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      <h1 id="top">8.5 Medical, Surgical Issues</h1>
      <div class="section" id="Diabetes_mellitus"><h2>Diabetes mellitus</h2>
    <div>Breastfeeding and diabetes have a close relationship - breastfeeding has an impact on pre-existing and potential diabetes and diabetes has a impact on breastfeeding. Lactation may be delayed or impaired for reasons both of diabetes and obesity, so women in the diabetic spectrum need special consideration and attention to breastfeeding and lactation assistance. <p><span class="term"><span style="font-weight: bold;">Gestational diabetes mellitus</span> (GD) </span></p> <ul><li> mothers who had GD and suppress lactation have higher serum glucose than had they breastfed </li><li> suppressing lactation has an immediate detrimental effect on their glucose tolerance and lasting effects on maternal metabolic profiles <sup><a href="#note1">1</a></sup> </li><li> mothers who had GD and suppress lactation will significantly increase their risk of developing Type 2 diabetes <sup><a href="#note1">1</a></sup> <sup><a href="#note2">2</a></sup> </li></ul> <span class="term"><span style="font-weight: bold;">Type 2 diabetes mellitus</span></span> <ul><li> Being artificially fed in infancy is associated with an increased risk of Type 2 diabetes. <sup><a href="#note3">3</a></sup> </li><li> Due to their decreased glucose metabolism and altered metabolic profiles women who suppress lactation do not receive the protection that delays or prevents Type 2 diabetes mellitus in women who breastfeed their babies.  </li><li> Being obese and suppressing lactation significantly increases the risk of developing Type 2 diabetes mellitus. <sup><a href="#note2">2</a></sup> </li></ul> <span class="term"><span style="font-weight: bold;">Type 1 diabetes mellitus</span></span> <ul><li> Onset of secretory activation (lactogenesis II) may be delayed. <sup><a href="#note4">4</a></sup> </li><li> Being artificially fed as an infant significantly increases the risk of developing Type 1 diabetes mellitus. <sup><a href="#note5">5</a></sup> <sup><a href="#note6">6</a></sup> <sup><a href="#note7">7</a></sup> </li><li> Glucose use increases during lactation; lactating mothers can reduce their insulin by 25% or more of pre-pregnancy dose, while increasing their carbohydrate intake. Insulin requirements of mothers who suppress lactation is greater. <sup><a href="#note8">8</a></sup> <sup><a href="#note9">9</a></sup> <sup><a href="#note10">10</a></sup> </li></ul></div>
    <div class="section" id="Impact_on_lactation"><h3>Impact on lactation</h3>
      <div>
        <ul>
          <li> women who are diabetic are more likely to birth preterm, have a caesarean section or assisted birth and experience other obstetric complications, all of which increase the risk of lactation difficulty </li>
          <li> mothers who are diabetics are more likely to NOT breastfeed or have a shorter breastfeeding duration <sup><a href="#note11">11</a></sup> <br /> </li>
          <li> separation of mother and baby is more likely due to preterm birth, Caesarean section and blood glucose testing  </li>
          <li> maternal diabetes delays the onset of lactogenesis II <sup><a href="#note12">12</a></sup> </li>
          <li> in some units the baby is at greater risk of being given artificial infant formula, causing various breastfeeding difficulties </li>
        </ul>
        <br />
      </div>
    </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"><img src="design/group.png" class="icon" alt="" /><h3>Recommendations</h3>
      <div>
        <p>It is unfortunate that mothers with diabetes are at increased risk of breastfeeding difficulties which not only impacts on their own health but also on the health of their child who then becomes at risk of developing the same diabetic condition.<br /> </p>
        <p>For the present and future health of the mother with diabetes and her baby:</p>
        <ul>
          <li>provide education about the effects of artificially feeding on herself and her baby <br /></li>
          <li>suggest prenatal expressing of breastmilk; give infant the milk prophylactically during first day<br /></li>
          <li>encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding</li>
          <li>support measures to establish milk supply if mother and infant separated or infant not able to latch</li>
        </ul>
