>
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          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
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          <h1 id="top">3.1 Early problems</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
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	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
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          <strong>
            <p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
          </strong>
          <p>
		Breast fullness is a physiological response to the initiation of copious milk production, and is a function of increased vascularity, increased milk production and increased oedema due to increased vascularity and milk production<sup><a href="#note1">1</a></sup>. Breast fullness is associated with some tenderness and pain beginning around day two and peaking by day five<sup><a href="#note2">2</a></sup>.
	</p>
          <p>
		Breast engorgement is an exaggeration of the physiological process, with breasts becoming swollen, hard and very painful, and the nipple being flattened by underlying breast fullness. The skin of the breast is often red and shiny and the mother may be slightly febrile (38°C). The baby is often unable to latch well, resulting in painful, cracked nipples and poor milk drainage. With severe engorgement, the breasts may extend from the clavicle to the lower rib cage and from the midaxillary to the midsternal line.<sup><a href="#note1">1</a></sup>
	</p>
          <p>
		<div class="captionBox"><img width="350" height="231" src="images/breast_engorgement.jpg" alt="Breast Engorgement" /><p> <br />&copy;  S.Cox IBCLC</p></div>
	</p>
          <p>
		Early and frequent emptying of the breast reduces the incidence of engorgement<sup><a href="#note3">3</a></sup>, while predisposing factors for engorgement include:
		<ul><li>delay with the first breastfeed;</li><li>infrequent feeding;</li><li>time-limited feeds;</li><li>late maturation of milk; and</li><li>supplementary feeds<sup><a href="#note4">4</a></sup></li></ul>
	</p>
          <p>
		Management of engorgement focuses on ensuring good breast drainage and maternal comfort (<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>), and includes the following points:
	</p>
          <p>
		<em>Click on some of the bullet points below for more detail:</em>
		<ul class="collapse"><li>
				Ensure frequent feeding
				<ul collapse="yes"><li>most neonates require between eight and twelve feeds a day.</li></ul>
			</li><li>
				Soften the areola
				<ul collapse="yes"><li>By expressing a small amount of milk before a feed so that the infant is able to latch more easily. The amount of milk expressed will depend on the individual woman and degree of engorgement.</li></ul>
			</li><li>Position the infant at the breast to ensure effective latch and breast drainage.</li><li>
				Allow the infant to drain the first breast well before offering the second side.
				<ul collapse="yes"><li>Some studies suggest feeding from only one breast at each feed while expressing small amounts of milk from the other breast for comfort <sup><a href="#note7">7</a></sup>.</li></ul>
			</li><li>
				Express by hand or pump until the breasts are soft if the infant is not feeding well at the breast.
				<ul collapse="yes"><li>When the infant has fed well but the breast is still full and painful, only express until the breasts feel more comfortable.</li></ul>
			</li><li>Warm compresses and massage before a feed encourage milk flow.</li><li>
				Cool/cold compresses after a feed result in vasoconstriction, reduction of oedema and a degree of pain relief.
				<ul collapse="yes"><li>Cold cabbage leaves are as effective as cold packs <sup><a href="#note8">8</a></sup>.</li></ul>
			</li><li>
				Breast support from a well-fitting bra or firm t-shirt assists some women.
				<ul collapse="yes"><li>Breast binding is not recommended <sup><a href="#note9">9</a></sup>.</li></ul>
			</li><li>Anti-inflammatory medications and other analgesics provide some pain relief.</li></ul>
	</p>
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                <td class="body"><a href="http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening" target="_blank"><img src="design/tip.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]</span><h3><a href="http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening" target="_blank">Reverse pressure softening for areolar oedema</a><span class="linkDescription">[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]</span></h3>
		<p>
			Some women, especially those who receive large amounts of IV fluids during labour, have oxytocin augmentation of labour, or use high suction electric breast pump early postpartum, develop pitting oedema of the breast and areola. In these situations, a technique of reverse pressure softening reduces the oedema surrounding the nipple so that the infant can attach/latch more easily. Click on the icon to be read how this is performed.
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_w">
<script type="text/javascript">
/* <![CDATA[ */
var wqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Sarah is to be discharged 48 hours after giving birth to a healthy baby girl weighing 3.3 kg. The baby is attaching well to the breast and appears to be feeding well. What plan of management would you give her to prevent and/or treat breast fullness/engorgement?</strong>\n			</p>\n		', r : '\n			<p>\n				Sarah should continue to feed at least every 2-3 hours, leaving the baby on the first breast until she spontaneously comes off before offering the second breast. Express a little milk before the feed if her breasts are full/engorged, and at other times if the breasts are very uncomfortable. Hot packs prior to a feed, cold packs following a feed and anti-inflammatory medications or analgesics may provide pain relief.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('w');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
              <li id="note2"><a href="references.html#hill94" title="See full details">#</a> Hill P et al. (1994) The occurrence of breast engorgement</li>
              <li id="note3"><a href="references.html#renf00" title="See full details">#</a> Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.</li>
              <li id="note4"><a href="references.html#moon89" title="See full details">#</a> Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention</li>
              <li id="note5"><a href="references.html#brod04a" title="See full details">#</a> Brodribb W (2004) Breastfeeding Management</li>
              <li id="note6"><a href="references.html#mass04" title="See full details">#</a> Mass S (2004) Breast pain: engorgement, nipple pain and mastitis</li>
              <li id="note7"><a href="references.html#evan95" title="See full details">#</a> Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic</li>
              <li id="note8"><a href="references.html#robe95" title="See full details">#</a> Roberts KL (1995) A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast engorgement</li>
              <li id="note9"><a href="references.html#swif03" title="See full details">#</a> Swift K et al. (2003) Breast binding... is it all that it's wrapped up to be?</li>
            </ol>
          </div>
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        <div id="topic_3-2" class="content">
          <h1 id="top">3.2 Risk of SIDS</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
	</stage>
		<p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.</dd></dl>
	</stage>
	</td>
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                  <img src="design/callout_06.png" width="10" height="80" alt="" />
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              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
          </strong>
          <p>
		As well as needing to breastfeed frequently, in the first few weeks of life infants have short sleep cycles and do not have a distinct daynight pattern (<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>). Therefore, it is normal for infants to wake frequently at night. Some studies have found that nearly two-thirds of infants aged 1012 months continued to wake regularly at night<sup><a href="#note3">3</a></sup>. Many families also bed-share (adults and infants sharing the same sleep surface) and bed-sharing has been associated with increased breastfeeding duration (<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup>).
	</p>
          <p>
		Studies investigating risk factors for <abbr title="Sudden Infant Death Syndrome">SIDS</abbr> have often not clearly defined the sleep environment with no distinction made between safe bed-sharing and co-sleeping (where the infant is in close physical and/or social relationship with another person), and unsafe practices. A recent meta-analysis suggests that there may be a relationship between <abbr title="Sudden Infant Death Syndrome">SIDS</abbr> and bed-sharing with mothers who smoke and also for young infants (less than eight to eleven weeks old<sup><a href="#note4">4</a></sup>), although further studies with better definitions of bed-sharing are needed to give a better understanding of risk factors.
	</p>
          <p>
		There is evidence that infants sleeping on a separate sleep surface in the parents' room have a reduced risk of <abbr title="Sudden Infant Death Syndrome">SIDS</abbr> compared with infants sleeping in another room<sup><a href="#note6">6</a></sup>. Some authorities suggest placing the infant's cot alongside the mother's bed so that she can easily communicate with and access the infant.
	</p>
          <p>
		Information about safe sleeping environments for parents who wish to bed-share include the following points (<sup><a href="#note7">7</a>,</sup><sup><a href="#note6">6</a></sup>):
		<ul><li>Bed-sharing is not recommended if either of the parents smoke, have consumed alcohol or drugs, are obese or extremely fatigued.</li><li>Sleeping on soft mattresses, waterbeds, couches, recliners or sofas is not safe for infants – use a firm mattress without soft bedding, doonas or pillows near the infant.</li><li>Ensure there are no gaps between the mattress and wall or headboard, or other gaps where the infant can get trapped or wedged.</li><li>Pets should not be on/in the bed with the infant. If other children are in the bed, there should be an adult between the child and the infant.</li><li>The infant should not be dressed too warmly – adult bed coverings and body heat provide significantly more heat than if the infant is sleeping alone.</li><li>Infants should always be placed supine to sleep, although they will usually be on their side to breastfeed.</li></ul>
	</p>
          <p>
		Most families will bed-share with their infant or child at some time, even though it may not be on a regular basis. Therefore, all parents should be aware of how to make the sleep environment as safe as possible.
	</p>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#peir03" title="See full details">#</a> Peirano P et al. (2003) Sleep-wake states and their regulatory mechanisms throughout early human development</li>
              <li id="note2"><a href="references.html#dewe03" title="See full details">#</a> de Weerd AW et al. (2003) The development of sleep during the first months of life</li>
              <li id="note3"><a href="references.html#arms94" title="See full details">#</a> Armstrong K et al. (1994) The sleep patterns of normal children</li>
              <li id="note4"><a href="references.html#hors07" title="See full details">#</a> Horsley T et al. (2007) Benefits and harms associated with the practice of bed sharing</li>
              <li id="note5"><a href="references.html#ball03" title="See full details">#</a> Ball HL (2003) Breastfeeding, bed-sharing, and infant sleep</li>
              <li id="note6"><a href="references.html#mcco08" title="See full details">#</a> McCoy R et al. (2008) Clinical protocol #6: Guideline on co-sleeping and breastfeeding</li>
              <li id="note7"><a href="references.html#brod04a" title="See full details">#</a> Brodribb W (2004) Breastfeeding Management</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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        <div id="topic_3-3" class="content">
          <h1 id="top">3.3 Contraception</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
	</stage>
		<p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.</dd></dl>
	</stage>
		<p>
			Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
		</p>
		<dl><dt><a href="topic_3-3.html"><cite>Topic 3.3: Contraception</cite></a></dt><dd class="topic-paragraph">Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.</dd></dl>
	</stage>
	</td>
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            </tbody>
          </table>
          <strong>
            <p>
			Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
		</p>
          </strong>
          <p>
		As long as Joanne remains amenorrhoeic and is fully or nearly fully breastfeeding, the chance of her becoming pregnant in the first six months postpartum is less than 2 percent – a similar failure rate to many other methods of contraception <sup><a href="#note1">1</a></sup>.
	</p>
          <p>
		Suckling of the infant inhibits maternal release of hypothalamic <abbr title="Gonadotropin Releasing Hormone">GnRH</abbr>, which controls the release of <abbr title="Luteinising Hormone">LH</abbr> and <abbr title="Follicle Stimulating Hormone">FSH</abbr> – hormones necessary for the development and maturation of the ovarian follicle. This effect is dependent on the total sucking stimulus rather than the frequency or length of feeds<sup><a href="#note2">2</a></sup>. Once follicular growth occurs, there also appears to be a feedback mechanism so that ovulation is inhibited, and if ovulation does occur before six months postpartum it is usually accompanied by an inadequate luteal phase, especially prior to the first menses<sup><a href="#note2">2</a></sup>. When the suckling stimulus decreases, especially after the introduction of supplementary feeds or solids, <abbr title="Gonadotropin Releasing Hormone">GnRH</abbr> is released and ovulation occurs.
	</p>
          <p>
		After extensive observational and controlled trials in both developed and developing countries, the conditions under which this suppression of fertility could be used as an effective form of contraception were codified in 1991. The resulting contraceptive method (Lactational Amenorrhoea Method) consists of three criteria:
		<ul><li>amenorrhoea (return of menses indicated by bleeding for two consecutive days, or a bleed like a menses after day 56);</li><li>exclusive or full breastfeeding  (no regular supplementation or solids; breastfeeding frequently on demand); and</li><li>less than six months postpartum.</li></ul>
	</p>
          <p>
		When any of the three criteria are no longer applicable another method of contraception should be employed as pregnancy rates increase<sup><a href="#note3">3</a></sup>. The percentage of women whose menses return prior to six months varies considerably (26.569.5%)<sup><a href="#note4">4</a></sup>, perhaps reflecting different cultural expectations of the frequency and length of breastfeeds and the introduction of other fluids and foods.
	</p>
          <div class="captionBox">
            <img width="400" height="478" src="images/algorithm.jpg" alt="LAM algorithm" />
            <p> <br />&copy;  Health e-Learning</p>
          </div>
          <p>
		Further studies suggest that the pregnancy rate when <abbr title="Lactational Amenorrhoea Method">LAM</abbr> is continued for up to 12 months with the addition of solid foods is still quite small, although the incidence of an adequate luteal phase with ovulation before the first menses increases<sup><a href="#note3">3</a></sup>.
	</p>
          <p>
		Non-hormonal forms of contraception, such as condoms, diaphragms and some forms of <abbr title="Intrauterine Device">IUD</abbr>s, have little or no effect on lactation and are the methods of choice when another form of contraception in addition to, or instead of, <abbr title="Lactational Amenorrhoea Method">LAM</abbr> is required.
	</p>
          <p>
		Studies of progesterone-only contraceptive methods (mini-pill, progesterone-containing <abbr title="Intrauterine Device">IUD</abbr>s, depo or implants) used during lactation also show minimal effect on lactation, although some women report a reduction in milk supply. Therefore, these methods should be used cautiously in women who have, or are at risk of having, problems maintaining an adequate milk supply. There is also a theoretical risk of disturbing the initiation of lactation if progestogens are prescribed early in the postpartum period as lactogenesis II is triggered by a drop in progesterone levels.
	</p>
          <p>
		Contraceptives containing oestrogen are known to cause a reduction in milk supply and should preferably not be used during lactation. If it is the most suitable contraceptive method for a woman, delaying its introduction until six months postpartum is recommended (<sup><a href="#note1">1</a>,</sup><sup><a href="#note3">3</a></sup>).
	</p>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_x">
<script type="text/javascript">
/* <![CDATA[ */
var xqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>As part of a routine consultation at six weeks postpartum, you normally discuss contraception. What benefits and risks of the following methods of contraception would you discuss with Elizabeth, who is exclusively breastfeeding<!--: <abbr title=\"Lactational Amenorrhoea Method\">LAM</abbr>; progesterone-only pill; injectable progesterone contraceptive; combined oral contraceptive; and non-hormonal <abbr title=\"Intrauterine Device\">IUD</abbr>-->?</strong>\n			</p>\n		', r : '\n			<p>\n				The Lactational Amenorrhoea Method (LAM) of contraception is effective in preventing pregnancy during the first six months postpartum as long as the baby is exclusively or fully breastfed and Elizabeth has not begun to menstruate. Non-hormonal forms of contraception would be the next methods of choice followed by progesterone containing products. Pills, vaginal rings or patches containing oestrogen and progesterone are not recommended during lactation.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('x');</script>
	</td>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#labb08" title="See full details">#</a> Labbok MH et al. (2005) Clinical protocol #13: Contraception during breastfeeding</li>
              <li id="note2"><a href="references.html#mcne01" title="See full details">#</a> McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women</li>
              <li id="note3"><a href="references.html#labb07" title="See full details">#</a> Labbok M (2007) Breastfeeding, Birth Spacing and Family Planning</li>
              <li id="note4"><a href="references.html#worl99" title="See full details">#</a>  (1999) World Health Organization task force on methods for the natural regluation of fertility</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_3-4" class="content">
          <h1 id="top">3.4 Milk composition</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
	</stage>
		<p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.</dd></dl>
	</stage>
		<p>
			Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
		</p>
		<dl><dt><a href="topic_3-3.html"><cite>Topic 3.3: Contraception</cite></a></dt><dd class="topic-paragraph">Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.</dd></dl>
	</stage>
		<p>
			Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
		</p>
		<dl><dt><a href="topic_3-4.html"><cite>Topic 3.4: Milk composition</cite></a></dt><dd class="topic-paragraph">The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant. </dd></dl>
	</stage>
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          <strong>
            <p>
			Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
		</p>
          </strong>
          <p>
		Breastmilk is a complete food and drink for infants until six months of age. The composition of breastmilk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infants.
	</p>
          <div class="section display-accordion" id="Breastmilk_Composition"><h2>Breastmilk Composition</h2>
		<div class="section" id="Carbohydrates"><h3>Carbohydrates</h3><div class="section" id="">
			<dl><dt>Lactose</dt><dd>
					Breastmilk contains the highest lactose concentration of any mammalian milk (approximately 68g/L), providing up to 40 percent of the infant's energy requirements<sup><a href="#note1">1</a></sup>. Lactose is synthesised in the breast and is one of the most stable components of breastmilk, being independent of maternal diet. The osmotic effect of lactose in the alveoli is the main determinant of breastmilk volume<sup><a href="#note2">2</a></sup>. As well as being broken down to galactose and glucose by lactase found in the brush borders of the small intestine, lactose also enhances calcium absorption. Galactose and glucose are absorbed and provide energy for the infant, especially the rapidly developing brain. Galactose is also used to produce galactolipids – important in the development of the central nervous system (<sup><a href="#note3">3</a>,</sup><sup><a href="#note2">2</a></sup>).
				</dd><dt>Oligosaccharides, glycoproteins and glycolipids</dt><dd>
					These molecules encourage the growth of non-pathogenic bacteria such as <span class="term">Lactobacillus bifidus</span> in the infant's gut and provide the basis for important components of the central nervous system<sup><a href="#note3">3</a></sup>. Oligosaccharides also appear to provide alternate binding sites for pathogenic bacteria and reduce the adherence of bacteria to epithelial cells. Some oligosaccharides are absorbed and excreted in the urine and may be the mechanism for the reduced incidence of urinary tract infections in breastfed infants<sup><a href="#note1">1</a></sup>.
				</dd></dl>
		</div></div>
		<div class="section" id="Protein_and_non-protein_nitrogen"><h3>Protein and non-protein nitrogen</h3><div class="section" id="">
			<dl><dt>Non-protein nitrogen</dt><dd>
					This comprises up to 25 percent of the nitrogen found in breastmilk and consists of more than 200 nitrogenous compounds, including free amino acids, nucleotides, carnitine and urea – some of which appear to be essential for metabolism and growth. Nucleotides also stimulate the growth of Lactobacillus bifidus and inhibit the growth of pathogenic bacteria in the gut (<sup><a href="#note1">1</a>,</sup><sup><a href="#note4">4</a></sup>).
