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      <h1 id="top">5.3 Assessing breastfeeding</h1>
      <div class="section" id="The_five-step_process"><h2>The five-step process</h2>
    <div>Wolf and Glass<sup><a href="#note1">1</a></sup> suggest a five-step assessment/evaluation process:<br /><ol><li>Gather information and plan for the visit</li><li>Feeding observation</li><li>Exploration of strategies for improvement</li><li>Develop an action plan</li><li>Communication of results<br /></li></ol></div>
    <div class="section" id="_._Gather_information_and_plan_for_the_visit"><h3>1. Gather information and plan for the visit</h3>
      <div>
        <p><strong>Review</strong> pertinent information including mother's/infant's chart, notes from telephone conversations, notes from referral source, etc, prior to meeting with the mother and infant. </p>
        <p><strong>Planning</strong> includes assembling any items and equipment you expect to use during the assessment (eg. comfortable chair for mother, infant scale, etc.). </p>
      </div>
    </div>
    <div class="section" id="_._Feeding_observation"><h3>2. Feeding observation</h3>
      <div>Breastfeeding observation entails three parts:<br /><ul><li><strong>General observation</strong>: general interaction between the mother and infant. Health of mother, health of baby, health of the mother's breasts.</li><li><strong>Naturalistic observation</strong>: observation of a portion of a usual breastfeeding. This is best performed without intervention from the assessor.</li><li><strong>Elicited observation</strong>: observation of the outcome of suggested modifications (eg changes to position, attachment, etc.).</li></ul><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/thinker.gif" class="icon" alt="" /><h3>Use your communication skills</h3>
        <div>It can help to put the mother at ease if you explain that you would like to watch the baby feeding, rather than saying you are watching what the mother is doing. And don't forget to praise the mother for something she is doing that is good.</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 class="section" id="What_is_involved_in_a_naturalistic_observation_"><h4>What is involved in a 'naturalistic observation'?</h4>
        <div>
          <p style="font-weight: bold;" class="listTitle">Mother's and baby's position</p>
          <ul>
            <li>Do the mother and baby appear comfortable and relaxed?</li>
            <li>Is the baby well positioned? <ul><li>Good sensory input: breast wasn't washed prior to feeding; baby in firm contact with mother chest-to-chest, either no clothing or minimal clothing between them.</li><li>Good positional stability: a stable base; proximal stability; midline symmetry</li></ul> </li>
          </ul>
          <p style="font-weight: bold;" class="listTitle">Latching</p>
          <ul>
            <li>Did mother position baby, then allow baby to latch himself? If not, why not? eg. breast may have needed to be shaped; is the mother controlling the baby's latching? </li>
            <li>Where is baby's chin? Is it firmly applied to the breast? Is the baby's nose free to breathe without the need to hold the breast tissue away? <span class="aside">Exceptions only with very large, soft pendulous breasts.</span></li>
            <li>Is baby's mouth very wide open with both lips flanged outwards? <span class="aside">Exceptions to this are in mothers with soft, elastic breast tissue where a baby can achieve a deep latch with lots of breast tissue and not need to continue the wide gape throughout the feed.</span></li>
            <li>Can you see more areola visible above the top lip than beneath the bottom lip (or, if areola small, another sign that the baby has a large amount of breast tissue in mouth).<br /></li>
          </ul>
          <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/warning.png" class="icon" alt="" /><h3>Really important!</h3>
          <div>One author <sup><a href="#note2">2</a></sup> viewed the positioning and latching procedures adopted by mothers with painful nipples and concluded that the whole process from pre-feeding behaviors to the suck rhythm need to be assessed.<br /><br />Observe the moment of latching of the baby to the breast and as much of the feed as you can, then be there again to observe the nipple as it leaves baby's mouth.<br /><br /></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>
          <p style="font-weight: bold;" class="listTitle">Sucking pattern</p>
          <ul>
            <li>When first latched was sucking rapid for up to a minute? <span class="aside">This is a stimulation pattern to elicit the milk ejection reflex.</span></li>
