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            <label><input type="checkbox" checked="checked" topic="topic_1-0" onclick="setTopicVis(this)" />1.0: Why Breastfeeding is Important</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-1" onclick="setTopicVis(this)" />1.1: Biochemistry</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-2" onclick="setTopicVis(this)" />1.2: Immunology</label>
            <label><input type="checkbox" checked="checked" topic="topic_1-3" onclick="setTopicVis(this)" />1.3: Relative risks</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-0" onclick="setTopicVis(this)" />2.0: Communication Skills</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-1" onclick="setTopicVis(this)" />2.1: Non-verbal</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-2" onclick="setTopicVis(this)" />2.2: Listening skills</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-3" onclick="setTopicVis(this)" />2.3: Building confidence</label>
            <label><input type="checkbox" checked="checked" topic="topic_2-4" onclick="setTopicVis(this)" />2.4: An example</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-0" onclick="setTopicVis(this)" />3.0: Pregnancy Care</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-1" onclick="setTopicVis(this)" />3.1: The feeding decision</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-2" onclick="setTopicVis(this)" />3.2: The barriers</label>
            <label><input type="checkbox" checked="checked" topic="topic_3-3" onclick="setTopicVis(this)" />3.3: Physical preparation</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-0" onclick="setTopicVis(this)" />4.0: The Birth Experience</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-1" onclick="setTopicVis(this)" />4.1: The first hours</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-2" onclick="setTopicVis(this)" />4.2: Labor interventions</label>
            <label><input type="checkbox" checked="checked" topic="topic_4-3" onclick="setTopicVis(this)" />4.3: Postnatal interventions</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-0" onclick="setTopicVis(this)" />5.0: Breastfeeding the Baby</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-1" onclick="setTopicVis(this)" />5.1: Positioning Principles</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-2" onclick="setTopicVis(this)" />5.2: Breastmilk transfer</label>
            <label><input type="checkbox" checked="checked" topic="topic_5-3" onclick="setTopicVis(this)" />5.3: Assessing breastfeeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_6-0" onclick="setTopicVis(this)" />6.0: A time to learn</label>
            <label><input type="checkbox" checked="checked" topic="topic_6-1" onclick="setTopicVis(this)" />6.1: Practical skills</label>
            <label><input type="checkbox" checked="checked" topic="topic_6-2" onclick="setTopicVis(this)" />6.2: Breastfeeding messages</label>
            <label><input type="checkbox" checked="checked" topic="topic_6-3" onclick="setTopicVis(this)" />6.3: Normal growth</label>
            <label><input type="checkbox" checked="checked" topic="topic_6-4" onclick="setTopicVis(this)" />6.4: Sleep</label>
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            <label><input type="checkbox" checked="checked" topic="topic_6-5" onclick="setTopicVis(this)" />6.5: Psychological support</label>
            <label><input type="checkbox" checked="checked" topic="topic_6-6" onclick="setTopicVis(this)" />6.6: Discharge planning</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-0" onclick="setTopicVis(this)" />7.0: Infant Challenges</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-1" onclick="setTopicVis(this)" />7.1: Late preterm infant; Non-latching</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-2" onclick="setTopicVis(this)" />7.2: Hypoglycemia; Jaundice</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-3" onclick="setTopicVis(this)" />7.3: Supplementation</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-4" onclick="setTopicVis(this)" />7.4: Crying baby</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-5" onclick="setTopicVis(this)" />7.5: Inadequate weight gain</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-5-1" onclick="setTopicVis(this)" />7.5.1: Feeding-line device at the breast</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-5-2" onclick="setTopicVis(this)" />7.5.2: Cup feeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-5-3" onclick="setTopicVis(this)" />7.5.3: Finger Feeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_7-5-4" onclick="setTopicVis(this)" />7.5.4: Bottle feeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_8-0" onclick="setTopicVis(this)" />8.0: Maternal Challenges</label>
            <label><input type="checkbox" checked="checked" topic="topic_8-1" onclick="setTopicVis(this)" />8.1: Engorgement</label>
            <label><input type="checkbox" checked="checked" topic="topic_8-2" onclick="setTopicVis(this)" />8.2: Nipple Pain</label>
            <label><input type="checkbox" checked="checked" topic="topic_8-3" onclick="setTopicVis(this)" />8.3: Breast Problems</label>
            <label><input type="checkbox" checked="checked" topic="topic_8-4" onclick="setTopicVis(this)" />8.4: Insufficient breastmilk</label>
            <label><input type="checkbox" checked="checked" topic="topic_8-5" onclick="setTopicVis(this)" />8.5: Medical, Surgical Issues</label>
            <label><input type="checkbox" checked="checked" topic="topic_9-0" onclick="setTopicVis(this)" />9.0: Promotion, Protection and Support</label>
            <label><input type="checkbox" checked="checked" topic="topic_9-1" onclick="setTopicVis(this)" />9.1: The International Code of Marketing of Breastmilk Substitutes</label>
            <label><input type="checkbox" checked="checked" topic="topic_9-2" onclick="setTopicVis(this)" />9.2: The Baby Friendly Initiative</label>
            <label><input type="checkbox" checked="checked" topic="topic_9-3" onclick="setTopicVis(this)" />9.3: Young Child Feeding</label>
            <label><input type="checkbox" checked="checked" topic="topic_9-4" onclick="setTopicVis(this)" />9.4: Local initiatives</label>
            <label><input type="checkbox" checked="checked" topic="topic_9-5" onclick="setTopicVis(this)" />9.5: Infant feeding in emergencies</label>
            <label><input type="checkbox" checked="checked" topic="topic_10-0" onclick="setTopicVis(this)" />10.0: Closing session</label>
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        <div id="topic_1-0" class="content">
          <h1 id="top">1.0 Why Breastfeeding is Important</h1>
          <div>
    <p> Exclusive breastfeeding for the first 6 months after birth is the reference, or normative model, against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes.<sup><a href="#note1">1</a></sup> </p>
    <p> Breastmilk is the natural first food for babies, with breastfeeding being the natural means of delivery of this food source. Breastmilk is the only single food that can meet ALL of the nutritional needs of a human for at least 6 months, and this is at a time when that human is growing at the fastest rate he will ever grow after birth. </p>
    <p class="listTitle">Breastmilk has many ways to protect the infant's health. These include</p>
    <ul>
      <li> the completeness of its composition and the superiority of each of those components for growth and development (biochemistry); and </li>
      <li> the ability of breastmilk to kill or inactivate pathogens, cause the infant to resist disease and allergies, and stimulate the infant's own immune defences (immunology) </li>
    </ul>
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>What would you say?</h3>
    <div>
      <p>
			A mother, pregnant with her second baby, says to you &ldquo;<q>I breastfed my first baby for 6 weeks then gave him infant formula. He's a beautiful, healthy little boy today. Is breastfeeding really worth all the effort it takes?</q>&rdquo;
		</p>
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    <p>
		Breastmilk is impossible to replicate and infants who don't receive breastmilk cannot grow and develop to their potential. Read on to learn more about the uniqueness of breastmilk.
	</p>
  </div>
          <div class="captionBox">
            <img width="440" height="328" src="images/kangaroo_joey.jpg" alt="A kangaroo and her joey - There is no mammal species on earth, other than humans, that would trust the growth, development and health of their young to the milk of another species. " />
            <p>A kangaroo and her joey - There is no mammal species on earth, other than humans, that would trust the growth, development and health of their young to the milk of another species. . <br />Image &copy;  D.Fisher, IBCLC</p>
          </div>
          <div class="section" id="Baby_Friendly_Initiative"><h2>Baby Friendly Initiative</h2>
    <div>
      <p>The Baby Friendly Hospital Initiative (BFHI) was launched worldwide in 1991, with the goal being to accredit hospitals that apply the best-practice Ten Steps to Successful Breastfeeding. <br />To continue in the community the best practices initiated in the hospital situation UNICEF/BFI United Kingdom developed the <span style="font-style: italic;">Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Services</span> which was<span style="font-style: italic;"> </span>subsequently modified and adopted in Australia, New Zealand, Canada, Argentina and Italy. </p>
      <p>The Baby Friendly Initiative 10 Steps for hospital facilities and the 7-Point Plan for community health centres are supported by the Innocenti Declaration, the World Health Organisation Code on the Marketing of Breastmilk Substitutes and the Global Strategy for Infant and Young Child Feeding. <br /></p>
      <p>The Steps and Points of the Baby Friendly Initiative are the practical 'how-to' guides to ensure clinical practice conforms with these international standards. Throughout this course you will be referring to these Steps and Points as they are applicable to your course.<br /></p>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#aapp05" title="See full details">#</a> AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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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        <div id="topic_1-1" class="content">
          <h1 id="top">1.1 Biochemistry</h1>
          <div>
    <p>The World Health Organisation (WHO) encourages breastfeeding up to and beyond 2 years - after 6 months of exclusive breastfeeding, other nutritionally adequate and safe foods may be introduced.<sup><a href="#note1">1</a></sup> Exclusive breastfeeding provides all the nutrients and water that an infant needs to grow and develop in the first six months. <br /></p>
    <p> The composition of breastmilk is relatively constant with minimal fluctuations caused by maternal diet. Unlike the nutrition received by the fetus through the placenta, the <strong>nutrition received by breastfed infants is not dependent on the status of maternal metabolism.</strong> The mechanisms that cause breastmilk to be synthesized are insulated from variations in maternal nutritional intake, ensuring that sufficient milk of adequate composition is available to the infant even during inadequate food intake by the mother.<sup><a href="#note2">2</a></sup><br /></p>
    <p>The infant will more than double his birth weight during the first 6 months, a time when he is fed on a diet exclusively of his mother's breastmilk. Maternal metabolism is adjusted to redirect nutrients to the breast to meet this additional need. However, for her own well-being a well-nourished woman should aim to consume an additional 500 kcal per day in the form of nutritious snacks.<sup><a href="#note3">3</a></sup> Additional fluid requirements are met by recommending drinking sufficient water to avoid thirst. Consuming volumes of water in excess to needs will NOT increase breastmilk production.<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup> </p>
  </div>
          <div class="section" id="a._Protein"><h2>a. Protein</h2>
    <div>
      <p>Human milk has a low protein content, approximately 9g/L, decreasing as lactation progresses.<sup><a href="#note6">6</a></sup> This is less than measured protein in bovine milk, however it is of higher biological value and perfect for a human infant.<sup><a href="#note7">7</a></sup> </p>
      <p>Whey proteins form the predominant proteins in breastmilk - approximately 60%. Casein forms the remaining 40%. These values are approximate... some texts showing the ratio may be between 50:50 (in very late lactation) to 80:20 at different stages of lactation, with whey predominating. </p>
      <p> The high concentration of whey proteins are digested quickly and easily in the infant's stomach. Breastmilk casein has a mainly nutritive function, providing minerals and essential amino acids to the infant and forms a soft, flocculent curd during digestion. Bovine casein (the predominant protein in cows' milk) forms a tough, less digestible curd.</p>
      <p>You will be aware that proteins have significant nutritional properties. Proteins in breastmilk also have other functions such as:</p>
      <ul>
        <li>essential amino acids for growth</li>
        <li>protective factors (eg. immunoglobulins, lactoferrin, etc.)</li>
        <li>carriers for hormones (eg. thyroxine, cortisone-binding proteins)</li>
        <li>carriers for vitamins (eg folate, Vit D, Vit B12 binding proteins)</li>
        <li>enzymatic activity (eg amylase, lipase)</li>
        <li>growth factors (eg insulin-like growth factor, epidermal growth factor)<br /></li>
      </ul>
      <br />
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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"><img src="design/thinker.gif" class="icon" alt="" /><h3>Did you know...?</h3>
      <div>
        <p> The high concentration of whey proteins and the soft, flocculent curds formed by the casein is the reason why breastfed babies do not get constipated. If a mother is concerned her baby might be constipated it is important to investigate the cause, because this is NOT normal for the (exclusively) breastfed baby. </p>
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    <div>
      <ul>
        <li>The proteins of cow's milk, goat's milk and soy beans (all used to make artificial infant formula) are different in structure, quantity and quality to the proteins in breastmilk.
				<ul><li>allergic reactions commonly occur</li><li>any protective factors that remain after manufacture will not function in the same way they do from human milk</li><li>the baby's immune system will not be supported as it gradually matures</li></ul>
			</li>
      </ul>
      <p>
        <span class="aside">Below is the first of your Workbook Activities. Have you printed your Workbook yet? If not, return to the course information page, click on the link and print the Workbook. Fill out the activities as you progress through this course.</span>
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          <div class="section" id="b._Carbohydrates"><h2>b. Carbohydrates</h2>
    <div>
      <p> Lactose (milk sugar) is the principle carbohydrate in human milk. Lactose is the most stable component of mature breastmilk. Average concentration is 68g/L (some texts report 70g/L). Lactose is synthesized in the mother's breast and broken down by the enzyme lactase in the baby's small intestine. Lactase breaks lactose into glucose and galactose, ready for absorption into the blood stream. </p>
      <p class="listTitle">The role of lactose:</p>
      <ul>
        <li>The rapid increase of lactose levels in colostrum at lactogenesis II causes osmotic drawing of water into the breast secretion resulting in copious breastmilk production.</li>
        <li>Provides energy to the body - and particularly to the rapidly growing infant brain.</li>
        <li>Enhances absorption of calcium and iron.</li>
        <li>Galactose is ultimately essential for development of central nervous system.</li>
      </ul>
      <p> There have been around 130 different oligosaccharides (short chains of sugar molecules) identified in human milk.<sup><a href="#note8">8</a></sup> These important sugars comprise up to 1.2% of mature human milk, compared to only 0.1% of bovine milk. Their role is in protection of the infant from infections. </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/thinker.gif" class="icon" alt="" /><h3>Food for thought...</h3>
      <div>
        <p> At a concentration of 70g/L, human milk has the highest concentration of lactose of <strong>all</strong> the mammalian milks. Have you ever wondered why? Could it be because the human brain has the MOST growth of all mammal species to accomplish over the next two years and lactose contains elements essential to brain growth?</p>
        <p>Consider what effects a lactose-free artificial infant formula could have on the infant fed on it. Discuss this with your colleagues.<br /></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>
    <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 1.2</h3><p>Complete Activity 1.2 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>
          <div class="section" id="c._Milk_Lipids_fats_"><h2>c. Milk Lipids (fats)</h2>
    <div><br />Properties of milk lipids:<br /><ul><li>provide around half of the energy (kilojoules) in breastmilk</li><li>97 - 98% of milk lipids are triglycerides</li><li>essential for the synthesis and development of retinal and neural tissues</li><li>are a rich source of the essential fatty acids linoleic acid and alpha-linolenic acid and their long-chain derivatives arachidonic acid (AA) and docosahexaenoic acid (DHA). DHA is essential for the developing visual system.</li></ul><ul></ul><p class="listTitle">Milk lipids are the most variable constituent of human milk. <br /> </p><p class="listTitle">The change in fat concentration in breastmilk is directly related to the amount of milk held in the breast at that time. Milk removed when the breast is fullest has a low concentration which increases in a linear fashion as more and more milk is removed. Variations in fat content also occur with time of day, stage of lactation, parity, age, and between women.<sup><a href="#note9">9</a></sup><br /></p></div>
    <div class="captionBox"><img width="259" height="316" src="images/fat_increase_test_tubes_cropped.jpg" alt="" /><p> <br />&copy; Dr Jacqueline Kent, Biochemistry and Molecular Biology, The University of Western Australia</p></div>
    <div>
      <p> Illustrated above is a series of samples from an expression collected in 1mL fractions. The samples are, in order from left to right, a fore-milk sample (hand-expressed), a stimulation sample (the first milk removed by the breast pump), 7 samples collected during the expression, and a final sample hand-expressed after the expression. The initial sample is 5.6% cream (fat) and the final is 18.3% cream (fat). <br /></p>
      <p>The fat is seen as small clumps of white towards the top of each tube - the amount of fat increases as the breast is progressively drained.</p>
      <p>For this mother this represents a change in degree of fullness from 0.55 (about half full) to 0.0 (well-drained).<sup><a href="#note10">10</a></sup><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/books.png" class="icon" alt="" /><h3>Workbook Activity 1.3</h3><p>Complete Activity 1.3 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="Foremilk_vs_Hindmilk"><h3>Foremilk vs Hindmilk</h3>
      <div>
        <p> Many misunderstandings surround the use of these terms. The milk available at the beginning of a breastfeed is sometimes known as foremilk, and hindmilk is often used to describe the milk consumed by the infant at the end of the breastfeed. </p>
        <p> The only difference between foremilk and hindmilk is in fat content, with foremilk having a lower fat content than hindmilk <strong>at a given breastfeed</strong>. You have just learned that the fat content increases in a linear fashion as milk is removed from the breast during that breastfeed, therefore, the change from foremilk to hindmilk is not defined. Use of the terms 'foremilk' and 'hindmilk' may be misrepresentative. <br /></p>
      </div>
    </div>
    <div class="section" id="Breastmilk_storage_capacity"><h3>Breastmilk storage capacity</h3>
      <div>
        <p> Breastmilk is stored in the alveoli of the breast, and storage capacity of the breast is unique for every woman and every breast. Some mothers may have a large storage capacity, while others may have a very small capacity, and most women have differing capacity in each breast.<sup><a href="#note11">11</a>,</sup><sup><a href="#note12">12</a>,</sup><sup><a href="#note13">13</a></sup> <span class="aside">You cannot accurately judge a woman's breast capacity visually - don't assume that a large breasted woman has a large capacity.</span> </p>
        <p>For a mother who has a large storage capacity the milk received by her baby while the breast is at its fullest will be low in fat. After breastfeeding several times the volume in the breast will be reduced and the fat content of subsequent feeds will be much higher. However, for the mother with a small storage capacity, her baby may remove all or most of the breastmilk at most feeds. The fat content of breastmilk at each feed will be similar. </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/tip.png" class="icon" alt="" /><h3>Clinical Tip</h3>
        <div>
          <p>Mothers should follow their baby's feeding cues. The mother with the smaller breastmilk storage capacity will find her baby will cue to feed frequently. The mother with the larger storage capacity may find her baby takes larger feeds and requests fewer feedings. Both babies may consume similar amounts of breastmilk over a 24-hour period and both will grow equally as well. Scheduling feeding may work for some babies but cause other babies to be very unhappy and cause failure to thrive.