				</dd><dt>Protein</dt><dd>
					Protein levels in breastmilk are approximately 9g/L, the lowest level among mammalian species, reflected in the human infant's slow growth. Casein contains a number of peptides that bind calcium, phosphorus and magnesium and are insoluble in the low pH of the stomach, forming a curd. Casein enables the delivery of calcium and phosphorus as well as other amino acids to the infant (<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup>). In contrast, the whey portion of the milk contains the following soluble proteins:
					<ul><li><span class="term">α-lactalbumin</span>, the most common whey protein, appears to have a mainly nutritional role, providing amino acids necessary for growth and development of the infant, although it also has anti-infective properties. α-lactalbumin is also involved in lactose synthesis in the breast<sup><a href="#note4">4</a></sup>.</li><li><span class="term">Immunoglobulins (especially IgA), lactoferrin and lysozyme</span> are bacteriostatic and bactericidal to many bacteria, protozoa, viruses and fungi. Lactoferrin binds iron in milk and enhances iron absorption by the infant.</li><li><span class="term">Carrier proteins for vitamins and hormones</span> – for example Vitamin B12 binding protein and corticosteroid-binding protein.</li><li><span class="term">Enzymes</span> such as bile-salt stimulated lipase and amylase.</li><li><span class="term">Other active components</span> such as epidermal growth factor, insulin, insulin-like-growth factor and relaxin<sup><a href="#note5">5</a></sup>.</li></ul>
					There is some evidence that women who have protein-deficient diets, particularly if there are deficiencies in other dietary components, have a reduction in total protein and non-protein nitrogen in their breastmilk. There is not data to date to indicate whether there is an adverse effect on infant growth or development<sup><a href="#note1">1</a></sup>.
				</dd></dl>
		</div></div>
		<div class="section" id="Fat"><h3>Fat</h3><div class="section" id="">
			<p>
				The fat content of human milk is approximately 40 g/L<sup><a href="#note6">6</a></sup> but varies (35 and 45 g/L) between women, between breastfeeds for the same woman and within a breastfeed<sup><a href="#note1">1</a></sup>. Fats provide between 45 and 55 percent of the total energy needs of the infant as well as providing essential fatty acids and a mechanism for the delivery of fat-soluble vitamins<sup><a href="#note1">1</a></sup>. The majority of fats (9899%) are in the form of triglycerides – 85 percent of which are medium and long chain fatty acids. These include essential fatty acids linoleic and alpha-linolenic acid as well as the omega-3 and omega-6 <abbr title="Long Chain Polyunsaturated Fatty Acids">LCPUFAs</abbr> arachindonic acid and docosahexaenoic acids, important for the development of the nervous system and membrane structure. Small amounts of phospholipids (integral for myelinization and development of the retina) and cholesterol are also present (<sup><a href="#note1">1</a>,</sup><sup><a href="#note6">6</a></sup>).
			</p>
			<p>
				Medium chain fatty acids are synthesised in the breast while other fats are primarily derived from dietary sources. When the maternal diet is unable to provide the fats needed, long chain fatty acids are derived from the breakdown of maternal fat stores. Therefore the composition of fat in human milk, but not the concentration, will vary depending on maternal diet. Cholesterol levels are not affected by the maternal diet or blood levels<sup><a href="#note6">6</a></sup>.
			</p>
			<p>
				Fat concentration in breastmilk rises throughout the feed. However fat content is closely related to the degree of breast fullness with fat concentration being lowest when the breasts are full, and highest when the breasts are well drained. A milk sample with a fat content of more than 10 percent indicates that the breast is well drained<sup><a href="#note7">7</a></sup>. For a woman with a large milk storage capacity whose infant does not drain the breast at each feed, the fat concentration at the beginning of one feed may be higher than the fat concentration at the end of another feed<sup><a href="#note8">8</a></sup>. As a reflection of breast drainage, fat content is higher in the day and evening than in the morning and night<sup><a href="#note8">8</a></sup>.
			</p>
			<div class="columns"><div class="column" style="width: 50%">
					<div class="captionBox"><img width="259" height="316" src="images/fat_increase_test_tubes_cropped.jpg" alt="" /><p> <br />&copy;  J.Kent, Biochemistry &amp; Molecular Biology, UWA</p></div>
				</div><div class="column" style="width: 50%">
					This is a series of sample from an expression collected in 10mL fractions. The samples are, in order from left to right, a foremilk sample (hand-expressed), a stimulation sample (the first milk removed by the breast pump), 7 samples collected during the expression, and a final sample hand-expressed after theexpression. the initial sample is 5.6% cream (fat) and the final is 18.3% cream (fat).
				</div></div><br style="clear: both" />
			<p>
				Breastmilk contains bile-salt stimulated lipase that assists lingula, gastric and pancreatic lipase to digest milk fats<sup><a href="#note1">1</a></sup>.
			</p>
		</div></div>
		<div class="section" id="Vitamins"><h3>Vitamins</h3><div class="section" id="">
			<p>
				Women with adequate vitamin intake and stores produce milk that is also has adequate vitamin concentrations. Increasing vitamin intake in these women does not necessarily increase milk vitamin concentrations. However, if the maternal vitamin status is low, milk vitamin concentrations also tend to be low and the infant may become deficient. Maternal supplementation in most of these situations rapidly returns milk concentrations to normal. Two vitamins require special mention.
			</p>
			<dl><dt>Vitamin D</dt><dd>
					Vitamin D levels in breastmilk are not adequate to completely supply the needs of the infant, with sunlight being the natural source of Vitamin D for infants and their mothers. When direct sun exposure is restricted (e.g. climatic conditions, cultural clothing or to protect skin from solar damage) or skin colour reduces the effect of sun exposure, mothers and their infants may become Vitamin D deficient. Those most at risk of Vitamin D deficiency are dark-skinned women, women who are veiled and those who live in high latitudes where sun exposure, especially in winter, is limited. Some countries recommend supplementing all breastfed infants with Vitamin D<sup><a href="#note9">9</a></sup> while others recommend women at risk be monitored and their infants supplemented when necessary<sup><a href="#note10">10</a></sup>.
				</dd><dt>Vitamin B12</dt><dd>
					Women with pernicious anaemia, on a strict vegan diet that is deficient in Vitamin B12 or with other causes of Vitamin B12 deficiency will produce milk that is also deficient in the vitamin. The infants may develop irreversible neurological sequelae if not diagnosed and supplemented<sup><a href="#note11">11</a></sup>.
				</dd></dl>
		</div></div>
		<div class="section" id="Minerals"><h3>Minerals</h3><div class="section" id="">
			<p>
				In contrast to vitamins, mineral levels in milk are usually independent of maternal intake. Binding proteins and other transfer factors present in breastmilk enhance the absorption by the infant of minerals and other trace elements so that even apparent low concentrations of specific minerals have a high bioavailability. In contrast, infant formulas often have high mineral concentrations (up to 100 times that of breastmilk) to compensate for their low bioavailability<sup><a href="#note12">12</a></sup>.
			</p>
			<dl><dt>Calcium</dt><dd>
					Calcium levels in breastmilk are 2530 g/L and appear to be independent of maternal dietary calcium intake (<sup><a href="#note12">12</a>,</sup><sup><a href="#note13">13</a></sup>). Lactose and citrate in breastmilk aid calcium absorption. During the early months of lactation, there is a reduction in maternal bone mineralisation, particularly of the trabecular bones such as the spine and hip, although this is reversed later in lactation and after breastfeeding ceases. This demineralisation is not related to maternal calcium intake – calcium supplementation does not prevent or reduce the effect<sup><a href="#note14">14</a></sup>. There is no evidence that breastfeeding has a detrimental effect on long-term bone mineralisation or is a risk factor for the development of osteoporosis. Women who become pregnant during or soon after lactation remineralise their bones in early pregnancy<sup><a href="#note13">13</a></sup>.
				</dd><dt>Iron</dt><dd>
					Breastmilk appears to have very low iron levels (0.2-0.4mg/L), but its bioavailability is high so that term infants, who have laid down iron stores before birth, do not require additional sources of iron until around six months of age. Breastmilk concentrations appear to be independent of maternal iron status<sup><a href="#note12">12</a></sup>. Lactoferrin binds iron in breastmilk and is thought to play a role in its absorption although other factors are also relevant. Vitamin C is known to increase iron absorption<sup><a href="#note12">12</a></sup>. Phylates, present in cereals, interfere with the absorption of iron. As infant cereals (often supplemented with iron) are often the first weaning foods, this may be a reason why breastfed infants given solids before six months are more likely to be iron deficient at nine months than infants exclusively breastfed for at least six months<sup><a href="#note12">12</a></sup>. Iron supplementation of infants who are not iron deficient appears to increase episodes of diarrhoea<sup><a href="#note15">15</a></sup>.
				</dd><dt>Iodine</dt><dd>
					Iodine concentration in breastmilk varies depending on maternal iodine status. Although iodine is concentrated in breastmilk, in areas where iodine deficiency is prevalent and goitre formation common, iodine deficiency in breastfed infants can occur<sup><a href="#note16">16</a></sup>. The use of iodised salt and other iodine supplements by the mother, where appropriate, ensures maternal iodine sufficiency and adequate iodine intake for the infant<sup><a href="#note17">17</a></sup>.
				</dd></dl>
		</div></div>
		<div class="section" id="Changes_in_milk_composition"><h3>Changes in milk composition</h3><div class="section" id="">
			<dl><dt>Over time</dt><dd>
					The concentration of various components of breastmilk changes over the course of lactation. Compared with mature milk (outlined previously), colostrum has higher concentrations of protein (especially immunoglobulins), sodium and chloride and lower concentrations of lactose, potassium, calcium and citrate<sup><a href="#note7">7</a></sup>. Many of these differences are due to the closure of the tight junctions between the lactocytes with the onset of lactogenesis II. Lactose levels remain relatively stable over the course of lactation. However, fat content falls during the first four months of lactation, but rises again until 12 months while protein concentration decreases until six months and then remains stable<sup><a href="#note18">18</a></sup>. While most micronutrient levels stay constant over time, there is a gradual fall in zinc, copper, Vitamin A and potassium levels. None of these variations reduces the overall nutritional value of breastmilk consumed by the infant – infant growth is related to milk volume consumed and not the concentration of particular macronutrients<sup><a href="#note7">7</a></sup>. During weaning, breastmilk returns to a more colostral composition with higher concentrations of immunoglobulins, sodium and chloride<sup><a href="#note19">19</a></sup>.
				</dd><dt>Length of gestation</dt><dd>
					The milk produced by mothers who have delivered prematurely differs from milk produced by mothers delivered at term. In particular, there are higher concentrations of protein, mainly IgA and lactoferrin, as well has increased levels of calcium, phosphorus and zinc<sup><a href="#note3">3</a></sup>. While fat levels are similar, there is a higher proportion of medium chain fatty acids in pre-term milk<sup><a href="#note6">6</a></sup>.
				</dd></dl>
		</div></div>
		<div class="section" id="Milk_yield"><h3>Milk yield</h3><div class="section" id="">
			<p>
				Milk production remains at a similar level from the end of the first month until the sixth month of lactation. Although the amount of milk needed for adequate growth varies considerably (4401220 ml/day) most women will produce between 710 and 803 mls/day<sup><a href="#note8">8</a></sup>. Volume of milk produced at the end of the first week postpartum is predictive of milk production at six weeks<sup><a href="#note20">20</a></sup>. From six months, with the addition of solid foods to the infant's diet, milk production gradually falls, although many women still produce over 500mls of breastmilk a day at 12 months<sup><a href="#note21">21</a></sup>.
			</p>
		</div></div>
	</div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#picc01" title="See full details">#</a> Picciano MF (2001) Nutrient Composition of Human Milk</li>
              <li id="note2"><a href="references.html#czan07" title="See full details">#</a> Czank C et al. (2007) Human milk composition - carbohydrates</li>
              <li id="note3"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
              <li id="note4"><a href="references.html#czan07c" title="See full details">#</a> Czank C et al. Human milk composition - nitrogen and energy content</li>
              <li id="note5"><a href="references.html#walk93" title="See full details">#</a> Walker M (1993) A fresh look at the risks of artificial infant feeding</li>
              <li id="note6"><a href="references.html#czan07a" title="See full details">#</a> Czank C et al. (2007) Human milk composition - fat</li>
              <li id="note7"><a href="references.html#kent07" title="See full details">#</a> Kent JC (2007) How breastfeeding works</li>
              <li id="note8"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
              <li id="note9"><a href="references.html#aapp05" title="See full details">#</a> AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk</li>
              <li id="note10"><a href="references.html#munn06" title="See full details">#</a> Munns C et al. (2006) Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement</li>
              <li id="note11"><a href="references.html#rass01" title="See full details">#</a> Rasmussen SA et al. (2001) Vitamin B12 deficiency in children and adolescents</li>
              <li id="note12"><a href="references.html#lonn97" title="See full details">#</a> Lonnerdal B (1997) Effects of milk and milk components on calcium, magnesium, and trace element absorption during infancy</li>
              <li id="note13"><a href="references.html#pren03" title="See full details">#</a> Prentice A (2003) Micronutrients and the bone mineral content of the mother, fetus and newborn</li>
              <li id="note14"><a href="references.html#kova05" title="See full details">#</a> Kovacs CS (2005) Calcium and bone metabolism during pregnancy and lactation</li>
              <li id="note15"><a href="references.html#alle05" title="See full details">#</a> Allen LH (2005) Multiple micronutrients in pregnancy and lactation: an overview</li>
              <li id="note16"><a href="references.html#semb01" title="See full details">#</a> Semba RD et al. (2001) Iodine in human milk: perspectives for infant health</li>
              <li id="note17"><a href="references.html#zimm07" title="See full details">#</a> Zimmermann MB (2007) The impact of iodised salt or iodine supplements on iodine status during pregnancy, lactation and infancy</li>
              <li id="note18"><a href="references.html#mito02a" title="See full details">#</a> Mitoulas LR et al. (2002) Variations in fat, lactose and protein in human milk over 24 h and throughout the first year of life</li>
              <li id="note19"><a href="references.html#hart85" title="See full details">#</a> Hartmann PE et al. (1985) Variations in the yield and composition of human milk</li>
              <li id="note20"><a href="references.html#hill05" title="See full details">#</a> Hill PD et al. (2005) Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth</li>
              <li id="note21"><a href="references.html#kent99" title="See full details">#</a> Kent JC et al. (1999) Breast volume and milk production during extended lactation in women</li>
            </ol>
          </div>
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          <h1 id="top">3.5 Slowing of growth</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
	</stage>
		<p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.</dd></dl>
	</stage>
		<p>
			Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
		</p>
		<dl><dt><a href="topic_3-3.html"><cite>Topic 3.3: Contraception</cite></a></dt><dd class="topic-paragraph">Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.</dd></dl>
	</stage>
		<p>
			Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
		</p>
		<dl><dt><a href="topic_3-4.html"><cite>Topic 3.4: Milk composition</cite></a></dt><dd class="topic-paragraph">The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant. </dd></dl>
	</stage>
		<p>
			Is there any concern about a slowing of growth around this time?
		</p>
		<dl><dt><a href="topic_3-5.html"><cite>Topic 3.5: Slowing of growth</cite></a></dt><dd class="topic-paragraph">Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.</dd></dl>
	</stage>
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          <strong>
            <p>
			Is there any concern about a slowing of growth around this time?
		</p>
          </strong>
          <p>
		Infant growth is highest in the first few months postpartum and then begins to slow so a decrease in the rate of growth at this age is normal. Additionally, after three months of age breastfed infants gain weight at a slower rate than formula-fed infants, so that by six months they are lighter<sup><a href="#note1">1</a></sup> and this is maintained until at least twelve months<sup><a href="#note2">2</a></sup>.
	</p>
          <p>
		Most growth charts in use were developed in the United States from cross-sectional data of cohorts of infants who were mainly formula-fed, or contained a mixture of formula-fed and breastfed infants. On these charts, breastfed infants often began to deviate from a specific percentile after four to five months although they continued to thrive otherwise. In 2006 the <abbr title="World Health Organisation">WHO</abbr> released new growth standards based on longitudinal data of healthy breastfed infants and children from seven countries. These charts reflect how well-nourished breastfed infants 'should' grow rather than the actual growth in a given population. In comparison to the CDC charts commonly used, the mean weight in the <abbr title="World Health Organisation">WHO</abbr> standards is higher for the first six months but is lower from 6 to 32 months<sup><a href="#note3">3</a></sup>. <abbr title="World Health Organisation">WHO</abbr> standards for infant <abbr title="Body Mass Index">BMI</abbr> are also available to allow for difference in growth parameters between different racial groups.
	</p>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#dewe92" title="See full details">#</a> Dewey KG et al. (1992) Growth of breast-fed and formula-fed infants from 0 to 18 months: The DARLING study</li>
              <li id="note2"><a href="references.html#dewe93a" title="See full details">#</a> Dewey KG et al. (1993) Breast-fed infants are leaner than formula-fed infants at 1 y of age: the DARLING study</li>
              <li id="note3"><a href="references.html#deon07" title="See full details">#</a> de Onis M et al. (2007) Comparison of the WHO Child Growth Standards and the CDC 2000 Growth Charts</li>
            </ol>
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          <h1 id="top">3.6 Introducing solids</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
	</stage>
		<p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.</dd></dl>
	</stage>
		<p>
			Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
		</p>
		<dl><dt><a href="topic_3-3.html"><cite>Topic 3.3: Contraception</cite></a></dt><dd class="topic-paragraph">Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.</dd></dl>
	</stage>
		<p>
			Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
		</p>
		<dl><dt><a href="topic_3-4.html"><cite>Topic 3.4: Milk composition</cite></a></dt><dd class="topic-paragraph">The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant. </dd></dl>
	</stage>
		<p>
			Is there any concern about a slowing of growth around this time?