        <p> In light of the increased risk to the health of this woman and her child practices which interfere with breastfeeding, such as separation and giving artificial infant formula should be reviewed. </p>
      </div>
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      <div class="section" id="Maternal_overweight_and_obesity"><h2>Maternal overweight and obesity</h2>
    <div>Obesity is a risk factor for diabetes. Both impact on breastfeeding. <br /> <ul><li> being artificially-fed correlates to obesity in childhood and adulthood <sup><a href="#note13">13</a></sup> <sup><a href="#note14">14</a></sup> <sup><a href="#note15">15</a></sup> <br /> </li><li> overweight and obesity increases obstetric complications and is associated with a greater risk of operative delivery <p class="listTitle"> </p> </li><li><p class="listTitle"> mothers who artifically feed compared to those who breastfeed (&gt;6 months) have </p><ul><li> a 2 kg greater weight gain by 1 year postpartum </li><li> larger waist girth </li><li> greater weight gain 10-15 years later <br /> <br /> </li></ul></li><li><dl><dt> Lactation difficulty </dt></dl><ul><li> lactogenesis II may be delayed <sup><a href="#note16">16</a></sup> </li><li> positioning the baby to facilitate good latching is more difficult </li><li> the greater the BMI the greater the risk of early cessation of breastfeeding compared to women with normal BMI  </li><li> overweight and obese women are less likely to plan to breastfeed, initiate breastfeeding and wean earlier <sup><a href="#note17">17</a></sup></li></ul><dl><dd><br /></dd></dl></li></ul></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"><img src="design/group.png" class="icon" alt="" /><h3>Recommendations</h3>
      <div>
        <p> Give additional education and support to breastfeed to overweight and obese mothers -</p>
        <ul>
          <li>encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding</li>
          <li>support measures to establish milk supply if mother and infant separated or infant not able to latch<br /></li>
          <li>assistance with positioning infant could include using the underarm hold, raising their breast on a pillow or using a rolled up cloth or towel under the breast, and using a mirror to allow them to view their infant latching correctly to their breast. </li>
        </ul>
        <p>Social measures that increase breastfeeding will result in less overweight and obese adults. Pre-conception education should provide help for women to achieve a normal BMI before pregnancy. </p>
        <p>Urgently needed are qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour. </p>
      </div>
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  </div>
      <div class="section" id="Thyroid_disease"><h2>Thyroid disease</h2>
    <div>
      <p> Autoimmune thyroid dysfunctions are a common cause of both hyper- and hypo-thyroidism. <br /> </p>
      <p> Graves' disease (hyperthyroid) and postpartum thyroiditis are two major causes of thyrotoxicosis in the postpartum period. Antithyroid drugs, propylthiouracil or methimazole, are the mainstay of the treatment of postpartum thyrotoxicosis and both are safe to take while breastfeeding. Radioiodine treatment is contraindicated during lactation. <sup><a href="#note18">18</a></sup> </p>
      <p> There is a relatively high prevalence of hypothyroidism, especially subclinical hypothyroidism. Hypothyroidism is associated with insufficient breastmilk supply and may be one of the symptoms which alerts you to this condition. Thyroxine replacement therapy is safe for the breastfeeding baby and milk levels will improve once the mother becomes euthyroid. </p>
      <p> Thyroid status varies considerably postpartum. Medication dosage may need adjusting during the postpartum months. Be mindful of symptoms such as fatigue, palpitations, weight loss, loss of concentration and depression. Facilitate medical review of the mother. <br /> </p>
    </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"><img src="design/group.png" class="icon" alt="" /><h3>Recommendations</h3>
      <div>
        <p>
			All women with diagnosed thyroid disease should have their therapy re-evaluated frequently during pregnancy and lactation and medication dosage adjusted as necessary. This is particularly necessary for women who are being treated for hypothyroidism because of the impact on breastmilk sufficiency.
		</p>
        <p>
			Evaluate all mothers who have breastmilk insufficiency for hypothyroidism.