            <li>After about a minute (or less) did sucking settle into a regular, slower suck/swallow/breathe/suck/swallow/breathe pattern with some short pauses? <span class="aside">This is a nutritive sucking pattern. You may hear baby swallowing milk; milk may leak from the other breast; or mother may report feeling the milk ejection reflex.</span></li>
            <li>What are baby's jaw movements like? <span class="aside">They should be 'deep' movements visible right up to the temporo-mandibular joint below the ears.</span></li>
            <li>How long did the nutritive sucking pattern persist? <span class="aside">Milk ejection usually lasts about 2 minutes and therefore the nutritive sucking pattern should last about that long</span>. </li>
            <li>What happened after the nutritive sucking pattern stopped? <span class="aside">Sucking usually returns to the short, quick stimulation pattern again with smaller jaw movement, fewer swallows and longer resting pauses.</span></li>
            <li>Was the nutritive pattern repeated? <span class="aside">It doesn't have to be, but this cycle may be repeated as baby stimulates a second or more milk ejections during one breastfeed.</span></li>
          </ul>
          <p style="font-weight: bold;" class="listTitle">How was the breastfeed completed?</p>
          <ul>
            <li>Did the baby fall asleep at the breast being completely satiated, or detach himself contented, or wanting more milk from the other breast, or did the mother remove the baby when she felt he'd had enough?</li>
          </ul>
          <p style="font-weight: bold;" class="listTitle">What did the nipple look like as it came out of the baby's mouth?</p>
          <ul>
            <li>Observe the nipple immediately when it comes out of the baby's mouth. It should look very similar to its pre-feeding state. There should be no ridges or 'squashed' appearance or white compression lines.</li>
          </ul>
          <p style="font-weight: bold;" class="listTitle">How did it feel?</p>
          <ul>
            <li>Of course you will ask the mother how it feels at each stage, and also observe her for signs of anxiety or pain.</li>
            <li>In the first few days for the first minute or less she may describe it as painful, but settles to be pain free quickly. This initial pain is called 'nipple stretch pain' and occurs as the nipple and areola form the teat. Breastfeeding may 'tug' but for the majority of mothers it should not be painful.</li>
          </ul>
        </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/books.png" class="icon" alt="" /><h3>Workbook Activity 5.6</h3>
        <div>Complete workbook activity 5.6<br /></div>
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    <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>Observation skills</h3>
      <div>Look closely at these photos, noting all the details of positioning and latch.<br />When you are ready, answer the response activity below.<br /></div>
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          <div class="captionBox"><img width="208" height="300" src="images/Annie8a.gif" alt="" /><p> <br />&copy; D.Fisher IBCLC</p></div>
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          <div class="captionBox"><img width="273" height="302" src="images/ANNIE1.GIF" alt="" /><p> <br />&copy; D.Fisher IBCLC</p></div>
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    </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"><h3></h3>
      <div></div><div class="activity" id="activity_n">
<script type="text/javascript">
/* <![CDATA[ */
var nqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>Using the format of the \'General\' and \'Naturalistic\' observation from above, type in the observations you can make of the mother, her baby and the breastfeed in the box below, then click on \'Check\'.</p>', r : '<p>Did your response cover most of the following?</p><ul><li>General observation\n					<ul><li>This mother looks healthy, she\'s holding her baby with confidence, looking lovingly at baby.</li><li>The baby appears \'cared for\', is chubby, is relaxed at the breast and looks healthy with clear skin.</li><li>From the little we can see of the mother\'s breast it is healthy with prominent veins, a feature of the lactating breast.</li><li>In a real life situation you could make more observations of the interaction between mother and baby, what stimulated the mother to offer a breastfeed, what feeding cues did the baby exhibit, etc.</li></ul>\n				</li><li>Naturalistic observation of a breastfeed\n					<ul><li>Mother\'s and baby\'s position\n							<ul><li>The mother is relaxed, comfortable and well supported.</li><li>The baby is being held firmly chest-to-chest against mother. The baby is not wrapped in a blanket that would interfere with sensory input and alter positioning.