		</p>
		<dl><dt><a href="topic_3-5.html"><cite>Topic 3.5: Slowing of growth</cite></a></dt><dd class="topic-paragraph">Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.</dd></dl>
	</stage>
		<p>
			Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?
		</p>
		<dl><dt><a href="topic_3-6.html"><cite>Topic 3.6: Introducing solids</cite></a></dt><dd class="topic-paragraph">Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.</dd></dl>
	</stage>
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          <strong>
            <p>
			Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?
		</p>
          </strong>
          <p>
		A systematic review commissioned by <abbr title="World Health Organisation">WHO</abbr> and released in 2001 found that in most circumstances growth and nutrition of infants exclusively breastfed until six months was no different from those who had complementary foods added to their diet at four months<sup><a href="#note1">1</a></sup>. In addition, there appeared to be an increase in gastrointestinal illness in infants exclusively breastfed for three instead of six months<sup><a href="#note2">2</a></sup>. A recent United States study also suggests that the incidence of otitis media and respiratory infection is higher when infants are introduced to complementary foods at four months rather than six months<sup><a href="#note3">3</a></sup>. The <abbr title="World Health Organisation">WHO</abbr>, the <abbr title="National Health &amp; Medical Research Council">NHMRC</abbr> in Australia, the <abbr title="American Academy of Pediatrics">AAP</abbr> and bodies throughout the world recommend, at a population level, that infants be exclusively breastfed for the first six months of life(<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>). Infants who are at risk of becoming deficient in micronutrients such as iron (e.g. premature infants who have limited iron stores) benefit from medicinal supplements rather than the early introduction of solids<sup><a href="#note7">7</a></sup>.
	</p>
          <p>
		After six months, breast milk alone may not provide enough energy (especially protein) for adequate growth, and deficiencies in some micronutrients such as iron and zinc may occur. Therefore, nutrient-rich foods with adequate iron content are the most appropriate solid foods at this age. In developed countries, infants aged six to eight months require approximately 130kcal/day from two or three meals of complementary food. This increases to three or four meals plus one or two nutritious snacks to provide 310 kcal/day at nine to 11 months and 580 kcal/day at 12 to 23 months. Although foods at six months tend to be pureed, mashed or semi-solid, by eight months most infants can manage finger food and by 12 months should be eating the same foods as the rest of the family<sup><a href="#note7">7</a></sup>. If possible, meats should be introduced early as good sources of protein and micronutrients<sup><a href="#note8">8</a></sup>. Low-fat products are not appropriate for infants or toddlers.
	</p>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kram02" title="See full details">#</a> Kramer M et al. (2002) The optimal duration of exclusive breastfeeding. A systematic review.</li>
              <li id="note2"><a href="references.html#kram03" title="See full details">#</a> Kramer M et al. (2003) Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding</li>
              <li id="note3"><a href="references.html#chan06" title="See full details">#</a> Chantry CJ et al. (2006) Full breastfeeding duration and associated decrease in respiratory tract infection in US children</li>
              <li id="note4"><a href="references.html#nati03" title="See full details">#</a> National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers</li>
              <li id="note5"><a href="references.html#aapp05" title="See full details">#</a> AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk</li>
              <li id="note6"><a href="references.html#worl03a" title="See full details">#</a> World Health Organization (2003) Global Strategy for Infant and Young Child Feeding</li>
              <li id="note7"><a href="references.html#dewe02" title="See full details">#</a> Dewey KG (2002) Guiding Principles for Complementary Feeding of the Breastfed Child</li>
              <li id="note8"><a href="references.html#kreb07" title="See full details">#</a> Krebs NF et al. (2007) Complementary feeding: clinically relevant factors affecting timing and composition</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
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          <h1 id="top">3.7 Weaning</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
		</p>
		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
	</stage>
		<p>
			You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
		</p>
		<dl><dt><a href="topic_3-2.html"><cite>Topic 3.2: Risk of SIDS</cite></a></dt><dd class="topic-paragraph">It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.</dd></dl>
	</stage>
		<p>
			Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
		</p>
		<dl><dt><a href="topic_3-3.html"><cite>Topic 3.3: Contraception</cite></a></dt><dd class="topic-paragraph">Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.</dd></dl>
	</stage>
		<p>
			Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
		</p>
		<dl><dt><a href="topic_3-4.html"><cite>Topic 3.4: Milk composition</cite></a></dt><dd class="topic-paragraph">The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant. </dd></dl>
	</stage>
		<p>
			Is there any concern about a slowing of growth around this time?
		</p>
		<dl><dt><a href="topic_3-5.html"><cite>Topic 3.5: Slowing of growth</cite></a></dt><dd class="topic-paragraph">Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.</dd></dl>
	</stage>
		<p>
			Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?
		</p>
		<dl><dt><a href="topic_3-6.html"><cite>Topic 3.6: Introducing solids</cite></a></dt><dd class="topic-paragraph">Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.</dd></dl>
	</stage>
		<p>
			What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?
		</p>
		<dl><dt><a href="topic_3-7.html"><cite>Topic 3.7: Weaning</cite></a></dt><dd class="topic-paragraph">There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months (NHMRC, AAP) or two years (WHO). Gradual weaning is ideal.</dd></dl>
	</stage>
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          <strong>
            <p>
			What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?
		</p>
          </strong>
          <p>
		There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months. The <abbr title="World Health Organisation">WHO</abbr> recommends breastfeeding for at least two years, with continued breastfeeding for as long as the mother and infant wish<sup><a href="#note1">1</a></sup>, while the <abbr title="National Health &amp; Medical Research Council">NHMRC</abbr> recommends continued breastfeeding for at least the first 12 months and then for as long as the mother and infant wish<sup><a href="#note2">2</a></sup>. Katherine Dettwyler, an anthropologist who has studied the natural weaning age of primates, suggests that without social constraints human children would naturally wean aged between two and a half and seven years<sup><a href="#note3">3</a></sup>. Breast milk continues to provide immunological benefits to the infant/child until weaning<sup><a href="#note4">4</a></sup>, and adequate growth is maintained when appropriate complementary foods are given in addition to breastfeeding<sup><a href="#note5">5</a></sup>.
	</p>
          <p>
		Gradual weaning, regardless of the age of the infant or child, is ideal. When the child is older, other foods and fluids gradually replace breastfeeds as a source of nourishment so that the child may only be breastfeeding night and morning. These feeds can then be dropped one at a time by providing other foods or distractions at the time. If the child or infant is younger and breastfeeding constitutes all or most of their nourishment, a more structured weaning process is usually required. First, one breastfed is replaced by infant formula. The mother may experience breast engorgement because of this change in feeding routines. A second breastfeed is replaced when the mother feels ready, but it is ideal to wait at least a few days. A similar process continues until the infant is not having any breastfeeds.
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                <td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Rapid or immediate weaning is not recommended</h3>
		<p>
			Rapid or immediate weaning is not recommended unless there is no alternative. It is often physically and psychologically very distressing for both the mother and infant. The mother will also experience painful engorgement and is at increased risk of mastitis. Beyond the immediate postpartum period, lactation suppression medications such as cabergoline have reduced effectiveness.
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_y">
<script type="text/javascript">
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var yqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Rebecca tells you that her nine-month-old son Simon is still exclusively breastfed, as she has heard that breast milk alone is sufficient until the baby is 12 months old. What would you be concerned about in this situation? What would you tell Rebecca about continuing to breastfeed?</strong>\n			</p>\n		', r : '\n			<p>\n				At around 6 months breast milk may no longer provide iron, zinc, or energy (especially protein) for adequate growth and prevention on micronutrient deficiencies. Simon may be iron or zinc deficient or his growth may be affected at this stage. Breastfeeding is still an important source of food and nutrients for at least the first 12 months and longer, so Rebecca should continue to breastfeed. However, additional foods need to be added.\n			</p>\n		' }
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<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('y');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#worl03a" title="See full details">#</a> World Health Organization (2003) Global Strategy for Infant and Young Child Feeding</li>
              <li id="note2"><a href="references.html#nati03" title="See full details">#</a> National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers</li>
              <li id="note3"><a href="references.html#dett04" title="See full details">#</a> Dettwyler KA (2004) When to wean: biological versus cultural perspectives</li>
              <li id="note4"><a href="references.html#gold83" title="See full details">#</a> Goldman A et al. (1983) Immunologic components in human milk during the second year of lactation</li>
              <li id="note5"><a href="references.html#buck01" title="See full details">#</a> Buckley KM (2001) Long-term breastfeeding: nourishment or nurturance?</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_4-0" class="content">
          <h1 id="top">4.0 Case Study D (Sally)</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study D</h3>
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		<p>
			Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
		</p>
		<dl><dt><a href="topic_4-1.html"><cite>Topic 4.1: Initial assessment</cite></a></dt><dd class="topic-paragraph">To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.</dd></dl>
	</stage>
		<p>
			Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.
		</p>
		<dl><dt><a href="topic_4-2.html"><cite>Topic 4.2: Milk production</cite></a></dt><dd class="topic-paragraph">Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.</dd></dl>
	</stage>
		<p>
			What may cause inadequate growth in breastfed infants such as Emily?
		</p>
		<dl><dt><a href="topic_4-3.html"><cite>Topic 4.3: Causes of inadequate infant growth</cite></a></dt><dd class="topic-paragraph">The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.</dd></dl>
	</stage>
		<p>
			How could Sally increase her milk supply?
		</p>
		<dl><dt><a href="topic_4-4.html"><cite>Topic 4.4: Increasing milk supply</cite></a></dt><dd class="topic-paragraph">To increase a mother's milk supply correct any underlying problems, if possible, and increase breast drainage. Encourage adequate rest and a balanced diet. Some women require galactagogues. Some infants who are malnourished at presentation, or do not respond to effective, frequent feeding, may need supplementation with donor breast milk or infant formula.</dd></dl>
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          <h1 id="top">4.1 Initial assessment</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study D</h3>
		<stage>
		<stage>
		
	</stage>
		<p>
			Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
		</p>
		<dl><dt><a href="topic_4-1.html"><cite>Topic 4.1: Initial assessment</cite></a></dt><dd class="topic-paragraph">To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.</dd></dl>
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          <strong>
            <p>
			Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
		</p>
          </strong>
          <p>
		Assessment would need to include information relating to the adequacy of breast milk intake, breast or nipple problems and maternal confidence, and physical examination of the infant.
	</p>
          <div class="section display-accordion" id="">
		<div class="section" id="Questions_related_to_adequacy_of_breast_milk_intake_in_the_infant"><h3>Questions related to adequacy of breast milk intake in the infant</h3><div class="section" id="">
			<dl><dt>Number and length of feeds</dt><dd>
					<p>
						If the infant feeds well soon after delivery, he or she may have a prolonged sleep (occasionally 10 hours or longer) before feeding again. From that time, most infants will require more than eight breastfeeds within a 24 hour period (usually between eight and twelve times)(<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup>), with at least one breastfeed between midnight and 6am. The length of a breastfeed also varies, although most breastfeeds will include between 10 and 40 minutes of active feeding.
					</p>
					<p>
						Take note if the infant:
						<ul><li>regularly has less than eight or more than 12 breastfeeds a day;</li><li>is routinely at the breast for more than 5060 minutes for each feed;</li><li>continually slips off the breast; or</li><li>makes a clicking sound throughout the feed.</li></ul>
					</p>
				</dd><dt>Elimination patterns</dt><dd>
					<p>
						Both urine and stool outputs are important signs of adequate breast milk intake in the first few weeks. Until day three, infants are expected to void at least the same number of times/day as the day postpartum. Urine output after day three increases with at least six very wet nappies per day of pale odourless urine considered normal. It is harder to judge urine output with disposable nappies, but at least four heavy wet disposable nappies is appropriate. Most adequately breastfed infants will have three or more bowel movements a day (<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>). Transition stools usually begin around day three to four with normal breastfed stools (yellow, curdy, fairly liquid) occurring from day five. Higher numbers of bowel motions per day and an earlier transition to yellow stools are associated with less weight loss, earlier return to birth weight and heavier weight on day 14<sup><a href="#note4">4</a></sup>.
					</p>
					<p>
						Take note if the infant:
						<ul><li>has less than four to six voids a day;</li><li>has strong-smelling or dark-coloured urine;</li><li>has urate deposits after day three;</li><li>has less than two to three bowel motions per day; or</li><li>passes meconium or transition stools to the end of the first week.</li></ul>
					</p>
				</dd><dt>General behaviour</dt><dd>
					<p>
						Adequately fed infants usually go to the breast and feed effectively for at least 10 to 15 minutes without falling asleep or slipping off the breast. Swallowing can be heard throughout most of the feed. He or she will be content after some feeds, is alert and responsive and will wake spontaneously to feed at least eight times a day.
					</p>
					<p>
						Take note if:
						<ul><li>the infant appears to be very placid and wakes for a feed infrequently;</li><li>the infant falls asleep soon after going to the breast with the mother spending the remainder of the feed trying to keep the infant interested in feeding;</li><li>the infant always appears to be hungry;</li><li>the infant is unhappy and unsettled; or</li><li>little or no swallowing can be heard during the feed.</li></ul>
					</p>
				</dd></dl>
		</div></div>
		<div class="section" id="Questions_about_breast_or_nipple_problems_and_maternal_confidence"><h3>Questions about breast or nipple problems and maternal confidence</h3><div class="section" id="">
			<dl><dt>Breast and nipple concerns</dt><dd>
					<p>
						Although the nipples may have been tender in the first week, tenderness usually subsides by 10 to 14 days postpartum, with some latch-on tenderness remaining<sup><a href="#note7">7</a></sup>. Breasts feel fuller before a feed and softer after the infant has fed.
					</p>
					<p>
						Take note if the:
						<ul><li>nipples are sore and cracked;</li><li>breasts are soft most of the time; or</li><li>breasts are hard and painful.</li></ul>
					</p>
				</dd><dt>Confidence</dt><dd>
					<p>
						Is the mother feeling confident attaching the infant to the breast and knowing that he or she is feeding well? Although it takes time to feel confident with all aspects of infant care, increasing confidence is often a sign that the mother is adapting to motherhood and breastfeeding.
					</p>
					<p>
						Take note if the mother:
						<ul><li>is having difficulties attaching the infant to the breast;</li><li>lacks confidence with her mothering skills and her milk supply; or</li><li>appears depressed.</li></ul>
					</p>
				</dd></dl>
		</div></div>
		<div class="section" id="Infant_examination"><h3>Infant examination</h3><div class="section" id="">
			<dl><dt>Weight gain</dt><dd>
					<p>
						Most infants will lose some weight (usually &lt;7 percent of their body weight) in the first two to three days postpartum but begin to gain again with the onset of copious milk production around day three. Weight loss of &gt;10 percent is suggestive of insufficient breast milk intake<sup><a href="#note8">8</a></sup>. It is expected that infants will regain their birth weight by day 10 to 14<sup><a href="#note8">8</a></sup> and continue to gain more than 150 g/week (or 500g/month) in the first three months<sup><a href="#note9">9</a></sup>. It is important the scales used are accurate and have sufficient precision to be able to monitor weights correctly. Variations in weight can occur with elimination and feeding patterns (e.g. weighing before or after a large bowel motion, or before or after a breastfeed may make a significant difference to estimated weight gain), as well as different scales.
					</p>
					<p>
						Take note if the infant:
						<ul><li>loses more than 7 percent of body weight (especially if the loss is &gt;10 percent); or has not regained birth weight by two weeks;</li><li>regularly gains less than 125gms per week.</li></ul>
					</p>
				</dd><dt>Jaundice</dt><dd>
					<p>
						Jaundice is a common condition in the first week. Breastfed infants are more likely to become jaundiced and remain jaundiced for longer if their energy intake is low. (See Case B for further information about breastfeeding and jaundice.)
					</p>
					<p>
						Take note if jaundice continues to progress after hospital discharge.
					</p>
				</dd><dt>General examination</dt><dd>
					<p>
						Assess the infant's state of hydration, muscle tone, subcutaneous fat and general demeanour.
					</p>
					<p>
						Take note if the infant:
						<ul><li>appears dehydrated;</li><li>has little subcutaneous fat; or</li><li>is apathetic and listless.</li></ul>
					</p>
					<p>
						An abnormality in any one of the indicators listed above must be assessed in the context of any previous assessments and with the remaining indicators. Sometimes the best indicators of underfeeding are a change in some of the indicators mentioned – for example, a reduction in the wetness or number of wet nappies, fewer bowel motions or excessive sleepiness.
					</p>
				</dd></dl>
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			<div></div><div class="activity" id="activity_z">
<script type="text/javascript">
/* <![CDATA[ */
var zqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>During an audit of your postnatal patients, you find that a significant proportion of women wean between two and six weeks because of a low milk supply. You want to trial an intervention to assess the adequacy of breastfeeding at one week, and review those mother/infant couples with \"red flags\" more frequently to see if this improves breastfeeding rates at six weeks. What would you consider a \"red flag\" at one week?</strong>\n			</p>\n		', r : '\n			<p>\n				Red flags would include:\n				<ul>\n					<li>less than 8 or more than 12 feeds regularly lasting more than 50-60 minutes;</li>\n					<li>less than 4-6 voids a day with strong smelling or dark coloured urine or urate deposits;</li>\n					<li>passing meconium or transition stools or less than 2-3 bowel motions a day;</li>\n					<li>a very placid infant who has to be woken to feed, quickly falls asleep at the breast, or continually slips off the breast;</li>\n					<li>an unhappy or unsettled infant;</li>\n					<li>no or little swallowing heard during a feed;</li>\n					<li>weight loss of more than 7%;</li> \n					<li>increasing jaundice;</li>\n					<li>difficulty attaching the baby to the breast;</li>\n					<li>baby having breast milk substitutes.</li>\n				</ul>\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('z');</script>
	</td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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	</div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
              <li id="note2"><a href="references.html#butt85" title="See full details">#</a> Butte NF et al. (1985) Feeding patterns of exclusively breast-fed infants during the first four months of life</li>
              <li id="note3"><a href="references.html#hill05a" title="See full details">#</a> Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants</li>
              <li id="note4"><a href="references.html#shra06" title="See full details">#</a> Shrago LC et al. (2006) The Neonatal Bowel Output Study: indicators of adequate breast milk intake in neonates</li>
              <li id="note5"><a href="references.html#nomm08" title="See full details">#</a> Nommsen-Rivers LA et al. (2008) Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy</li>
              <li id="note6"><a href="references.html#weav88" title="See full details">#</a> Weaver LT et al. (1988) The bowel habit of milk-fed infants</li>
              <li id="note7"><a href="references.html#ziem93" title="See full details">#</a> Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation</li>
              <li id="note8"><a href="references.html#powe01a" title="See full details">#</a> Powers NG (2001) How to assess slow growth in the breastfed infant. Birth to 3 months.</li>
              <li id="note9"><a href="references.html#nati03" title="See full details">#</a> National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_4-2" class="content">
          <h1 id="top">4.2 Milk production</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points</h3>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
		</p>
		<dl><dt><a href="topic_4-1.html"><cite>Topic 4.1: Initial assessment</cite></a></dt><dd class="topic-paragraph">To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.</dd></dl>
	</stage>
		<p>
			Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.