		</p>
      </div>
    </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 class="section" id="Hepatitis"><h2>Hepatitis</h2>
    <div>
      <dl>
        <dt> Hepatitis B (HBV) </dt>
        <dd> With appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breastfeeding does not contribute to mother-to-child transfer of HBV. <sup><a href="#note19">19</a></sup> <sup><a href="#note20">20</a></sup> <br /> Prior to vaccination, concern of transmission of HBV via cracked nipples was speculated but not recorded. </dd>
        <br />
        <dt> Hepatitis C (HCV) </dt>
        <dd> There is no evidence of mother-to-infant transmission of hepatitis C from breastfeeding.  </dd>
      </dl>
      <br />
    </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"><img src="design/group.png" class="icon" alt="" /><h3>Recommendations</h3>
      <div>
        <p>Women who are hepatitis B or C positive should be encouraged to breastfeed their babies.</p>
      </div>
    </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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              <img src="design/books.png" class="icon" alt="" />
              <h3>Workbook Activity 8.10</h3>
              <p>Complete Activity 8.10 in your workbook.</p>
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      <div class="section" id="HIV"><h2>HIV</h2>
    <div><ul> </ul> About 5-15% (1 in 20, to 1 in 7) of babies born to women who are HIV infected will become HIV-positive through breastfeeding. This means <strong>most</strong> infants born to women who are HIV-positive will not be infected through breastfeeding. <ul> </ul> <span style="font-weight: bold;"> Exclusive </span> breastfeeding reduces the risk of transfer by about half for HIV +ve mothers. Artificial feeding damages the gut allowing transfer of the virus. <br /> <span style="font-style: italic;"> Note: Before giving a supplement to ANY breastfed baby consider the risk you are submitting the baby to should the mother unknowingly be HIV positive. </span> <br /></div>
    <div class="section" id="WHO_Recommendations_for_infant_feeding"><h3>WHO Recommendations for infant feeding</h3>
      <div>
        <span style="font-weight: bold;">When the mother is HIV negative OR her status is unknown</span>
        <ul>
          <li><span style="font-style: italic;"><span style="font-weight: bold;">exclusive</span></span> breastfeeding for the first 6 months, then </li>
          <li> introduce complementary foods while continuing to breastfeed for 24 months and beyond. </li>
        </ul>
        <span style="font-weight: bold;">When the mother is HIV positive </span>
        <ul>
          <li> commence anti-retroviral therapy (ARV) during pregnancy and continue for the duration of breastfeeding </li>
          <li> infants to receive ARV therapy </li>
          <li><span style="font-style: italic;"><span style="font-weight: bold;">exclusive</span></span> breastfeeding for 6 months, then </li>
          <li> introduce complementary foods while continuing to breastfeed for 24 months and beyond</li>
          <li> continue ARV therapy for the duration of breastfeeding. <sup><a href="#note21">21</a></sup> </li>
        </ul>
        <br />
      </div>
    </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"><h3>HIV and NOT breastfeeding</h3>
      <div>Safe alternatives to exclusive breastfeeding are heat-treated mother's own breastmilk,<sup><a href="#note22">22</a></sup> donor breastmilk from a safe source, or artificial infant formula. <br />Support the mother in her choice of infant feeding, ensuring that whatever she chooses is as safe as possible. <p class="listTitle"> </p> <p class="listTitle"> Issues to discuss with the mother who is NOT breastfeeding: </p> <ul><li> What are the replacement feeding options and which, if any, are acceptable, feasible, affordable, sustainable and safe in her situation; </li><li> What she will need in order to use the method she chooses - source of milk, water, equipment, cost, time. </li><li> If artificial infant formula is used, the difference between types of formula and what types are suitable for her infant; </li><li> If a home-prepared recipe is used, what are the available sources of milk and whether they are suitable and safe? </li><li> Is the household water supply accessible and safe? If it is not safe, what water can the mother use? </li><li> Water will need to be boiled to mix formula, and hot water is needed for pasteurizing her breastmilk and washing the equipment. Is there fuel available? </li><li> How will she keep the equipment clean? </li><li> Who will help her learn to prepare her chosen method and when will she learn these things? </li></ul></div>
    </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>
    <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/books.png" class="icon" alt="" /><h3>Workbook Activity 8.11</h3><p>Complete Activity 8.11 in your workbook.</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>Unfortunately most HIV-infected women do not have the resources for safe replacement feeding. Breastfeeding, though not exclusive breastfeeding, is the cultural norm in those countries most affected by HIV. It has been found that adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than those who replacement feed.<sup><a href="#note23">23</a></sup> <p> In a study in Botswana<sup><a href="#note24">24</a></sup>, breastfeeding with zidovudine prophylaxis was not as effective as formula feeding in preventing postnatal HIV transmission, but was associated with a lower mortality rate at 7 months. Both breastfed and artificially-fed had comparable HIV-free survival at 18 months. </p></div>
  </div>
      <div class="section" id="Breast_surgery"><h2>Breast surgery</h2>
    <div>
