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      <h1 id="top">8.3 Breast Problems</h1>
      <div class="section" id="Blocked_Plugged_Duct"><h2>Blocked (Plugged) Duct</h2>
    <div>
      <p> Blocked ducts are a common occurrence for breastfeeding mothers at any stage of lactation. Milk ducts become blocked and distended and are palpable as a tender, small lump in the breast. The skin over the lump may be reddened and warm to touch. </p>
      <p> Blockage may occur as a result of <br /> </p>
      <ul>
        <li> occlusion of a duct from pressure applied by an ill-fitting bra, a strap or clothing or mother compressing the breast during feeds <br /> </li>
        <li> excessive movement of the breasts such as running or aerobics </li>
        <li> poorly drained breast - mechanical causes of infant/mother, poor positioning or unfinished feeds <br /> </li>
      </ul>
      <p> It has been noted that some mothers who experience repeated duct blockages have thicker milk, or the blockage may contain more fatty material than usual. <sup><a href="#note1">1</a></sup> <sup><a href="#note2">2</a></sup> (<span style="font-style: italic;">Note: this should not be your first assumption - always investigate other causes first</span>) </p>
      <p class="listTitle"> Management involves </p>
      <ul>
        <li> identification of the cause<br /></li>
        <li>meticulous attention to position and latch <br /></li>
        <li>warm compresses to the affected area or a soak in warm water prior to gentle, but firm massage </li>
        <li> massage the lump towards the nipple as the baby suckles, or when hand or pump expressing </li>
        <li>feed more frequently until lumps clears<br /></li>
        <li> massage and hand expressing under a warm shower </li>
      </ul>
      <p> If a blocked duct fails to be cleared it may progress to mastitis from the milk backed up; infective mastitis may follow. </p>
    </div>
  </div>
      <div class="section" id="Mastitis"><h2>Mastitis</h2>
    <div>
      <p> Lactational mastitis most commonly occurs during the second and third weeks of the puerperium, either as a result of hospital management or the infective organism having been hospital-acquired <sup><a href="#note3">3</a></sup> <sup><a href="#note2">2</a></sup>however it may occur at any stage of lactation. </p>
    </div>
    <div class="section" id="Aetiology"><h3>Aetiology</h3>
      <div><p><span style="font-style: italic;"> </span><span class="term"><span style="font-style: italic;"> </span> Mast -itis </span><span style="font-style: italic;"> </span> (inflammation of the breast) is a general term which encompasses different aetiology. The inflammatory process in lactational masitis is caused by either milk stasis or infection. <br /> </p><p> One author <sup><a href="#note4">4</a></sup> found evidence that " <span style="font-style: italic;"> without effective removal of milk, non-infectious mastitis was likely to progress to infectious mastitis... </span> " <br /> </p><ul><li><p class="listTitle"> Milk stasis is non-infective, but may progress to an infective state if good clinical management is not implemented. Milk stasis is most commonly associated with: </p><ul><li> engorgement </li><li> infrequent feeds, or scheduling the frequency and/or duration of feeds </li><li> poor latching leading to inefficient removal of milk </li><li> rapid weaning </li><li> missing feeds, eg. overnight or because baby has received a bottle feed </li><li> pressure on the breast (eg. tight bra, car seatbelt) </li><li> a blocked nipple pore or duct </li></ul></li><li><p class="listTitle"> Associated factors which increase incidence of mastitis </p><ul><li> nipple damage - especially if colonised with <dfn> Staphylococcus aureus </dfn> </li><li> illness in mother or baby </li><li> oversupply of milk </li><li> maternal stress or fatigue </li><li> anaemia or malnutrition </li></ul></li><li><p class="listTitle"> Infection </p><ul><li> usually by a penicillin-resistant <dfn> Staphylococcus aureus </dfn> </li><li> less commonly the organism is a streptococcus or <dfn> Escherichia coli </dfn> </li></ul></li></ul><br /> (Sources: WHO <sup><a href="#note5">5</a></sup> ABM protocols <sup><a href="#note6">6</a></sup> ) <br /> <br /> Milk stasis and mastitis causes movement of sodium and chloride into the milk space <sup><a href="#note7">7</a></sup> and milk supply will fall as synthesis temporarily slows in the affected area. The infant may fuss during breastfeeds as a result of these factors. <br /> <br /> <br /> <p> </p></div>
    </div>
    <div class="section" id="Preventing_Mastitis"><h3>Preventing Mastitis</h3>
      <div>
        <p>
			Educate mothers about the importance of good breastfeeding management, caring for themselves and their breasts.