</li><li>Stable base: mother\'s hand is supporting the middle of the baby\'s back. Proximal stability: baby\'s head is supported on mother\'s forearm. Midline symmetry: whole of baby is facing mother, no twists in the spine from neck to bottom, and arms are on either side of the breast. <br/><em>In the close-up photograph the baby has been rolled away slightly for the purposes of the photograph.</em></li></ul>\n						</li><li>Latching\n							<ul><li>We can\'t see how the mother facilitated latching unfortunately.</li><li>Baby\'s neck is slightly extended, so we can assume he latched from beneath the breast, not coming directly onto the nipple.</li><li>Areola is visible above the top lip and you can anticipate from the level of the chin that the bottom lip will be covering the areola.</li><li>The chin is firmly against the breast while the nose is free to breathe.</li><li>The top lip is flanged outwards; the chin is low on the breast indicating the bottom lip will also be flanged outward.</li><li>The mouth is very wide open with a deep latch evident.</li></ul>\n						</li></ul>\n				</li></ul><p>That\'s all we\'re able to observe from these photographs, which appears to indicate a thriving baby who is breastfeeding successfully.</p>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('n');</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 class="section" id="_._Exploration_of_strategies_for_improvement"><h3>3. Exploration of strategies for improvement</h3>
      <div>
        <ul>
          <li>The development of hypotheses for improving the feeding interaction based on history and observations.</li>
          <li>Discussion with mother of hypotheses generated, including pros and cons of various methods for improving the feeding outcome.</li>
          <li>Testing of agreed strategies.</li>
        </ul>
      </div>
    </div>
    <div class="section" id="_._Develop_an_action_plan"><h3>4. Develop an action plan</h3>
      <div>Using all gathered data, hypotheses and strategies, develop an action plan for feeding management that is agreed upon between yourself and the mother. <br />Record this in the mother's file and give a copy to the mother or write a list for her to refer to at home.<br /></div>
    </div>
    <div class="section" id="_._Communication_of_results"><h3>5. Communication of results</h3>
      <div>
        <ul> </ul>
        <ul>
          <li> Reiterate findings and action plans for the mother. The language used to describe the situation is extremely important. The assessor should take great care to avoid terminology that blames, negatively characterizes, or labels the mother or infant.</li>
          <li>After learning new skills of how to position her baby to overcome previous breastfeeding difficulties the mother sits and cradles her baby as he feeds and explains to the consultant how she positioned her baby. Cox (2011)<sup><a href="#note3">3</a></sup> contends that the consultant is then able to be confident that this mother and baby will now be independent as she has:<br /><ul><li>watched the mother position, as suggested, so that the baby could latch comfortably</li><li>written down, in the mothers words, how she positioned her baby</li></ul></li>
        </ul>
        <ul>
          <li>Document the outcomes of the assessment and evaluation.</li>
          <li> Review plans with the mother to assure that the plan is achievable and agreeable to all parties.</li>
          <li>Communicate findings to key healthcare providers in accordance with mother's consent to release information. Clearly identify and refer any items that need further medical evaluation.<sup><a href="#note1">1</a></sup></li>
        </ul>
      </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></h3>
      <div>Look carefully at this baby breastfeeding and complete the response activity below.<br /></div>
      <div class="captionBox"><img width="500" height="424" src="images/assess_latchUNICEF500.jpg" alt="" /><p> <br />&copy; Photo copyright UNICEF C107-5</p></div>
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      <div></div><div class="activity" id="activity_o">
<script type="text/javascript">
/* <![CDATA[ */
var oqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>Using the format of the \'General\' and \'Naturalistic\' observation from above, type in the observations you can make of this mother and her baby breastfeeding in the box below, then click on \'Check\'.</p>', r : '<p>Did your response cover most of the following?</p><ul><li>General observation\n					<ul><li>The mother looks healthy and is looking in a loving way at her baby. </li><li>Her breasts look unusual. Are they very engorged, or is the bra and clothing she is wearing too tight and squeezing the breasts together? The veins commonly seen on lactating breasts are evident.</li><li>The baby looks healthy, \'cared for\', calm and relaxed. It\'s good to see him undressed making skin-to-skin sensory possible. He\'s quite young.