				</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="Cholesterol"><h3>Cholesterol</h3>
      <div>
        <p> The level of cholesterol in breastmilk remains constant (10-20mg/dL) despite dietary manipulation of the mother's cholesterol intake. There is negligible cholesterol in artificial infant formula. </p>
        <p> Cholesterol is required to build and maintain cell membranes. Amongst other important tissues it is involved in laying down the myelin sheath which covers the axons of nerve cells in the rapidly growing brain and spinal cord. Multiple sclerosis, a problem of myelinisation, is much more prevalent in countries where artificial infant feeding is common.<sup><a href="#note14">14</a></sup> </p>
        <p> The high level of cholesterol in breastmilk appears to have a 'programming' effect on infants, protecting them from detrimental effects in later life, with adults who were artificially-fed having significantly higher total cholesterol levels and incidence of coronary heart disease.<sup><a href="#note15">15</a>,</sup><sup><a href="#note16">16</a>,</sup><sup><a href="#note17">17</a></sup> </p>
      </div>
    </div>
  </div>
          <div class="section" id="d._Vitamins"><h2>d. Vitamins</h2>
    <div>
      <dl>
        <dt style="font-weight: bold;">Vitamin A</dt>
      </dl>
      <ul>
        <li>necessary for vision and maintenance of epithelial structures</li>
        <li>adequate stores laid down in the fetal liver during the last trimester</li>
        <li>human milk is an excellent source of vitamin A</li>
      </ul>
      <dl>
        <dt style="font-weight: bold;">Vitamin D</dt>
      </dl>
      <ul>
        <li>synthesized in the skin from cholesterol on exposure to UVB radiation (sunshine)</li>
        <li>stimulates intestinal absorption and renal reabsorption of calcium and phosphorus</li>
        <li>involved in bone resorption and bone formation</li>
        <li>fetal stores of Vitamin D in infants born to mothers with normal status may be depleted by 2 months of age in the absence of any exposure to sunlight</li>
        <li>breastmilk is a negligible source (20 IU/L) for a recommended need of 300 - 400 IU per day</li>
        <li>very dark skinned breastfed infants or those infants not exposed to adequate sunlight may require oral supplementation</li>
      </ul>
      <dl style="font-weight: bold;">
        <dt>Vitamin E</dt>
      </dl>
      <ul>
        <li>mature human milk meets the daily recommended intake</li>
      </ul>
      <dl>
        <dt style="font-weight: bold;">Vitamin K</dt>
      </dl>
      <ul>
        <li>prothrombin, coagulation Factors VII and IX and some plasma proteins are vitamin K-dependent proteins. These are blood clotting factors.</li>
        <li>Vitamin K (phylloquinone) levels in human milk vary considerably depending on maternal diet. Maternal supplementation of 5mg/day increases breastmilk concentration to levels which provide the infant's daily requirement.</li>
        <li>Vitamin K synthesis by bacteria in the large intestine in the first week of life provides insufficient levels for the fully breastfed infant because the predominant gut bacteria (bifidobacteria) does not synthesize Vitamin K.</li>
        <li>Once only intramuscular injection of Vitamin K is recommended for all infants at birth. No other supplementation is required.</li>
      </ul>
      <dl>
        <dt style="font-weight: bold;">Vitamin B</dt>
      </dl>
      <ul>
        <li> Most B vitamins are in appropriate concentrations in breastmilk irrespective of maternal intake. Precaution should be taken with Vitamin B6 as mega-doses (ie 600mg/day) have been shown in some studies to reduce maternal prolactin levels. <span class="aside">Usual supplement is 25mg per day</span>. Mothers with a long-term history of oral contraceptive use may be deficient in Vitamin B6. </li>
        <li> A strict maternal vegan diet without B12 supplementation has resulted in serious infant morbidity.<sup><a href="#note18">18</a>,</sup><sup><a href="#note19">19</a></sup> Likewise mothers with gastric bypass surgery are also at risk of Vitamin B12 deficiency.<sup><a href="#note20">20</a></sup> </li>
      </ul>
      <dl>
        <dt style="font-weight: bold;">Vitamin C</dt>
      </dl>
      <ul>
        <li>Vitamin C levels in breastmilk remain within a normal range, regardless of maternal supplementation.</li>
      </ul>
      <br />
    </div>
  </div>
          <div class="section" id="e._Minerals"><h2>e. Minerals</h2>
    <div>
      <p>
			Concentration of minerals in human milk appears to be quite low, however they have a very high bioavailability and their interrelationship with other nutrients may affect their absorption, metabolism and excretion.
		</p>
    </div>
    <div class="section" id="Calcium"><h3>Calcium</h3>
      <div>
        <p> Lactating women are often advised to take a calcium supplement or to increase, above normal, their intake of calcium-rich foods. However, in a large study of a group of women in Cambridge UK<sup><a href="#note21">21</a></sup> there was no correlation found between calcium intake (ranging from 600 to 2300mg/day) and the amount of calcium in their breastmilk. </p>
        <p> The infant's daily requirement for calcium is adequately met by breastmilk. Bone growth in the infant is unaffected by maternal supplements. </p>
        <p> Maternal bone mineral density is not affected adversely by breastfeeding, or enhanced by calcium intake above normal levels. Within 3 months of weaning bone mineral density in breastfeeding women has returned to normal, or is even enhanced<sup><a href="#note21">21</a>,</sup><sup><a href="#note22">22</a></sup>. Breastfeeding decreases incidence of osteoporosis in post-menopausal women<sup><a href="#note23">23</a></sup> and parity with prolonged total duration of breastfeeding has no detrimental effect on bone mineral density.<sup><a href="#note24">24</a></sup><br /></p>
      </div>
    </div>
    <div class="section" id="Iron"><h3>Iron</h3>
      <div>
        <ul>
          <li>levels relatively low but highly bioavailable to infant - five-fold more efficient absorption from human milk than from bovine milk<sup><a href="#note25">25</a></sup></li>
          <li>heat treatment of breastmilk does not alter the iron-absorption rate</li>
          <li>the presence of high lactose and Vitamin C levels in breastmilk also aid its absorption</li>
          <li>iron supplements for term infants during the first 6 months of exclusive breastfeeding is unnecessary. Complementary foods after 6 months of age should include iron-rich foods. Some infants who continue to be exclusively breastfed for much longer than 6 months may maintain an adequate iron status - biochemical analysis on an individual basis may be indicated.<sup><a href="#note26">26</a></sup></li>
        </ul>
      </div>
    </div>
    <div class="section" id="Iodine"><h3>Iodine</h3>
      <div>
        <ul>
          <li>required for synthesis of thyroid hormones that are required for brain development during fetal and early postnatal life</li>
          <li>iodine deficiency is a leading cause of brain damage</li>
          <li>breastmilk levels vary widely according to geographic region and maternal intake</li>
          <li>supplementation of women during pregnancy and lactation in iodine-deficient areas will reverse this leading cause of mental impairment<sup><a href="#note25">25</a></sup></li>
        </ul>
      </div>
    </div>
  </div>
          <div class="section" id="f._Water"><h2>f. Water</h2>
    <div>
      <p> Breastmilk contains a high percentage of water. When babies have unrestricted access to the breast they DO NOT need additional water, even in hot climates. Giving water or other fluids such as teas, will decrease the infant's desire to breastfeed decreasing nutrient intake and breastmilk synthesis, and increasing the infant's risk of infections. </p>
    </div>
  </div>
          <div class="section" id="The_taste_of_breastmilk"><h2>The taste of breastmilk</h2>
    <div>
      <p> The flavour (flavor) of breastmilk is affected by the foods in the maternal diet. This daily variation in flavour can help the infant to become used to the tastes of the family foods and ease the transition to these foods after six months of age. Artificial infant formula tastes the same for every feed. The taste of formula is not related to any foods the baby will eat when older. </p>
    </div>
    <div class="section" id="Dietary_advice"><h3>Dietary advice</h3>
      <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_q">
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	{ c : '<p>\n				At her first antenatal clinic visit a young woman expecting her first baby tells you she probably won\'t be able to breastfeed because she doesn\'t eat well enough, mostly cheap \'fast foods\', and thinks her milk won\'t be good enough.\n			</p><p>\n				In the box below type in a general response you would make to this woman. When you\'ve completed it click on \'Check\'.\n			</p>', r : '<p>\n				You may have explored why the young woman was eating such foods... perhaps she didn\'t know how to cook, or thought that preparing fresh food for herself would cost more money than buying cheap ready-prepared food. It is important to discuss her concerns and encourage good food choices for the health of herself and her growing fetus. \n			</p><p>\n				However, did you reassure her that her body can only ever produce top-quality breastmilk? Even if she reverts to her former diet after her pregnancy her breastmilk will be perfect for her baby.\n			</p>' }
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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>
    </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>
        <ol>
          <li>The quality of breastmilk is NOT dependent on maternal diet.</li>
          <li>Proteins: several functions, including immunological protection.</li>
          <li>Carbohydrates: provide energy and support brain development.</li>
          <li>Lipids: most variable; provide energy; support retinal and brain growth.</li>
          <li>Vitamins and minerals have high bioavailability. Supplementation is not necessary. Exceptions: vitamin B12 in strict vegans; iodine in iodine-deficient areas; vitamin D when exposure to sunlight restricted.</li>
          <li>Additional water is not required.</li>
          <li>Breastmilk meets all of the infant's nutritional needs for the first 6 months.</li>
        </ol>
      </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_r">
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	new CWWord('lactose', 'This is the predominant form of carbohydrate in breastmilk.', 0, 5, 1),
	new CWWord('cholesterol', 'With negligible amounts of this in artificial infant formula but high levels in breastmilk this component protects those breastfed from coronary heart disease in adult life.', 2, 5, 0),
	new CWWord('glucose', 'In combination with galactose this simple sugar forms lactose.', 11, 6, 0),
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	new CWWord('vitamind', 'The primary source of this vitamin for infants is firstly from stores laid down during fetal life, then from sunlight on the skin.', 0, 11, 1),
	new CWWord('whey', 'The majority of protein in breastmilk is this type.', 9, 12, 1),
	new CWWord('protein', 'This macronutrient provides essential amino acids for growth.', 1, 13, 1),
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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>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#who02a" title="See full details">#</a> WHO (2002) Global Strategy on Infant and Younf Child Feeding</li>
              <li id="note2"><a href="references.html#nevi01" title="See full details">#</a> Neville MC (2001) Anatomy and Physiology of Lactation</li>
              <li id="note3"><a href="references.html#picc03" title="See full details">#</a> Picciano MF (2003) Pregnancy and Lactation: Physiological Adjustments, Nutritional Requirements and the Role of Dietary Supplements</li>
              <li id="note4"><a href="references.html#dusd90" title="See full details">#</a> Dusdieker LB et al. (1990) Prolonged maternal fluid supplementation in breast-feeding.</li>
              <li id="note5"><a href="references.html#dusd85" title="See full details">#</a> Dusdieker LB et al. (1985) Effect of supplemental fluids on human milk production.</li>
              <li id="note6"><a href="references.html#rior05" title="See full details">#</a> Riordan J (2005) Breastfeeding and Human Lactation</li>
              <li id="note7"><a href="references.html#hale07" title="See full details">#</a> Hale TW et al. (2007) Textbook of Human Lactation</li>
              <li id="note8"><a href="references.html#mcve97" title="See full details">#</a> McVeagh P et al. (1997) Human milk oligosaccharides: only the breast</li>
              <li id="note9"><a href="references.html#daly93" title="See full details">#</a> Daly SE et al. (1993) Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk</li>
              <li id="note10"><a href="references.html#kent05" title="See full details">#</a> Kent J (2005) Personal communication</li>
              <li id="note11"><a href="references.html#engs07" title="See full details">#</a> Engstrom JL et al. (2007) Comparison of milk output from the right and left breasts during simultaneous pumping in mothers of very low birthweight infants.</li>
              <li id="note12"><a href="references.html#rams05" title="See full details">#</a> Ramsay DT et al. (2005) Anatomy of the lactation human breast redefined with ultrasound imaging</li>
              <li id="note13"><a href="references.html#coxd97" title="See full details">#</a> Cox DB et al. (1997) Studies on Human Lactation: The Development of the Computerized Breast Measurement System</li>
              <li id="note14"><a href="references.html#pisa94" title="See full details">#</a> Pisacane A et al. (1994) Breastfeeding and multiple sclerosis</li>
              <li id="note15"><a href="references.html#dasu03" title="See full details">#</a> Das UN (2003) A perinatal strategy to prevent coronary heart disease</li>
              <li id="note16"><a href="references.html#mart05a" title="See full details">#</a> Martin RM et al. (2005) Breastfeeding and atherosclerosis: intima-media thickness and plaques at 65-year follow-up of the Boyd Orr cohort</li>
              <li id="note17"><a href="references.html#owen08" title="See full details">#</a> Owen CG et al. (2008) Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence.</li>
              <li id="note18"><a href="references.html#coda05" title="See full details">#</a> Codazzi D et al. (2005) Coma and respiratory failure in a child with severe vitamin B12 deficiency</li>
              <li id="note19"><a href="references.html#alle08" title="See full details">#</a> Allen LH (2008) Causes of vitamin B12 and folate deficiency.</li>
              <li id="note20"><a href="references.html#gran94" title="See full details">#</a> Grange DK et al. (1994) Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass</li>
              <li id="note21"><a href="references.html#pren00" title="See full details">#</a> Prentice A (2000) Calcium in pregnancy and lactation</li>
              <li id="note22"><a href="references.html#kova05" title="See full details">#</a> Kovacs CS (2005) Calcium and bone metabolism during pregnancy and lactation</li>
              <li id="note23"><a href="references.html#schn10" title="See full details">#</a> Schnatz PF et al. (2010) Effects of age at first pregnancy and breast-feeding on the development of postmenopausal osteoporosis.</li>
              <li id="note24"><a href="references.html#leno09" title="See full details">#</a> Lenora J et al. (2009) Effects of multiparity and prolonged breast-feeding on maternal bone mineral density: a community-based cross-sectional study.</li>
              <li id="note25"><a href="references.html#picc01" title="See full details">#</a> Picciano MF (2001) Nutrient Composition of Human Milk</li>
              <li id="note26"><a href="references.html#grif01" title="See full details">#</a> Griffin IJ (2001) Iron and Breastfeeding</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_1-2" class="content">
          <h1 id="top">1.2 Immunology</h1>
          <div>
    <p>At birth, the baby's skin and gut is sterile, but is quickly colonized by the bacterial flora of those with whom he comes in contact.</p>
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                <td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Clinical Tip:</h3>
    <div>
      <p>A simple strategy to ensure the baby's skin is colonized by the flora common to his mother is to limit the handling of the newborn by health care workers until after the mother and baby have been together, in skin-to-skin contact, for a number of hours. Prolonged skin-to-skin contact also reduces the risk of the baby acquiring nosocomial infections. <br />Careful attention to hand hygiene is essential when it becomes necessary for staff members to handle the baby.</p>
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    <p>Soon after birth, the infant's gut is colonised by potentially harmful aerobic bacteria. The environment quickly changes as harmless anaerobic bacteria take over. Breastmilk supports this development of a protective anaerobic flora which may function as probiotics. Artificially-fed babies are colonized by aerobes and other anaerobes in addition to bifidobacteria, with a predominance of enterococci and enterobacteria. <em>Clostridia, Enterococci, E. Coli</em> and <em>Bacteroides</em> are also a common part of the gut flora of the artificially fed.<sup><a href="#note1">1</a></sup> </p>
  </div>
          <div class="section" id="Protective_components_of_breastmilk"><h2>Protective components of breastmilk</h2>
    <div class="section" id="Proteins"><h3>Proteins</h3>
      <div class="section" id="Immunoglobulins"><h4>Immunoglobulins</h4>
        <div>
          <p>Immunoglobulins are present in human milk. The special structure <strong>secretory IgA (sIgA) is the main immunoglobulin</strong>. Concentration in colostrum is particularly high to provide immediate protection for the infant entering a world of microbes.</p>
          <ul>
            <li>sIgA protection is 'targeted' against organisms with which the mother, and consequently her baby, come into contact, killing the offending pathogen</li>
            <li>sIgA coats the infant's intestine preventing adherence of pathogens, blocking them from getting onto and into the infant's tissues</li>
            <li>sIgA encourages the growth of the normal, non-virulent gut bacteria.</li>
          </ul>
          <ul> </ul>
        </div>
      </div>
      <div class="section" id="Lactoferrin"><h4>Lactoferrin</h4>
        <div>
          <ul>
            <li> has antibacterial (to gram-positive and gram-negative), antiviral and antifungal (Candida albicans) effects </li>
            <li> promotes the growth of intestinal epithelium </li>
          </ul>
        </div>
      </div>
      <div class="section" id="Alpha-Lactalbumin"><h4>Alpha-Lactalbumin</h4>
        <div>
          <ul>
            <li>antiinfective and immunostimulatory functions<br /></li>
            <li>forms a complex that induces apoptosis (= cell death) of all malignant cells tested, but not normal cells - known as HAMLET <span class="aside">(human alpha-lactalbumin made lethal to tumour cells)<sup><a href="#note2">2</a></sup></span></li>
          </ul>
        </div>
      </div>
      <div class="section" id="Lysozyme"><h4>Lysozyme</h4>
        <div>
          <ul>
            <li>this enzyme effectively attacks E. coli in concert with lactoferrin and sIgA</li>
          </ul>
        </div>
      </div>
    </div>
    <div class="section" id="Carbohydrates"><h3>Carbohydrates</h3>
      <div class="section" id="Oligosaccharides"><h4>Oligosaccharides</h4>
        <div>
          <ul>
            <li>prebiotic effect - produce an increased proliferation of bifidobacteria and lactobacilli (probiotics) which are not digested in the infant's small intestine, but enter the colon as intact, large carbohydrates that are then fermented by the resident bacteria.<br /></li>
            <li>block receptors on epithelial surfaces by resembling binding sites for bacteria, sweeping the bacteria from the gut with them as they are eliminated<br /></li>
            <li> defend infants against pathogens that cause otitis media, respiratory tract infections, urinary tract infections, diarrhoea.</li>
          </ul>
          <ul> </ul>
        </div>
      </div>
    </div>
    <div class="section" id="Lipids_and_milk_fat_globules"><h3>Lipids and milk fat globules</h3>
      <div>
        <p>Fatty acids and monoglycerides attack or neutralise <em>G lamblia, Entamoeba, E coli,</em> and Shiga-like toxins.
			</p>
      </div>
    </div>
    <div class="section" id="Cellular_components"><h3>Cellular components</h3>
      <div>
        <p>The neutrophils and macrophages in breastmilk most likely protect the maternal breasts.</p>
        <p>Lymphocytes in breastmilk are absorbed and may possibly confer immunological information to the baby.
			</p>
      </div>
    </div>
    <div class="section" id="Other_protective_factors"><h3>Other protective factors</h3>
      <div>
        <p>Breastmilk contains a myriad of other factors that work to protect and enhance the development of the breastfed child, including nucleotides, defensins, cytokines, hormones and growth factors, anti-secretory factor, anti-inflammatory components, soluble CD14 and soluble Toll-like Receptor, etc.
			</p>
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                  <h3>Workbook Activity 1.4</h3>
                  <p>Complete Activity 1.4 in your workbook.</p>
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Take a minute to reflect...</h3>
    <div>
      <p>Breastmilk truly is a living food that is unique to each mother and baby. While artificial infant milk is life-saving for some babies, for the majority, it is an inferior source of food and protection.</p>
    </div>
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          <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
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      <div>
        <ul>
          <li> Breastmilk is not just for nutrition</li>
          <li>There are many components which prevent and fight infections - know the main protective factors<br /></li>
          <li>Artificial infant milk does not contain any immunological properties </li>
        </ul>
      </div>
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          <div class="section" id="Self-test_Quiz"><h2>Self-test Quiz</h2>
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      <div></div><div class="activity" id="activity_s">
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	new Matching('oligosaccharides', 'pass through the gut unchanged, taking bacteria from the gut with them'),
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<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('s');</script>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#hans04" title="See full details">#</a> Hanson L (2004) Immunology of Human Milk: How breastfeeding protects babies</li>
              <li id="note2"><a href="references.html#lonn03" title="See full details">#</a> Lonnerdal B et al. (2003) Nutritional and physiologic significance of alpha-lactalbumin in infants</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_1-3" class="content">
          <h1 id="top">1.3 Relative risks</h1>
          <div>
    <p class="listTitle">Artificial feeding increases illnesses in infants by:</p>
    <ol>
      <li>denying the infant the many special, unique protective factors, both antibody and non-antibody, found in human milk</li>
      <li>exposing the infant to bacterial pathogens in other food sources</li>
      <li>not providing optimal nutrition, decreasing the infant's ablility to fight infections<br /></li>
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    <br />
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                <td class="body"><h3>Clinical Note:</h3>
    <div>
      <p> To obtain true and fair scientifically-relevant results in research studies, the researcher must compare the variable being studied to the norm. For example: compare state of disease in adults who smoke (variable), to state of disease in adults who do not smoke (the norm). Results are then written up as a change from the norm - ie 'incidence of lung cancer is increased in those who smoke by X.' </p>
      <p> Breastfeeding is normal and breastfed babies enjoy a NORMAL state of health. Studies of infant health are notoriously reported incorrectly, making statements that equate to 'Breastfed babies are healthier' whereas correct breastfeeding language should read 'Artificially-fed babies are sicker'. </p>
      <p> Whenever you discuss feeding outcomes with your colleagues or with parents, ensure you are speaking factually using breastmilk and breastfeeding as the norm.</p>
    </div>
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>A little statistics...</h3>
    <div>
      <p>Relative risk (RR) is a ratio of the probability of a disease, in this case, occuring in the experimental group (ie artificially-fed) versus the control (breastfed) group. The equation to work it out is: RR = Probability in experimental group <em>divided by</em> Probability in control group.</p>
      <p>For example: If the probability of an infant contracting diarrhoea in the first month of life is 1% when breastfed, but 14% if artificially-fed then the RR=14. An artificially-fed infant has 14 times the risk of getting diarrhoea in the first month of life compared to the risk for a breastfed infant. <br /></p>
    </div>
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          <div class="section" id="Acute_diseases_attributable_to_artificial_feeding"><h2>Acute diseases attributable to artificial feeding</h2>
    <div class="section" id="Diarrhoea_diarrhea_"><h3>Diarrhoea (diarrhea)</h3>
      <div>
        <p>
			Dewey et al (1995)<sup><a href="#note1">1</a></sup> reported twice the incidence of gastrointestinal morbidity in artificially-fed infants in a relatively affluent community in the United States while Kramer et al (2001)<sup><a href="#note2">2</a></sup> reported a 66% increase in a socially advantaged group where artificial feeding was predominant.