		</p>
        <ul>
          <li>
				A well-latched baby who breastfeeds according to his needs will help to regulate the mother's milk supply and avoid nipple damage.
			</li>
          <li>Teach mothers to hand express to prevent engorgement.</li>
          <li>Encourage rest and a healthy diet to support her immune system.</li>
          <li>
				Encourage an awareness of breast lumps or areas of milk stasis and discuss treatment with massage, extra feeding, expressing and heat packs.
			</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/tip.png" class="icon" alt="" /><h3>Be fore-armed</h3>
        <div>Whilst we need to be very familiar with appropriate diagnosis and treatment of mastitis, prevention is a better approach.<br /><br />During pregnancy, and as you educate mothers about effective breastfeeding, try not to focus your talk about mastitis in a way which will make mothers fear breastfeeding.<br />Emphasise good position and latch, and effective breast drainage as the basis for all markers of good breastfeeding. Then the mother will understand that problems such as mastitis can be avoided - she can aim for success rather than presume that mastitis always comes with breastfeeding.<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>
    <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 8.6</h3><p>Complete Activity 8.6 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 class="section" id="Diagnosis"><h3>Diagnosis</h3>
      <div class="columns"><div class="column" style="width: 50%">
          <div>
            <p class="listTitle"> Diagnosis is usually made by clinical presentation. </p>
            <ul>
              <li> inflamed area of the breast</li>
              <li>a painful wedge-shaped lump </li>
              <li> associated with fever of 38.5ºC (101.3ºF) or greater, and </li>
              <li> chills, flu-like aching and systemic illness. </li>
            </ul>
            <p> One researcher<sup><a href="#note8">8</a></sup> desribes her criteria for mastitis as "<span style="font-style: italic;">at least 2 breast symptoms (pain, redness or lump) AND at least one of fever or flu-like symptoms."</span></p>
            <p>Laboratory cultures of the breastmilk are rarely performed unless it does not respond to classical management strategies, or the mother has repeated episodes. </p>
          </div>
        </div><div class="column" style="width: 50%">
          <div class="captionBox"><img width="300" height="227" src="images/mastitis_GBC_300w.jpg" alt="" /><p> <br />&copy; Goldfarb Breastfeeding Clinic</p></div>
        </div></div><br style="clear: both" />
    </div>
    <div class="section" id="Management"><h3>Management</h3>
      <div>
        <p> Knowing that milk stasis is the most common predisposing factor to mastitis, it stands to reason that the first management strategy will be to ensure frequent and effective milk drainage from the affected breast. </p>
        <p class="listTitle">
          <span style="font-weight: bold;"> Effective milk removal </span>
        </p>
        <ul>
          <li>measures to support return of milk supply </li>
          <li>ensure baby latching and suckling well. Observe the baby breastfeeding! </li>
          <li> warm breast soak or applying warm compresses prior to breastfeeding may help milk ejection </li>
          <li> massage the breast gently during the breastfeed </li>
          <li> review the frequency of breastfeeding; most babies will feed 6 to 18 times in 24 hours, and feeding should not be regulated by the mother <sup><a href="#note9">9</a></sup> </li>
          <li> hand expressing, or pumping after a breastfeed may be necessary </li>
        </ul>
        <p class="listTitle">
          <span style="font-weight: bold;"> Supportive measures </span>
        </p>
        <ul>
          <li> bed rest </li>
          <li> adequate fluids and nutrition </li>
          <li> practical help at home </li>
          <li> vitamin E-rich sunflower oil, echinacea and vitamin C supplements have been suggested to assist immune and inflammatory responses. <sup><a href="#note10">10</a></sup> </li>
        </ul>
        <p class="listTitle">
          <span style="font-weight: bold;"> Pain relief </span>
        </p>
        <p> Researchers and clinicians have yet to conclude whether heat or cold is preferred, most suggesting both with heat being used prior to breastfeeding or expressing and cold afterwards. </p>
        <ul>
          <li>
            <p class="listTitle"> Use of moist heat... </p>
            <ul>
              <li> soak a cloth in warm water and apply to affected breast </li>
              <li> immerse the breast in a container of warm water. Some mothers have obtained relief from putting magnesium sulphate (Epsom Salts) into the water.</li>