      <p><span class="term">Reduction mammoplasty</span> surgery which has involved severing large numbers of lactiferous ducts, removal of large amounts of glandular tissue, or severing the 4th intercostal nerve innervating the nipple/areola, will affect breastfeeding ability to varying degrees. <span class="aside"> (The 4th intercostal nerve is the stimulus for the milk ejection reflex, some severed ducts will re-anastomose) </span> </p>
      <p><span class="term">Breast augmentation</span> also has the potential to negatively affect breastfeeding because of severed 4th intercostal nerve and ducts with peri-areola incision method, and compression of glandular tissue with sub-glandular placement of implant.<br /> </p>
      <p> Breastfeeding, milk transfer and the baby's condition should be closely monitored to ensure the baby continues to thrive. An antenatal consultation with a Lactation Consultant followed by close supervision of initial and ongoing breastfeeding management and early interventions to increase supply is important. </p>
    </div>
  </div>
      <div class="section" id="Breastfeeding_and_medication_usage"><h2>Breastfeeding and medication usage</h2>
    <div>
      <p> Some women need to take medications while breastfeeding. It is important to ensure the baby will not be harmed via breastmilk transfer of the medication. It is equally as important not to forfeit breastfeeding when there are safe, effective medications. In most cases, it is far preferable to continue breastfeeding with small amounts of drug present in milk rather than risk many more hazardous effects of infant formula feeding. <br /> </p>
      <p> All medications transfer into breastmilk to some degree but very, very few medications are contraindicated during breastfeeding. As a general rule of thumb less than 1% of the maternal dose passes via the breastmilk to the baby. Up to 10% of maternal dose is usually considered to be safe. <sup><a href="#note25">25</a></sup> <br /> </p>
      <p> Several factors influence the ultimate medication dose which the infant will receive via breastmilk: </p>
      <ul>
        <li> the transfer of the drug into the breastmilk - influenced by specific drug properties such as maternal drug level reached, molecular weight, protein binding capacity. <br /> </li>
        <li> the uptake of the drug by the infant from the breastmilk - daily intake of infant, stomach acidity, gut absorption. <br /> </li>
      </ul>
      <p> Everyone who prescribes medications for breastfeeding women should have access to a recent text that specifically reviews medications for mothers. This is the link to an excellent online resource. <img alt="External" src="design/external.gif" /><a href="http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT" title="External link" target="_blank">http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT</a> . Bookmark this resource for future reference. </p>
      <p> The known detrimental effect of artificial infant formula feeding for both mother and baby needs to be seriously considered prior to ceasing breastfeeding due to maternal medication use. An alternative drug should be sought if the one usually prescribed is contraindicated. </p>
    </div>
  </div>
      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <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/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <ul>
          <li> The important cause/effect cycle of each type of diabetes and breastfeeding. </li>
          <li> The important cause/effect cycle of obesity and breastfeeding. </li>
          <li> How thyroid conditions may impact on breastfeeding. </li>
          <li> That HBV and HCV infection is not a contraindication for breastfeeding. </li>
          <li> Exclusive breastfeeding for 6 months reduces risk of HIV mother-to-child transfer. </li>
          <li> The WHO guidelines for HIV and infant feeding. </li>
          <li> What type of breast surgery may impact on breastfeeding and why. </li>
          <li> Most medications are safe to continue with breastfeeding and if not, a safe alternate can be found. </li>
        </ul>
      </div>
    </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 class="section" id="Self-test_quiz"><h2>Self-test quiz</h2>
    <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"><h3></h3>
      <div></div><div class="activity" id="activity_rj">
<script type="text/javascript">
/* <![CDATA[ */
var rjqs = {settings : {type : 'matching', shuffle : 'both'}, questions : [
	new Matching('Delay in onset of secretory activation is expected with this condition', 'Type I diabetes'),
	new Matching('Breastfeeding is not contraindicated with this disease', 'hepatitis virus'),
	new Matching('This condition causes delayed prolactin response', 'obesity'),
	new Matching('Exclusive breastfeeding for 6 months is the strongest protector for the infant against becoming infected with his mother\'s condition', 'HIV'),
	new Matching('This surgery has a high chance of severing ducts and 4th intercostal nerve', 'reduction mammoplasty'),
	new Matching('Mothers with gestational diabetes are at greater risk of developing this condition if they artificially feed their infant', 'Type II diabetes'),
	new Matching('Most drugs will pass into breastmilk at this level', '1%'),
	new Matching('Surgery which may result in glandular tissue compression', 'breast augmentation'),
	new Matching('Drug levels up to this amount are considered safe to continue breastfeeding', '10%')
]};

/* ]]> */</script>
<p class="instructions">Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column</p></div><script type="text/javascript">renderActivity('rj');</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>
      <div class="section" id="Assessment_Quiz"><h2>Assessment Quiz</h2>
    <div>
      <p>
		When you are happy that you've understood all the information in this topic you will be ready to complete the Module 8 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 8.