		</p>
        <p>
			In countries where poverty and poor hygiene are factors breastfeeding means the difference between healthy normal development, and malnutrition or possibly death.
		</p>
      </div>
    </div>
    <div class="section" id="Otitis_media_middle_ear_infection_"><h3>Otitis media (middle ear infection)</h3>
      <div>
        <p> A large literature review concluded that formula-fed infants' risk of otitis media is doubled in the first year.<sup><a href="#note3">3</a></sup> It has also been found that they experience a 75% increased incidence of otitis media of 10 or more days duration.<sup><a href="#note1">1</a></sup> Saarinen et al (1982)<sup><a href="#note4">4</a></sup> followed healthy term infants, noting that no exclusively breastfed infant suffered from otitis media in the first 6 months of life, while 10% of babies who were given any cow's milk did. </p>
      </div>
    </div>
    <div class="section" id="Pneumonia"><h3>Pneumonia</h3>
      <div>
        <p> The occurrence of pneumonia in infants living in poor socio-economic regions is significantly increased if they are artificially fed.<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup></p>
        <p>A meta-analysis of research has found that artificial feeding contributed a 3.6-fold increased risk of hospitalisation for lower respiratory tract infections.<sup><a href="#note8">8</a></sup><br /></p>
      </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/chart.png" class="icon" alt="" /><h3>Summary of diarrhoea, otitis media and pneumonia</h3>
      <div>
        <p></p>
        <table>
          <caption><br />The relative risk of developing diseases throughout life for artificially-fed as compared to human milk-fed infants. (Heinz Sight, 2001)<sup><a href="#note9">9</a></sup></caption>
          <thead>
            <tr>
              <th></th>
              <th>0 - 1 month</th>
              <th>1 - 12 months</th>
              <th>1 - 6 years</th>
            </tr>
          </thead>
          <tbody>
            <tr class="row0">
              <th>Diarrhea </th>
              <td>14 </td>
              <td>4 - 10 </td>
              <td></td>
            </tr>
            <tr class="row1">
              <th>Otitis media</th>
              <td></td>
              <td>8.6</td>
              <td>3.3 - 4.3</td>
            </tr>
            <tr class="row0">
              <th>Respiratory illness</th>
              <td></td>
              <td>3.3 - 4.3</td>
              <td></td>
            </tr>
          </tbody>
        </table>
      </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="Urinary_Tract_Infection"><h3>Urinary Tract Infection</h3>
      <div>
        <p>
			Marild et al (2004)<sup><a href="#note10">10</a></sup> demonstrated a significant increase in UTI amongst artificially-fed infants in Sweden; this protection for the breastfed infant persisted after weaning.
		</p>
      </div>
    </div>
    <div class="section" id="Necrotising_Enterocolitis"><h3>Necrotising Enterocolitis</h3>
      <div>Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in the NICU, with often devastating consequences.The key risk factors leading to NEC are prematurity, formula feeding, intestinal ischemia, and bacterial colonization.<sup><a href="#note11">11</a></sup> The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years.</div>
    </div>
    <div class="section" id="Septicemia_and_Meningitis"><h3>Septicemia and Meningitis</h3>
      <div>
        <p> Neonatal septicemia and meningitis is associated with severe morbidity and high mortality rates. Artificially fed infants in neonatal intensive care units, and artificially fed infants in developing countries, are most at risk. </p>
        <p> In a comparison of breastmilk-fed and artificially-fed babies in neonatal intensive care units the incidence of sepsis was:<sup><a href="#note12">12</a></sup> </p>
        <table>
          <thead>
            <tr>
              <th>Postnatal Age</th>
              <th>Breastmilk Fed</th>
              <th>Artificial Milk Fed</th>
            </tr>
          </thead>
          <tbody>
            <tr class="row0">
              <th>first 10 days</th>
              <td>5%</td>
              <td>10%</td>
            </tr>
            <tr class="row1">
              <th>11 - 24 days</th>
              <td>9%</td>
              <td>20%</td>
            </tr>
            <tr class="row0">
              <th>25 - 38 days</th>
              <td>0%</td>
              <td>15%</td>
            </tr>
          </tbody>
        </table>
      </div>
    </div>
  </div>
          <div class="section" id="Chronic_diseases_attributable_to_artificial_feeding"><h2>Chronic diseases attributable to artificial feeding</h2>
    <div class="section" id="Type_1_Diabetes_Mellitus_Insulin-dependent_diabetes_"><h3>Type 1 Diabetes Mellitus (Insulin-dependent diabetes)</h3>
      <div>
        <p class="listTitle">Type 1 diabetes is an auto-immune disease determined by a combination of genetic and environmental factors. <br /></p>
        <ul>
          <li> general population risk of developing Type 1 diabetes = 0.4%</li>
          <li>when a first-degree relative is affected = 6%</li>
        </ul>
        <p>Environmental factors provide the trigger that causes a child to develop diabetes.</p>
        <p class="listTitle">There are several hypotheses as to what these environmental factors are:</p>
        <ul>
          <li>early exposure to cow's milk protein</li>
          <li>introduction to solid food before 3 months</li>
          <li>not having all the protective benefits of breastmilk <br /></li>
        </ul>
        <p class="listTitle">Meta-analyses of the published research found a strong link between early introduction of artificial milks and the development of Type 1 diabetes:</p>
        <ul>
          <li>exposure to cow's milk in the first 3 months<sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup> <br /></li>
          <li>children who breastfed &lt;3 months, OR of 1.43 (1.15-1.77)<sup><a href="#note15">15</a></sup></li>
          <li> no-breastfeeding increased the risk (OR=1.93 [95% CI: 1.33-2.80]), while breastfeeding for more than 12 months was protective (OR=0.42 [95% CI: 0.22-0.81]).<sup><a href="#note16">16</a></sup> </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>The cycle of diabetic risk</h3>
        <div>Mothers who have type 1 diabetes are more likely to NOT breastfeed.<sup><a href="#note17">17</a></sup> Cesarian section birth, prematurity and unstable baby's condition at birth are among the reasons given for this occurrence. The same author also found that breastfeeding duration is likely to be shorter amongst this group of mothers with breastfeeding &lt;4 weeks being associated with overweight at age 2 years.<sup><a href="#note18">18</a></sup> <br /><br />Can you see how the risk of type 1 diabetes can spiral through the generations? The birth and post-birth circumstances and management of the diabetic mother can lead to an intervention (ie. infant being not-breastfed/early exposure to cow's milk protein in artifical infant milk) which triggers the infant to later develop diabetes.<br /><br />Would mothers put their baby at risk if they knew this?<br />What can you do at your workplace to help break this cycle?<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 class="section" id="Type_2_Diabetes"><h4>Type 2 Diabetes</h4>
        <div>The mechanism is not entirely understood, however, studies report that formula-fed infants have higher basal and post-prandial concentrations of insulin and neurotensin.<sup><a href="#note19">19</a>,</sup><sup><a href="#note20">20</a></sup> Being formula-fed in infancy is associated with a 1.6 fold risk of developing type 2 diabetes.<sup><a href="#note21">21</a></sup> <sup><a href="#note22">22</a></sup></div>
      </div>
    </div>
    <div class="section" id="Coeliac_Celiac_Disease"><h3>Coeliac (Celiac) Disease</h3>
      <div>
        <p> Celiac disease is an autoimmune enteropathy. Genetic susceptibility and dietary exposure to gluten are necessary for it to occur. Controlled studies looking at infant feeding have shown an approximately four-fold increased risk, as well as an earlier onset, among artificially fed children. <sup><a href="#note23">23</a></sup> </p>
        <p> A meta-analysis of the literature <sup><a href="#note24">24</a></sup> reported more than double the incidence of celiac disease in infants who received breastmilk substitutes before 6 months and were not receiving any breastmilk during the introduction of gluten-containing foods. <br /> <br /> The current recommendation to prevent the development of celiac disease is for children to be breastfed exclusively for 6 months and for breastfeeding to continue while, and for several months after, gluten is introduced into the diet. <br /> </p>
      </div>
    </div>
    <div class="section" id="Obesity"><h3>Obesity</h3>
      <div>
        <p> Obesity is a serious condition that leads to chronic diseases such as heart disease, diabetes, hypertension, some cancers and an earlier death. Prevention of obesity starts at birth and is greatly influenced by the feeding method chosen. <br /></p>
        <p>Breastmilk contains an appetite regulator, leptin. Artifically-fed infants have half the normal serum leptin.<sup><a href="#note25">25</a></sup><br /></p>
        <p> Artificial feeding is significantly correlated with obesity in childhood and adulthood.<sup><a href="#note26">26</a>,</sup><sup><a href="#note27">27</a>,</sup><sup><a href="#note28">28</a>,</sup><sup><a href="#note3">3</a></sup> </p>
        <p class="listTitle">Closely associated with childhood obesity:</p>
        <ul>
          <li>early weaning to artificial infant formula</li>
          <li>introduction of artificial infant formula before 6 months of age while breastfeeding</li>
          <li>introduction of foods before 6 months of age</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Childhood_Cancer"><h3>Childhood Cancer</h3>
      <div>
        <p>Fortunately childhood cancers are rare, but their rarity makes quality research difficult to achieve.</p>
        <p>There is a strong link between being artificially fed and the following cancers:<sup><a href="#note29">29</a>,</sup><sup><a href="#note30">30</a></sup></p>
        <ul>
          <li>acute lymphoblastic leukemia (leukaemia)</li>
          <li>lymphomas - Hodgkin's and non-Hodgkin's</li>
          <li>neuroblastomas</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Inflammatory_Bowel_Diseases"><h3>Inflammatory Bowel Diseases</h3>
      <div>
        <ul>
          <li>Inflammatory bowel disease</li>
          <li>Ulcerative colitis</li>
          <li>Crohn's disease</li>
        </ul>
        <p> The causes of these conditions are multifactorial. However, researchers have been able to link infant feeding method to their development, finding that cases were much more common in those who had been artificially fed. </p>
      </div>
    </div>
    <div class="section" id="Allergic_Responses"><h3>Allergic Responses</h3>
      <div>
        <p> Cow's milk is the most common single allergen affecting infants. The proteins in cow's milk are the allergen, NOT lactose. Standard infant formulas are made from cow's milk. </p>
        <p> Compared to breastfed infants, artificially-fed infants have a significantly higher incidence of all forms of atopy.<sup><a href="#note31">31</a></sup>Feeding soy-based artificial baby milk, compared to standard cow's milk-based artifical baby milk does not reduce the risk.<sup><a href="#note32">32</a></sup> </p>
        <p> Asthma, eczema, urticaria, rhinitis, failure-to-thrive, colic, chronic respiratory disease, gastro-oesophageal reflux and gastro-intestinal disease are all examples of conditions caused by an allergy or intolerance to cow's milk protein. </p>
      </div>
    </div>
  </div>
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                  <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 1.5</h3>
                  <p>Complete Activity 1.5 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="" />
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          <div class="section" id="Developmental_Deficits"><h2>Developmental Deficits</h2>
    <div class="section" id="Intelligence"><h3>Intelligence</h3>
      <div>
        <p> The brain of the newborn infant continues to develop rapidly after full term birth, doubling in size by one year of age. The brain growth in the preterm infant is even more rapid and therefore has an even greater potential to be harmed by inappropriate nutrition. </p>
        <p> Since Lucas in 1992<sup><a href="#note33">33</a></sup> was able to demonstrate an intellectual deficit caused by artificial infant formula feeding, there have been numerous research papers confirming those findings. </p>
        <p> Assessment of children at 6.5 years of age reveals: </p>
        <ul>
          <li>
            <p class="listTitle">exclusive artificial feeding, or early introduction of artificial infant formula, contributes significantly to</p>
            <ul>
              <li>reduced total IQ</li>
              <li>reduced verbal IQ</li>
              <li>reduced performance IQ<sup><a href="#note34">34</a></sup></li>
            </ul>
          </li>
        </ul>
        <p> 90% of children artificially fed will have an average 7-point IQ deficit that is directly attributable to being artificially fed.<sup><a href="#note35">35</a></sup> </p>
      </div>
    </div>
  </div>
          <div class="section" id="Sudden_Infant_Death_Syndrome_SIDS_"><h2>Sudden Infant Death Syndrome (SIDS)</h2>
    <div>
      <p>Artificial feeding at one month of age was associated with double the risk for SIDS.<sup><a href="#note36">36</a></sup> The majority of babies older than one month who die of SIDS were infant formula fed. <sup><a href="#note37">37</a>,</sup><sup><a href="#note38">38</a>,</sup><sup><a href="#note39">39</a></sup></p>
      <p>A meta analysis of 23 SIDS studies revealed 19 studies which favourably supported breastfeeding in protection against SIDS. The combined analysis indicated that artificially-fed infants were twice as likely to die from SIDS.<sup><a href="#note37">37</a></sup></p>
    </div>
  </div>
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                  <img src="design/callout_04.png" width="10" height="80" alt="" />
                </td>
                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Think about it:</h3>
    <div>
      <p>Most new parents do not know of the research that clearly demonstrates these poor health and developmental outcomes from artificial feeding. As a health professional do you feel it is fair to withhold this information from parents who generally just want to do the best thing for their children?
		</p>
      <p>Who do you think is being protected when this information is not shared with parents? Who stands to lose by withholding this information? Who stands to gain by withholding this information?</p>
    </div>
  </td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
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                </td>
                <td class="body"><a href="images/Center_Update_BFGuilt.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/Center_Update_BFGuilt.pdf" target="_blank">But we shouldn't make mothers feel guilty!</a></h3>
    <div>
      <p>
			Click on the icon above to read an article about making mothers feel guilty.
		</p>
    </div>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>What would you say?</h3>
    <div>Well, have you thought about what you would say now if a mother said to you, "Is breastfeeding really worth all the effort it takes?"</div>
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          <div>
    <p class="listTitle">In Module 3 you'll learn that discussing specific effects of breastfeeding and artificial infant formula feeding is required of you. However, the next module will help you to see how you can discuss this topic (and many others) giving</p>
    <ul>
      <li>accurate, factual <strong>information</strong>,</li>
      <li>that the mother will be able to <strong>understand</strong> in the context of her situation,</li>
      <li>while building the mother's <strong>confidence</strong> to make decisions that suit her situation, and </li>
      <li>that she feels <strong>supported</strong> to carry out.</li>
    </ul>
  </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 absence of breastmilk properties is the first contributing factor to disease processes</li>
          <li>the exposure to artificial substances such as artificial infant milk has a strong association with acute and chronic illness</li>
          <li>the acute conditions which are associated with infant formula feeding<br /></li>
          <li>the chronic conditions which are associated with infant formula feeding<br /></li>
          <li>there is a positive correlation between artificial infant formula feeding rates and the incidence of infant mortality and morbidity in <strong>every</strong> country in the World</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_t">
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	new MCQ('Gastroenteritis is unlikely to affect artificially-fed babies who live in a clean environment where the mother is careful to prepare the bottle feed hygienically.', [{text:'True',score:0},{text:'False',feedback:'Even when preparation conditions are hygenic, artifical infant milk feeding increases risk of gastrointestinal illnesses',score:1}]),
	new MCQ('Compared to breastfed infants what was the incidence of septicemia and/or meningitis in artificially-fed infants in a neonatal intensive care unit at all age points during the first month of life?', [{text:'double, or more than double',score:1},{text:'about 50% more',feedback:'It\'s a greater incidence than this',score:0},{text:'about half',feedback:'No, they get this serious illness much more frequently.',score:0},{text:'about the same',feedback:'No, they get this serious illness much more frequently.',score:0}]),
	new MCQ('All of the following have been identified as increasing the risk of obesity in children, EXCEPT...', [{text:'early introduction of solids, ie before 6 months of age.',feedback:'That is a factor noted in obese children.',score:0},{text:'partial breastfeeding before 6 months of age',feedback:'That is a factor noted in obese children.',score:0},{text:'maternal high fat diet while lactating',feedback:'Correct! The mother\'s diet will not affect her child adversely in this manner.',score:1},{text:'early weaning to artificial infant formula',feedback:'That is a factor noted in obese children.',score:0}]),
	new MCQ('Which of the following cancers affecting children were found to be more prevalent in children who were artificially fed? Choose all correct answers.', [{text:'Hodgkins lymphoma',score:1},{text:'neuroblastoma',score:1},{text:'acute lymphoblastic leukemia',score:1},{text:'osteosarcoma',feedback:'Not this one. It appears to be the soft-tissue cancers that are more affected by an unsuitable first diet.',score:0}])
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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>
  </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 1 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 1.