              <li>limit use of heat if significant inflammation is present <br /> </li>
            </ul>
          </li>
          <li> Application of cold - either a chilled moist cloth or a covered ice pack. </li>
        </ul>
        <p><span style="font-style: italic;"> Paracetamol (acetaminophen) </span> and <span style="font-style: italic;"> ibuprofen </span> are both safe analgesics to use during lactation; paracetamol (acetaminophen) having better antipyretic properties, while ibuprofen has better anti-inflammatory properties. </p>
        <dt>
          <span style="font-weight: bold;"> Antibiotics </span>
        </dt>
        <dd> If symptoms of mastitis are mild and have been present for less than 24 hours: conservative management (effective milk removal and supportive measures) may resolve the problem without need for antibiotic therapy. <br /> </dd>
        <dd> If symptoms are not improving after 12-24 hours of conservative management (or if the woman is acutely ill): antibiotics should be started. <sup><a href="#note11">11</a></sup> <br /> </dd>
        <dd> Preferred antibiotics are usually penicillinase-resistant penicillins <span style="font-style: italic;"> (dicloxacillin or flucloxacillin). </span> <span style="font-style: italic;"> Cephalexin </span> is indicated in suspected penicillin allergy. <span style="font-style: italic;"> Clindamycin </span> when penicillin hypersensitivity is severe. <br /> </dd>
        <dd> Infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are being increasingly observed. <sup><a href="#note12">12</a></sup> </dd>
      </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/tip.png" class="icon" alt="" /><h3>Will weaning help?</h3>
        <div>The mother may be planning to wean her baby - this is <strong>not</strong> the time to do it! <br /><br />Weaning now (as tempting as it may seem) will increase milk stasis (and yes, begin to reduce milk supply), however the milk stasis increases the inflammatory response, further increasing risk of worsening mastitis and possible development of a breast abscess.<br /><br />It is important to clear the milk and allow the time for the breast to recover. <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>
      <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 8.7</h3><p>Complete Activity 8.7 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></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/group.png" class="icon" alt="" /><h3>Educational material</h3>
        <div>
          <p>
				Develop an information sheet to be discussed with mothers who have a blocked duct or mastitis, outlining the supportive measures they can take to facilitate a speedy recovery. This should be suitable for them to take home with them. 
			</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="Complications"><h3>Complications</h3>
      <div>
        <ul>
          <li>reduced milk supply<br /></li>
          <li>early weaning</li>
          <li>candida overgrowth</li>
          <li>breast abscess</li>
        </ul>
      </div>
    </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>That unresolved blocked ducts can progress to mastitis.</li>
          <li>The 2 classifications of mastitis.</li>
          <li>The predisposing factors which increase risk of mastitis.</li>
          <li>How can this be prevented?</li>
          <li>The practical management and possible medical support for mastitis.<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="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_rg">
<p class="instructions">Click and drag the missing words below into their correct place</p><p class="missingWords">The missing words are: <strong>Staph</strong> <strong>antibiotic</strong> <strong>before</strong> <strong>blocked</strong> <strong>breastfeeds</strong> <strong>cold</strong> <strong>damaged</strong> <strong>drainage</strong> <strong>ducts</strong> <strong>express</strong> <strong>fever</strong> <strong>flu-like</strong> <strong>frequency</strong> <strong>infection</strong> <strong>inflammation</strong> <strong>inflammation</strong> <strong>lactational</strong> <strong>latch</strong> <strong>less</strong> <strong>lump</strong> <strong>massage</strong> <strong>position</strong> <strong>pressure</strong> <strong>rest</strong> <strong>stasis</strong> <strong>towards</strong> <strong>warm</strong></p>Mastitis is <span value="inflammation" class="dropper">__________</span> of the breast. When it occurs during breastfeeding it is called <span value="lactational" class="dropper">__________</span> mastitis. This condition may have its origin from milk <span value="stasis" class="dropper">__________</span> or <span value="infection" class="dropper">__________</span>.