		</p>
		<dl><dt><a href="topic_4-2.html"><cite>Topic 4.2: Milk production</cite></a></dt><dd class="topic-paragraph">Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.</dd></dl>
	</stage>
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          <strong>
            <p>
			Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.
		</p>
          </strong>
          <div class="section" id="What_initiates_and_controls_milk_production_"><h2>What initiates and controls milk production?</h2>
		<p>
			Hormones necessary for the development of the breasts during pregnancy and the subsequent secretion of colostrum and milk include (but are not limited to) placental lactogen, oestrogen, progesterone, prolactin, glucocorticoids, thyroxin and growth hormone.
		</p>
		<p>
			During the first half of the pregnancy, mammogenesis occurs with growth and proliferation of the <abbr title="Terminal Duct Lobular Unit">TDLU</abbr>s, resulting in an increase in breast size for most women. Continued growth occurs during the second half of pregnancy, along with the differentiation of alveolar cells into lactocytes and the production of small quantities of secretion (colostrum) (lactogenesis I)(<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>). High oestrogen levels during the pregnancy stimulate the release of prolactin. However, progesterone inhibits the effect of prolactin on the lactocytes and thus production of milk. Nevertheless, colostrum production is related to prolactin levels. Junctions between the lactocytes are not tightly closed during pregnancy, enabling lactose secreted into the alveoli to enter the maternal bloodstream and be excreted by the kidney. Urinary lactose levels indicate lactogenesis I has occurred and have been used to calculate the amount of colostrum produced each day (30mls)<sup><a href="#note3">3</a></sup>. As the breasts are capable of producing milk from the middle of pregnancy, delivery of the foetus/infant from that time will result in an increase in milk production – often an unexpected and unwanted development if the pregnancy ends in miscarriage or the infant is not viable.
		</p>
		<p>
			In the presence of high levels of prolactin and with a primed mammary epithelium lactogenesis II, the onset of copious milk production begins with the delivery of the placenta and the subsequent drop in progesterone levels<sup><a href="#note4">4</a></sup>. The tight junctions between lactocytes close, preventing the passage of molecules from the maternal circulation to alveolar spaces and resulting in an increase in lactose and a decrease in sodium and chloride levels in the milk secreted. As lactogenesis II progresses, the fat levels increase, as does the concentration of citrate, potassium, casein, calcium and phosphate<sup><a href="#note1">1</a></sup>. Concentrations of Secretory IgA and lactoferrin also rise during the first 48 hours, but then fall – mainly due to an increase in milk volume rather than a decrease in the total amount secreted. Copious milk production begins around 36 hours postpartum with the volume increasing up to ten times over the next 36 hours. Lactose synthesis largely determines the volume of milk produced as its osmotic activity draws water into the lactocytes and thus to milk<sup><a href="#note2">2</a></sup>. Women experience this increase in milk volume as "milk coming in"<sup><a href="#note5">5</a></sup>.
		</p>
		<p>
			Although lactogenesis II is primarily hormonally driven, regardless of milk removal, there is some evidence that early, frequent feeding increases subsequent breast milk volumes and it is hypothesised that for some women milk removal is necessary for closure of the tight junctions<sup><a href="#note4">4</a></sup>. Regardless, by day three milk removal is essential for continued milk production.
		</p>
		<p>
			Prolactin is produced by the anterior pituitary gland under the control of the hypothalamus. In response to tactile stimulation of the nipple (usually the infant breastfeeding), levels rise, peaking after 25 to 40 minutes and returning to resting levels by 180 minutes<sup><a href="#note6">6</a></sup>. Both resting levels and suckling-evoked peaks are highest in the first month or so after birth, and then gradually fall so that by six months postpartum the resting levels are only slightly higher than those of non-lactating women<sup><a href="#note7">7</a></sup>, although milk volumes appear unaltered. Therefore, while prolactin is essential for the initiation of lactation, it is not the main determinant of ongoing milk production.
		</p>
		<p>
			Oxytocin, an octapeptide produced by the posterior pituitary, is released in a pulsatile fashion in response to the infant suckling at the breast. Oxytocin causes contraction of myoepithelial cells surrounding the mammary ducts, resulting in shortening and widening of the ductal structures and expulsion of milk through the nipple. This reflex, called the milk-ejection or let-down reflex, is essential for the removal of milk already stored in the breast. It can be conditioned so that seeing the infant, or hearing the infant cry in preparation for a breastfeed, results in a rise in oxytocin levels<sup><a href="#note8">8</a></sup> and in a milk-ejection. Conversely, the milk-ejection reflex can be inhibited by stimuli such as pain and other stressful events (<sup><a href="#note6">6</a>,</sup><sup><a href="#note9">9</a></sup>). Mothers often recognise milk ejection by a tingling sensation in the breast soon after the infant begins to feed, milk dripping from the "other" breast, or a change in the infant's sucking pattern.
		</p>
	</div>
          <div class="section" id="Risk_factors_for_a_delay_in_Lactogenesis_II"><h2>Risk factors for a delay in Lactogenesis II</h2>
		<p>
			<em>Click on the bullet points below for more detail:</em>
			<ul class="collapse"><li>
					Diabetes
					<ul collapse="yes"><li>Women with <abbr title="Insulin-Dependent Diabetes Mellitus">IDDM</abbr> have a delay in the onset of copious milk production of approximately 28 hours, although their milk volumes by day seven are within the normal range. As insulin is necessary for lactogenesis and glucose is an important substrate for milk production, it is uncertain whether women with poorly controlled diabetes are more at risk (<sup><a href="#note10">10</a>,</sup><sup><a href="#note11">11</a></sup>). There does not appear to be a similar delay in women with gestational diabetes<sup><a href="#note11">11</a></sup>.</li></ul>
				</li><li>
					Primiparity
					<ul collapse="yes"><li>Primiparous women, especially those with large infants, notice an increase in breast fullness later than multiparous women<sup><a href="#note12">12</a></sup>. In addition, multiparous women produce higher milk volumes on day seven (<sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup>).</li></ul>
				</li><li>
					Caesarean section
					<ul collapse="yes"><li>After adjusting for timing of the first feed and other confounders, the amount of milk an infant delivered by caesarean section receives during the first six days of life is less than that received by infants delivered vaginally<sup><a href="#note15">15</a></sup>. Other studies have also noted a delay in the onset of milk production for women who have undergone caesarean section<sup><a href="#note12">12</a></sup>, especially if the caesarean section was unplanned<sup><a href="#note16">16</a></sup>.</li></ul>
				</li><li>
					Stress and pain in labour
					<ul collapse="yes"><li>Difficult and protracted labours, especially with a long second stage, have also been associated with a delay in lactogenesis II<sup><a href="#note16">16</a></sup>.</li></ul>
				</li><li>
					Obesity
					<ul collapse="yes"><li>The onset of lactation for women with a body mass index in the obese range is delayed (<sup><a href="#note12">12</a>,</sup><sup><a href="#note16">16</a>,</sup><sup><a href="#note17">17</a></sup>). Additionally, overweight and obese women are less likely to be breastfeeding at six months than normal weight women<sup><a href="#note18">18</a></sup>.</li></ul>
				</li><li>
					Preterm delivery
					<ul collapse="yes"><li>Women who deliver prematurely tend to produce less milk than women whose infants are born at term<sup><a href="#note19">19</a></sup>. This effect is often thought to be due to the differences in both the frequency and mechanism of milk removal. However, 82 percent of women who delivered prematurely had at least one of four markers for lactogenesis II outside the normal range on day five (compared with no abnormal markers for women who delivered at term)<sup><a href="#note20">20</a></sup>. These women also had reduced milk production.</li></ul>
				</li></ul>
		</p>
	</div>
          <p>
		After the initiation of lactation, the most important determinant of ongoing milk production (lactogenesis III or galactopoiesis) is milk removal. Short-term milk synthesis rates are related to the degree of fullness of the breast so that milk is made at a much faster rate when the breasts are drained, compared with when they are full<sup><a href="#note21">21</a></sup>. A milk protein that inhibits milk production has been found in animal studies, and it is thought that a similar autocrine mechanism is also present in humans. Thus the daily amount of milk a mother makes will be determined by the frequency with which her infant feeds, and the degree of breast emptying at each feed (i.e. the infant's appetite).
	</p>
          <p>
		There is great variation between mothers in the amount of milk each breast is able to store (e.g. 74 to 382 mls)<sup><a href="#note22">22</a></sup>. The infants of women with small storage capacities will tend to remove all or most of the available milk at each feed and feed more frequently<sup><a href="#note1">1</a></sup>, while infants of mothers with large storage capacities may only remove a proportion of the milk available even though they may consume more milk per feed. On average, infants do not remove all available milk at each feed<sup><a href="#note22">22</a></sup>. The differences in storage capacities between mothers helps explain the differences in feeding patterns between motherinfant couples – including the number and timing of feeds, and whether the infant feeds from one or two breasts at each feed. Therefore, watching for feeding cues and following the infant's lead regarding the pattern of feeding is the most appropriate way to ensure adequate milk production and infant growth.
	</p>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kent07" title="See full details">#</a> Kent JC (2007) How breastfeeding works</li>
              <li id="note2"><a href="references.html#czan07b" title="See full details">#</a> Czank C et al. (2007) Hormonal control of the lactation cycle</li>
              <li id="note3"><a href="references.html#coxd99" title="See full details">#</a> Cox DB et al. (1999) Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships</li>
              <li id="note4"><a href="references.html#nevi01a" title="See full details">#</a> Neville M et al. (2001) Physiology and Endocrine Changes Underlying Human Lactogenesis II</li>
              <li id="note5"><a href="references.html#nevi01b" title="See full details">#</a> Neville M et al. (2001) Lactogenesis: The transition from pregnancy to lactation</li>
              <li id="note6"><a href="references.html#hart95" title="See full details">#</a> Hartmann PE et al. (1995) Endocrine and autocrine strategies for the control of lactation in women and sows</li>
              <li id="note7"><a href="references.html#coxd96" title="See full details">#</a> Cox DB et al. (1996) Blood and milk prolactin and the rate of milk synthesis in women</li>
              <li id="note8"><a href="references.html#mcne83" title="See full details">#</a> McNeilly A et al. (1983) Release of oxytocin and prolactin in response to suckling</li>
              <li id="note9"><a href="references.html#ueda94" title="See full details">#</a> Ueda T et al. (1994) Influence of psychological stress on suckling-induced pulsatile oxytocin release</li>
              <li id="note10"><a href="references.html#arth89" title="See full details">#</a> Arthur PG et al. (1989) Milk lactose, citrate, and glucose as markers of lactogenesis in normal and diabetic women</li>
              <li id="note11"><a href="references.html#hart01a" title="See full details">#</a> Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity</li>
              <li id="note12"><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="note13"><a href="references.html#hill05a" title="See full details">#</a> Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants</li>
              <li id="note14"><a href="references.html#ingr01" title="See full details">#</a> Ingram J et al. (2001) Breastfeeding: it is worth trying with a second baby</li>
              <li id="note15"><a href="references.html#evan03" title="See full details">#</a> Evans K et al. (2003) Effect of casearean section on breast milk transfer to the normal term newborn over the first week of life</li>
              <li id="note16"><a href="references.html#chap99" title="See full details">#</a> Chapman D et al. (1999) Identification of risk factors for delayed onset of lactation</li>
              <li id="note17"><a href="references.html#rasm01" title="See full details">#</a> Rasmussen KM et al. (2001) Obesity may impair lactogenesis II</li>
              <li id="note18"><a href="references.html#oddy06" title="See full details">#</a> Oddy WH et al. (2006) The association of maternal overweight and obesity with breastfeeding duration</li>
              <li id="note19"><a href="references.html#hill05" title="See full details">#</a> Hill PD et al. (2005) Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth</li>
              <li id="note20"><a href="references.html#creg02b" title="See full details">#</a> Cregan MD et al. (2002) Initiation of lactation in women after preterm delivery</li>
              <li id="note21"><a href="references.html#daly93a" title="See full details">#</a> Daly SE et al. (1993) The short-term synthesis and infant-regulated removal of milk in lactating women</li>
              <li id="note22"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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          <h1 id="top">4.3 Causes of inadequate infant growth</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study D</h3>
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		<p>
			Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
		</p>
		<dl><dt><a href="topic_4-1.html"><cite>Topic 4.1: Initial assessment</cite></a></dt><dd class="topic-paragraph">To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.</dd></dl>
	</stage>
		<p>
			Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.
		</p>
		<dl><dt><a href="topic_4-2.html"><cite>Topic 4.2: Milk production</cite></a></dt><dd class="topic-paragraph">Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.</dd></dl>
	</stage>
		<p>
			What may cause inadequate growth in breastfed infants such as Emily?
		</p>
		<dl><dt><a href="topic_4-3.html"><cite>Topic 4.3: Causes of inadequate infant growth</cite></a></dt><dd class="topic-paragraph">The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.</dd></dl>
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          <strong>
            <p>
			What may cause inadequate growth in breastfed infants such as Emily?
		</p>
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          <div class="section display-accordion" id="">
		<div class="section" id="Reduced_milk_intake_due_to_feeding_patterns_or_routines"><h3>Reduced milk intake due to feeding patterns or routines</h3><div class="section" id="">
			<dl><dt>Frequency</dt><dd>
					As mentioned earlier, most infants require at least eight breastfeeds a day in the early months of life (i.e. at least every three hours). However, breastfeeds are not usually spaced evenly throughout the day. At times the infant may want to feed every 3060 minutes (cluster feeds) while they may go for a longer stretch during the night. Feeding frequency is positively correlated with milk volume in the early weeks<sup><a href="#note1">1</a></sup>. Additionally, because of the differences in maternal storage capacities and infant feeding cues, stipulating a specific number of breastfeeds at equal intervals throughout the day limits the volume of milk the infant receives and reduces breast stimulation and drainage necessary for further milk production. Night-time feeds are also important for ongoing breastfeeding, especially in the early weeks and months.
				</dd><dt>Length of feeds</dt><dd>
					In the first few weeks postpartum, most infants will take between 20 and 40 minutes to feed; however, the length of effective sucking will vary between infants and between feeds by the same infant. However, limiting the time at the breast, or removing the infant from the breast after a specified time, may not allow the infant to receive as much milk as he or she needs, especially if the milk-ejection reflex is slow. Conversely, infants who spend a long time at the breast (&gt;50 minutes routinely) may not be feeding effectively for some or all of that time, and the breastfeeds may need to be assessed by a trained observer.
				</dd><dt>One breast or two</dt><dd>
					<p>
						Fat concentration of breast milk is correlated with the degree of breast fullness – with the fat concentration increasing as the breast is drained. Concern has been expressed that infants feeding from both breasts at each feed when their mothers' milk supply is large would receive a low-fat, high-volume feed resulting in symptoms of lactose intolerance and large, or rarely low weight gain<sup><a href="#note2">2</a></sup>. Conversely, mothers may initially be encouraged to feed from only one breast at each feed while their breasts are very full or engorged, or to ensure their infant receives the higher fat milk when the breast is drained. This advice can be interpreted as only ever feeding from one breast at each feed. For many infants, this routine will not provide sufficient milk volume for adequate growth.
					</p>
					<p>
						The ideal situation is to allow the infant to feed from one breast for as long as he or she is feeding effectively, and then offer the second breast. Most infants (57%) will take one breast at some feeds and two breasts at others, while some infants will only ever use one breast at each feed (30%) and others will always use two breasts (13%)<sup><a href="#note3">3</a></sup>. Most infants with signs and symptoms of lactose overload respond well when allowed to determine whether they feed from one breast or two at a feed. Lactose-free formula is not necessary nor appropriate management.
					</p>
				</dd><dt>Use of breast/breast milk substitutes</dt><dd>
					<p>
						Dummy or pacifier use has been associated with reduced breastfeeding duration (<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup>). Dummies are thought to reduce the desire of the infant to feed at the breast, especially if used to quieten the infant rather than feeding him or her, or alter the infant's sucking pattern. However, it is difficult to determine whether dummies initiate breastfeeding problems or are used because of them.
					</p>
					<p>
						Complementary feeds also reduce the infant's desire to feed at the breast. If the complement is infant formula, the infant's weight may not be affected, but milk supply will invariable decrease unless measures are instituted to increase milk production.
					</p>
					<p>
						Feeding routines that reduce breast drainage not only affect infant growth, but also adversely affect ongoing milk supply.