	</p>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#dewe95" title="See full details">#</a> Dewey KG et al. (1995) Differences in morbidity between breast-fed and formula-fed infants.</li>
              <li id="note2"><a href="references.html#kram01" title="See full details">#</a> Kramer MS et al. (2001) Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus.</li>
              <li id="note3"><a href="references.html#ips07" title="See full details">#</a> Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries.</li>
              <li id="note4"><a href="references.html#saar82" title="See full details">#</a> Saarinen UM (1982) Prolonged breast feeding as prophylaxis for recurrent otitis media.</li>
              <li id="note5"><a href="references.html#vict87" title="See full details">#</a> Victora CG et al. (1987) Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil.</li>
              <li id="note6"><a href="references.html#wrig89" title="See full details">#</a> Wright AL et al. (1989) Breast feeding and lower respiratory tract illness in the first year of life</li>
              <li id="note7"><a href="references.html#oddy03" title="See full details">#</a> Oddy WH et al. (2003) Breast feeding and respiratory morbidity in infancy: a birth cohort study</li>
              <li id="note8"><a href="references.html#bach03" title="See full details">#</a> Bachrach VR et al. (2003) Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis.</li>
              <li id="note9"><a href="references.html#hein01" title="See full details">#</a> Heinz (2001-02) Heinz Sight: Infant Nutrition Newsletter</li>
              <li id="note10"><a href="references.html#mari04" title="See full details">#</a> Marild S et al. (2004) Protective effect of breastfeeding against urinary tract infection</li>
              <li id="note11"><a href="references.html#yeos06" title="See full details">#</a> Yeo SL (2006) NICU update: state of the science of NEC.</li>
              <li id="note12"><a href="references.html#elmo97" title="See full details">#</a> el-Mohandes AE et al. (1997) Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis</li>
              <li id="note13"><a href="references.html#kost93" title="See full details">#</a> Kostraba JN et al. (1993) Early exposure to cow's milk and solid foods in infancy, genetic predisposition, and risk of IDDM.</li>
              <li id="note14"><a href="references.html#gers94" title="See full details">#</a> Gerstein HC (1994) Cow's milk exposure and type 1 diabetes mellitus. A critical overview of the clinical literature.</li>
              <li id="note15"><a href="references.html#pere96" title="See full details">#</a> Perez-Bravo E et al. (1996) Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children</li>
              <li id="note16"><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="note17"><a href="references.html#humm07" title="See full details">#</a> Hummel S et al. (2007) Breastfeeding habits in families with Type 1 diabetes</li>
              <li id="note18"><a href="references.html#humm08" title="See full details">#</a> Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]</li>
              <li id="note19"><a href="references.html#luca80" title="See full details">#</a> Lucas A et al. (1980) Breast vs Bottle: endocrine responses are different with formula feeding</li>
              <li id="note20"><a href="references.html#salm88" title="See full details">#</a> Salmenperä L et al. (1988) Effects of feeding regimen on blood glucose levels and plasma concentrations of pancreatic hormones and gut regulatory peptides at 9 months of age: comparison between infants fed with milk formula and infants exclusively breast-fed from birth.</li>
              <li id="note21"><a href="references.html#ipsc07" title="See full details">#</a> Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries</li>
              <li id="note22"><a href="references.html#who07a" title="See full details">#</a> Horta BL et al. (2007) Evidence on the long term efects of breastfeeding:systematic review and meta-analyses</li>
              <li id="note23"><a href="references.html#davi01" title="See full details">#</a> Davis MK (2001) Breastfeeding and chronic disease in childhood and adolescence</li>
              <li id="note24"><a href="references.html#akob06" title="See full details">#</a> Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies</li>
              <li id="note25"><a href="references.html#savi04" title="See full details">#</a> Savino F et al. (2004) Breast-fed infants have higher leptin values than formula-fed infants in the first four months of life</li>
              <li id="note26"><a href="references.html#bake04" title="See full details">#</a> Baker JL et al. (2004) Maternal prepregnant body mass index, duration of breastfeeding, and timing of complementary food introduction are associated with infant weight gain.</li>
              <li id="note27"><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="note28"><a href="references.html#lick05" title="See full details">#</a> Li C et al. (2005) Additive interactions of maternal prepregnancy BMI and breast-feeding on childhood overweight</li>
              <li id="note29"><a href="references.html#shux99" title="See full details">#</a> Shu XO et al. (1999) Breast-feeding and risk of childhood acute leukemia</li>
              <li id="note30"><a href="references.html#mart05" title="See full details">#</a> Martin RM et al. (2005) Breast-feeding and childhood cancer: A systematic review with metaanalysis</li>
              <li id="note31"><a href="references.html#frie05" title="See full details">#</a> Friedman NJ et al. (2005) The role of breast-feeding in the development of allergies and asthma</li>
              <li id="note32"><a href="references.html#ramf02" title="See full details">#</a> Ram FS et al. (2002) Cow's milk protein avoidance and development of childhood wheeze in children with a family history of atopy.</li>
              <li id="note33"><a href="references.html#luca92" title="See full details">#</a> Lucas A et al. (1992) Breast milk and subsequent intelligence quotient in children born preterm</li>
              <li id="note34"><a href="references.html#gust04" title="See full details">#</a> Gustafsson PA et al. (2004) Breastfeeding, very long polyunsaturated fatty acids (PUFA) and IQ at 6 1/2 years of age.</li>
              <li id="note35"><a href="references.html#casp07" title="See full details">#</a> Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism</li>
              <li id="note36"><a href="references.html#venn09" title="See full details">#</a> Vennemann MM et al. (2009) Does breastfeeding reduce the risk of sudden infant death syndrome?</li>
              <li id="note37"><a href="references.html#mcve00" title="See full details">#</a> McVea KL et al. (2000) The role of breastfeeding in sudden infant death syndrome</li>
              <li id="note38"><a href="references.html#almb02" title="See full details">#</a> Alm B et al. (2002) Breastfeeding and the sudden infant death syndrome in Scandinavia, 1992-95</li>
              <li id="note39"><a href="references.html#horn04" title="See full details">#</a> Horne RS et al. (2004) Comparison of evoked arousability in breast and formula fed infants.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-0" class="content">
          <h1 id="top">2.0 Communication Skills</h1>
          <div>
    <p>Information cannot be effectively received, transferred or exchanged without using good communication skills.<br /> </p>
    <p>The skills you will be learning in this module are skills that can be used in your everyday communication with friends, family, colleagues and the families you work with. Good communication skills will enhance your relationships with other people as you determine accurately what they are saying, and they know they are being listened to. <br /></p>
    <p>When working with women good communication means that you respect the women's own thoughts, beliefs, and culture. Telling or advising her what you think she should do or pushing a woman towards a particular action is disrespectful. </p>
    <p> Some health care workers may find this difficult as they have been trained to look for problems and fix them. However, once at home with her baby, the mother will benefit most from the information you shared and the confidence she gained from making her own decisions.<br /></p>
    <p class="listTitle">You can use communication skills to:</p>
    <ul>
      <li>Listen and learn about the woman's beliefs, level of knowledge and her practices</li>
      <li>Build her confidence and praise practices that you want to encourage</li>
      <li>Offer information</li>
      <li>Suggest changes the woman could consider if changes are needed</li>
    </ul>
  </div>
          <div>
    <p class="listTitle">Good communication skills results in the person with whom you are having a conversation:</p>
    <ul>
      <li>developing trust in you</li>
      <li>confiding in you</li>
      <li>reflecting on their personal predicament</li>
      <li>problem-solving for themselves</li>
      <li>accepting the outcome of their actions</li>
      <li>being empowered in other spheres of their life</li>
    </ul>
    <p class="listTitle">Lack of communication skills results in the person with whom you are having a conversation:</p>
    <ul>
      <li>distrusting you</li>
      <li>treating you as an authority figure (may not disclose crucial information)</li>
      <li>dwelling on the problem</li>
      <li>allowing you to provide a 'solution' to their situation</li>
      <li>being resentful of the outcome of your instructions</li>
      <li>may cause further feelings of 'uselessness' or 'dependence', being unable to deal with future problems</li>
    </ul>
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                  <img src="design/books.png" class="icon" alt="" />
                  <h3>Workbook Activity 2.1</h3>
                  <p>Complete Activity 2.1 in your workbook.</p>
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                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Practise makes perfect!</h3>
    <div>
      <p>
			Communication skills are not something to be turned on and turned off at particular times. Develop your skills talking with your family and friends - practise them <strong>all</strong> the time.
		</p>
    </div>
  </td>
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          <div class="section" id="Personal_Qualities"><h2>Personal Qualities</h2>
    <div>
      <p>
			You will need to develop a trusting relationship with the women, men and families you are assisting at this important stage of their life. Carl Rogers, a world-renowned psychotherapist, described three qualities essential to constructive communication: genuineness, non-possessive love and empathy. Communication skills, without the presence of these three factors, are associated with harmful therapist-client interactions.
		</p>
    </div>
    <div class="section" id="Genuineness"><h3>Genuineness</h3>
      <div>
        <p> The first of these is genuineness. Sometimes called congruence, it means being honest and open - what you really are without front or façade. The genuine person knows it is impossible to be completely self-revealing, but is committed to a responsible honesty and openness with others. </p>
      </div>
    </div>
    <div class="section" id="Non-possessive_love"><h3>Non-possessive love</h3>
      <div>
        <p>
				Also referred to in some texts as 'unconditional positive regard', but probably meaning more than this phrase allows. 'Non-possessive love' refers to your ability to accept, respect and support another person in a non-paternalistic way. This includes all of the client's frailties and weaknesses, as well as their strengths and positive qualities.
			</p>
        <p>
				The 'love' you exhibit has the characteristics of patience, fairness, consistency, rationality and kindliness. It encourages freedom.
			</p>
      </div>
    </div>
    <div class="section" id="Empathy"><h3>Empathy</h3>
      <div>
        <p>
		  		Empathy refers to the ability to really see and hear another person and understand that person from their perspective. 'Putting yourself in their shoes.' Psychologists describe the Apathy-Empathy-Sympathy continuum.
		  	</p>
        <table>
          <thead>
            <tr>
              <th>Apathy</th>
              <th>Empathy</th>
              <th>Sympathy</th>
            </tr>
          </thead>
          <tbody>
            <tr class="row0">
              <td>"Yes, well mothers are constantly tired."</td>
              <td>"Broken nights can be very tiring."</td>
              <td>"I don't know how you cope with being woken so often."</td>
            </tr>
            <tr class="row1">
              <td>"There's nothing wrong with breastmilk."</td>
              <td>"You're worried your breastmilk may be too thin."</td>
              <td>"It's so scary when all your baby has is your milk."</td>
            </tr>
          </tbody>
        </table>
        <p>
	  			Apathy is a lack of feeling, while sympathy is 'feeling for' another person. Empathy is 'feeling with' the other person. Empathy involves experiencing the feelings of another without losing one's own identity. If you lose the ability to separate your own feelings from the feelings of another person, you are no longer empathetic.
	  		</p>
      </div>
    </div>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Implementing Baby Friendly</h3>
    <div>For some, the implementation of Baby Friendly Initiative best-practice principles will involve change. The success of any change management strategy is dependent on effectively communicating the benefits of successful implementation as well as the details of the change. The communication skills you use will be the same whether it is explaining the benefits and details of the implementation to the administrators of your organisation, to your colleagues, to mothers or to community-based peer counsellors.</div>
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          <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 outcome when you use good communication skills; and the corollary when you don't</li>
          <li>that communication skills are improved by practise</li>
          <li>the difference between apathy, empathy and sympathy<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_u">
<script type="text/javascript">
/* <![CDATA[ */
var uqs = {settings : {type : 'matching', shuffle : 'both'}, questions : [
	new Matching('One of your goals in using good communication skills will be to', 'learn about the woman\'s beliefs, level of knowledge and her practices'),
	new Matching('When you use good communication skills the mother is more likely to', 'reflect on her personal predicament.'),
	new Matching('When communication skills are poor the mother is more likely to', 'allow you to provide a solution for her.'),
	new Matching('When displaying the quality of genuineness you will', 'be open and honest.'),
	new Matching('When you are able to accept, respect and support another person in a non-paternalistic way you will', 'be demonstrating non-possessive love.'),
	new Matching('Being empathic is to', 'experience the feelings of another without losing one\'s own identity.')
]};

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<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('u');</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 id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-1" class="content">
          <h1 id="top">2.1 Non-verbal</h1>
          <div>
    <p> You will have heard the phrase &ldquo;<q>It's not what you say, it's the way you say it!</q>&rdquo;. <br />Verbal communication allows you to express yourself, while nonverbal communication enhances and reinforces the effect of your spoken word.<span style="font-weight: bold;"><br />Nonverbal communication is a reliable indicator of the real feelings. </span><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"><h3>Consider how the mother will interpret these messages.</h3>
    <div>
      <p>The mother is sitting in a chair breastfeeding her baby. In each situation the health care worker says, &ldquo;<q>Good morning. How is breastfeeding going?</q>&rdquo;</p>
      <ul>
        <li>Health care worker stands over the mother.</li>
        <li>Health care worker sits behind desk, writing in notes at the same time.</li>
        <li>Health care worker checks her watch as she asks the question.</li>
        <li>Health care worker is holding a stack of files in her hands.</li>
        <li>Health care worker moves mother's clothing aside and touches her breast and jiggles baby's chin.</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 class="section" id="What_do_you_want_to_communicate_"><h2>What do you want to communicate?</h2>
    <div>Hearing and effective listening are not the same thing. <br />To be a good communicator you must first pay attention to the speaker. Your posture, eye contact, gestures, facial expressions and short responses are all nonverbal cues that help the speaker to understand whether the listener is following their conversation.<br /></div>
    <div class="section" id="Posture"><h3>Posture</h3>
      <div>
        <ul>
          <li>Relaxed alertness.</li>
          <li>Body leaning slightly forward.</li>
          <li>Face the other squarely and be at eye level.</li>
          <li>Maintain an open posture (no crossed arms or legs).</li>
          <li>Position yourself at an appropriate distance. This is influenced by cultural and individual differences. Both too near and too far positioning causes anxiety. Generally, in Western cultures, about one metre (3 feet) is about right.</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Appropriate_body_motion"><h3>Appropriate body motion</h3>
      <div>
        <p>Movements should be in response to what the speaker is saying. Lack of movement signifies the listener is controlled, cold, aloof and reserved. Sometimes the listener may be so in tune with the speaker that their gestures synchronise.</p>
      </div>
    </div>
    <div class="section" id="Eye_contact"><h3>Eye contact</h3>
      <div>
        <p>Eye contact allows the speaker to appraise your receptiveness and affords you to 'see' if there are deeper meanings than those being expressed. Eye contact involves softly focusing on the speaker's eyes, occasionally shifting the gaze from her face to other parts of her body, a gesturing hand for example, and then back to the face and eye contact once again.</p>
        <p>Repeatedly looking away from the speaker, staring at her constantly or blankly, or looking away as soon as she looks at you are examples of poor eye contact.</p>
        <p>Consider cultural differences. For example Australian aboriginal people prefer to avoid direct eye contact.</p>
      </div>
    </div>
    <div class="section" id="Minimal_encouragers"><h3>Minimal encouragers</h3>
      <div>
        <p>Minimal encouragers are simple responses that indicate you are 'with them'. They aid the speaker to continue speaking, but don't direct the flow of the conversation. They are usually sprinkled throughout a conversation.</p>
        <p>Examples are: mm-hmm, yes, right, I see, then?, go on, yeah, etc... They shouldn't imply agreement or disapproval.</p>
      </div>
    </div>
    <div class="section" id="Non-distracting_environment"><h3>Non-distracting environment</h3>
      <div>
        <ul>
          <li>pleasant, uncluttered room</li>
          <li>turn off television or intrusive music</li>
          <li>do not allow phone calls to interrupt the conversation<br /></li>
          <li>in hospital setting, curtain off the mother's bed; put <span style="font-style: italic;">Do Not Disturb</span> sign on door</li>
          <li>in an office: place chairs away from desk, avoid having a desk between you</li>
          <li>be aware of the mother's need for privacy, seeking a private area or asking others to leave if necessary</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Time"><h3>Time</h3>
      <div>
        <p>The way a person perceives time, structures their time and reacts to time is a powerful communication tool. How you and your conversational partner react to punctuality and a willingness to wait will have an impact on your communication. How long are you or they prepared to listen?<br />Also consider the timing of your conversation as it relates to other activities for both parties.</p>
        <p></p>
      </div>
    </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/tip.png" class="icon" alt="" /><h3>Non-verbal communication is two-way</h3>
    <div>While you are ensuring that your nonverbal communication is congruent with your message and demonstrating effective listening, don't neglect to read the communication signs being given by your conversational partner. <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 class="captionBox">
            <img width="440" height="302" src="images/counsel_position.jpg" alt="Note all of the aspects of non-verbal communication being exhibited in this photograph. Did you notice the body motion? Note the eye contact between the two." />
            <p>Note all of the aspects of non-verbal communication being exhibited in this photograph. Did you notice the body motion? Note the eye contact between the two.</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/books.png" class="icon" alt="" />
                  <h3>Workbook Activity 2.2</h3>
                  <p>Complete Activity 2.2 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="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>all facets of nonverbal communication<br /></li>
          <li>consider the immediate environment</li>
          <li>consider the implications of time and timing<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_v">
<script type="text/javascript">
/* <![CDATA[ */
var vqs = {settings : {type : 'mcq'}, questions : [
	new MCQ('Which of the following actions a mother might take during a conversation with you would alert you to the possibility that she is not effectively listening to you?', [{text:'She is sitting comfortably in her chair with her knees crossed and arms folded across her chest.',feedback:'Correct. The closed position of both legs and arms folded is indicative that you are not getting through to her.',score:1},{text:'Her gaze is not fixed on you all the time. She occasionally glances away or towards your gesturing hand.',feedback:'No. This is an appropriate way a person will shift their focus while still being actively engaged.',score:0},{text:'She appears to be mimicking your actions, moving her arms similarly to the way you move yours during the conversation.',feedback:'This is a sign she is closely relating to what you are saying.',score:0},{text:'She leans forward in her chair.',feedback:'No. This action usually indicates increasing interest.',score:0}]),
	new MCQ('What effect will you keeping a mother waiting for half an hour longer after your appointment time have on the quality of your counseling session?', [{text:'The mother will be annoyed at the delay and keep the conversation to a minimum so she can leave as soon as possible.',feedback:'That\'s possible. It could have a serious negative impact on the counseling session with her. But it might not!',score:0},{text:'The communication you have with her will be enhanced as she\'ll have time to sit and relax, read some of the literature you\'ve provided and talk to other mothers who are also waiting.',feedback:'This is a possibility - but then again ....',score:0},{text:'It will have little effect because she understands the type of services you offer can\'t be rushed.',feedback:'She may feel like that. But then again, she may feel her time is limited and precious.',score:0},{text:'It\'s impossible to know as everyone perceives the use of their time differently.',feedback:'Yes, that\'s right. Oh the whole though punctuality is usually greatly appreciated, while being delayed causes annoyance.',score:1}]),
	new MCQ('Which of the following is a reliable way to know how a mother is feeling?', [{text:'Watch her nonverbal communication - the look in her eyes, the emotion being displayed on her face, her hand and body movements.',feedback:'Yes that\'s right. It was easy to pick the right answer, but it is good to be reminded to always take note of the nonverbal communication that is happening between both you and the person with whom you are speaking.',score:1},{text:'Listen carefully to what she is saying; listening for words that describe emotions.',feedback:'No. Though if the mother\'s words are congruent with her body language you can feel more assured that you understand her feelings.',score:0},{text:'Ask her outright.',feedback:'You may get a forthright response, but you may also get just what she thinks you want to hear.',score:0}])
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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>
  </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-2" class="content">
          <h1 id="top">2.2 Listening skills</h1>
          <div>
    <p class="listTitle">Listening skills involve</p>
    <ul>
      <li>Reflecting back what you have understood the mother said.</li>
      <li>Appropriate questioning.</li>
    </ul>
  </div>
          <div class="section" id="Reflective_listening"><h2>Reflective listening</h2>
    <div>
      <p>Reflective listening communicates to the mother your interpretation of what she has said and how she feels, and does so in a way that demonstrates understanding and acceptance.</p>
    </div>
    <div class="section" id="Paraphrasing"><h3>Paraphrasing</h3>
      <div>
        <p> Paraphrasing typically explains or clarifies what was said. A good paraphrase is succinct, cutting directly to the message and is restated the way you understood the message. Paraphrasing is not parroting (or copying). Parroting stifles conversation, paraphrasing contributes to the communication between people. </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"><h3>An example:</h3>
        <div>
          <p>Mother: &ldquo;<q>I love my baby and I love breastfeeding her. My mother says it's the best thing for babies. But I'm so tired every day from getting up for the night feeds. I just wish my husband could give her a bottle sometimes.</q>&rdquo;</p>
          <p>Health care worker: &ldquo;<q>So breastfeeding is good, but fatigue is causing you to think of weaning.</q>&rdquo;</p>
          <p>At this point the mother will either agree or she'll disagree and clarify her intent.</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>
        <p>
				Applying paraphrasing more often in our everyday conversations would improve the fluency and accuracy of what was said and what was understood to have been said.