</li></ul>\n				</li><li>Naturalistic observation\n					<ul><li>Positioning\n							<ul><li>The mother doesn\'t appear comfortable - she\'s sitting with a rounded back and shoulders hunched over her baby.</li><li>Sensory input: \n									<ul><li>baby is held away from the mother\'s body; skin-to-skin or firm chest-to-chest contact is absent = poor touch sensory input. Baby is undressed ready for skin-to-skin but you can see no part of the baby is touching the mother\'s skin except his lips.</li><li>baby is not coming to the breast from underneath with nose aligned with nipple, therefore poor smell sensory input</li></ul>\n								</li><li>Positional stability:\n									<ul><li>mother\'s hand is on baby\'s bottom, not in the middle of baby\'s back, therefore a stable base for the head and neck is not provided. This baby would not be able to control his head movements effectively.</li><li>the baby\'s head and neck are flexed rather than extended, to reach the nipple, therefore there is no midline symmetry and baby would have difficulty swallowing when the milk flow is fast.</li><li>there is proximal stability as the baby\'s head is supported. </li><li>When you see a young baby\'s head supported in the mother\'s elbow it\'s unlikely the baby will be well positioned. In this position it\'s the forearm that should be supporting the head. Compare with the photograph of the mother above.</li></ul>\n								</li></ul>\n						</li><li>Latching\n							<ul><li>Because the baby has minimal sensory input, and components of positioning are absent, it will have been impossible for this baby to have latched himself.</li><li>Baby\'s lips are flanged outwards.</li><li>Baby\'s mouth is directly opposite the nipple with substantial amounts of areola visible equally around the mouth. This mother has a wide areola which we wouldn\'t expect the baby to completely cover. It looks as though only the nipple is in baby\'s mouth.</li><li>Baby\'s mouth is only slightly open.</li><li>Baby\'s chin is quite a distance from the breast, with the nose being nearly blocked by the top lip. If baby were to be closer to the breast, which he should, he would block his nose completely.</li><li>The latch is very shallow.</li></ul>\n						</li></ul>\n				</li></ul><p>\n				This baby is quite poorly latched and milk transfer will be poor. If the baby continues to breastfeed like this the mother will also have nipple damage.\n			</p>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('o');</script>
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            <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 5.7</h3>
              <p>Complete Activity 5.7 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>
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        </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/tip.png" class="icon" alt="" /><h3>Make your work easy!</h3>
    <div>
      <p> When a mother quickly becomes confident positioning her baby and facilitating his latch baby will be fed well, nipple and breast problems prevented and your workload will be reduced. </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 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>Meticulous attention to the principles of positioning is the basis of good breastfeeding technique.</li>
          <li>Good positioning facilitates correct latch.</li>
          <li>The infant uses sensory input to find the breast.</li>
          <li>The sequence of actions which allow the infant to latch correctly to the breast.</li>
          <li>The important observations to make during a breastfeed<br /></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="Assessment_Quiz"><h2>Assessment Quiz</h2>
    <div>When you are happy that you've understood all the information in this topic you will be ready to complete the Module 5 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 5.</div>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#wolf92" title="See full details">#</a> Wolf LS et al. (1992) Assessment and Management: Feeding and Swallowing Disorders in Infancy</li>
          <li id="note2"><a href="references.html#blai03" title="See full details">#</a> Blair A et al. (2003) The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples.</li>
          <li id="note3"><a href="references.html#cox11a" title="See full details">#</a> Cox SG (2011) Planning with the mother to overcome breastfeeding difficulties - manuscript pending publication.</li>
        </ol>
      </div>
      <div id="footer"><a href="topic_5-2.html" rel="prev" class="prev">&laquo; Previous</a><a href="topic_6-0.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 class="current">5.3 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><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>8.5 <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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