					</p>
				</dd></dl>
		</div></div>
		<div class="section" id="Low_milk_supply"><h3>Low milk supply</h3><div class="section" id="">
			<dl><dt>Hormonal reasons</dt><dd>
					<ul><li><span class="term">Retained products of conception</span>. A rapid decrease in progesterone levels is essential for the initiation of lactation. When progesterone levels fail to fall to pre-pregnancy levels due to retained products of conception, milk production is often slow to begin and does not reach normal levels. Removal of the retained products usually results in a rapid increase in milk volume (<sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup>).</li><li><span class="term">Sheehan's syndrome and postpartum haemorrhage</span>. Sheehan's syndrome, due to ischaemic necrosis of the pituitary gland following hypotension related to severe postpartum haemorrhage, may present initially with failure to lactate. Some authors report women experiencing a delay in the initiation of lactation, or low milk supply following episodes of postpartum hypotension (usually due to postpartum haemorrhage), although the remainder of the pituitary function is intact (<sup><a href="#note8">8</a>,</sup><sup><a href="#note9">9</a></sup>). Another study showed a relationship between postpartum anaemia and apparent insufficient milk, leading to early weaning<sup><a href="#note10">10</a></sup>. Although the study did not report the reasons for anaemia, excessive peripartum blood loss may have contributed.</li><li><span class="term">Thyroid disorders</span>. As thyroxine is also required for ongoing milk production, women with hypothyroidism are at risk of having a low milk supply. Adequate treatment with thyroxine allows breastfeeding to commence and continue normally<sup><a href="#note11">11</a></sup>. Postpartum thyroiditis often presents initially with hyperthyroidism, with many women becoming hypothyroid with time<sup><a href="#note12">12</a></sup>.</li><li><span class="term">Other hormonal disorders</span>. There is some evidence that women with polycystic ovaries (<sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup>) and theca-lutean cysts (<sup><a href="#note15">15</a>,</sup><sup><a href="#note16">16</a></sup>) are more likely to have difficulty establishing their milk supply or produce a low milk volume. In rare instances, an isolated prolactin deficiency leads to alactogenesis (<sup><a href="#note17">17</a>,</sup><sup><a href="#note18">18</a>,</sup><sup><a href="#note19">19</a></sup>).</li></ul>
				</dd><dt>Smoking</dt><dd>
					Women who smoke are less likely to initiate lactation and breastfeed for a shorter length of time. However, it is uncertain whether this effect is due to a lack of maternal motivation or a direct effect of nicotine or other substance on milk production (<sup><a href="#note20">20</a>,</sup><sup><a href="#note21">21</a>,</sup><sup><a href="#note22">22</a></sup>).
				</dd><dt>Obesity</dt><dd>
					As described previously, women who are overweight or obese have difficulty establishing breastfeeding are less likely to continue to breastfeed.
				</dd><dt>Medications</dt><dd>
					Some medications such as the oral contraceptive pill<sup><a href="#note23">23</a></sup>, pseudoephedrine<sup><a href="#note24">24</a></sup> and herbal preparations such as sage tea<sup><a href="#note11">11</a></sup> are known to inhibit milk production.
				</dd><dt>Anatomical problems</dt><dd>
					Some women lack sufficient mammary tissue to produce enough milk for their infant<sup><a href="#note25">25</a></sup>. These women are more likely to have asymmetric underdeveloped breasts that are more widely spaced than normal (&gt;4 cms). In extreme cases, the breasts sit on a small base with severe breast constriction and large nipple-areola complexes (tubular breasts)<sup><a href="#note26">26</a></sup>. Lack of breast development during pregnancy and lack of postpartum breast fullness are often noted (<sup><a href="#note26">26</a>,</sup><sup><a href="#note27">27</a></sup>).
				</dd><dt>Breast surgery</dt><dd>
					Disturbance of ductal structures, reduction in the amount of glandular tissue and the severing of the afferent arm of the milk-ejection reflex (usually the lateral cutaneous branch of the 4th intercostal nerve) as a consequence of breast surgery can all impact on the mother's capacity to produce milk<sup><a href="#note27">27</a></sup>. Breast reduction surgery nearly always results in reduced milk volume. Periareolar incisions, although cosmetically desirable, are more likely to interfere with the major lactiferous ducts and the milk-ejection reflex and have been associated with a reduction in nipple sensitivity (<sup><a href="#note11">11</a>,</sup><sup><a href="#note27">27</a></sup>).
				</dd></dl>
		</div></div>
		<div class="section" id="Difficulty_transferring_milk"><h3>Difficulty transferring milk</h3><div class="section" id="">
			<dl><dt>Poor positioning and attachment</dt><dd>
					Breast drainage is facilitated by optimal positioning and attachment of the infant at the breast. Case E describes the assessment of effective positioning and attachment.
				</dd><dt>Efficacy of the milk-ejection reflex</dt><dd>
					Contraction of the myoepithelial cells around the lactiferous ducts (the milk-ejection reflex), either stimulated by the infant or by expressing, is essential for the removal of milk from the breasts. Stress, pain or other factors may inhibit this reflex and must be considered when an infant is not gaining weight. While most mothers will be aware of this reflex working, it is often less noticeable for women with a low milk supply. Watching for changes in the infant's sucking pattern (from suck-suck-suck-swallow to suck-swallow, suck-swallow) may be a more reliable sign that milk is flowing.
				</dd><dt>Sucking problems</dt><dd>
					Some infants, even though they are positioned and attached to the breast well, have a poor or ineffective suck. Contributing factors include hyper or hypotonia, thumb-sucking in-utero, prematurity or illness. However, other infants may have tonic bites or are not able to coordinate tongue movements or maintain sufficient negative pressure to extract milk. These infants tend to slip off the breast easily and may "click" during the feed every time suction is broken. Their mothers often have damaged nipples.
				</dd><dt>Tongue-tie (ankyloglossia)</dt><dd>
					Further information about tongue-tie and its effect on breastfeeding is found in Case E.
				</dd></dl>
		</div></div>
		<div class="section" id="Increased_energy_expenditure"><h3>Increased energy expenditure</h3><div class="section" id="">
			<dl><dt>Other medical conditions</dt><dd>
					Congenital heart disease, urinary tract infections and other medical conditions may initially present with low weight gain and failure to thrive. As well as having an increased energy expenditure, the infant may not be robust enough to adequately stimulate the breast, resulting in a secondary low supply problem.
				</dd></dl>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
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<script type="text/javascript">
/* <![CDATA[ */
var aqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Miriam is one month old, weighs 3.5 kg and has gained on average 80g a week since birth. She is otherwise well and is not compromised. What history would you obtain and what examinations would you perform on Miriam and her mother to assess causes of her slow weight gain?</strong>\n			</p>\n		', r : '\n			<p>\n				History would include:\n				<ul>\n					<li>number, length and pattern of breastfeeds;</li>\n					<li>breastfeeding difficulties (painful nipples, difficulty attaching baby to the breast, inhibited milk-ejection reflex);</li>\n					<li>use of breast milk substitutes or a dummy;</li> \n					<li>previous hormonal problems (eg thyroid disorders, PCOS);</li>\n					<li>delivery complications (large PPH, retained products of conception);</li>\n					<li>maternal smoking, medications, breast surgery.</li>\n				</ul>\n			</p>\n			<p>\n				Examination would include:\n				<ul>\n					<li>mother\'s breasts and nipples;</li>\n					<li>positioning and attachment;</li>\n					<li>sucking efficiency;</li>\n					<li>infant oral anatomy;</li>\n					<li>other infant medical conditions (eg. congenital heart disease, UTI)</li>\n				</ul>\n			</p>\n		' }
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/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('a');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#hill05a" title="See full details">#</a> Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants</li>
              <li id="note2"><a href="references.html#wool88" title="See full details">#</a> Woolridge MW et al. (1988) Colic, "overfeeding", and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management?</li>
              <li id="note3"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
              <li id="note4"><a href="references.html#howa03" title="See full details">#</a> Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding</li>
              <li id="note5"><a href="references.html#kram01a" title="See full details">#</a> Kramer MS et al. (2001) Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial</li>
              <li id="note6"><a href="references.html#ande01" title="See full details">#</a> Anderson AM (2001) Disruption of lactogenesis by retained placental fragments</li>
              <li id="note7"><a href="references.html#neif81" title="See full details">#</a> Neifert MR et al. (1981) Failure of lactogenesis associated with placental retention</li>
              <li id="note8"><a href="references.html#will95" title="See full details">#</a> Willis C et al. (1995) Infant insufficient milk syndrome associated with maternal postpartum hemorrhage</li>
              <li id="note9"><a href="references.html#livi06" title="See full details">#</a> Livingstone V (2006) Failure to thrive while breastfeeding</li>
              <li id="note10"><a href="references.html#henl95" title="See full details">#</a> Henly SJ et al. (1995) Anemia and insufficient milk in first-time mothers</li>
              <li id="note11"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
              <li id="note12"><a href="references.html#desw95" title="See full details">#</a> de Swiet M (1995) Medical disorders in obstetric practice</li>
              <li id="note13"><a href="references.html#vank08" title="See full details">#</a> Vanky E et al. (2008) Breastfeeding in polycystic ovary syndrome</li>
              <li id="note14"><a href="references.html#mara00" title="See full details">#</a> Marasco L et al. (2000, May) Polycystic ovary syndrome: a connection to insufficient milk supply?</li>
              <li id="note15"><a href="references.html#betz04" title="See full details">#</a> Betzold CM et al. (2004) Delayed lactogenesis II: a comparison of four cases</li>
              <li id="note16"><a href="references.html#hoov02a" title="See full details">#</a> Hoover KL et al. (2002) Delayed lactogenesis II secondary to gestational ovarian theca lutein cysts in two normal singleton pregnancies</li>
              <li id="note17"><a href="references.html#sait07" title="See full details">#</a> Saito T et al. (2007) A case of prolactin deficiency with familial puerperal alactogenesis accompanying impaired ACTH secretion</li>
              <li id="note18"><a href="references.html#douc01" title="See full details">#</a> Douchi T et al. (2001) A woman with isolated prolactin deficiency</li>
              <li id="note19"><a href="references.html#kaup97" title="See full details">#</a> Kauppila A (1997) Isolated prolactin deficiency</li>
              <li id="note20"><a href="references.html#dona04" title="See full details">#</a> Donath SM et al. (2004) The relationship between maternal smoking and breastfeeding duration after adjustment for maternal infant feeding intention</li>
              <li id="note21"><a href="references.html#gigl06" title="See full details">#</a> Giglia R et al. (2006) Maternal cigarette smoking and breastfeeding duration.</li>
              <li id="note22"><a href="references.html#mcaf07" title="See full details">#</a> McAfee G ( 2007) Drugs of abuse and breastfeeding.</li>
              <li id="note23"><a href="references.html#hale07a" title="See full details">#</a> Hale TW (2007) Medications that alter milk production</li>
              <li id="note24"><a href="references.html#alja03" title="See full details">#</a> Aljazaf K (2003) Pseudoephidrine: effects on milk production in women and estimation of infant exposure via breastmilk</li>
              <li id="note25"><a href="references.html#neif85" title="See full details">#</a> Neifert MR et al. (1985) Lactation failure due to insufficient glandular development of the breast</li>
              <li id="note26"><a href="references.html#hugg00" title="See full details">#</a> Huggins K et al. (2000) Markers of Lactation Insufficiency: A study of 34 mothers</li>
              <li id="note27"><a href="references.html#neif90" title="See full details">#</a> Neifert MR et al. (1990) The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain</li>
            </ol>
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          <h1 id="top">4.4 Increasing milk supply</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study D</h3>
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			Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
		</p>
		<dl><dt><a href="topic_4-1.html"><cite>Topic 4.1: Initial assessment</cite></a></dt><dd class="topic-paragraph">To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.</dd></dl>
	</stage>
		<p>
			Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.
		</p>
		<dl><dt><a href="topic_4-2.html"><cite>Topic 4.2: Milk production</cite></a></dt><dd class="topic-paragraph">Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.</dd></dl>
	</stage>
		<p>
			What may cause inadequate growth in breastfed infants such as Emily?
		</p>
		<dl><dt><a href="topic_4-3.html"><cite>Topic 4.3: Causes of inadequate infant growth</cite></a></dt><dd class="topic-paragraph">The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.</dd></dl>
	</stage>
		<p>
			How could Sally increase her milk supply?
		</p>
		<dl><dt><a href="topic_4-4.html"><cite>Topic 4.4: Increasing milk supply</cite></a></dt><dd class="topic-paragraph">To increase a mother's milk supply correct any underlying problems, if possible, and increase breast drainage. Encourage adequate rest and a balanced diet. Some women require galactagogues. Some infants who are malnourished at presentation, or do not respond to effective, frequent feeding, may need supplementation with donor breast milk or infant formula.</dd></dl>
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            <p>
			How could Sally increase her milk supply?
		</p>
          </strong>
          <p>
		First, ensure there are no medical problems or other underlying factors that could be affecting Sally's milk supply or Emily's growth. Appropriate management of these factors is necessary in addition to the following suggestions to increase milk production.
	</p>
          <div class="section" id="Increase_breast_drainage"><h2>Increase breast drainage</h2>
		<p>
			<em>Click on the bullet points below for more detail:</em>
			<ul class="collapse"><li>
					Positioning and attachment
					<ul collapse="yes"><li>Ensure that the infant is positioned and attached well to the breast to maximise breast drainage (see Case E).</li></ul>
				</li><li>
					Feeds  frequency and length
					<ul collapse="yes"><li>Recommend that the infant be fed at least eight times a day. This may mean waking the infant to feed every two and a half to three hours during the day if he/she is sleeping for long periods of time. Feeding at least once during the night is also important. Switch feeds by swapping to the second breast once the infant ceases feeding effectively from the first and then swapping back to the first and then the second again until the infant is satisfied<sup><a href="#note1">1</a></sup>.</li></ul>
				</li><li>
					Expressing
					<ul collapse="yes"><li>Because the rate of milk synthesis is higher with well-drained breasts, fully draining the breasts by expressing by hand or pump can increase overall milk production. This is especially important if the infant does not drain the breasts as a result of an ineffective suck, or due to tiring at the breast. Expressing immediately after a feed may yield very little milk if the infant is feeding effectively. Waiting an hour or so after a feed and then expressing may be more effective in increasing milk supply. The expressed milk can be fed to the infant by cup, spoon, dropper or bottle if the infant continues to be hungry after he or she has been fed.</li></ul>
				</li><li>
					Breast compression
					<ul collapse="yes"><li>By firmly compressing the breast when the baby stops sucking well, the milk flow increases and the infant begins to suck effectively again. Click on this link for <strong><img alt="PDF" src="design/page_white_acrobat.png" /><a href="http://www.beyondbirth.ca/BeyondBirthDownloads/Breast%20compression-January%202005.pdf">further information about breast compression</a><span class="linkDescription">[link: http://www.beyondbirth.ca/BeyondBirthDownloads/Breast%20compression-January%202005.pdf]</span></strong>.</li></ul>
				</li><li>
					Inappropriate use of dummies and complements
					<ul collapse="yes"><li>As described previously, using dummies or providing the infant with other fluids or solids (under six months of age) may reduce the infant's desire to breastfeed and thus reduce breast drainage. Reducing the use of a dummy and complements increases the opportunities for the infant to breastfeed, thus increasing his or her milk input and increasing breast drainage.</li></ul>
				</li></ul>
		</p>
	</div>
          <div class="section" id="Food_and_rest"><h2>Food and rest</h2>
		<p>
			While poor maternal diet and fatigue do not necessarily result in low milk supply, some women find improving their diet and resting when possible increases their milk production<sup><a href="#note2">2</a></sup>. There is no evidence that increasing a mother's fluid intake will increase her milk supply, especially in women who are adequately hydrated (<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup>).
		</p>
	</div>
          <div class="section" id="Galactagogues"><h2>Galactagogues</h2>
		<p>
			Herbal remedies such as fenugreek, goat's rue, blessed thistle and marshmallow have been used as galactagogues, although there is little evidence-based research to suggest that they have a significant effect on milk supply<sup><a href="#note5">5</a></sup>. The two most commonly prescribed galactagogues are metoclopramide and domperidone, which increase prolactin levels by their antidopaminergic action. Both have been shown to increase prolactin levels and increase milk production in lactating women when prolactin levels are low, at doses of 10 mg three times a day (metoclopramide) and 1020 mg three to four times a day (domperidone). Women appear to suffer few side-effects at these doses, although domperidone appears to cause fewer side-effects than metoclopramide. Milk transfer of the drugs to the infant is minimal. Tapering of the dose once the desired effect on milk supply has been achieved is recommended to minimise any reduction in supply (<sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup>).
		</p>
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          <div class="section" id="Supplementation"><h2>Supplementation</h2>
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			<p>
				Most infants will stabilise any weight loss and begin to gain weight using these suggestions without the need for additional supplementation. However, supplements of donor milk or infant formula may be required if the infant appears malnourished at presentation or does not respond to effective, frequent breastfeeding. A suggested minimum amount of supplement is 50ml/kg/day given in divided volumes after breastfeeds when the infant appears hungry<sup><a href="#note1">1</a></sup>. As the mother's milk supply increases, the amount of supplement can be decreased. A supplemental nursing system can provide the supplement to the infant while he or she is feeding at the breast. This form of supplementation encourages further breast stimulation, and is often time efficient for the mother.
			</p>
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				<div class="captionBox"><img width="450" height="327" src="images/supply_line_Downs450.jpg" alt="" /><p> <br />&copy;  B.Ingle IBCLC</p></div>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_b">
<script type="text/javascript">
/* <![CDATA[ */
var bqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Erin, Miriam\'s mother, does not appear to have any underlying physical reasons for a low milk supply and Miriam\'s examination is normal. What would be your initial management plan to improve Miriam\'s weight gain?</strong>\n			</p>\n		', r : '\n			<p>\n				Management would include:\n				<ul>\n					<li>optimizing positioning and attachment;</li>\n					<li>increasing the frequency and efficiency of feeds;</li>\n					<li>using both breasts at each feed and expressing if they were not well drained;</li>\n					<li>breast compression during the feed;</li>\n					<li>reducing or removing inappropriate supplements and dummy use;</li>\n					<li>optimizing maternal diet and rest.</li>\n				</ul>\n			</p>\n			<p>\n				If these options do not improve weight gain galactagogues may be beneficial.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('b');</script>
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            <h3>Notes</h3>
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              <li id="note1"><a href="references.html#powe01a" title="See full details">#</a> Powers NG (2001) How to assess slow growth in the breastfed infant. Birth to 3 months.</li>
              <li id="note2"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
              <li id="note3"><a href="references.html#dusd90" title="See full details">#</a> Dusdieker LB et al. (1990) Prolonged maternal fluid supplementation in breast-feeding.</li>
              <li id="note4"><a href="references.html#mors92" title="See full details">#</a> Morse JM et al. (1992) The effect of maternal fluid intake on breast milk supply: a pilot study</li>
              <li id="note5"><a href="references.html#hump07" title="See full details">#</a> Humphrey S (2007) Herbal therapeutics during lactation</li>
              <li id="note6"><a href="references.html#hale07a" title="See full details">#</a> Hale TW (2007) Medications that alter milk production</li>
              <li id="note7"><a href="references.html#mont04" title="See full details">#</a> Montgomery A et al. (2004) Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk supply</li>
            </ol>
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          <h1 id="top">5.0 Case Study E (Anna)</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
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		<p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
	</stage>
		<p>
			What other conditions may contribute to nipple damage occurring in the first week postpartum?