			</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"><h3>Paraphrasing exercise</h3>
        <div></div><div class="activity" id="activity_w">
<script type="text/javascript">
/* <![CDATA[ */
var wqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>How would you paraphrase this conversation?</p><blockquote>John wants us to have another baby as soon as possible. You know\n				the problems I have getting pregnant and my doctor told us I might\n				not regain my fertility until I stop breastfeeding. Sharney is\n				only 10 months old and still a baby. Even if I do wean her I\n				probably won\'t get pregnant anyway.</blockquote>', r : '<blockquote>You don\'t want to wean Sharney so soon, particularly if it\'s not\n				going to make much difference to whether you can get pregnant again.</blockquote><p>\n				Is your response concise? Does your response capture the essence\n				of the conversation? Have you used your own words?\n			</p>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('w');</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="Reflecting_feelings"><h3>Reflecting feelings</h3>
      <div>
        <p>You don't have to state the mother's feelings if it isn't appropriate. However, you must be aware of what they are.</p>
        <p class="listTitle">How do you correctly interpret her feelings? Try these tips.</p>
        <ul>
          <li>Sometimes they may be spoken and leave you in no doubt: &ldquo;<q>I felt so angry when he said that to me.</q>&rdquo;</li>
          <li>You may need to infer it from the content: &ldquo;<q>I spent two hours yesterday when I was really busy helping her to breastfeed. Now she's artificially feeding, and says she was going to when she got home anyway.</q>&rdquo;</li>
          <li>Observe her body language. Much of your understanding of body language is 'innate'; something you pick up during a lifetime of interpersonal relationships. However, there is still so much you could learn. This is beyond the scope of this course but you will find it very rewarding if you pursue this interesting topic.</li>
          <li>How would you be feeling in that situation? Each person's emotional experience is unique, but by applying the previous points and thinking about how you would feel you can have a fairly good guess. If you reflect that feeling, eg. &ldquo;<q>That's so frustrating</q>&rdquo;, she will either agree readily or tell you how she actually feels.</li>
        </ul>
      </div>
    </div>
  </div>
          <div class="section" id="Appropriate_questioning"><h2>Appropriate questioning</h2>
    <div>
      <p>Consider the following conversation:</p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>Good morning. Are you feeling well today?</td></tr><tr class="speaker1"><th>Mother:</th><td>Yes. I'm well.</td></tr><tr class="speaker0"><th>Health worker:</th><td>Is baby breasfeeding OK?</td></tr><tr class="speaker1"><th>Mother:</th><td>Yes.</td></tr><tr class="speaker0"><th>Health worker:</th><td>Are you having any problems?</td></tr><tr class="speaker1"><th>Mother:</th><td>No.</td></tr></tbody></table>
      <p>Now consider how it could have been more productive.</p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>Good morning. How are you feeling?</td></tr><tr class="speaker1"><th>Mother:</th><td>I'm feeling well. Thank you.</td></tr><tr class="speaker0"><th>Health worker:</th><td>Tell me about how breastfeeding your baby is going.</td></tr><tr class="speaker1"><th>Mother:</th><td>I breastfeed often during the day, and give him a bottle at night.</td></tr><tr class="speaker0"><th>Health worker:</th><td>What made you decide to give a bottle at night?</td></tr><tr class="speaker1"><th>Mother:</th><td>He wakes up at night, so I don't think my milk is strong enough to satisfy him.</td></tr></tbody></table>
      <p>Do you see how questions that require only a one-word answer (closed questions) limit the amount of information you receive, while open questions encourage more conversation?</p>
      <p> We often rely on questions excessively and use them poorly. Questions usually focus on our own intent, perspective, and concerns rather than on the mother's orientation. When that happens, questions are a barrier to communication. </p>
    </div>
    <div class="section" id="About_questioning"><h3>About questioning</h3>
      <div>
        <dl>
          <dt>Closed questions</dt>
          <dd> A closed question can be answered with either a single word or a short reply, eg yes/no. Closed questions direct the conversation, keeping control of the conversation with the questioner, and should therefore rarely be used. <br />This type of question is used to obtain information on a specific point. &ldquo;<q>Do you want to keep using the nipple shield?</q>&rdquo;; &ldquo;<q>How old are your other children?</q>&rdquo; Because these questions are so directed, the mother may reply with what she thinks you want to hear for fear of getting the question wrong. <br />Closed questions are useful for starting a conversation while retaining control, &ldquo;<q>It's great weather, isn't it?</q>&rdquo; and for facts, &ldquo;<q>What was your baby's birth weight?</q>&rdquo;</dd>
          <dt>
            <br />
          </dt>
          <dt>Open questions</dt>
          <dd> Open questions deliberately seek longer answers, asking the mother to think and reflect, before responding with opinions and feelings. The control of the conversation moves to the respondent. <br />The question should be designed to help her to clarify her own problem, rather than provide information for the interviewer. &ldquo;<q>How do you feel your baby is latching when you use the nipple shield?</q>&rdquo; &ldquo;<q>Can you describe what your other children do while baby is feeding?</q>&rdquo; </dd>
        </dl>
        <p><strong>Ask only one question at a time</strong> - and not too many even then.</p>
      </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>Converting closed to open questions</h3>
      <div></div><div class="activity" id="activity_x">
<script type="text/javascript">
/* <![CDATA[ */
var xqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>Rewrite the following closed questions as open questions that will stimulate conversation.</p><ol><li>Are you breastfeeding your baby?</li><li>How many feeds a day are you giving baby?</li><li>Is he sleeping through the night yet?</li><li>Did your baby gain weight this week?</li></ol>', r : '<p> The following are suggested answers. Test your questions by seeing if they can be answered in only one or two words. </p><ol><li>Tell me about how you\'re feeding your baby.</li><li>What\'s your baby\'s feeding pattern like?</li><li>Can you describe to me baby\'s feeding and sleeping habits at night?</li><li>How do you feel baby is growing?</li></ol>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('x');</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="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 two aspects of listening skills</li>
          <li>the goal of paraphrasing, and how to paraphrase<br /></li>
          <li>the best use of closed and open questions<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 id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-3" class="content">
          <h1 id="top">2.3 Building confidence</h1>
          <div>
    <p>In topic 3 you will learn of the importance of nurturing maternal self-efficacy and self-confidence for a mother to breastfeed her infant confidently. Your communication skills can help the mother to feel good about herself and confident in her role as a mother. Confidence can help a mother to carry out her decisions and to resist pressures from other people.</p>
    <p>To build confidence the mother must trust that you <span style="font-weight: bold;">accept her</span> and her decisions <span style="font-weight: bold;">without judgment</span>; that you notice and praise what she is <span style="font-weight: bold;">doing right</span> and you offer <span style="font-weight: bold;">additional information</span> in an <span style="font-weight: bold;">easily understood</span> manner that will allow her to make her own informed decisions.<br /></p>
  </div>
          <div class="section" id="Acceptance"><h2>Acceptance</h2>
    <div>
      <p>Acceptance of a person's actions or beliefs is the starting point of any relationship.<br /></p>
      <p>Accepting what a mother says helps her to trust you and encourages her to continue the conversation. Accepting what a mother says is not the same as agreeing that she is right. You can accept what she is saying and give correct information later. </p>
      <p class="listTitle">Which one of these statements demonstrates acceptance?</p>
      <dl>
        <dt>Mother: &ldquo;<q>I give my baby a bottle each night because he was waking up.</q>&rdquo;</dt>
        <dd>Health worker: &ldquo;<q>It's normal for babies to wake at night. That's not a reason to give a bottle.</q>&rdquo;</dd>
        <dd>Health worker: &ldquo;<q>A bottle just at night will stop him waking so often.</q>&rdquo;</dd>
        <dd>Health worker: &ldquo;<q>Getting up to settle a baby at night is very tiring.</q>&rdquo;</dd>
      </dl>
      <p>The first response disagreed with the mother. The second response agreed with the mother even though the information was incorrect. The third response demonstrates acceptance of her statement without either agreeing or disagreeing.</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"><h3>Acceptance statements quiz</h3>
      <div><br />Choose the response that demonstrates acceptance of the mother's statement. <br /><br /></div>
      <div></div><div class="activity" id="activity_y">
<script type="text/javascript">
/* <![CDATA[ */
var yqs = {settings : {type : 'mcq'}, questions : [
	new MCQ('Mother says, \"I give drinks of water if the day is hot.\"', [{text:'That isn\'t necessary! Breastmilk has enough water.',feedback:'This statement disagrees with the mother.',score:0},{text:'Drinking more water in hot weather is important for everyone.',feedback:'This statement agrees with the mistaken information the mother has made.',score:0},{text:'In hot weather we all want to drink more.',feedback:'Accepting. Correct information can be given later.',score:1}]),
	new MCQ('Mother says, \"My baby has diarrhoea, so I am not breastfeeding until it is gone.\"', [{text:'Yes, while he\'s sick he won\'t want to drink warm milk.',feedback:'Agreeing to incorrect statement.',score:0},{text:'You\'re worrying that your breastmilk will make the diarrhea worse.',feedback:'Accepting.',score:1},{text:'Breastmilk is the best food for your baby now.',feedback:'Disagreeing.',score:0}]),
	new MCQ('Mother says, \"The first milk is not good. I\'ll breastfeed when it is gone.\"', [{text:'You\'re concerned the first milk will harm your baby.',feedback:'Accepting.',score:1},{text:'The first milk is very important for your baby.',feedback:'Disagreeing with mother.',score:0},{text:'There\'s only a small amount of the first milk anyway, so he won\'t be missing out on much.',feedback:'Agreeing with an incorrect statement.',score:0}])
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('y');</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="Avoiding_judgmental_words"><h2>Avoiding judgmental words</h2>
    <div>
      <p>Words that may sound like you are judging include: right, wrong, well, bad, good, enough, properly, adequate, problem, still. <br />Words like this can make a woman feel that she has a standard to reach or that her baby is not behaving normally. Examples: "Is your baby latching properly?", "Does he have enough wet and dirty nappies/diapers?". <br /></p>
      <p>The mother may hide how things are going if she feels she is being judged. In addition, the mother and the health worker may have different ideas about what "properly" or "enough" means. It is more helpful to ask open questions such as "How do you feel he is going with latching now?", "Could you describe his wet and dirty nappies/diapers to me?"</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"><h3>Practice avoiding judging words</h3>
      <div></div><div class="activity" id="activity_z">
<script type="text/javascript">
/* <![CDATA[ */
var zqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>Rewrite each of the sentences below, avoiding words that appear to judge the mother.</p><ol><li>Is your baby feeding well?</li><li>You\'ve just had baby weighed. Has he put on plenty of weight this month?<br/></li><li>Is he still being a naughty baby and waking at night?</li></ol>', r : '<p>The following are suggestions. Look carefully at what you have written. Did you use any words that would make a mother feel you had an expectation of what she should be doing or saying?<br/></p><ol><li>How is breastfeeding going for you and baby?</li><li>You\'ve just had baby weighed. Are you happy with his progress?<br/></li><li>How are things at night with sleeping and breastfeeding?</li></ol>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('z');</script>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
          <div class="section" id="Acknowledge_what_is_right"><h2>Acknowledge what is right</h2>
    <div>
      <p>Notice and praise what the mother and baby are achieving. An example might be to comment that it is good to see she responds to early feeding cues, or that her baby opens his mouth really well just before latching.</p>
    </div>
  </div>
          <div class="section" id="Use_language_that_is_easily_understood"><h2>Use language that is easily understood</h2>
    <div>
      <p>Regardless of the mother's educational level, using simple language and avoiding medical terms or jargon provides greater clarity and better understanding.</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"><h3>Using simple language</h3>
      <div></div><div class="activity" id="activity_a">
<script type="text/javascript">
/* <![CDATA[ */
var aqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>Rewrite the following statements using language that would be more easily understood.</p><ol><li>The milk will flow when baby has stimulated hormones in your breast that will cause the milk ejection reflex.<br/></li><li>Exclusive breastfeeding for 6 months provides all the nutrients your baby needs.</li><li>The immunoglobulins in breastmilk provide your baby with protection from viral and bacterial infections.</li></ol>', r : '<p>The following are examples of how you could have rephrased the statements.</p><ol><li>You can tell the milk is flowing when the baby\'s suck slows and you can hear him swallowing.</li><li>Breastmilk provides everything your baby needs to grow strong and healthy for the first 6 months.</li><li>Your milk has disease-fighting components in it to keep your baby healthy.<br/></li></ol>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('a');</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="Provide_relevant_information"><h2>Provide relevant information</h2>
    <div>
      <p>Additional ideas and options can be added to the ones the mother has already tried or knows about. Limit your suggestions to only a few that would be relevant to her. Don't overwhelm her with information. Use phrases such as: &ldquo;<q>How would you feel about...?</q>&rdquo; or &ldquo;<q>Some recent research shows that... Could this apply in your situation?</q>&rdquo;</p>
      <p>Your aim is to ensure the mother has enough information to make an informed decision. The mother solves her own problem.<br /></p>
      <p>If you've applied the communication skills discussed so far you may find that the mother has already found her own solution. Sometimes just a good listener who can accurately reflect her feelings and provides a well-organized summary is sufficient for her to see her situation in a new light.</p>
    </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 2.3</h3>
                  <p>Complete Activity 2.3 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="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>WHAT you say and HOW you say it affects a mother's self-confidence<br /></li>
          <li>how to phrase sentences to reflect acceptance without judgment</li>
          <li>praise is important</li>
          <li>how to provide additional information in a manner that is easily understood and leads to informed decision-making<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>
  </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_2-4" class="content">
          <h1 id="top">2.4 An example</h1>
          <div class="section" id="An_example_of_good_communication_skills"><h2>An example of good communication skills</h2>
    <div>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Mother:</th><td>My child won't eat even though she is eight months old. She is only breastfeeding.</td></tr><tr class="speaker1"><th>Health Worker:</th><td>It is wonderful that you are breastfeeding - that's still her best food. <em>(approval)</em> But you are right to offer her other food too. <em>(agreement)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>I give her porridge in her bottle but she spits it out and cries.</td></tr><tr class="speaker1"><th>Health Worker:</th><td>I see <em>(acceptance, no criticism)</em>. What have you thought of doing? <em>(exploring)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>Well, I tried not breastfeeding her so much but she cried too much.</td></tr><tr class="speaker1"><th>Health Worker:</th><td>She really likes your breastmilk - she's a clever girl! <em>(approval)</em> How does she act when the other children are eating? <em>(open question)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>She cries and reaches for their food, but she is still too little for the foods they are eating.</td></tr><tr class="speaker1"><th>Health Worker:</th><td>So she is eager to eat with the other children <em>(summarising)</em>. Have you tried preparing food for her specially? Or feeding her while the others are eating? <em>(offering ideas)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>Do you mean cooking her special meals? I am really very busy.</td></tr><tr class="speaker1"><th>Health Worker:</th><td>Of course you are! <em>(accepting)</em> Some mothers cook all the vegetables and then just take some out, remove the skins and mash them. Then they can spoon feed the baby while the others are eating whole vegetables. <em>(offering ideas)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>Well, I could try that. It doesn't sound like a lot of extra work. <em>(mother makes decision)</em></td></tr><tr class="speaker1"><th>Health Worker:</th><td>You mentioned using a bottle? <em>(exploring)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>I know I shouldn't, but sugar water keeps her quiet when I'm cooking.</td></tr><tr class="speaker1"><th rowspan="2">Health Worker:</th><td>It's difficult to get everything done <em>(accepting)</em>, but I agree that the bottle isn't the best solution. <em>(agreement, no criticism)</em></td></tr><tr class="speaker1"><td>How would you feel about giving her a piece of soft chapati or fruit to try her teeth on while you are cooking? <em>(offering ideas)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>Well, perhaps <em>(mother making decision)</em>. But won't she choke on these things? I thought babies needed to drink.</td></tr><tr class="speaker1"><th>Health Worker:</th><td>You're right, they do need drinks <em>(agreement)</em> but just your breastmilk. That gives all the sugar and water they need <em>(information)</em>. Now that she sits alone, she can start learning about your family food, too.</td></tr><tr class="speaker0"><th>Mother:</th><td>Should I go on giving her porridge?</td></tr><tr class="speaker1"><th rowspan="5">Health Worker:</th><td>Yes, that's very good food, especially with some mashed pumpkin or mashed banana added. <em>(information)</em>.</td></tr><tr class="speaker1"><td>Bottles are not the best way to feed babies <em>(correct by giving information, not criticism)</em>.</td></tr><tr class="speaker1"><td>She might enjoy porridge more from a spoon or cup <em>(offering ideas)</em>.</td></tr><tr class="speaker1"><td>They are easier to keep clean than a bottle anyway <em>(information)</em>.</td></tr><tr class="speaker1"><td>So, how do you think you can best feed your daughter now? <em>(checking)</em></td></tr><tr class="speaker0"><th>Mother:</th><td>Well, let's see. I will go on breastfeeding and giving her porridge. I could add some fruit or pumpkin, and mashed beans and vegetables that the others are eating. Did you say I can give her some chapati? <em>(shows understanding)</em></td></tr><tr class="speaker1"><th>Health Worker:</th><td>Yes, that's fine.</td></tr></tbody></table>
      <p> Good counselling makes a mother more confident and readier to learn. Notice that the healthworker responded to the mother's concerns. She came back to correct the mistakes of the bottle and the sugar water but gave information in a gentle way that did not criticise the mother. She checked that the mother understood what to continue doing and what to change. </p>
      <p>(Counselling scenario adapted from WHO Counselling Course, Helen Armstrong)</p>
    </div>
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          <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 2 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 2.
