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    <meta name="author" content="Denise Fisher" />
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      <h1 id="top">3.1 Early problems</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study C</h3>
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			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
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		<dl><dt><a href="topic_3-1.html"><cite>Topic 3.1: Early problems</cite></a></dt><dd class="topic-paragraph">There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.</dd></dl>
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			Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
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		Breast fullness is a physiological response to the initiation of copious milk production, and is a function of increased vascularity, increased milk production and increased oedema due to increased vascularity and milk production<sup><a href="#note1">1</a></sup>. Breast fullness is associated with some tenderness and pain beginning around day two and peaking by day five<sup><a href="#note2">2</a></sup>.
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		Breast engorgement is an exaggeration of the physiological process, with breasts becoming swollen, hard and very painful, and the nipple being flattened by underlying breast fullness. The skin of the breast is often red and shiny and the mother may be slightly febrile (38°C). The baby is often unable to latch well, resulting in painful, cracked nipples and poor milk drainage. With severe engorgement, the breasts may extend from the clavicle to the lower rib cage and from the midaxillary to the midsternal line.<sup><a href="#note1">1</a></sup>
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		<div class="captionBox"><img width="350" height="231" src="images/breast_engorgement.jpg" alt="Breast Engorgement" /><p> <br />&copy;  S.Cox IBCLC</p></div>
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		Early and frequent emptying of the breast reduces the incidence of engorgement<sup><a href="#note3">3</a></sup>, while predisposing factors for engorgement include:
		<ul><li>delay with the first breastfeed;</li><li>infrequent feeding;</li><li>time-limited feeds;</li><li>late maturation of milk; and</li><li>supplementary feeds<sup><a href="#note4">4</a></sup></li></ul>
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		Management of engorgement focuses on ensuring good breast drainage and maternal comfort (<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup>), and includes the following points:
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		<em>Click on some of the bullet points below for more detail:</em>
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				Ensure frequent feeding
				<ul collapse="yes"><li>most neonates require between eight and twelve feeds a day.</li></ul>
			</li><li>
				Soften the areola
				<ul collapse="yes"><li>By expressing a small amount of milk before a feed so that the infant is able to latch more easily. The amount of milk expressed will depend on the individual woman and degree of engorgement.</li></ul>
			</li><li>Position the infant at the breast to ensure effective latch and breast drainage.</li><li>
				Allow the infant to drain the first breast well before offering the second side.
				<ul collapse="yes"><li>Some studies suggest feeding from only one breast at each feed while expressing small amounts of milk from the other breast for comfort <sup><a href="#note7">7</a></sup>.</li></ul>
			</li><li>
				Express by hand or pump until the breasts are soft if the infant is not feeding well at the breast.
				<ul collapse="yes"><li>When the infant has fed well but the breast is still full and painful, only express until the breasts feel more comfortable.</li></ul>
			</li><li>Warm compresses and massage before a feed encourage milk flow.</li><li>
				Cool/cold compresses after a feed result in vasoconstriction, reduction of oedema and a degree of pain relief.
				<ul collapse="yes"><li>Cold cabbage leaves are as effective as cold packs <sup><a href="#note8">8</a></sup>.</li></ul>
			</li><li>
				Breast support from a well-fitting bra or firm t-shirt assists some women.
				<ul collapse="yes"><li>Breast binding is not recommended <sup><a href="#note9">9</a></sup>.</li></ul>
			</li><li>Anti-inflammatory medications and other analgesics provide some pain relief.</li></ul>
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            <td class="body"><a href="http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening" target="_blank"><img src="design/tip.png" class="icon" alt="" /></a><h3><a href="http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening" target="_blank">Reverse pressure softening for areolar oedema</a></h3>
		<p>
			Some women, especially those who receive large amounts of IV fluids during labour, have oxytocin augmentation of labour, or use high suction electric breast pump early postpartum, develop pitting oedema of the breast and areola. In these situations, a technique of reverse pressure softening reduces the oedema surrounding the nipple so that the infant can attach/latch more easily. Click on the icon to be read how this is performed.
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            <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
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	{ c : '\n			<p>\n				<strong>Sarah is to be discharged 48 hours after giving birth to a healthy baby girl weighing 3.3 kg. The baby is attaching well to the breast and appears to be feeding well. What plan of management would you give her to prevent and/or treat breast fullness/engorgement?</strong>\n			</p>\n		', r : '\n			<p>\n				Sarah should continue to feed at least every 2-3 hours, leaving the baby on the first breast until she spontaneously comes off before offering the second breast. Express a little milk before the feed if her breasts are full/engorged, and at other times if the breasts are very uncomfortable. Hot packs prior to a feed, cold packs following a feed and anti-inflammatory medications or analgesics may provide pain relief.\n			</p>\n		' }
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<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('w');</script>
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        <h3>Notes</h3>
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          <li id="note1"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
          <li id="note2"><a href="references.html#hill94" title="See full details">#</a> Hill P et al. (1994) The occurrence of breast engorgement</li>
          <li id="note3"><a href="references.html#renf00" title="See full details">#</a> Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.</li>
          <li id="note4"><a href="references.html#moon89" title="See full details">#</a> Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention</li>
          <li id="note5"><a href="references.html#brod04a" title="See full details">#</a> Brodribb W (2004) Breastfeeding Management</li>
          <li id="note6"><a href="references.html#mass04" title="See full details">#</a> Mass S (2004) Breast pain: engorgement, nipple pain and mastitis</li>
          <li id="note7"><a href="references.html#evan95" title="See full details">#</a> Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic</li>
          <li id="note8"><a href="references.html#robe95" title="See full details">#</a> Roberts KL (1995) A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast engorgement</li>
          <li id="note9"><a href="references.html#swif03" title="See full details">#</a> Swift K et al. (2003) Breast binding... is it all that it's wrapped up to be?</li>
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      <h1>Breastfeeding Essentials</h1>
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        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li>2.2 <a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li>2.3 <a href="topic_2-3.html">Management After Birth</a></li><li>2.4 <a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li>2.6 <a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li class="current">3.1 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li>3.3 <a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li>4.3 <a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li>5.2 <a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
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