		</p>
		<dl><dt><a href="topic_5-2.html"><cite>Topic 5.2: Factors causing nipple damage</cite></a></dt><dd class="topic-paragraph">Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.</dd></dl>
	</stage>
		<p>
			After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
		</p>
		<dl><dt><a href="topic_5-3.html"><cite>Topic 5.3: General treatment for sore nipples</cite></a></dt><dd class="topic-paragraph">The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.</dd></dl>
	</stage>
		<p>
			Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?
		</p>
		<dl><dt><a href="topic_5-4.html"><cite>Topic 5.4: Further causes of nipple pain</cite></a></dt><dd class="topic-paragraph">Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.</dd></dl>
	</stage>
		<p>
			Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?
		</p>
		<dl><dt><a href="topic_5-5.html"><cite>Topic 5.5: Mastitis – diagnosis</cite></a></dt><dd class="topic-paragraph">Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.</dd></dl>
	</stage>
		<p>
			What would be the appropriate treatment to give her now?
		</p>
		<dl><dt><a href="topic_5-6.html"><cite>Topic 5.6: Mastitis – treatment and complications</cite></a></dt><dd class="topic-paragraph">Good breast drainage is an essential component of the treatment of mastitis. Antibiotics may be required, especially if the mother has moderate to severe local or systemic symptoms, that she has cracked nipples, or the symptoms have been present for more than 12 hours without improving. Recurrent infection, Candida and a breast abscess are complications of mastitis.</dd></dl>
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          <h1 id="top">5.1 Sore nipples</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
		<stage>
		<stage>
		
	</stage>
		<p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
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          <strong>
            <p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
          </strong>
          <p>
		Nipple tenderness, related to changes in the hormonal milieu<sup><a href="#note1">1</a></sup>, is common in the first seven to 10 days postpartum, often peaking between days three and five (<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup>). Antenatal nipple preparation<sup><a href="#note4">4</a></sup> or restricting the number or length of breastfeeds in the immediate postpartum period<sup><a href="#note5">5</a></sup> has not been shown to reduce the incidence of nipple tenderness or damage. Nipple cracks, grazes or significant pain indicate the occurrence of nipple trauma, usually associated with sub-optimal positioning and attachment of the infant at the breast<sup><a href="#note6">6</a></sup>.
	</p>
          <p>
		<div class="captionBox"><img width="200" height="212" src="images/poorly_positioned_baby.jpg" alt="Poorly positioned and latched baby" /><p>Poorly positioned and latched baby. <br />&copy;  WHO</p></div>
	</p>
          <div class="section" id="What_is_good_attachment_"><h2>What is good attachment?</h2>
		<p>
			When an infant attaches well to the breast, his tongue is down and forward over the lower gum, his mouth is open wide so that the breast fills the oral cavity and the tip of the nipple reaches towards the junction of the hard and soft palate. In this position, there is little friction or trauma to the nipple. The nipple lying along the tongue and at the back of the hard palate is thought to elicit the sucking reflex. It is important to note that the infant <em>breast</em>feeds not nipple feeds.
		</p>
		<p>
			<div class="captionBox"><img width="300" height="310" src="images/well_positioned_baby.jpg" alt="Well positioned and latched baby" /><p>Well positioned and latched baby. <br />&copy;  D.Fisher, IBCLC</p></div>
		</p>
		<p>
			To facilitate optimal attachment to the breast, the infant has to receive appropriate sensory input and positional stability to enable his or her innate reflexes to function<sup><a href="#note7">7</a></sup>.
		</p>
		<ul><li>The mother holds the slightly flexed infant firmly and close to her body, ventral surface to ventral surface.</li><li>Support across the shoulders and lower neck provides the stability for appropriate head and neck movement.</li><li>The head, neck and body are aligned.</li><li>The infant is at breast level with the nipple opposite the infant's nose.</li><li>The mother often holds and shapes the breast in the plane of the infant's mouth, although her fingers should not be close enough to the nipple to interfere with attachment<sup><a href="#note8">8</a></sup>.</li><li>As the infant opens his/her mouth wide, either instinctively or in response to contact with the breast/nipple, the mother brings the infant closer to the breast – chin first so that he/she takes more breast from the underside side of the breast than the upper side (asymmetric latch)<sup><a href="#note8">8</a></sup>.</li></ul>
	</div>
          <div class="section" id="What_to_look_for_when_assessing_positioning_and_attachment"><h2>What to look for when assessing positioning and attachment</h2>
		<ul><li>Mother is comfortable and has minimal pain or discomfort.</li><li>The infant faces the mothers body and is held firmly.</li><li>The head, neck and body are aligned.</li><li>The chin is pressed into the breast, the nose is clear and the neck slightly extended.</li><li>Upper and lower lips are flanged and wide.</li><li>More areola is evident above the upper lip than below the lower lip.</li><li>The tip of the tongue is over the lower lip and may be seen. However, the infant is usually too close to the breast for this to be routinely observed.</li><li>After the first few minutes, the infant takes deep rhythmic sucks with wide excursion of the mandible. The cheeks do not cave in and there is no clicking noise, although audible swallowing is evident.</li><li>The nipple should not appear pinched or deformed after a feed.</li></ul>
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                <td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Pause a moment</h3>
		<p>
			Visual assessment of positioning and attachment is only one aspect. If the mother is experiencing pain, something is wrong.<sup><a href="#note9">9</a></sup>.
		</p>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#robi77" title="See full details">#</a> Robinson JE et al. (1977) Changes in breast sensitivity at puberty, during the menstrual cycle, and at parturition</li>
              <li id="note2"><a href="references.html#hewa87" title="See full details">#</a> Hewat RJ et al. (1987) A comparison of the effectiveness of two methods of nipple care</li>
              <li id="note3"><a href="references.html#ziem93" title="See full details">#</a> Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation</li>
              <li id="note4"><a href="references.html#more05a" title="See full details">#</a> Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review</li>
              <li id="note5"><a href="references.html#deca84" title="See full details">#</a> de Carvalho M et al. (1984) Does the duration and frequency of early breastfeeding affect nipple pain?</li>
              <li id="note6"><a href="references.html#nati03" title="See full details">#</a> National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers</li>
              <li id="note7"><a href="references.html#glov04" title="See full details">#</a> Glover R (July 14-18 2004) Lessons from Innate Feeding Abilities Transforms Breastfeed Outcomes</li>
              <li id="note8"><a href="references.html#neif04" title="See full details">#</a> Neifert MR (2004) Breastmilk transfer: Positioning, latch-on, and screening for problems in milk transfer</li>
              <li id="note9"><a href="references.html#renf89" title="See full details">#</a> Renfrew MJ (1989) Positioning the baby at the breast: More than a visual skill</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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          <h1 id="top">5.2 Factors causing nipple damage</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
	</stage>
		<p>
			What other conditions may contribute to nipple damage occurring in the first week postpartum?
		</p>
		<dl><dt><a href="topic_5-2.html"><cite>Topic 5.2: Factors causing nipple damage</cite></a></dt><dd class="topic-paragraph">Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.</dd></dl>
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          <strong>
            <p>
			What other conditions may contribute to nipple damage occurring in the first week postpartum?
		</p>
          </strong>
          <p>
		<div class="captionBox"><img width="400" height="257" src="images/nipple_damage.jpg" alt="Nipple damage" /><p>Nipple damage caused by poor latch. <br />&copy;  S.Cox IBCLC</p></div>
	</p>
          <div class="section" id="Engorgement"><h2>Engorgement</h2>
		<p>
			As the breasts become full with the onset of copious milk production (usually day three or four), they tend to loose their elasticity, the nipples become flatter and some infants have difficulty attaching properly to the breast. This is a common time for nipple damage to occur. Relieving breast fullness before commencing a feed by expressing a small amount of milk usually allows the infant to attach well and prevents or relieves further nipple trauma (see Case C).
		</p>
	</div>
          <div class="section" id="Anatomical_variations_of_mother"><h2>Anatomical variations of mother</h2>
		<p>
			There are many variations in the size and shape of mothers' nipples and breasts, with most not interfering with breastfeeding. As long as the infant can draw sufficient breast into his/her mouth to form a teat so that the nipple area is near the junction of the hard and soft palate, breastfeeding can proceed normally. When the infant attaches but is unable to draw the nipple/breast far enough into his/her mouth, the nipple may become sore and cracked/traumatised.
		</p>
		<p>
			Concern is often expressed regarding the ability to breastfeed, with flat or inverted nipples that were described in Case A. No specific treatment has been shown to "improve" nipple protractility antenatally (<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>), although flat nipples often become more elastic and flexible during pregnancy.
		</p>
		<p>
			Infants find it easiest to attach to breasts with flat or inverted nipples when their reflexes are at their peak and the breasts are soft, usually within the first hour of birth. Being very careful about correct positioning and attachment from the first feed is important. Firm nipple substitutes such as bottle teats and dummies are a different shape and texture to the breast, and their use before the infant has had an opportunity to attach and breastfeed independently often leads to ongoing attachment difficulties. Devices, including breast pumps, the Avent Niplette™<sup><a href="#note3">3</a></sup> and modified disposable syringes<sup><a href="#note4">4</a></sup>, can help draw out the nipple prior to a breastfeed. Some women also use these devices antenatally. Nipple shields may also provide protection to the nipple and a firm surface for the infant to attach to if he/she cannot attach unaided<sup><a href="#note5">5</a></sup>.
		</p>
		<div class="columns"><div class="column" style="width: 50%">
				<div class="captionBox"><img width="200" height="300" src="images/modified_syringe.jpg" alt="A Modified Syringe" /><p>A Modified Syringe. <br />&copy;  Health e-Learning</p></div>
			</div><div class="column" style="width: 50%">
				<div class="captionBox"><img width="250" height="167" src="images/well_latched_bwc.gif" alt="Using a nipple shield" /><p>Using a nipple shield. <br />&copy;  Breastfeeding Atlas</p></div>
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	</div>
          <div class="section" id="Anatomical_variations_of_the_infant"><h2>Anatomical variations of the infant</h2>
		<p>
			Tongue-tie (ankyloglossia) and a high arched palate (genetic) or other palatal abnormalities from intubation (particularly in premature infants) can cause sore and traumatised nipples.
		</p>
		<p>
			<div class="captionBox"><img width="435" height="300" src="images/tongue_tie_BI.jpg" alt="Ankyloglossia" /><p>Ankyloglossia. <br />&copy;  B.Ingle, IBCLC</p></div>
		</p>
		<p>
			Between 3.2 and 4.6 percent of infants are born with a tongue-tie (<sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup>). Tongue movement, such as the ability to protrude the tongue over the lower gum, cup a finger or the breast<sup><a href="#note8">8</a></sup> or to generate a normally shaped peristaltic wave may be limited when the sub-lingual frenulum extends further towards the tip of the tongue than normal. The degree to which breastfeeding is affected will depend on the movement restriction, the shape of the infant's mouth and the elasticity and shape of the mother's breast and nipple. In some situations (but not all), ankyloglossia results in ongoing severe nipple trauma that is not improved with corrections to positioning and attachment, and poor breast drainage<sup><a href="#note9">9</a></sup>. Frenotomy (division of the tongue-tie) provides almost instantaneous pain relief, no further nipple trauma and improved attachment of the infant (<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup>). The Hazelbaker Assessment Tool for Lingual Frenulum Function is an objective method of assessing the impact of a tongue tie on breastfeeding effectiveness and can be useful in deciding whether a frenotomy is necessary<sup><a href="#note10">10</a></sup>.
		</p>
	</div>
          <div class="section" id="Neurological_issues_with_the_infant"><h2>Neurological issues with the infant</h2>
		<p>
			Neurological problems resulting in uncoordinated tongue movements, tonic bites or other abnormalities that preclude good attachment may present initially with sore/cracked nipples. Infants with these conditions require appropriate assessment and specialised assistance outside the scope of this resource<sup><a href="#note11">11</a></sup>.
		</p>
	</div>
          <div class="section" id="Inappropriate_use_of_lactation_aids"><h2>Inappropriate use of lactation aids</h2>
		<p>
			If the base of a nipple shield or the flange of a breast pump is too small for the nipple, pressure and friction can occur during use, exacerbating any nipple trauma already present. Different sized shields and pump flanges are available if needed. Pump pressure set too high can also prolong nipple pain.
		</p>
	</div>
          <div class="section" id="High_intra-oral_pressure"><h2>High intra-oral pressure</h2>
		<p>
			Recent research indicates that the infants of some mothers who suffer from ongoing sore nipples without apparent cause generate much higher intraoral pressures than other infants<sup><a href="#note12">12</a></sup>. Other researchers have identified different sucking behaviours amongst infants that may have an effect on their mothers' nipples<sup><a href="#note13">13</a></sup>. Further research in this area will help elucidate further causes and treatments for nipple pain and trauma.
		</p>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_c">
<script type="text/javascript">
/* <![CDATA[ */
var cqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Mary Jane is ready for hospital discharge on day three. She and the infant appear to be well, but she complains of painful nipples that are beginning to crack. What needs to be assessed to determine the cause of her sore nipples before she is discharged?</strong>\n			</p>\n		', r : '\n			<p>\n				Positioning and attachment of the baby at the breast must be assessed first as this would be the most likely cause of sore nipples. In addition, assessment should be made of Mary Jane\'s breasts and nipples (eg inverted or dimpled nipples) and the infant\'s oral anatomy (tongue-tie, high arched palate); sucking rhythm; and neurological competency.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('c');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#alex92" title="See full details">#</a> Alexander JM et al. (1992) Randomised controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples.</li>
              <li id="note2"><a href="references.html#mcca95" title="See full details">#</a> McCandlish R et al. (1995) MAIN Trial Collaborative Group. Antenatal treatments for flat or inverted nipples: the MAIN Trial results</li>
              <li id="note3"><a href="references.html#mcge94" title="See full details">#</a> McGeorge DD (1994) The "Niplette": an instrument for the non-surgical correction of inverted nipples</li>
              <li id="note4"><a href="references.html#arse97" title="See full details">#</a> Arsenault G (1997) Using a disposable syringe to treat inverted nipples</li>
              <li id="note5"><a href="references.html#wils96" title="See full details">#</a> Wilson-Clay B (1996) Clinical use of silicone nipple shields</li>
              <li id="note6"><a href="references.html#mess00" title="See full details">#</a> Messner AH et al. (2000) Ankyloglossia: incidence and associated feeding difficulties</li>
              <li id="note7"><a href="references.html#ball02" title="See full details">#</a> Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad</li>
              <li id="note8"><a href="references.html#srin06" title="See full details">#</a> Srinivasan A et al. (2006) Ankyloglossia in breastfeeding infants: The effect of frenotomy on maternal nipple pain and latch</li>
              <li id="note9"><a href="references.html#lala03" title="See full details">#</a> Lalalea ML et al. (2003) Ankyloglossia: does it matter?</li>
              <li id="note10"><a href="references.html#amir06" title="See full details">#</a> Amir LH et al. (2006) Reliability of the hazelbaker assessment tool for lingual frenulum function</li>
              <li id="note11"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
              <li id="note12"><a href="references.html#mccl08" title="See full details">#</a> McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums</li>
              <li id="note13"><a href="references.html#mizu04" title="See full details">#</a> Mizuno K et al. (2004) Sucking behavior at breast during the early newborn period affects later breast-feeding rate and duration of breast-feeding</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
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          <h1 id="top">5.3 General treatment for sore nipples</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
	</stage>
		<p>
			What other conditions may contribute to nipple damage occurring in the first week postpartum?
		</p>
		<dl><dt><a href="topic_5-2.html"><cite>Topic 5.2: Factors causing nipple damage</cite></a></dt><dd class="topic-paragraph">Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.</dd></dl>
	</stage>
		<p>
			After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
		</p>
		<dl><dt><a href="topic_5-3.html"><cite>Topic 5.3: General treatment for sore nipples</cite></a></dt><dd class="topic-paragraph">The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.</dd></dl>
	</stage>
	</td>
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          <strong>
            <p>
			After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
		</p>
          </strong>
          <div class="section" id="Assess_positioning_and_attachment"><h2>Assess positioning and attachment</h2>
		<ul><li>Provide appropriate assistance to ensure optimal attachment at all feeds.</li></ul>
	</div>
          <div class="section" id="Advice_about_breastfeeds"><h2>Advice about breastfeeds</h2>
		<ul><li>Commence feeds when the infant initiates feeding cues (beginning to root, hands to mouth), rather than waiting until he is very hungry and crying.</li><li>Start feeds on the least sore side. The baby can be swapped to the other side once milk is flowing freely.</li><li>If both sides are very painful, express (preferably by hand) until the milk is flowing freely, and then attach the infant.</li><li>Gently remove the infant from the breast by releasing the suction when he has stopped sucking effectively.</li><li>Suggest using different feeding positions.</li></ul>
	</div>
          <div class="section" id="Advice_about_nipple_treatment"><h2>Advice about nipple treatment</h2>
		<ul><li>Warm water compresses provide some pain relief between feeds<sup><a href="#note1">1</a></sup>.</li><li>Breast milk left to dry on the nipple may also be beneficial and is simple and readily available<sup><a href="#note1">1</a></sup>.</li><li>There is no evidence that any particular topical treatment is effective in preventing or relieving nipple pain or cracks<sup><a href="#note1">1</a></sup>.</li></ul>
	</div>
          <div class="section" id="Lactation_aids"><h2>Lactation aids</h2>
		<p>
			Breast shells or nipple airers lift clothing from the nipple and allow air to circulate<sup><a href="#note2">2</a></sup>, providing pain relief for some women.