	</p>
    </div>
  </div>
          <div id="footer"><br style="clear: both" /><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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        <div id="topic_3-0" class="content">
          <h1 id="top">3.0 Pregnancy Care</h1>
          <div class="section" id="Baby_Friendly_Step_3_and_Point_3"><h2>Baby Friendly Step 3 and Point 3</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><span style="font-weight: bold;">Step 3</span> of the Ten Steps to Successful Breastfeeding, and <span style="font-weight: bold;">Point 3</span> of the Seven-point Plan for Sustaining Breastfeeding in the Community both state:<cite></cite> <br /></div>
      <blockquote>
        <div>Inform all pregnant women about the benefits and management of breastfeeding.</div>
      </blockquote>
      <div>
        <p>
          <span class="aside">Australia: Point 3 - Inform women and their families about breastfeeding being the biologically normal way to feed a baby and about the risks associated with not breastfeeding</span>
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    <div><p class="listTitle">The prenatal discussion should cover</p><ul><li>the importance of exclusive breastfeeding for the first 6 months,</li><li>the health associations of breastfeeding</li><li>the risks of artificial feeding, and<br /></li><li>basic breastfeeding management.</li></ul><p class="listTitle">Pregnant women of 32 weeks or more gestation should confirm that the health associations of breastfeeding and implications of not-breastfeeding have been discussed with them, including at least two of the following:</p><ul><li>infant nutrition,<br /></li><li>disease protection,</li><li>maternal-infant bonding,</li><li>health benefits to the mother, and</li><li>that they have received no group education on the use of infant formula.</li></ul><p class="listTitle">They should be able to describe at least two of the following breastfeeding management topics:</p><ul><li>importance of rooming-in,</li><li>importance of feeding on demand,</li><li>how to assure enough milk, and</li><li>positioning and attachment.</li></ul>(Source: The Global Criteria for the WHO/UNICEF Baby Friendly Hospital Initiative)<sup><a href="#note1">1</a></sup><br /></div>
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    <div>
      <p>Some of these topics we've already covered, the remainder will be covered in following modules. Review the <span style="font-style: italic;">Topic 1.3 Relative Risks</span> to ensure that you are confident to talk to mothers about risks of artificial feeding as well as the 'benefits' of breastfeeding.</p>
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  </div>
          <div class="section" id="Broaching_the_topic"><h2>Broaching the topic</h2>
    <div>
      <p>Consider how you would continue the discussion following the mother's reply to the following questions.</p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>How are you going to feed your baby?</td></tr><tr class="speaker1"><th>Mother:</th><td>I'm going to bottle feed.</td></tr></tbody></table>
      <p>OR</p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>Are you going to breastfeed?</td></tr><tr class="speaker1"><th>Mother:</th><td>Yes.</td></tr></tbody></table>
      <p> These are closed questions and don't allow you to broaden the discussion without it being challenging to the mother, regardless of her response. </p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>What do you know about breastfeeding?</td></tr></tbody></table>
      <p> This open question will give you the opportunity to discuss any barriers that the woman may see to breastfeeding, or to discuss problems she may have had with previous breastfeeding and to begin discussion of the topics listed above. </p>
      <p> It is also implicit in the question and following conversation that you consider breastfeeding to be relevant. The importance of the health care provider's attitude is significant when we find that a woman's attitude to breastfeeding has been shown to correspond closely to that of her health care provider.<sup><a href="#note2">2</a></sup></p>
      <p> Discussing breastfeeding with pregnant women needn't take more than a few minutes at each visit. For example, at the first visit... </p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>What changes have you noticed in your body so far?</td></tr><tr class="speaker1"><th>Mother:</th><td>I have noticed that my breasts seem to have grown. What's causing that?</td></tr><tr class="speaker0"><th>Health worker:</th><td>Your breasts are preparing themselves for breastfeeding your baby, growing extra milk-making ducts. Look, here's a diagram of what is happening inside your breasts.</td></tr></tbody></table>
      <p> At this point you could give her some more information on how her breasts will make and release her breastmilk according to how often her baby feeds. In just a few minutes you've covered how to assure enough milk and importance of feeding on demand, without it becoming a 'lecture' for the mother. </p>
      <p> A little bit of information given like this at each visit normalises breastfeeding as a part of childbearing and motherhood. At a later visit, closer to 32 weeks when you feel you've gradually covered all the information necessary and answered any questions raised, you could spend more time confirming the mother's understanding of breastfeeding. </p>
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                <td class="body"><a href="images/UKanchecklist.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/UKanchecklist.pdf" target="_blank">Audit tool</a></h3>
    <div>
      <p> Does your clinic have a method that records that all the topics listed above have been discussed with all pregnant women? If not, a sample checklist is available from Baby Friendly UK. Clicking on the icon to the left will take you to their checklist. Another sample checklist, developed by WHO/UNICEF is available by clicking <img alt="PDF" src="design/page_white_acrobat.png" /><a href="images/antenatal_checklist.pdf" target="_blank" title="PDF file (21.1KiB)">here</a>. </p>
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Don't force a premature, uninformed decision</h3>
    <div><p>Many health units ask the pregnant mother what her feeding intention is early in pregnancy prior to providing education. <br />It is not reasonable to expect anyone to make an informed decision without knowledge; but once she has given an answer, particularly if she chose artificial feeding, education about breastfeeding is frequently withheld. <br /> </p>Think about the impact of such a simple question, asked at the wrong time, could have.<br />If this is a practice at your Unit discuss the implications with your colleagues with view to providing the education first.<br /></div>
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          <div class="section" id="When_the_mother_does_not_breastfeed"><h2>When the mother does not breastfeed</h2>
    <div>There are circumstances when breastfeeding is contraindicated. Be aware that this could be a difficult emotional situation for the mother, requiring thoughtful counseling. Some of these circumstances include: <br /> <ul><li> Infant conditions: <ul><li> classic galactosemia </li><li> maple syrup urine disease </li></ul> </li><li> Mother: <ul><li> radio-active iodine-131 precludes breastfeeding for about 2 months. This should be avoided given that safer alternatives are available. </li><li> during cytotoxic chemotherapy </li><li> HIV, only if replacement feeding is acceptable, feasible, affordable, sustainable and safe. </li></ul> Other conditions may require the mother to temporarily withhold her breastmilk, or the infant to receive only limited amounts of breastmilk in conjunction with a specialized formulation. <ul><li> very low birth-weight or very preterm infants </li><li> infants with phenylketonuria; with careful monitoring </li><li> infants with hypoglycemia that does not respond to breastfeeding or breastmilk feeding; though due to the seriousness of this condition intravenous therapy is preferred management. </li></ul> </li></ul> <p> A mother may also choose not to breastfeed for reasons of her own. It is important that the mother receives the education already mentioned and is aware of the short- and long-term effects of breastmilk substitutes on her child before she makes this decision. A mother who is forewarned about the effects will be in the best position to prevent or seek early treatment of those risks. </p></div>
    <div class="section" id="Prenatal_education_"><h3>Prenatal education </h3>
      <div>
        <p> The choice of a breastmilk substitute should be made in conjunction with a pediatrician or other health professional who will have responsibility for the infant's health and growth. Factors such as a family history of allergies, weight gain issues and feeding difficulties with other siblings will guide this choice and the choice of feeding implements. The mother should bring these with her to the hospital or clinic so that she can learn how to prepare them and feed her infant while being supervised. </p>
        <p> Infants fed a breastmilk substitute that is not prepared in a safe manner are prone to hypernatremic dehydration, malnutrition, obesity and gastrointestinal infections. <sup><a href="#note3">3</a></sup> A large American study reported more than 3/4 of mothers using breastmilk substitutes did not receive instruction on formula preparation or storage from a health professional. <sup><a href="#note4">4</a></sup> Similarly in the United Kingdom a systematic review of the literature found errors in reconstitution, with a tendency to over-concentrate feeds, though under-concentration also occurred. <sup><a href="#note5">5</a></sup> </p>
        <p> Because of the frequency and seriousness of these errors, instruction on formula preparation, storage and safe feeding practices must be given individually to the parents by a health professional at the time they need it. This teaching is not effective when given prenatally. <a href="topic_7-5-4.html">Topic 7.5.4</a> details how to teach this skill. <br /> </p>
        <p> The WHO Code on the Marketing of Breastmilk Substitutes precludes group instruction of this important skill. Likewise it stipulates that instruction is to occur after the infant is born, at the time of need. <sup><a href="#note6">6</a></sup> <br /> </p>
      </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> Step 3 (BFHI) and Point 3 (Plan for the Community) <br /> </li>
          <li> the 3 important breastfeeding knowledge areas which must be covered with all pregnant women </li>
          <li> using open questioning and conversation techniques which can open discussion about infant feeding </li>
          <li> when breastfeeding is contraindicated</li>
          <li>when artificially-feeding parents are to receive instruction on infant formula preparation<br /></li>
        </ul>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#who" title="See full details">#</a> World Health Organisation et al. (1992) Global Criteria fort he Baby-Friendly Hospital Initiative</li>
              <li id="note2"><a href="references.html#lumc01" title="See full details">#</a> Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey</li>
              <li id="note3"><a href="references.html#egem02" title="See full details">#</a> Egemen A et al. (2002) A generally neglected threat in infant nutrition: incorrect preparation of infant formulae.</li>
              <li id="note4"><a href="references.html#labi08" title="See full details">#</a> Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.</li>
              <li id="note5"><a href="references.html#renf03" title="See full details">#</a> Renfrew MJ et al. (2003) Formula feed preparation: helping reduce the risks; a systematic review.</li>
              <li id="note6"><a href="references.html#who08" title="See full details">#</a> World Health Organization (2008) The International Code of Marketing of Breast-Milk Substitutes: frequently asked questions. Updated version 2008</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_3-1" class="content">
          <h1 id="top">3.1 The feeding decision</h1>
          <div class="section" id="What_is_most_influential_"><h2>What is most influential?</h2>
    <div>Demographic data, such as age, ethnicity, social class, education, etc may be used to predict feeding decisions. These, however, are rarely amenable to change.<br /><br />Less well known are psychosocial variables. Researchers found that maternal attitudes are better predictors of feeding method than are sociodemographic factors,<sup><a href="#note1">1</a></sup> and that a woman's prenatal intention was a stronger predictor than the standard demographic factors combined.<sup><a href="#note2">2</a></sup> Fathers' attitudes also influence maternal decisions.<sup><a href="#note3">3</a></sup><br /><br />In a study of women who were already breastfeeding 95.5% gave breastmilk as being <span style="font-style: italic;">better for the baby</span> as the major reason they chose to breastfeed, with convenience for the mother another common reason. Another researcher<sup><a href="#note4">4</a></sup> explored why both breastfeeding and artificial formula-feeding mothers chose their method of feeding. They found ... <br /></div>
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          <ul>
            <li>
              <p class="listTitle">Mothers chose to feed artificial infant formula</p>
              <ul>
                <li>not because they embraced artificial infant formula-feeding, rather that they rejected breastfeeding</li>
                <li>found breastfeeding embarrassing</li>
                <li>feared the pain or discomfort</li>
                <li>felt it limits freedom and social life</li>
                <li>were concerned that the father would not be involved</li>
                <li>but acknowledged that human milk is better for the baby</li>
              </ul>
            </li>
          </ul>
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            <li>
              <p class="listTitle">Mothers who chose to breastfeed had the following in common</p>
              <ul>
                <li>a positive attitude toward breastfeeding and human milk</li>
                <li>considered human milk to be healthier or 'better' for babies than artificial infant formula</li>
                <li>felt breastfeeding was more natural</li>
                <li>felt it resulted in better bonding or closeness with the baby</li>
                <li>and their self-confidence was linked to longer duration of breastfeeding</li>
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          <div>Mothers' greatest concerns about breastfeeding were found to be:<br /> • breastfeeding in public,<br /> • combining breastfeeding and working, and<br /> • management of breastfeeding by health professionals<sup><a href="#note5">5</a></sup> <p> </p> <p> Pregnant women are influenced in their attitude towards breastfeeding and will tend to adopt similar attitudes and opinions to that of their health care provider. Women who are encouraged to breastfeed by their doctor or nurse are more than four times as likely to initiate breastfeeding as women who do not receive encouragement.<sup><a href="#note6">6</a></sup></p></div>
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                <td class="body"><img src="design/warning.png" class="icon" alt="" /><h3>Play your part...</h3>
    <div>This is an indication of the mother's respect for her health provider's opinion, and the responsibility that rests on your shoulders to be a positive influence on pregnant women at a time when they are so open to receiving information.<span style="font-style: italic;"><br />You have a very important role to play in encouraging a positive breastfeeding attitude.</span></div>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Influencing attitudes</h3>
    <div>
      <p> Look again at the reasons mothers have given for them to artificially feed, and what mothers' concerns about breastfeeding are. Be aware that these personal attitudes may exist for some women. <br />Could a small group at your workplace look at ways to address each of those concerns even if a mother hasn't mentioned it herself. They may, for example, develop a poster with photographs showing how a mother could breastfeed discreetly in public, etc. </p>
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                <td class="body"><h3><a href="images/Center_Update_BFGuilt.pdf" target="_blank">Guilt and not breastfeeding</a></h3>
    <div>This is a good opportunity for you to re-read about how feelings of guilt develop in the infant feeding decision. Understanding this will assist you to communicate effectively with pregnant women.<br /></div>
  </td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
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          <div class="section" id="But_not_everyone_can_breastfeed_"><h2>But not everyone can breastfeed!</h2>
    <div>That is true. Physically a small percentage of women, perhaps up to 5%, <sup><a href="#note7">7</a></sup> are not able to meet all of their infant's nutritional needs. For these women and their infants the choices are few - donor breastmilk, or wet nursing is not possible for the majority and therefore we are to be grateful that artificial infant formula has been developed that will at least meet the majority of an infant's nutritional needs. <br /><br /> For other infants breastmilk may be contraindicated.<sup><a href="#note8">8</a></sup> These include: <br /> <ul><li> Infants with inborn errors of metabolism who require special formulations: <ul><li>classic galactosemia</li><li>maple syrup urine disease</li><li>phenyloketonuria, though some breastfeeding is possible, and desirable, under careful monitoring</li></ul> </li><li>Mothers who may need to avoid breastfeeding <ul><li>HIV positive, but only when replacement feeding is acceptable, feasible, affordable, sustainable and safe</li></ul> </li><li>Mothers who may need to avoid breastfeeding temporarily <ul><li>severe illness, eg sepsis</li><li>herpes simplex virus (HSV-1) on mother's breast where it will contact the infant's mouth (though breastfeeding from the other breast would not be contraindicated)</li><li>medication usage: cytotoxic chemotherapy; radioactive iodine-131 (safer alternatives are available); excessive use of topical iodine, eg on open wounds or mucous membranes; some sedating psychotherapeutic drugs, anti-epilepsy drugs, opioids though safe alternatives are usually available; drugs of addiction</li></ul> </li></ul></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 factors which most influence a woman's infant feeding decision</li>
          <li>The prenatal circumstances which can positively influence the maternal attitude towards breastfeeding</li>
          <li>Your role as a health professional in relaying a positive breastfeeding attitude to all women</li>
          <li>An understanding of the reasons why mothers chose to artificially feed their infants</li>
          <li>When breastfeeding is contraindicated<br /></li>
        </ul>
      </div>
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  </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_b">
<script type="text/javascript">
/* <![CDATA[ */
var bqs = {settings : {type : 'mcq'}, questions : [
	new MCQ('Janey is an 18 year old, single mother who lives with her mother and her 18 month-old toddler in a two-bedroom urban housing complex. Janey is pregnant. She belongs to an ethnic minority and both she and her mother do some paid work when they can get it. Which of the following factors will have the strongest influence on how Janey chooses to feed her baby?', [{text:'Her ethnic background',feedback:'This demographic may be a predictor but does not influence individual maternal decision.',score:0},{text:'Her social class',feedback:'Social class does not influence attitude.',score:0},{text:'She imagines the loving feelings she will have for her baby as baby falls off to sleep after breastfeeding well.',feedback:'Yes. Demographics are not modifiable, but positive attitude influences feeding decision.',score:1},{text:'She weaned her first baby after 2 weeks because her nipples were cracked.',feedback:'Past experience is not the determining factor for infant feeding decision. An unsuccessful first experience may instill a more positive attitude with this baby which is more influential on the feeding decision.',score:0}]),
	new MCQ('People who are close to Janey, such as her own mother and the baby\'s father, will also influence Janey\'s infant feeding decision. What usually impacts on these other people\'s attitude to breastfeeding?', [{text:'A billboard promoting breastfeeding.',feedback:'Billboard advertising will only impact partner\'s decision if the advertising has positive effect on whole community.',score:0},{text:'Their demographics.',feedback:'Janey\' partner and mother are not able to change their demographic.',score:0},{text:'The attitudes of the community in which they live.',feedback:'Community attitudes surround them all the time and are highly influential on attitude.',score:1},{text:'Whether they had been breastfed as infants.',feedback:'They may not know how they were fed as a baby. This is not a highly influential.',score:0}]),
	new MCQ('Which of the following comments, made to Janey by her doctor or nurse during a prenatal appointment, is most likely to positively influence Janey\'s thoughts towards breastfeeding?', [{text:'You may have noticed swelling of your breasts. This is due to hormones that are already preparing your breasts for feeding your baby.',feedback:'That\'s right. This comment is a subtle way of explaining what is happening and encouraging Janey by being positive about breastfeeding.',score:1},{text:'It\'s very early yet to be thinking about how you might feed your baby. We\'ll talk about it closer to when the baby is due.',feedback:'No. This shows Janey that you do think breastfeeding is not important to learn about now.',score:0},{text:'Here\'s a gift pack for you. This one is for breastfeeding mothers, but does contain some artificial infant milk. You won\'t need that, but all the other things in the pack are great.',feedback:'No. The comment seems positive about breastfeeding, Janey is now exposed to artificial infant milk as equal to breastfeeding.',score:0},{text:'It\'s a good idea to let the staff feed your baby in the nursery for the first night. You don\'t have much milk in the beginning and you\'ll need a good night\'s sleep to recover from the birth.',feedback:'No. Colostrum is super concentrated and highly valuable to the newborn. Separation of mother and baby will inhibit processes which are necessary for effective milk production and learning to breastfeed.',score:0}]),
	new MCQ('A student nurse is concerned that you present such a positive aspect to breastfeeding to all the women you see prenatally, feeling that a significant number won\'t be able to breastfeed. You ask her to list the occasions when she feels breastfeeding should be contraindicated and to reflect on how many women or infants that would involve. She lists the following. Indicate which is the only one she listed correctly.', [{text:'mother with hepatitis C',feedback:'Mothers with hepatitis A, B or C are all able to continue to safely breastfeed their infants.',score:0},{text:'extremely premature infant',feedback:'Breastmilk is probably THE most important therapeutic agent the infant\'s neonatologist will employ - and if the mother\'s is unavailable donor breastmilk would be the next milk of choice.',score:0},{text:'infant has classic galactosemia',feedback:'Correct. This infant will require a special galactose-free formulation.',score:1},{text:'Mother being treated with the antibiotic combination metronidazole, gentamycin and ampicillin.',feedback:'Each of those antibiotics is safe for the breastfeeding infant; therefore not contraindicated when used as therapy for the mother.',score:0}])
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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>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#dung94" title="See full details">#</a> Dungy CI et al. (1994) Maternal attitudes as predictors of infant feeding decisions</li>
              <li id="note2"><a href="references.html#dona03" title="See full details">#</a> Donath SM et al. (2003) Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study</li>
              <li id="note3"><a href="references.html#free93" title="See full details">#</a> Freed GL et al. (1993) Effect of expectant mothers' feeding plan on prediction of fathers' attitudes regarding breast-feeding</li>
              <li id="note4"><a href="references.html#brod07" title="See full details">#</a> Brodribb W et al. (2007) Identifying predictors of the reasons women give for choosing to breastfeed.</li>
              <li id="note5"><a href="references.html#mcin01" title="See full details">#</a> McIntyre E et al. (2001) Attitudes towards infant feeding among adults in a low socioeconomic community: what social support is there for breastfeeding?</li>
              <li id="note6"><a href="references.html#lumc01" title="See full details">#</a> Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey</li>
              <li id="note7"><a href="references.html#spen38" title="See full details">#</a> Spence JC (1938) The Modern Decline of Breast-Feeding</li>
              <li id="note8"><a href="references.html#who98" title="See full details">#</a> World Health Organization (1998) Evidence for the ten steps to successful breastfeeding</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_3-2" class="content">
          <h1 id="top">3.2 The barriers</h1>
          <div>
    <p class="listTitle">Barriers to breastfeeding can be divided into 3 main categories:</p>
    <ul>
      <li><strong>societal barriers,</strong> such as attitudes of the general population, the mother and her support networks. These are influenced by commercial interests, among other things.</li>
      <li><strong>health professionals</strong> who lack knowledge, skills and management of breastfeeding</li>
      <li><strong>postnatal perceptions</strong> of ability to continue breastfeeding. The mother's lack of knowledge of normal newborn behaviour, breastfeeding management and a need or expectation to work away from her baby influence this perception.</li>
    </ul>
  </div>
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                  <img src="design/books.png" class="icon" alt="" />
                  <h3>Workbook Activity 3.2</h3>
                  <p>Complete Activity 3.2 in your workbook.</p>
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          <div class="section" id="Societal_barriers"><h2>Societal barriers</h2>
    <div>
      <p>
		Worldwide campaigns, eg. World Breastfeeding Week, a WABA initiative; the Global Strategy for Infant and Young Child Feeding, a WHO/UNICEF initiative, as well as national and local initiatives attempt to influence community attitudes.