	</p>
    </div>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#kjos93" title="See full details">#</a> Kjos SL et al. (1993) The effect of lactation on glucose and lipid metabolism in women with recent gestational diabetes</li>
          <li id="note2"><a href="references.html#gund07" title="See full details">#</a> Gunderson EP (2007) Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring</li>
          <li id="note3"><a href="references.html#dasu07" title="See full details">#</a> Das UN (2007) Breastfeeding prevents type 2 diabetes mellitus: but, how and why?</li>
          <li id="note4"><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="note5"><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="note6"><a href="references.html#malc06" title="See full details">#</a> Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence</li>
          <li id="note7"><a href="references.html#tenc07" title="See full details">#</a> Tenconi MT et al. (2007) Major childhood infectious diseases and other determinants associated with type 1 diabetes: a case-control study</li>
          <li id="note8"><a href="references.html#illi89" title="See full details">#</a> Illingworth P et al. (1989) Insulin requirements during breast feeding</li>
          <li id="note9"><a href="references.html#davi89" title="See full details">#</a> Davies HA et al. (1989) Insulin requirements of diabetic women who breast feed</li>
          <li id="note10"><a href="references.html#rivi09" title="See full details">#</a> Riviello C et al. (2009) Breastfeeding and the basal insulin requirement in type 1 diabetic women.</li>
          <li id="note11"><a href="references.html#humm08" title="See full details">#</a> Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]</li>
          <li id="note12"><a href="references.html#hart01" title="See full details">#</a> Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity</li>
          <li id="note13"><a href="references.html#vonk99" title="See full details">#</a> von Kries R et al. (1999) Breast feeding and obesity: cross sectional study.</li>
          <li id="note14"><a href="references.html#kali05" title="See full details">#</a> Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study</li>
          <li id="note15"><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="note16"><a href="references.html#rasm04" title="See full details">#</a> Rasmussen KM et al. (2004) Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum.</li>
          <li id="note17"><a href="references.html#amir07" title="See full details">#</a> Amir LH et al. (2007) A systematic review of maternal obesity and breastfeeding intention, initiation and duration</li>
          <li id="note18"><a href="references.html#aziz03" title="See full details">#</a> Azizi F (2003) Thyroid function in breast-fed infants is not affected by methimazole-induced maternal hypothyroidism: results of a retrospective study</li>
          <li id="note19"><a href="references.html#hill02" title="See full details">#</a> Hill JB et al. (2002) Risk of hepatitis B transmission in breast-fed infants of chronic hepatitis B carriers</li>
          <li id="note20"><a href="references.html#zhon11" title="See full details">#</a> Zhongjie Shi (2011) Breastfeeding of newborns by mothers carrying Hepatitis B virus</li>
          <li id="note21"><a href="references.html#who10a" title="See full details">#</a> World Health Organisation and UNICEF (2010) HIV and infant feeding</li>
          <li id="note22"><a href="references.html#isra07" title="See full details">#</a> Israel-Ballard K et al. (2007) Flash-heat inactivation of HIV-1 in human milk: a potential method to reduce postnatal transmission in developing countries.</li>
          <li id="note23"><a href="references.html#blan07" title="See full details">#</a> Bland RM et al. (2007) Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice</li>
          <li id="note24"><a href="references.html#thio06" title="See full details">#</a> Thior I et al. (2006) Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study</li>
          <li id="note25"><a href="references.html#hale2010" title="See full details">#</a> Hale T (2010) Medications and Mothers Milk</li>
        </ol>
      </div>
      <div id="footer"><a href="topic_8-4.html" rel="prev" class="prev">&laquo; Previous</a><a href="topic_9-0.html" rel="next" class="next">Next &raquo;</a><br style="clear: both" /><a href="#top" id="topLink">Back to top</a><a href="javascript: window.print()" id="printLink">Print this page</a><span class="noPrint"> | </span>&copy; 2012 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>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li class="current">8.5 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
      </ol>
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