		</p>
	</div>
          <div class="section" id="Rest_nipples"><h2>Rest nipples</h2>
		<p>
			If Anna finds it too painful to continue to breastfeed, she can express her milk (hand expression creates less nipple trauma) for 24 to 48 hours and feed this milk to Joshua with a cup, spoon or bottle. Once the nipples begin to heal, breastfeeds can gradually be reintroduced.
		</p>
		<p>
			These measures should be used for all women with sore/cracked nipple, regardless of the cause, in conjunction with other treatments if necessary.
		</p>
	</div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#more05a" title="See full details">#</a> Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review</li>
              <li id="note2"><a href="references.html#brod04a" title="See full details">#</a> Brodribb W (2004) Breastfeeding Management</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_5-4" class="content">
          <h1 id="top">5.4 Further causes of nipple pain</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
	</stage>
		<p>
			What other conditions may contribute to nipple damage occurring in the first week postpartum?
		</p>
		<dl><dt><a href="topic_5-2.html"><cite>Topic 5.2: Factors causing nipple damage</cite></a></dt><dd class="topic-paragraph">Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.</dd></dl>
	</stage>
		<p>
			After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
		</p>
		<dl><dt><a href="topic_5-3.html"><cite>Topic 5.3: General treatment for sore nipples</cite></a></dt><dd class="topic-paragraph">The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.</dd></dl>
	</stage>
		<p>
			Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?
		</p>
		<dl><dt><a href="topic_5-4.html"><cite>Topic 5.4: Further causes of nipple pain</cite></a></dt><dd class="topic-paragraph">Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.</dd></dl>
	</stage>
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          <strong>
            <p>
			Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?
		</p>
          </strong>
          <div class="section" id="Infection"><h2>Infection</h2>
		<p>
			<em>Click on the points below for more detail:</em>
			<ul class="collapse"><li>
					Staphylococcal infection
					<ul collapse="yes"><li>
							Colonisation of the nipple with Staphylococcus aureus appears to be a common occurrence in women with sore, cracked or fissured nipples. Symptoms include persistent sore nipples or non-healing cracks or fissures after resolution of any obvious cause. A yellow exudate in cracks or fissures may be evident. Women with proven Staphylococcus aureus colonisation have a much higher risk of mastitis than other breastfeeding women<sup><a href="#note1">1</a></sup>.
						</li></ul>
					<ul collapse="yes"><li>
							Treatment (in addition to the measures discussed previously):
							<ul><li>Clean affected nipples with warm salty water, especially if cracks and/or exudate are evident<sup><a href="#note2">2</a></sup>.</li><li>Treat with ointment such as mupirocin (Bactroban) or oral antibiotics such as dicloxacillin or cephalexin. One study showed a reduction in the incidence of mastitis in women with infected nipples who were treated with oral rather than topical antibiotics<sup><a href="#note1">1</a></sup>.</li></ul>
						</li></ul>
				</li><li>
					Thrush
					<ul collapse="yes"><li>
							Symptoms attributed to candida (usually Candida albicans) infection of the nipple and/or breast include persistent nipple pain (burning or stinging that last throughout and after a feed), very tender nipples, and breast pain (stabbing, shooting, like hot cords) that often radiates through the breast to the back. There may be no obvious abnormality seen on clinical examination or the skin of the nipple/areola may be red, shiny or flaky. Nipple fissures and cracks may fail to heal<sup><a href="#note3">3</a></sup>. The infant may have oral thrush or candida nappy rash and the mother may have a history of vaginal thrush.
						
						<div class="columns"><div class="column" style="width: 50%">
								<ul collapse="yes"><li>
										Treatment (both mother and infant need to be treated):
										<ul><li>Infant – miconazole oral gel qid<sup><a href="#note4">4</a></sup>, or nystatin oral drops, one drop in each cheek qid for a week and then daily until one week after symptoms resolve.</li><li>Mother – wash nipples with a solution of a cup of water and one tablespoon of white vinegar (<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>).</li><li>Mother – Miconozole oral gel or cream or Nystatin cream applied to nipples four to six times a day after feeds.</li><li>Mother – If symptoms are severe or long-standing, The Royal Women's Hospital (Melbourne) Clinical Practice Guidelines<sup><a href="#note4">4</a></sup> recommend Nystatin tablets or capsules 500,000 units two tds for a course of 50 tables. If pain has not resolved in a week continue Nystatin and add Fluconazole 150mg on alternate days for three doses.</li></ul>
									</li></ul>
							</div><div class="column" style="width: 50%">
								<div class="captionBox"><img width="300" height="225" src="images/thrush10.jpg" alt="Nipple candidiasis" /><p>Nipple candidiasis. <br />&copy;  B.Ingle, IBCLC</p></div>
							</div></div><br style="clear: both" />
					</li></ul>
				</li><li>
					Herpes
					<ul collapse="yes"><li>
							Blisters occurring on the nipple or areola associated with significant pain may be due to Herpes simplex infection. Because of the risk to young infants if they contract Herpes infection, breastfeeding from the affected breast should be withheld until the blisters have healed, or another diagnosis is confirmed<sup><a href="#note7">7</a></sup>. If the infant is older, or the infant transmits the infection to the mother, the risk of continued breastfeeding is less of an issue.
						</li></ul>
				</li><li>
					Investigations for infected nipples
					<ul collapse="yes"><li>
							Swabbing sore nipples and those with cracks, fissures or vesicles often enables a more definitive diagnosis and appropriate treatment of Staphyloccus or Herpes infection. Candida, however, is difficult to grow and a negative result does not preclude the diagnosis. Culture media with added iron has a higher positive culture rate<sup><a href="#note8">8</a></sup>.
						</li></ul>
				</li></ul>
		</p>
	</div>
          <div class="section" id="Vasospasm"><h2>Vasospasm</h2>
		<p>
			Women with nipple vasospasm present with nipple and breast pain, often throbbing, sharp or burning, that begins towards the end of the feed, after the feed or independent of the feed. Vasospasm is similar to Raynaud's phenomenon and is associated with bi- or tri-colour change of the nipple. Blanching of the face of the nipple when pain occurs is usually the most obvious clinical sign. Vasospasm does not cause nipple tenderness at other times. Vasospasm is more common in women with a history of Raynaud's phenomenon; in colder weather; in association with other nipple conditions such as trauma or infection; or with medications (theophylline, diflucan) and other drugs (nicotine and caffeine)<sup><a href="#note9">9</a></sup>.
		</p>
		<ul><li>
				Treatment:
				<ul><li>Give an explanation of the pain, and reduce stress if possible<sup><a href="#note10">10</a></sup>.</li><li>Apply warmth to nipples and breast.</li><li>Correct any underlying causes.</li><li>Reduce smoking/caffeine.</li><li>Ca++ 2000mg/day and Mg 1000mg/day.</li><li>Nifedipine 30mg/day (<sup><a href="#note9">9</a>,</sup><sup><a href="#note11">11</a></sup>).</li></ul>
			</li></ul>
		<div class="columns"><div class="column" style="width: 50%">
				<div class="captionBox"><img width="200" height="154" src="images/vasospasm_white_small_GBC.jpg" alt="Vasospasm - white" /><p>Vasospasm - blanched nipple. <br />&copy;  Goldfarb Breastfeeding Clinic</p></div>
			</div><div class="column" style="width: 50%">
				<div class="captionBox"><img width="200" height="154" src="images/vasospasm_red_smallGBC.jpg" alt="Vasospasm - red" /><p>Vasospasm - perfused nipple. <br />&copy;  Goldfarb Breastfeeding Clinic</p></div>
			</div></div><br style="clear: both" />
	</div>
          <div class="section" id="Other_dermatological_conditions"><h2>Other dermatological conditions</h2>
		<em>Click on the points below for more detail:</em>
		<ul class="collapse"><li>
				Eczema
				<ul collapse="yes"><li>
						Symptoms and signs of eczema of the nipple and areola (endogenous atopic eczema, irritant contact dermatitis and allergic contact dermatitis) may include an itchy, painful erythematous rash that may be associated with dry, flaky skin, or crusting vesicular eruptions<sup><a href="#note12">12</a></sup>. The rash may be more prominent where the infant's mouth would rest during a breastfeed. It occurs more commonly on the areola and tends to spare the area around the junction of the nipple and areola. Women may have a history of eczema on other parts of the body or it may be in response to contact with allergens such as nipple creams, soaps, detergents, or with food particles in the infant's mouth following the introduction of solids.
					</li></ul>
				<ul collapse="yes"><ul><li>Avoid aggravating factors such as nipple creams, detergents or soaps.</li><li>Use topical corticosteroids (ointments in preference) sparingly after breastfeeds. Potent corticosteroids may be used for a short period (no longer than seven days) if necessary<sup><a href="#note12">12</a></sup>.</li></ul></ul>
			</li><li>
				Paget's disease of the nipple
				<ul collapse="yes"><li>
						Paget's disease of the nipple is a form of ductal carcinoma-in-situ where cancer cells track under the epidermis and causes skin changes<sup><a href="#note13">13</a></sup>. It begins as a red velvety rash on the face of the nipple but over time spreads outwards becoming ulcerated and crusting. Although non-painful to start with, itching and burning are not uncommon. Breast lumps are often not palpable. Urgent referral and biopsy is required.
					</li></ul>
			</li></ul>
	</div>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_d">
<script type="text/javascript">
/* <![CDATA[ */
var dqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Denise\'s baby Joel is now four weeks postpartum. Both nipples have been painful for most of that time, although the left is worse than the right. She has had assistance with positioning and attachment from a lactation consultant. How could you distinguish between the possible causes of Denise\'s sore nipples?<!-- Draw up a table to include history (onset, description of pain, timing of pain, relieving factors, etc.), examination and appropriate treatments.--></strong>\n			</p>\n		', r : '\n			<p>\n				Distinguishing features would include:\n				<ul>\n					<li>character of the pain;</li>\n					<li>when the pain began postpartum or if the pain changed in character;</li>\n					<li>timing of the pain in relation to feeds;</li> \n					<li>what (if anything) relieves the pain;</li>\n					<li>relationship of pain with nipple changes (compression, colour changes);</li>\n					<li>nipple cracks, grazes, rashes or other signs;</li>\n					<li>associated nipple sensitivity;</li>\n					<li>infant oral anatomy.</li>\n				</ul>\n			</p>\n		' }
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/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('d');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#livi99" title="See full details">#</a> Livingstone V et al. (1999) The treatment of staphylococcus aureus infected sore nipples: a randomized comparative study</li>
              <li id="note2"><a href="references.html#wils02" title="See full details">#</a> Wilson-Clay B et al. (2002) The Breastfeeding Atlas</li>
              <li id="note3"><a href="references.html#amir02" title="See full details">#</a> Amir LH et al. (2002) Candidiasis and breastfeeding Lactation Consultant Series 2</li>
              <li id="note4"><a href="references.html#roya06" title="See full details">#</a> Royal Women's Hospital (Melbourne) (2006) Thrush in lactation</li>
              <li id="note5"><a href="references.html#hein99" title="See full details">#</a> Heinig M et al. (1999) Mammary candidosis in lactating women</li>
              <li id="note6"><a href="references.html#hoov01" title="See full details">#</a> Hoover K (2001) The link between infants' oral thrush and nipple and breast pain in lactating women</li>
              <li id="note7"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
              <li id="note8"><a href="references.html#morr05" title="See full details">#</a> Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women</li>
              <li id="note9"><a href="references.html#ande04" title="See full details">#</a> Anderson JE et al. (April 2004) Raynaud's phenomenon of the nipple: a treatable cause of painful breastfeeding</li>
              <li id="note10"><a href="references.html#mori07" title="See full details">#</a> Morino C et al. (2007) Raynaud's Phenomenon of the nipples: An elusive diagnosis</li>
              <li id="note11"><a href="references.html#lawl97a" title="See full details">#</a> Lawlor-Smith L et al. (1997) Raynaud's phenomenon of the nipple: A treatable cause of breastfeeding failure</li>
              <li id="note12"><a href="references.html#bara04" title="See full details">#</a> Barankin B et al. (2004) Nipple and areolar eczema in the breastfeeding woman</li>
              <li id="note13"><a href="references.html#bass97" title="See full details">#</a> Bassett L et al. (1997) Diagnosis of diseases of the breast</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_5-5" class="content">
          <h1 id="top">5.5 Mastitis – diagnosis</h1>
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                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
	</stage>
		<p>
			What other conditions may contribute to nipple damage occurring in the first week postpartum?
		</p>
		<dl><dt><a href="topic_5-2.html"><cite>Topic 5.2: Factors causing nipple damage</cite></a></dt><dd class="topic-paragraph">Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.</dd></dl>
	</stage>
		<p>
			After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
		</p>
		<dl><dt><a href="topic_5-3.html"><cite>Topic 5.3: General treatment for sore nipples</cite></a></dt><dd class="topic-paragraph">The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.</dd></dl>
	</stage>
		<p>
			Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?
		</p>
		<dl><dt><a href="topic_5-4.html"><cite>Topic 5.4: Further causes of nipple pain</cite></a></dt><dd class="topic-paragraph">Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.</dd></dl>
	</stage>
		<p>
			Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?
		</p>
		<dl><dt><a href="topic_5-5.html"><cite>Topic 5.5: Mastitis – diagnosis</cite></a></dt><dd class="topic-paragraph">Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.</dd></dl>
	</stage>
	</td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
                  <img src="design/callout_06.png" width="10" height="80" alt="" />
                </td>
              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?
		</p>
          </strong>
          <p>
		<div class="captionBox"><img width="300" height="253" src="images/mastitis.jpg" alt="Mastitis" /><p> <br />&copy;  S.Cox IBCLC</p></div>
	</p>
          <p>
		The incidence of mastitis in breastfeeding women is approximately 20 percent, with most episodes occurring within the first three months (<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup>). Mastitis is simply an inflammation in the breast and in the lactating breast manifests by a combination of the following symptoms:
		<ul><div class="columns"><div class="column" style="width: 50%">			
					<li>
						<span class="term">Local breast symptoms</span> include:
						<ul><li>pain (can be quite severe and distressing);</li><li>erythema;</li><li>tenderness;</li><li>lump;</li><li>heat/warmth.</li></ul>
					</li>
				</div><div class="column" style="width: 50%">				
					<li>
						<span class="term">Systemic symptoms</span> include:
						<ul><li>ever;</li><li>rigors;</li><li>myalgia; and</li><li>malaise.</li></ul>
					</li>
				</div></div><br style="clear: both" /></ul>
	</p>
          <p>
		While usually unilateral, bilateral mastitis also occurs, especially in the first two weeks postpartum<sup><a href="#note1">1</a></sup>. The severity of the symptoms and signs of mastitis varies considerably and it is not unusual to have a discrepancy between the severity of the local and systemic symptoms. More severe local symptoms at presentation tend to persist for longer<sup><a href="#note1">1</a></sup>. Many women find mastitis quite debilitating, and some require hospitalisation. Some also report systemic symptoms before noticing any breast problems – mastitis should always be a differential diagnosis for a breastfeeding woman who presents with flu-like symptoms.
	</p>
          <p>
		Mastitis is not always due to bacterial infection. Milk stasis can also lead to the release of cytokines into surrounding breast tissue causing an inflammatory response with local and systemic symptoms indistinguishable from those caused by a bacterial infection (<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>). While measuring the quantity of leukocytes and bacteria in the milk has been used by researchers to distinguish between infective and non-infective (inflammatory mastitis)<sup><a href="#note7">7</a></sup>, it is of limited clinical use. Similarly, in the majority of circumstances, culturing breast milk provides only limited information for the clinician. First, it is difficult to obtain an adequate and uncontaminated specimen. Second, many specimens either do not grow anything, or grow bacteria regarded as normal skin flora. Additionally, it is often inappropriate to wait for microbiological results to commence treatment.
	</p>
          <p>
		Staphylococcus aureus is the most common pathogenic bacteria associated with mastitis (<sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup>). Streptococci, especially B-haemolyitic streptococci (implicated in bilateral disease) and Escherichia coli, have also been known to cause mastitis<sup><a href="#note9">9</a></sup>. MRSA has been cultured from breast milk and breast abscesses and should always be considered if mastitis is not responding to antibiotics as anticipated<sup><a href="#note10">10</a></sup>. Additionally, bacteria regarded as normal skin flora have been grown from the milk of women with mastitis, occasionally in high concentrations. It is uncertain whether these bacteria are contaminants or have a pathological role in some instances<sup><a href="#note6">6</a></sup>.
	</p>
          <dl>
            <dt>Investigations</dt>
            <dd>
			For most women, investigations prior to commencing treatment are unwarranted. However, culture of a mid-stream specimen of milk from the affected breast is indicated if there is no response to antibiotic treatment within 48 hours, mastitis recurs despite apparently adequate treatment or there are other unusual features. If the mother is extremely ill, blood cultures and other investigations may also be necessary<sup><a href="#note9">9</a></sup>.
		</dd>
            <dt>Differential diagnosis</dt>
            <dd>
			
			<ul><li>Engorgement.</li><li>Blocked duct.</li><li>Breast abscess – see below.</li><li>Inflammatory carcinoma.</li><li>Galactocoele.</li></ul>
			<p>
				<div class="captionBox"><a href="images/mastitis-differential-diagnosis.gif" rel="lightbox" title="Table E.1."><img width="300" height="192" src="images/mastitis-differential-diagnosis_thumb.gif" alt="Diagnosing Mastitis" /></a><p>Click on graphic for a larger image. Table E.1.</p></div>
			</p>
		</dd>
          </dl>
          <div class="section" id="What_may_predispose_Anna_to_developing_mastitis_"><h2>What may predispose Anna to developing mastitis?</h2>
		<p>
			<em>Click on the points below for more detail:</em>
			<ul class="collapse"><li>
					Sore/cracked nipples
					<ul collapse="yes"><li>
							Women with sore nipples only or with nipple cracks are more likely to develop mastitis, perhaps due to the retrograde spread of bacteria from the damaged nipple epithelium into the breast tissue. Nipple soreness with feeding, even when nipples look "normal", usually indicates some nipple trauma. Additionally, as discussed previously, nipple cracks may become colonised, with Staphylococcus aureus providing a ready source of infection. Anna's cracked nipple is an important predisposing factor for her developing mastitis (<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a>,</sup><sup><a href="#note11">11</a>,</sup><sup><a href="#note12">12</a>,</sup><sup><a href="#note13">13</a></sup>).