	</p>
    </div>
    <div class="captionBox"><img width="400" height="268" src="images/billboard_born2Bbreastfed.jpg" alt="National program to influence community attitudes.       The Ad Council, USA" /><p>National program to influence community attitudes.       The Ad Council, USA</p></div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="250" height="255" src="images/bfing_welcome250.gif" alt="from San Diego County Breastfeeding Coalition" /><p>from San Diego County Breastfeeding Coalition</p></div>
      </div><div class="column" style="width: 50%">
        <div>Acceptance of breastfeeding in public is a reflection of community attitudes. Discomfort in public breastfeeding is reported by many women and is noted as a significant barrier. Targeting this area specifically, organizations have developed public service announcements for various media.<br />Some countries and States have had to go to the extreme step of legislating for a mother's right to breastfeed her baby wherever she and her baby are when her baby requires feeding.</div>
      </div></div><br style="clear: both" />
    <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>What can you do to influence community attitudes?</h3>
      <div>
        <p> Before you can address barriers that mothers will have to overcome, you will need to understand what they are. Surveying the mothers and their relatives and friends that you meet in your unit could give you a starting point. From there, a small but enthusiastic committee could brainstorm ideas for local and community activities to address these concerns. <br /></p>
        <p>Share your findings in the forum.<br /></p>
      </div>
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  </div>
          <div class="section" id="Health_provider_knowledge_skills_and_management"><h2>Health provider knowledge, skills and management</h2>
    <div>
      <p> A common complaint from women is the amount of conflicting advice they receive from their health care providers. Also some of that advice may be detrimental to ongoing breastfeeding success. </p>
      <br />
    </div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="section" id="Step_1_and_Point_1"><h3>Step 1 and Point 1</h3>
          <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><span style="font-weight: bold;">Step 1</span> of the <span style="font-style: italic;">Ten Steps to Successful Breastfeeding</span> and<span style="font-weight: bold;"> Point 1</span> of the <span style="font-style: italic;">Seven Point Plan for Sustaining Breastfeeding in the Community </span>both state:</div>
            <blockquote>
              <div>
                <span style="font-style: italic;">Have a written breastfeeding policy that is routinely communicated to all staff</span>
              </div>
            </blockquote>
          </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> The policy should be displayed in all areas which serve mothers and babies and should cover all Ten Steps to Successful Breastfeeding in hospitals or all the Seven Point Plan, and prohibits the display or distribution of materials which promote breastmilk substitutes, feeding bottles, teats/artificial nipples and dummies/pacifiers. </p>
            <p class="listTitle">Having a written breastfeeding policy</p>
            <ul>
              <li>will eliminate the conflicting advice that is given to mothers; <span class="aside">All staff will be aware of what they must do.</span></li>
              <li>provides a stimulus for discussion for mothers<br /></li>
            </ul>
          </div>
        </div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="250" height="334" src="images/10_Steps_maori.jpg" alt="Display the Policy in the most common languages spoken." /><p>Display the Policy in the most common languages spoken. <br />&copy; D.Fisher, IBCLC</p></div>
      </div></div><br style="clear: both" />
    <div class="section" id="Baby_Friendly_Step_2_and_Point_2"><h3>Baby Friendly Step 2 and Point 2</h3>
      <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><span style="font-weight: bold;"> Step 2 </span> of the <span style="font-style: italic;"> Ten Steps to Successful Breastfeeding </span> and <span style="font-weight: bold;"> Point 2 </span> of the <span style="font-style: italic;"> Seven Point Plan for Sustaining Breastfeeding in the Community </span> both state:</div>
        <blockquote>
          <div>
            <span style="font-style: italic;">Train all health care staff in skills necessary to implement this breastfeeding policy</span>
            <br />
          </div>
        </blockquote>
      </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>
        <span style="font-weight: bold;">Congratulations on joining the ever-growing group of skilled and knowledgeable health professionals who protect, promote and support breastfeeding mothers and babies!</span>
        <br />
      </div>
    </div>
  </div>
          <div>
    <p>Education of health professionals using the curriculum developed for Step 2 of the Baby Friendly Hospitals Initiative produced staff who were significantly more knowledgeable about breastfeeding, had more positive attitudes and were more likely to employ correct practices for the promotion of exclusive breastfeeding.<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup> Another study showed that mothers who birthed in hospitals that had a high compliance to Baby Friendly Steps initiated breastfeeding in greater numbers and breastfed for longer than those in non-Baby Friendly hospitals.<sup><a href="#note3">3</a></sup> </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/thinker.gif" class="icon" alt="" /><h3>Support your colleagues</h3>
    <div><span style="font-weight: bold;">ALL</span> of your colleagues want to do what is best for both mother and baby. Encourage those colleagues who are unsure of current, evidence-based practices to complete an educational program such as this one. It will help them to achieve their goal, and benefit mothers and babies.<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 class="section" id="Postnatal_perceptions"><h2>Postnatal perceptions</h2>
    <div>
      <p>
		Educating mothers about maintaining milk supply and normal newborn behaviour will be discussed as you work through this course.
	</p>
      <p>
		An increasing number of women spend large amounts of time away from a baby or child who is still in the age range prior to earliest age of weaning ... ie the first two years. Returning to the paid workforce is the most common reason for regular separation of mother and baby, and a common reason given for premature weaning.
	</p>
    </div>
    <div class="section" id="Breastfeeding_and_separations"><h3>Breastfeeding and separations</h3>
      <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_c">
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	{ c : '<p>\n				Many women feel they have to wean completely when they return to work. However there are numerous options they can consider. List as many options as you can think of for a mother to continue to provide breastmilk to her baby after a return to employment outside the home.\n			</p>', r : '<ol><li>Reduce her working hours, or work mostly during baby\'s sleep time (eg. a night shift) so that she is not absent for breastfeeds.</li><li>Take the baby to work with her.</li><li>Have the baby cared for close enough for her to visit and breastfeed during her work breaks.</li><li>Have the child\'s carer bring him/her to her place of work when breastfeeding is required.</li><li>Express (pump) breastmilk each day to leave with the carer to give.</li><li>Breastfeed frequently when together, but have the carer give artificial infant formula.</li><li>If baby is older than 6 months, have carer give small amounts of complementary foods.</li></ol><p> What other alternatives did you think of? </p>' }
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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>
      <div>
        <p class="listTitle">Leaving her baby to go to work can be a highly stressful time for the mother. She will need to consider the physical and emotional effects of separation for long or short periods of time. <br /></p>
        <p class="listTitle">Continuing to provide breastmilk can</p>
        <ul>
          <li>present many challenges,</li>
          <li>help her to maintain an emotional connection to her baby, despite her physical absence,</li>
          <li>avoid the acute and chronic illnesses associated with artificial infant formula,</li>
          <li>make breastfeeding when they are reunited a very special and close time.</li>
        </ul>
        <p class="listTitle">Your professional role is to</p>
        <ul>
          <li>Educate her on the value of continuing to provide breastmilk for her baby, despite separation.</li>
          <li>Discuss the issues she will need to address to be successful.</li>
          <li>Provide her with contacts for peer-support services, to talk with other women in her situation.</li>
          <li>Inform the mother of her right to breastfeed, and what workplace legislation will protect her right.</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/thinker.gif" class="icon" alt="" /><h3>Do some action research</h3>
        <div>
          <p>
			Ask your colleagues, friends and the mothers you meet who continued to breastfeed until their baby was at least 12 months old what they did during periods of separation. You are likely to get many unique ideas which you can share with pregnant women.
		</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>
      <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 3.3</h3><p>Complete Activity 3.3 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>
  </div>
          <div class="section" id="Breastfeeding_in_special_circumstances"><h2>Breastfeeding in special circumstances</h2>
    <div>
      <p>
		Most women will be healthy, having no special needs regarding breastfeeding, and will be able to breastfeed without difficulty.
	</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"><h3></h3>
      <div></div><div class="activity" id="activity_d">
<script type="text/javascript">
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var dqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>\n				List the special circumstances that some women may have that will require additional counseling time.\n			</p>', r : '<p>\n				The following is a suggested list of women you may have identified. Your local area will have its own specific needs as well.\n			</p><ul><li>Had difficulties breastfeeding a previous baby; weaned very early or never started breastfeeding.</li><li>Must spend time away from her baby for employment or school.</li><li>Has non-supportive family members.</li><li>Is depressed, or previously had post-natal depression.</li><li>Is isolated, without social support.</li><li>Is a young or single mother.</li><li>Has had breast surgery or trauma.</li><li>Has a chronic illness or needs medication.</li><li>Is at high risk of baby needing special care, or has a multiple pregnancy.</li><li>Is tested and shown to be HIV-positive.</li><li>Has a physical, visual or auditory disability.</li></ul>' }
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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"><img src="design/group.png" class="icon" alt="" /><h3>When a referral is needed</h3>
      <div>
        <p>
			In some of the circumstances described the mother will need the help of other health professionals, such as a psychologist, or a lactation consultant, or a doctor, and perhaps referral to a peer-support group. Does your Unit have a procedure in place to ensure the mother is aware of these other services and able to access 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="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>
        <p> Addressing the following barriers will make breastfeeding possible for more women. </p>
        <ul>
          <li>Barriers caused by her health professionals who may lack knowledge or have routine practices that are detrimental.</li>
          <li>Attitudes of her family, friends and the society in which she lives. These are often formed by commercial interests.</li>
          <li>The mother's perception of her ability to breastfeed either physically or in her particular circumstances.</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 id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#gupt02" title="See full details">#</a> Gupta A et al. (2002) Training in Baby Friendly Hospital Initiative</li>
              <li id="note2"><a href="references.html#owoa02" title="See full details">#</a> Owoaje ET et al. (2002) Previous BFHI training and nurses' knowledge, attitudes and practices regarding exclusive breastfeeding</li>
              <li id="note3"><a href="references.html#mert05" title="See full details">#</a> Merten S et al. (2005) Do baby-friendly hospitals influence breastfeeding duration on a national level?</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_3-3" class="content">
          <h1 id="top">3.3 Physical preparation</h1>
          <div class="section" id="Nipple_preparation"><h2>Nipple preparation</h2>
    <div>
      <p> The old texts abound with advice on nipple preparation techniques. Studies from the 1970s all found that any physical preparation of the nipples is entirely unnecessary and should <strong>NOT</strong> be recommended.</p>
      <p> In several large international trials treatment of inverted or non-protractile nipples during pregnancy, the use of Hoffman's nipple stretching exercises and/or breast shells revealed NO difference to the nipples compared to a group who had no intervention. Women in the intervention groups were more likely to not initiate breastfeeding or wean early. Therefore this practice is also not to be recommended.<sup><a href="#note1">1</a></sup> </p>
      <p> Routine expression of colostrum is likewise not necessary and could cause anxiety in women who are not comfortable handling their breasts in this manner, or in those who are unable to express colostrum - a fact which is not related to ability to breastfeed. <br />However, antenatal expression and collection of colostrum may be recommended for certain maternal or newborn medical reasons.<sup><a href="#note2">2</a></sup> This ready supply of colostrum will negate the need for artificial infant milk if a supplement is necessary. It also provides an ideal opportunity to teach mothers how to hand express, a skill they will need to learn anyway. </p>
      <p> </p>
    </div>
  </div>
          <div class="section" id="Prenatal_breast_examination"><h2>Prenatal breast examination</h2>
    <div>
      <p> While there is no physical preparation necessary for breastfeeding, examination of the breasts during a routine prenatal check-up can reveal information that could assist with the care of the mother and baby postnatally, and it provides an ideal opportunity to discuss breastfeeding and any concerns the mother may have. Have the mother in a sitting position. </p>
      <p><span style="font-weight: bold;">The breast</span> is composed of glandular tissue (functional tissue), fibrous tissue and fatty tissue. Breast size is variable between women, and even in the same woman, being mostly dependent on the amount of fatty tissue present. Glandular tissue influences size to a lesser degree.</p>
      <p>The glandular tissue begins to function as a milk producing gland during pregnancy. The duct system and terminal milk-producing buds, called alveoli, proliferate during the first half of the pregnancy. Breast size increases for most women during this time. <br /></p>
      <p>Under the influence of the hormone prolactin, small amounts of colostrum are produced. Pregnancy progesterone inhibits full milk production. Breastmilk is synthesised and stored in the alveoli and travels through the duct system towards the nipple openings.</p>
      <p><span style="font-weight: bold;">The nipple</span> is in the centre of the areola and the least important structure of the breast during breastfeeding, being merely the structure through which the ends of the ductal system pass. Unfortunately, it is often the most commented on by the mother's advisors, forecasting success or failure of breastfeeding on the size and erectile nature of the nipple, which of course is incorrect. </p>
      <p> The areola may darken during pregnancy. Montgomery's follicles are tiny glands that have a pimple-like appearance on the areola and become more prominent during pregnancy. These follicles may secrete an oily substance, and some secrete tiny droplets of milk. Maternal areola odor is produced which enhances the newborn's sucking activity.<sup><a href="#note3">3</a></sup> Washing the breasts before feeding is not recommended as it washes away these protective secretions, and the important prefeeding stimulus provided by the unique smell.<br /></p>
    </div>
    <div class="section" id="Inspection"><h3>Inspection</h3>
      <div>
        <ul>
          <li><strong>Size and shape:</strong> Breasts and nipples come in an infinite variety of sizes and shapes. Breast size is not related to milk production. Remember, it's <em>breast</em>feeding, not nipple feeding. A 'different' nipple shape could provide mother and baby with a challenge - the key is to achieve good latch to the breast. </li>
          <li><strong>Asymmetry:</strong> Most women have asymmetrical breasts. Marked asymmetry should be noted, but no further action is necessary. If the smaller breast is felt to be hypoplastic, it is helpful to note that one breast can produce sufficient breastmilk for the baby. </li>
          <li><strong>Large breasts:</strong> Some women with very large breasts may like to discuss their feelings about their breasts and what breastfeeding is going to mean to them. Knowing how to help this mother to feed easily and discreetly could be the significant factor in her infant feeding decision. <br /></li>
          <li><strong>Skin appearance:</strong> The skin should appear smooth without thickening or dimpling, which, while rare in women of child-bearing age, could indicate an underlying tumour. Skin conditions such as psoriasis, dermatitis or bacterial or herpetic lesions should also be noted. </li>
          <li><strong>Scarring:</strong> Record the position and reason for surgical or injury scars noting their potential to impact on breastfeeding (eg. breast reduction surgery, areola incision, burns etc). <br /></li>
        </ul>
      </div>
      <div class="captionBox"><img width="307" height="242" src="images/montgom_foll_sc.jpg" alt="Nipple, areola and prominent Montgomery's follicles." /><p>Nipple, areola and prominent Montgomery's follicles. <br />&copy; S.Cox, IBCLC</p></div>
    </div>
    <div class="section" id="Palpation"><h3>Palpation</h3>
      <div>
        <p>
			This is an ideal health education opportunity to discuss and demonstrate breast self-examination as a routine breast screening technique for breast cancer, but which can also be useful to detect blocked ducts during lactation.
		</p>
      </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 3.4</h3><p>Complete Activity 3.4 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>
          <div class="section" id="Record-keeping"><h2>Record-keeping</h2>
    <div>
      <p> It is important to record the signs and symptoms you noted at this examination. Later in the pregnancy the mother could be referred to a Lactation Consultant to discuss any issues which may impact on breastfeeding, such as breast reduction, augmentation, or if the mother has a concern about her capability to breastfeed. A medical review is indicated for other abnormalities noted. </p>
      <p> Markedly small or asymmetrical breasts may, or may not, make breastfeeding difficult. Postnatally, routine procedures should readily identify babies who are receiving insufficient breastmilk. However, a note in the mother's chart will alert staff to remain vigilant. </p>
    </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/thinker.gif" class="icon" alt="" /><h3>The power of words.</h3>
    <div>
      <p>
			It's often been commented that the most important organ for successful breastfeeding is the brain. There are essential hormones released here, but of <strong>MORE</strong> importance is the belief by the mother that she can breastfeed. A positive attitude by all her health care providers is essential to prevent self-doubt limiting the mother's potential.
		</p>
      <p>
			Be aware of the words you use and the impact they have on a mother's self-confidence.
		</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>Prenatal preparation of the breasts and nipples is not necessary</li>
          <li>Breasts and nipples are all different and usually have no impact on breastfeeding ability or milk production</li>
          <li>The normal physiologic changes to the breasts during pregnancy</li>
          <li>How to note and record anomalies of a breast examination</li>
        </ul>
        <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>
          <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_e">
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	new MCQ('All of the following are reasons during her pregnancy that you may show a woman how to hand express some colostrum, EXCEPT:', [{text:'to see if she will have colostrum in her breasts when her baby is born.',feedback:'You are correct. Not being able to express anything during pregnancy is not indicative of her ability to provide colostrum after the baby is born.',score:1},{text:'the mother has Type 1 diabetes mellitus.',feedback:'That\'s a very good reason to express antenatally. Her baby is at greater risk of hypoglycaemia, and being given formula supplements in some units. Having her own milk ready for the baby is a good idea.',score:0},{text:'the mother is expecting twins.',feedback:'That\'s a good reason to have some extra colostrum available from the time they are born in case it\'s needed.',score:0},{text:'to teach the mother how to hand express.',feedback:'Should the opportunity arise this is a good time to teach this skill that she will require after the birth of the baby.',score:0}]),
	new MCQ('Which of the following would you recommend a mother do during pregnancy to prepare for breastfeeding?', [{text:'Hoffman\'s exercises if she has flat or inverted nipples.',feedback:'No. These have not been found to be effective, and are more likely to cause the mother to believe she will have problems breastfeeding.',score:0},{text:'Rubbing her nipples with a rough towel to toughen them up for breastfeeding.',feedback:'Absolutely NOT. This causes damage to the skin and is more likely to cause problems.',score:0},{text:'Wash her breasts as she normally does but take care not to use soap on the nipples.',feedback:'That\'s right. Just normal hygiene is all that is required. Soaps will wash away the protective oils secreted by the Montgomery\'s follicles.',score:1},{text:'Express a few drops of colostrum every day to clear the ducts.',feedback:'This is unnecessary. Expressing during the antenatal period is only indicated for a very small group of women.',score:0}]),
	new MCQ('A woman is expecting her first baby. She has very large breasts and is excited at the prospect of having a large milk supply for her baby. Which of the following comments would be most appropriate?', [{text:'You are lucky. You shouldn\'t have any problems feeding your baby.',feedback:'While this is very positive it is agreeing with information that is not accurate. You cannot tell the milk storage capacity of the breast by its size.',score:0},{text:'We don\'t know of any reasons you shouldn\'t be able to make plenty of milk.',feedback:'With this statement you are not disagreeing with her, and will be able to go on from this point to talk about how breastmilk is made, which will give her accurate information.',score:1},{text:'You may have lots of milk, but positioning your baby will be a challenge.',feedback:'This is very negative and may make the mother reconsider her decision.',score:0},{text:'Large breasts don\'t always mean a lot of milk.',feedback:'While this is factual it is disagreeing with the mother and may make her lose self-confidence.',score:0}]),
	new MCQ('All of the following are reasons you would do an examination of a woman\'s breasts at the first antenatal visit, EXCEPT', [{text:'to provide information that may impact on breastfeeding, for example the position of scars or noticing marked asymmetry of her breasts',feedback:'This information gathering can be very useful.',score:0},{text:'to teach her how to do breast self-examination.',feedback:'This simple activity is important for every woman to be able to do, and this may be the first time anyone has shown her how to do it.',score:0},{text:'to assess the nipples so that treatment can be initiated early if they are flat or inverted.',feedback:'Nipples continue to change thoughout pregnancy, and what may appear to be flat or inverted early in pregnancy may be quite normal at term. However, even if they aren\'t there is no intervention that will make any significant difference at this stage.',score:1},{text:'the mother has requested that you check her breasts for their suitability for breastfeeding.',feedback:'While examining her breasts will not tell you whether they are suitable for breastfeeding or not, it will give you the opportunity to discuss lactation with her and you should be able to allay her fears.',score:0}]),
	new MCQ('On examination of the mother\'s breasts she indicates small, raised lumps that look like pimples on her areola, telling you that they have become more numerous and prominent in the last few weeks and wondering what she should do about them. What would be the most appropriate response?', [{text:'They do look like pimples. You could try washing your breasts with an antibacterial soap.',feedback:'No.',score:0},{text:'That\'s just a normal part of pregnancy and nothing to worry about.',feedback:'This is dismissive and you\'ve missed an ideal educational opportunity.',score:0},{text:'I think they may be Montgomery\'s follicles, but perhaps you could ask your doctor to check, just in case.',feedback:'You should be able to recognise Montgomery\'s follicles and know they are a part of normal breast development during pregnancy.',score:0},{text:'This is a normal change to expect and is very good for breastfeeding. They secrete an oil which is protective, and also a very subtle smell that your baby will focus on when he\'s born.',feedback:'That\'s a good answer - reassuring, educational and normalising breastfeeding.',score:1}])
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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>
    <div class="section" id="Assessment_Quiz"><h3>Assessment Quiz</h3>
      <div>
        <p>
		When you are happy that you've understood all the information in this topic you will be ready to complete the Module 3 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 3.