<br /><br />Initially, <span value="blocked" class="dropper">__________</span> <span value="ducts" class="dropper">__________</span> may be the result of the milk stasis. The recommended management of this situation would include:<br /><ul><li><span value="warm" class="dropper">__________</span> compresses before the breastfeed </li><li>gentle <span value="massage" class="dropper">__________</span> of the lumps <span value="towards" class="dropper">__________</span> the nipple during breastfeeding</li><li>increase breastfeeding <span value="frequency" class="dropper">__________</span> until the blockages have cleared.</li></ul><br />Milk stasis may be the result of externally applied <span value="pressure" class="dropper">__________</span> from tight bra or clothing. However, the main reason for milk stasis is ineffective <span value="drainage" class="dropper">__________</span> of the breast. This can be achieved by meticulous attention to <span value="position" class="dropper">__________</span> and <span value="latch" class="dropper">__________</span> of the infant to the breast. If unresolved, milk forced into the tissues causes <span value="inflammation" class="dropper">__________</span> and resultant further milk stasis. <br /><br />Infection with organisms such as <span value="Staph" class="dropper">__________</span> aureus is the most common cause of infective mastitis. A strong risk factor for infective mastitis is <span value="damaged" class="dropper">__________</span> nipples. The mother will display breast symptoms such as a red, inflamed area over the site of a hard <span value="lump" class="dropper">__________</span> and the mother may also have a <span value="fever" class="dropper">__________</span> and <span value="flu-like" class="dropper">__________</span> symptoms. <br /><br />You can assist the mother to recover by suggesting supportive management such as <span value="rest" class="dropper">__________</span>, good fluid and nutritional intake. <br />During this time, the most important management is frequent drainage of the breast - this can be achieved by:<br /><ul><li>increasing the number of <span value="breastfeeds" class="dropper">__________</span></li><li>warmth applied to the breast <span value="before" class="dropper">__________</span> a feed and application of <span value="cold" class="dropper">__________</span> after the feed</li><li><span value="express" class="dropper">__________</span> regularly if the baby is not breastfeeding</li></ul>If the symptoms are mild or have been present for <span value="less" class="dropper">__________</span> than 24hrs, the mother can continue with these strategies. However, if symptoms are not improving within 12-24 hrs or the mother becomes acutely ill, <span value="antibiotic" class="dropper">__________</span> therapy should be started. <br /><script type="text/javascript">initCloze('activity_rg');</script></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 id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#egla98" title="See full details">#</a> Eglash A (1998) Delayed milk ejection reflex and plugged duct. Lecithin therapy</li>
          <li id="note2"><a href="references.html#feth98" title="See full details">#</a> Fetherston C (1998) Risk factors for lactation mastitis</li>
          <li id="note3"><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="note4"><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="note5"><a href="references.html#who2000" title="See full details">#</a> World Health Organisation (2000) Mastitis: causes and management</li>
          <li id="note6"><a href="references.html#abm08" title="See full details">#</a> Academy of Breastfeeding Medicine (2008) Clinical Protocol 4</li>
          <li id="note7"><a href="references.html#nguy98" title="See full details">#</a> Nguyen DA et al. (1998) Tight junction regulation in the mammary gland.</li>
          <li id="note8"><a href="references.html#amir07b" 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="note9"><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="note10"><a href="references.html#rior05" title="See full details">#</a> Riordan J (2005) Breastfeeding and Human Lactation</li>
          <li id="note11"><a href="references.html#worl01" title="See full details">#</a> World Health Organisation (WHO) (2001) The optimal duration of exclusive breastfeeding. Results of a WHO systematic review.</li>
          <li id="note12"><a href="references.html#saim03" title="See full details">#</a> Saiman L et al. (2003) Hospital transmission of community-acquired methicillin-resistant Staphylococcus aureus among postpartum women</li>
        </ol>
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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 class="current">8.3 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><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>
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