						</li></ul>
				</li><li>
					Milk stasis (poor breast drainage)
					<dl collapse="yes"><dt>Inadequate breast drainage</dt><dd>
							Suboptimal positioning and attachment of the infant at the breast, hurried or timed feeds, over-supply of milk, changes in feeding routines (i.e. infant sleeping through the night) or the replacement of breastfeeds with complementary feeds may all result in sections of one or both breasts not being adequately drained. While breasts are not fully emptied at every feed, each breast should be drained once per day. In Anna's case, her sore nipples suggest positioning and attachment difficulties. In addition, as breastfeeding with a cracked nipple is very painful, she may be hesitant attaching the infant to the breast and reluctant to allow the infant to stay attached for long enough to fully drain the breast (<sup><a href="#note11">11</a>,</sup><sup><a href="#note14">14</a></sup>).
						</dd><dt>Engorgement</dt><dd>
							Although engorgement usually occurs in the first week postpartum, women may develop engorged breasts if there is a long interval between feeds (<sup><a href="#note11">11</a>,</sup><sup><a href="#note15">15</a></sup>).
						</dd><dt>Blocked ducts</dt><dd>
							A description of the signs and symptoms of blocked ducts is in Table E.1. When milk is not removed from a section of the breast, for whatever reason, the risk of non-infective and then infective mastitis increases (<sup><a href="#note12">12</a>,</sup><sup><a href="#note14">14</a></sup>).
						</dd><dt>Mechanical obstruction</dt><dd>
							Mechanical obstruction of breast drainage. Pressure on the breast from clothing, seatbelts, breast pumps, nipple shields and nipple airers have been implicated in milk stasis and mastitis (<sup><a href="#note11">11</a>,</sup><sup><a href="#note13">13</a></sup>).
						</dd></dl>
				</li><li>
					Sources of staph infection
					<ul collapse="yes"><li>
							Nasal carriage of <span class="term">Staphylococcus aureus</span> in infants increases the risk of mastitis in their mothers<sup><a href="#note11">11</a></sup>. It is also suggested that other sources of Staph infections such as contaminated nipple creams or other family members may also be implicated.
						</li></ul>
				</li><li>
					Past history of mastitis
					<ul collapse="yes"><li>
							Women who have had a previous episode of mastitis in a past or present lactation have an increased risk of developing mastitis again (<sup><a href="#note12">12</a>,</sup><sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup>).
						</li></ul>
				</li><li>
					Maternal factors (illness, depressed immune system)
					<ul collapse="yes"><li>
							Stress, fatigue, anaemia, and low IgA, C3 and lactoferrin levels are also considered predisposing factors for mastitis (<sup><a href="#note14">14</a>,</sup><sup><a href="#note15">15</a></sup>).
						</li></ul>
				</li></ul>
		</p>
	</div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#feth97" title="See full details">#</a> Fetherston C (1997) Characteristics of lactation mastitis in a Western Australian cohort</li>
              <li id="note2"><a href="references.html#amir07a" title="See full details">#</a> Amir LH et al. (2007) A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants</li>
              <li id="note3"><a href="references.html#voge99a" title="See full details">#</a> Vogel A et al. (1999) Mastitis in the first year postpartum</li>
              <li id="note4"><a href="references.html#kinl98" title="See full details">#</a> Kinlay JR et al. (1998) Incidence of mastitis in breastfeeding women during the six months after delivery: a prospective cohort study</li>
              <li id="note5"><a href="references.html#feth01" title="See full details">#</a> Fetherston C (2001) Mastitis in lactating women: physiology or pathology?</li>
              <li id="note6"><a href="references.html#oste00" title="See full details">#</a> Osterman KL et al. (2000) Lactation mastitis: bacterial cultivation of breast milk, symptoms, treatment, and outcome</li>
              <li id="note7"><a href="references.html#thom84" title="See full details">#</a> Thomsen AC et al. (1984) Course and treatment of milk stasis, noninfectious inflammation of the breast, and infectious mastitis in nursing women</li>
              <li id="note8"><a href="references.html#amir99" title="See full details">#</a> Amir LH et al. (1999) An audit of mastitis in the emergency department</li>
              <li id="note9"><a href="references.html#worl00" title="See full details">#</a> World Health Organization WHO (2000) Mastitis: Causes and management</li>
              <li id="note10"><a href="references.html#redd07" title="See full details">#</a> Reddy P et al. (2007) Postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus</li>
              <li id="note11"><a href="references.html#amir06a" title="See full details">#</a> Amir LH et al. (2006) A case-control study of mastitis: nasal carriage of Staphylococcus aureus</li>
              <li id="note12"><a href="references.html#kinl01" title="See full details">#</a> Kinlay JR et al. (2001) Risk factors for mastitis in breastfeeding women: results of a prospective cohort study</li>
              <li id="note13"><a href="references.html#foxm02" title="See full details">#</a> Foxman B et al. (2002) Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States</li>
              <li id="note14"><a href="references.html#feth98" title="See full details">#</a> Fetherston C (1998) Risk factors for lactation mastitis</li>
              <li id="note15"><a href="references.html#wamb03" title="See full details">#</a> Wambach KA (2003) Lactation mastitis: a descriptive study of the experience</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_5-6" class="content">
          <h1 id="top">5.6 Mastitis – treatment and complications</h1>
          <table class="callout">
            <thead>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
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            </thead>
            <tfoot>
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                <td class="topcenter" style="background-image: url(design/callout_08.png);">
                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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            <tbody>
              <tr>
                <td class="middleleft" style="background: repeat-y url(design/callout_04.png);">
                  <img src="design/callout_04.png" width="10" height="80" alt="" />
                </td>
                <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		<stage>
		
	</stage>
		<p>
			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
		</p>
		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
	</stage>
		<p>
			What other conditions may contribute to nipple damage occurring in the first week postpartum?
		</p>
		<dl><dt><a href="topic_5-2.html"><cite>Topic 5.2: Factors causing nipple damage</cite></a></dt><dd class="topic-paragraph">Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.</dd></dl>
	</stage>
		<p>
			After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
		</p>
		<dl><dt><a href="topic_5-3.html"><cite>Topic 5.3: General treatment for sore nipples</cite></a></dt><dd class="topic-paragraph">The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.</dd></dl>
	</stage>
		<p>
			Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?
		</p>
		<dl><dt><a href="topic_5-4.html"><cite>Topic 5.4: Further causes of nipple pain</cite></a></dt><dd class="topic-paragraph">Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.</dd></dl>
	</stage>
		<p>
			Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?
		</p>
		<dl><dt><a href="topic_5-5.html"><cite>Topic 5.5: Mastitis – diagnosis</cite></a></dt><dd class="topic-paragraph">Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.</dd></dl>
	</stage>
		<p>
			What would be the appropriate treatment to give her now?
		</p>
		<dl><dt><a href="topic_5-6.html"><cite>Topic 5.6: Mastitis – treatment and complications</cite></a></dt><dd class="topic-paragraph">Good breast drainage is an essential component of the treatment of mastitis. Antibiotics may be required, especially if the mother has moderate to severe local or systemic symptoms, that she has cracked nipples, or the symptoms have been present for more than 12 hours without improving. Recurrent infection, Candida and a breast abscess are complications of mastitis.</dd></dl>
	</stage>
	</td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
                  <img src="design/callout_06.png" width="10" height="80" alt="" />
                </td>
              </tr>
            </tbody>
          </table>
          <strong>
            <p>
			What would be the appropriate treatment to give her now?
		</p>
          </strong>
          <div class="section" id="Effective_milk_removal_breast_drainage"><h2>Effective milk removal/breast drainage</h2>
		<p>
			As milk stasis is an important precursor for mastitis, good breast drainage is an essential component of treatment.
		</p>
		<table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Clinical Note</h3>
			<p>This is not a time to wean.</p>
		</td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
		<ul><li>The infant should be encouraged to feed frequently (at least eight times a day) from the affected breast. Occasionally expressing by hand or pump is also required to drain the breast well.</li><li>Frequent breast expression by hand or pump is required if the infant refuses the breast (milk often has higher sodium and chloride levels and lower lactose levels) or the mother finds it too painful to breastfeed.</li><li>Correcting any positioning and attachment problems is integral to good breast drainage.</li></ul>
		<div class="section display-accordion" id="">
			<div class="section" id="Analgesia"><h4>Analgesia</h4><div class="section" id="">
				<p>
					Paracetamol or anti-inflammatory medications such as Ibuprofen reduce local and systemic symptoms.
				</p>
			</div></div>
			<div class="section" id="Antibiotics"><h4>Antibiotics</h4><div class="section" id="">
				<p>
					Non-infective mastitis will resolve with good breast drainage and supportive measures. It is not possible to distinguish between non-infective and infective mastitis by symptoms and signs alone, therefore prescribing antibiotics initially is appropriate when:
					<ul><li>local symptoms are moderate to severe;</li><li>systemic symptoms are moderate to severe;</li><li>the woman has cracked nipples;</li><li>symptoms have been present for more than 12 hours and are not improving.</li></ul>
				</p>
				<p>
					The most appropriate antibiotics are:
					<ul><li>penicillinase-resistant penicillins such as dicloxacillin and flucloxicillin 500mg qid; or cephalexin 500mg qid;</li><li>Clindamycin 450mg qid can be used if there is concern about severe penicillin allergy or there are indications of an unusual or severe infection<sup><a href="#note1">1</a></sup>.</li></ul>
				</p>
				<p>
					Most authorities suggest a 1014 day course of antibiotics, although there are no trials of a shorter course (<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup>). Women with mild symptoms can be watched expectantly for 12 to 24 hours and treated with antibiotics if there is no improvement in symptoms.
				</p>
			</div></div>
			<div class="section" id="Supportive_measures"><h4>Supportive measures</h4><div class="section" id="">
				<ul><li>Bed rest.</li><li>Gentle breast massage.</li><li>Correcting underlying problems such as anaemia or constricting clothing.</li><li>Adequate fluid and nutrition.</li><li>Hot packs prior to a feed and cold packs following a feed may give symptomatic relief<sup><a href="#note3">3</a></sup>.</li></ul>
			</div></div>
			<div class="section" id="The_infant"><h4>The infant</h4><div class="section" id="">
				<p>
					Very few infants are affected adversely if their mother develops mastitis. There is no need to stop the infant feeding on the affected side, or to discard any milk expressed from that side, although as mentioned previously some infants will refuse the breast. The infant does not need to be treated at the same time as the mother. The antibiotics and anti-inflammatory medications mentioned are compatible with breastfeeding, although some infants may develop self-limiting diarrhoea due to maternal treatment<sup><a href="#note3">3</a></sup>.
				</p>
			</div></div>
		</div>
	</div>
          <div class="section" id="What_complications_may_arise_from_mastitis_"><h2>What complications may arise from mastitis?</h2>
		<div class="section display-accordion" id="">
			<div class="section" id="Recurrent_mastitis"><h4>Recurrent mastitis</h4><div class="section" id="">
				<p>
					Approximately 1727 percent of women with mastitis have recurrent episodes. It is often thought to be due to inadequate or inappropriate treatment for the original episode of mastitis, or the persistence of predisposing causes such as chronic over-supply or ongoing nipple problems. Mid-stream milk leukocyte counts, culture and sensitivity and nasal swabs of mother and infant may provide useful information for ongoing management. Further antibiotic treatment for at least 10 days is indicated. Long-term low-dose antibiotic therapy may be appropriate for some women.
				</p>
			</div></div>
			<div class="section" id="Candida_infection"><h4>Candida infection</h4><div class="section" id="">
				<p>
					Described previously may be secondary to antibiotic use.
				</p>
			</div></div>
		</div>
	</div>
          <div class="section" id="Occasionally_a_woman_with_mastitis_develops_a_breast_abscess._What_would_predispose_Anna_to_a_breast_abscess_"><h2>Occasionally, a woman with mastitis develops a breast abscess. What would predispose Anna to a breast abscess?</h2>
		<ul><li>Poor breast drainage during an episode of mastitis. These may be ongoing problems that predisposed to the development of mastitis in the first place (e.g. difficulties with positioning and attachment) or as a consequence of mastitis (e.g. weaning, infant refusing to breastfeed on the affected side, but the breast not being drained by expression).</li><li>Antibiotic treatment that is inappropriate or for a short duration.</li><li>A delay in seeking treatment for mastitis.</li><li>Occasionally, abscesses develop rapidly despite appropriate treatment. Approximately 3 percent of women who are treated for mastitis develop a breast abscess<sup><a href="#note4">4</a></sup>.</li></ul>
	</div>
          <div class="section" id="What_symptoms_or_signs_would_make_you_suspect_a_breast_abscess_"><h2>What symptoms or signs would make you suspect a breast abscess?</h2>
		<ul><li>A localised red, tender, indurated area that has not responded to antibiotic therapy.</li><li>Symptoms may range from palpable lump and few local or systemic symptoms to an extremely ill woman with a red, erythematous breast and a localised area of increased induration.</li><li>Fluctuant mass in a breastfeeding woman, particularly if she had recently been treated for mastitis.</li></ul>
	</div>
          <div class="section" id="How_would_you_investigate_a_suspected_breast_abscess_and_what_would_be_the_most_appropriate_treatment_"><h2>How would you investigate a suspected breast abscess, and what would be the most appropriate treatment?</h2>
		<div class="section display-accordion" id="">
			<div class="section" id="Ultrasound"><h4>Ultrasound</h4><div class="section" id="">
				<p>
					Ultrasound is the investigation of choice. It will distinguish between ongoing inflammation and the development of a fluid collection.
				</p>
			</div></div>
			<div class="section" id="Abscess_drainage"><h4>Abscess drainage</h4><div class="section" id="">
				<dl><dt>Fine needle aspiration biopsy (preferably under ultrasound control)</dt><dd>
						This provides material for culture and sensitivity and in many cases provides definitive treatment. Depending on the size and shape of the abscess, recurrent aspiration may be required (<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>).
					</dd><dt>Incision and drainage</dt><dd>
						This is the most appropriate treatment in some cases, particularly if the abscess is large and is multiloculated (<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>).
					</dd></dl>
			</div></div>
			<div class="section" id="Antibiotics"><h4>Antibiotics</h4><div class="section" id="">
				<p>
					Antibiotics should be commenced immediately but may need to be changed based on culture results when available. They should be continued until the abscess has resolved.
				</p>
			</div></div>
			<div class="section" id="Breast_emptying"><h4>Breast emptying</h4><div class="section" id="">
				<ul><li>Breastfeeding can continue on both breasts, providing the infant continues to attach to the breast properly (depends on position of abscess, incision and drain if necessary) (<sup><a href="#note2">2</a>,</sup><sup><a href="#note7">7</a></sup>).</li><li>Expressing (hand or pump) may be necessary if the infant is unable or refuses to breastfeed.</li></ul>
			</div></div>
		</div>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_e">
<script type="text/javascript">
/* <![CDATA[ */
var eqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>Rachel, six weeks postpartum, presents with a red, hot, painful right breast. She is febrile (39&#176;C) and has rigors. She has been unwell for 48 hours. On examination she has a large, very firm area in the upper outer quadrant. Her baby is refusing to feed from the right side.</strong>\n			</p>\n			<p>\n				<strong>What is your plan of management?</strong>\n			</p>\n		', r : '\n			<p>\n				Depending on how ill she is, she may need hospital admission and IV antibiotics. Otherwise she will require oral antibiotics and close follow-up. Until the baby will feed from the right breast again, milk should be expressed (gently) by hand or pump while the baby continues to feed from the left breast. An ultrasound will show if the firm area is an abscess that could be drained by needle aspiration under ultrasound control, or by incision and open drainage. Further ultrasounds may be necessary if the breast is not resolving or for further needle aspiration.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('e');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#ther03" title="See full details">#</a> Therapeutic Guidelines Ltd (2003) Therapeutic guidelines: Antibiotics</li>
              <li id="note2"><a href="references.html#worl00" title="See full details">#</a> World Health Organization WHO (2000) Mastitis: Causes and management</li>
              <li id="note3"><a href="references.html#amir08" title="See full details">#</a> Amir LH (2008) Clinical Protocol # 4: Mastitis</li>
              <li id="note4"><a href="references.html#amir04a" title="See full details">#</a> Amir LH et al. (2004) Incidence of breast abscess in lactating women: report from an Australian cohort</li>
              <li id="note5"><a href="references.html#dene03" title="See full details">#</a> Dener C et al. (2003) Breast abscesses in lactating women</li>
              <li id="note6"><a href="references.html#eryi05" title="See full details">#</a> Eryilmaz R et al. (2005) Management of lactational breast abscesses</li>
              <li id="note7"><a href="references.html#marc02" title="See full details">#</a> Marchant DJ (2002) Inflammation of the breast</li>
            </ol>
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          <h1 id="top">6.0 In conclusion</h1>
          <p>
		Thank you for completing Breastfeeding Foundations for Doctors. Please take time to complete the post-test quiz so that you can see the improvement in your knowledge base, and also see any areas that need further revision. Of course, the course does not cover all the breastfeeding problems that you will encounter during your medical career. However, you will be able to apply the general principles and management options contained in the course to consider the most appropriate response to other issues that arise. I hope this course will give you confidence to effectively assist pregnant and breastfeeding women in the future.
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          <div id="footer"><br style="clear: both" /><span class="noPrint"> | </span>&copy; 2011 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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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>2.4 <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>
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