	</p>
      </div>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#main94" title="See full details">#</a> MAIN Collaborative Group Preparing for Breast Feeding (1994) Treatment of inverted and nonprotractile nipples in pregnancy</li>
              <li id="note2"><a href="references.html#coxs06" title="See full details">#</a> Cox S (2006) Breastfeeding with Confidence</li>
              <li id="note3"><a href="references.html#scha06" title="See full details">#</a> Schaal B et al. (2006) Human breast areolae as scent organs: morphological data and possible involvement in maternal-neonatal coadaptation</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_4-0" class="content">
          <h1 id="top">4.0 The Birth Experience</h1>
          <div>
    <p> The benchmark outcome of pregnancy is the normal vaginal birth of the baby, without any medical or pharmacological intervention and without complication for either mother or baby, followed by the baby being able to latch and breastfeed well. This may not be achievable for some women for whom the availability of skilled medical, nursing and pharmacological assistance is essential, but it is possible for the majority of women in the World.</p>
  </div>
          <blockquote>
    <div>Normal labor is a fragile entity. Once intervention occurs then a cascade of interventions inevitably follow.<sup><a href="#note1">1</a></sup></div>
  <p class="cite">Kroeger, 2004</p></blockquote>
          <div>
    <p>Health care professionals have a responsibility to support and facilitate normal birthing. What happens to the mother during birthing has far-reaching effects on her relationship with her baby, her ability to breastfeed and the health of the mother and her child. </p>
  </div>
          <div class="captionBox">
            <img width="500" height="345" src="images/NHS_poster.jpg" alt="Poster available for purchase from NHS, UK" />
            <p>Poster available for purchase from NHS, UK</p>
          </div>
          <div class="section" id="Lactation_physiology"><h2>Lactation physiology</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>
        <p class="listTitle">Lactogenesis is the making of breastmilk. There are three distinct phases.</p>
        <ol>
          <li><strong style="font-weight: normal;">Lactogenesis I</strong> (LI) commences during pregnancy. Most women will see some evidence of a milky secretion (colostrum) from their breasts during their pregnancy.<br /><br /></li>
          <li><strong style="font-weight: normal;">Lactogenesis II</strong> (LII) begins biochemically around 30 - 40 hours after birth, and is felt as the milk 'coming in' around 70 hours after birthing. This is an <span style="font-weight: bold;">endocrine function</span>, entirely dependent on the right mix of hormones.<br /><br /></li>
          <li><strong style="font-weight: normal;">Lactogenesis III</strong> (LIII) is the maintenance of ongoing lactation. This is an <span style="font-weight: bold;">autocrine function</span>, dependent on frequent, effective removal of milk from the breasts.</li>
        </ol>
        <span class="aside">Lactogenesis I is scientifically referred to as Secretory Differentiation and Lactogenesis II is scientifically referred to as Secretory Activation.</span>
        <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 class="section" id="Lactogenesis_II"><h3>Lactogenesis II</h3>
      <div>
        <p class="listTitle">Lactogenesis II will occur when:</p>
        <ul foot="You will be aware that lactogenesis II occurs even in women who never put the baby to the breast or remove milk by other means.">
          <li><span style="font-style: italic;">progesterone levels drop</span> as a result of the removal of the placenta, AND</li>
          <li><span style="font-style: italic;">prolactin levels are high</span> as they are at the time of birthing, in the presence of</li>
          <li>normal insulin, thyroid hormones and glucocorticoids.</li>
          <li>Also, following birth, lactose secretion into colostrum increases, osmotically drawing water with it and increasing the volume of milk.</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 4.1</h3><p>Complete Activity 4.1 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="What_could_delay_or_inhibit_lactogenesis_II_"><h3>What could delay or inhibit lactogenesis II?</h3>
      <div>
        <p> Hint: <span class="aside">Remember it's an endocrine function, therefore consider hormonal causes.</span> </p>
        <p> Accidents at birthing may cause endocrine disruption. For example, retention of a functional portion of the placenta that continues to secrete progesterone, or a haemorrhage severe enough to cause Sheehan's syndrome (pituitary gland necrosis). </p>
        <p> A delay in lactogenesis II occurs after assisted deliveries.<sup><a href="#note2">2</a></sup> Finding the cause of this delay and relating it to the physiology of lactogenesis has led researchers to look at the effect of stress. </p>
      </div>
      <div class="section" id="Stress_and_breastfeeding"><h4>Stress and breastfeeding</h4>
        <div>
          <p> High stress levels are correlated with high cortisol levels. Cortisol, in normal concentrations, is also necessary to initiate lactogenesis II successfully, though what its role is isn't fully understood yet. </p>
          <ul>
            <li>Markers of both fetal and maternal stress during labor and delivery are associated with delayed breast fullness.<sup><a href="#note3">3</a></sup></li>
            <li>Maternal stress seems to interfere with the release of oxytocin causing poor milk removal, and a newborn who experienced stress during labor and delivery may be too weak or too sleepy to latch on and suckle effectively.<sup><a href="#note4">4</a></sup></li>
            <li>Onset of lactation occurred later in women who had higher cortisol levels. Primiparous women had higher levels than multiparous women. Stress during labor and/or delivery is likely to be a significant risk factor for delayed onset of lactation.<sup><a href="#note5">5</a></sup></li>
          </ul>
        </div>
      </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 interventions in labor have far-reaching effects on mother and infant</li>
          <li>the 3 stages of lactation<ul><li>when each commences</li><li>what controls their initiation or, in the case of LIII, what maintains it</li><li>the timing of their occurrence</li></ul></li>
          <li>the factors during or as a result of labor and birthing that can interfere with LII<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_f">
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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>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kroe04" title="See full details">#</a> Kroeger M et al. (2004) Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum</li>
              <li id="note2"><a href="references.html#dewe03b" title="See full details">#</a> Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss</li>
              <li id="note3"><a href="references.html#chen98" title="See full details">#</a> Chen DC et al. (1998) Stress during labor and delivery and early lactation performance</li>
              <li id="note4"><a href="references.html#dewe01a" title="See full details">#</a> Dewey KG (2001) Maternal and fetal stress are associated with impaired lactogenesis in humans</li>
              <li id="note5"><a href="references.html#graj02" title="See full details">#</a> Grajeda R et al. (2002) Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_4-1" class="content">
          <h1 id="top">4.1 The first hours</h1>
          <div class="captionBox">
            <img width="405" height="568" src="images/UK_BF_poster.jpg" alt="Promotional poster - from Baby Friendly UK" />
            <p>Promotional poster - from Baby Friendly UK</p>
          </div>
          <blockquote>
    <div>
      <p> The benefits to the mother of immediate breastfeeding are innumerable, not the least of which, after the weariness of labour and birth, is the emotional gratification, the feeling of strength, composure, and the sense of fulfillment that comes with the handling and suckling of the baby.<sup><a href="#note1">1</a></sup> </p>
    </div>
  <p class="cite">Ashley Montague, 1978</p></blockquote>
          <div class="section" id="Baby_Friendly_Step_4"><h2>Baby Friendly Step 4</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><span style="font-weight: bold;"> Step 4 </span> of the <span style="font-style: italic;"> Ten Steps to Successful Breastfeeding </span> states: <p> "Help mothers to initiate breastfeeding within a half-hour of birth." </p> <p> This step is now interpreted as: <strong style="font-weight: normal;"></strong> <br /> </p></div>
      <blockquote>
        <div>
          <strong style="font-weight: normal;">Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed.</strong>
          <sup><a href="#note2">2</a></sup>
        </div>
      </blockquote>
    </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="Immediately_following_birth"><h2>Immediately following birth</h2>
    <div>
      <p> At the time of birth nearly 90% of newborns are vigorous, term babies with no risk factors, who do not need to be separated from their mother in order to receive the initial steps of resuscitation.<sup><a href="#note3">3</a></sup> </p>
      <ul>
        <li>Immediately move newborn onto mother's abdomen with skin-to-skin contact.</li>
        <li>In this position: Upper airway can be cleared by wiping the mouth and nose, baby can be dried, assigned Apgar scores, visually assessed and vital signs recorded.</li>
        <li>Cover both mother and baby with dry linen.</li>
      </ul>
    </div>
  </div>
          <div class="section" id="The_first_breastfeed"><h2>The first breastfeed</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"><a href="images/Klaus_Pediatrics1998.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/Klaus_Pediatrics1998.pdf" target="_blank">Read this great article!</a></h3>
      <div>
        <p>
				What happens now is truly a miracle to watch! Click on the icon on the left to read this paper, then file it in your Workbook. If you are in contact with colleagues who are with birthing mothers, share it with them too.
			</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>
      <p> Several researchers have described this species-specific set of innate behaviors when baby is placed in skin-to-skin contact with the mother immediately following birth. It is clear that newborn babies are born with the instinct to breastfeed.<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup> </p>
    </div>
    <div class="captionBox"><img width="495" height="307" src="images/skin-to-skin_500_RC.png" alt="" /><p> <br />&copy; R.Cantrill, IBCLC</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/article.png" class="icon" alt="" /><h3>Research findings</h3>
      <div>
        <ul>
          <li>Newborn, full-term babies who spent more than 50 minutes in skin-to-skin care are 8 times more likely to breastfeed spontaneously than infants not in skin-to-skin care.<sup><a href="#note8">8</a></sup></li>
          <li>Newborn preterm infants in skin-to-skin care achieve thermo-cardio-respiratory stability within 6 hours, compared to babies in traditional incubator care who mostly do not.<sup><a href="#note9">9</a></sup><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="The_role_of_the_birth_attendants"><h2>The role of the birth attendants</h2>
    <div>
      <p> This critical period in the relationship between mother and baby is, in some birthing units, a high-intervention time when it should be exactly the opposite. Recall that the AAP Neonatal Resuscitation Program<sup><a href="#note3">3</a></sup> states that all observations can take place with infant in skin-to-skin contact with his mother. The role of the birth attendants at this time is to support the mother to provide the ideal environment for her baby to adapt to extrauterine life, orientate to the breast and coordinate suckling. </p>
      <p> Appropriate support is given by discussing with the mother, and others present, the importance of uninterrupted skin-to-skin contact. Some birth attendants tell of the mother and her support people being enthralled as they watch the baby move through this sequential pre-feeding behavior, not wishing to interrupt it. A little education can go a long way! </p>
    </div>
  </div>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                  <img src="design/callout_03.png" width="10" height="10" alt="" />
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                  <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 4.2</h3>
                  <p>Complete Activity 4.2 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="" />
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          <div class="section" id="Addressing_barriers_to_skin-to-skin"><h2>Addressing barriers to skin-to-skin</h2>
    <div>
      <p class="listTitle"> Concern that the baby will get cold. </p>
      <ul>
        <li><strong>Dry</strong> the baby and place in skin-to-skin contact on mother's chest. </li>
        <li> Put a dry cloth or blanket over both the mother and the baby. </li>
        <li> If the room is cold cover the baby's head with a bonnet to reduce heat loss. </li>
        <li> Babies in skin-to-skin contact have higher temperature than those dressed  and better temperature regulation than those under a heater or in incubator care. <sup><a href="#note10">10</a></sup> <sup><a href="#note11">11</a></sup> </li>
      </ul>
      <p class="listTitle"> Baby needs to be examined. </p>
      <ul>
        <li> Most examinations can be conducted with baby on mother's chest. </li>
        <li> There is no need to move the baby to monitor vital signs. </li>
        <li> Weighing can be delayed. </li>
      </ul>
      <p class="listTitle"> Mother needs to be stitched. </p>
      <ul>
        <li> Baby can stay on mother's abdomen while stitching an episiotomy. </li>
        <li> Baby can stay on mother's chest while stitching a caesarean section. </li>
      </ul>
      <p class="listTitle"> Baby needs to be bathed. </p>
      <ul>
        <li> Delaying the first bath provides better thermoregulation and allows the vernix to remain on the skin. <br /> <ul><li> Gently wipe the baby dry after birth, preserving the vernix. </li><li> Vernix retention is associated with significantly higher skin hydration, a lower skin pH and significantly less erythema. <sup><a href="#note12">12</a></sup> </li><li> Early bathing is associated with a significant fall in temperature. <sup><a href="#note13">13</a></sup> </li></ul> </li>
      </ul>
      <p class="listTitle"> Delivery room is busy. </p>
      <ul>
        <li> Mother and baby can be transferred to the postnatal ward while in skin-to-skin contact. </li>
      </ul>
      <p class="listTitle"> Insufficient staff to remain with the mother. </p>
      <ul>
        <li> A family member can stay with the mother and baby. </li>
        <li> Discuss routine precautions with the family member to ensure their safety. </li>
      </ul>
      <p class="listTitle"> Baby is not alert. </p>
      <ul>
        <li> If a baby is sleepy due to maternal medications it is even more important that the baby has contact as he/she needs extra support to bond and feed. </li>
      </ul>
      <p class="listTitle"> Mother is tired. </p>
      <ul>
        <li> A mother is rarely so tired that she does not want to hold her baby. </li>
        <li> Contact with her baby can help the mother to relax. </li>
        <li> Review labor practices such as withholding fluid and foods, and practices that may increase the length of labor. </li>
        <li> Skin-to-skin care and breastfeeding is best when the mother is in a reclined or semi-reclined position; a good position for resting. <br /> </li>
      </ul>
      <p class="listTitle"> Lack of knowledge of health professional wishing to move the baby </p>
      <ul>
        <li> This first step following birthing has far-reaching effects on mother, baby and breastfeeding. </li>
        <li> Train all birthing room staff in the effects of immediate and undisturbed skin-to-skin contact. </li>
        <li> Refer all staff to the hospital policy which they must follow. Hospital breastfeeding policies will reflect the 10 Steps to Successful Breastfeeding, including Step 4. </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>Just the thing for busy staff!</h3>
      <div>Supporting the mother to care for her baby with skin-to-skin contact will significantly reduce the workload of the health care staff looking after her.<br /><ul><li>The infant will adapt to extrauterine life more quickly, reducing any risk of hypothermia or cardio-respiratory instability.<br /></li><li>Breastfeeding will be initiated early and successfully, with minimal input from others.</li><li>Breastfeeding will stimulate the release of oxytocin, reducing the risk of maternal hemorrhage.<br /></li><li>Skin-to-skin care will colonize the baby with the mother's normal flora, which, when combined with breastfeeding, significantly reduces the risk of nosocomial infections.</li><li>Maternal self-confidence and independence will rise.</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="Maternal-infant_bonding"><h2>Maternal-infant bonding</h2>
    <div>
      <p> This is the beginning of a loving relationship between the parents and their newborn. The infant appears to play his part in the establishment of these bonds by actively interacting with his parents. Following an initial cry at birth the infant becomes quietly alert and seeks visual contact, massages the mother's chest and breasts and latches and breastfeeds. The high blood levels of beta endorphins, oxytocin and prolactin in both mother and infant facilitate falling in love.<sup><a href="#note14">14</a></sup> </p>
      <p class="listTitle">For this to occur the following factors have to be in place and considered. These are all influenced by the birth attendants.</p>
      <ul>
        <li>the availability of the infant to his/her parents,</li>
        <li>an environment conducive to parent and child interaction, and</li>
        <li>the attitude of those present at the delivery to the appearance of the infant<sup><a href="#note14">14</a></sup></li>
      </ul>
    </div>
  </div>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_03.png" width="10" height="10" alt="" />
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                <td class="body"><h3>What about a baby to be artificially fed?</h3>
    <div>Skin-to-skin time with mother is equally important for EVERY baby. In Topic 4.3 Postnatal interventions, you will read the effects of separating mothers and newborns - facilitating breastfeeding is only one of many, many benefits of skin-to-skin contact.<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="" />
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          </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>the interpretation of Step 4 of the Ten Steps</li>
          <li>the immediate care of the newborn following birth AND where it should take place</li>
          <li>the many important functions that skin-to-skin contact on the mother's chest has for both her and her infant</li>
          <li>how you could address the barriers to skin-to-skin care should your colleagues be concerned<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_g">
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	new MCQ('What is the FIRST action that should be taken after a baby is born?', [{text:'dry the baby thoroughly then move the baby onto the mother\'s abdomen for her to hold',feedback:'No. You\'ve got the order wrong.',score:0},{text:'assign Apgar scores, then if baby does not require resuscitation move the baby onto the mother\'s abdomen for her to hold',feedback:'The first Apgar score isn\'t assigned until 1 minute. You\'ll do something with the baby before then.',score:0},{text:'move the baby onto the mother\'s abdomen for her to hold, then dry the baby',feedback:'Yes, that\'s right. All routine resuscitation, care and observations can occur with baby in skin-to-skin contact on mother\'s abdomen.',score:1},{text:'assist the mother to latch the baby to the breast for his first breastfeed',feedback:'No. The baby won\'t require assistance if you just place baby and mother in skin-to-skin contact.',score:0}]),
	new MCQ('How will thermal stability be achieved most efficiently?', [{text:'dry, dress and wrap the baby in a warm blanket',feedback:'This is not the most efficient way to achieve thermal stability.',score:0},{text:'dry and dress infant, then place under a radiant heater',feedback:'This is not a very efficient method.',score:0},{text:'dry infant and place naked in a temperature-controlled isolette',feedback:'No, this is quite inefficient compared to the most efficient method.',score:0},{text:'dry the infant, then place him naked in skin-to-skin contact on the mother\'s chest, covering both with dry linen.',feedback:'This is the most efficient way to stabilise the baby\'s temperature.',score:1}]),
	new MCQ('The baby in skin-to-skin contact with his mother uses his knees and feet to move towards the breast. Apart from moving the baby, what function does this serve?', [{text:'it strengthens the baby\'s back muscles',feedback:'No. Baby isn\'t really in need of strengthening exercises at this stage of his life.',score:0},{text:'it causes the release of oxytocin in the mother',feedback:'Yes. This will cause her uterus to contract expelling the placenta and reducing bleeding, and the colostrum in the breast to move down towards the nipple.',score:1},{text:'it causes the mother to bring her baby to her breast',feedback:'No. Most mothers are happy to rest, allowing the baby to move as he wishes.',score:0},{text:'it stimulates the release of prolactin in the mother',feedback:'No, not from this action.',score:0}]),
	new MCQ('A newborn baby in skin-to-skin contact on his mother\'s abdomen does not appear to be making the usual progress towards self-attaching to the breast. You could do any of the following to to assist the normal progress of the baby, EXCEPT..', [{text:'Suggest mother expresses a drop or two of colostrum from the breasts and wipe it over her nipples.',feedback:'This is something you would try. The baby uses his sense of smell to locate the nipple.',score:0},{text:'Move the baby to the breast and help him to latch.',feedback:'Correct. Please don\'t do this. It interferes with the baby\'s innate reflexes and ability to learn.',score:1},{text:'Wipe some of the amniotic fluid over the mother\'s breasts.',feedback:'An excellent idea! If there\'s none obviously around at this time you\'ll find some if you uncurl baby\'s hands - gently wipe baby\'s hands over the nipples.',score:0},{text:'Don\'t do anything. Allow the baby extra time.',feedback:'This could also be very helpful, particularly if the baby had received intrapartum drugs.',score:0}]),
	new MCQ('Physiologically the mother and baby are primed at the time of birth to fall in love with each other. What are the three physical factors identified by one researcher that could interfere with this?(Choose all three factors)', [{text:'the availability of the infant to his/her parents',feedback:'Yes, that\'s one of them. Don\'t separate them at this critical time.',score:1},{text:'the baby not reaching the breast to lick, nuzzle or latch',feedback:'No. While this will enhance the hormonal milieu, skin-to-skin is even more important for artificially feeding mothers',score:0},{text:'an environment conducive to parent and child interaction',feedback:'Yes that\'s one of the factors.',score:1},{text:'the attitude of those present at the birth to the appearance of the infant',feedback:'That\'s one of the factors.',score:1},{text:'the baby not being the desired sex',feedback:'No. The hormones are there anyway.',score:0}]),
	new MCQ('When routine skin-to-skin care on the mother\'s chest is fully implemented into a birthing unit, does it increase or decrease the staff workload?', [{text:'Increase',feedback:'No. Skin-to-skin is the ultimate labor-saving action for birthing unit and postnatal ward staff. It prevents problems and gives mothers a greater sense of independence.',score:0},{text:'Decrease',feedback:'That\'s right. It\'s the ultimate labor-saving action in a birthing unit or postnatal ward. It prevents many problems and mothers gain independence faster.',score:1}])
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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>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#mont78" title="See full details">#</a> Montague A (1978) Touching: The Human Significance of the Skin</li>
              <li id="note2"><a href="references.html#worl06" title="See full details">#</a> World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care</li>
              <li id="note3"><a href="references.html#amer00" title="See full details">#</a> American Academy of Pediatrics (2000) The Textbook of Neonatal Resuscitation</li>
              <li id="note4"><a href="references.html#righ90" title="See full details">#</a> Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed</li>
              <li id="note5"><a href="references.html#wids90" title="See full details">#</a> Widstrom AM et al. (1990) Short-term effects of early suckling and touch of the nipple on maternal behaviour</li>
              <li id="note6"><a href="references.html#vare98" title="See full details">#</a> Varendi H et al. (1998) Soothing effect of amniotic fluid smell in newborns</li>
              <li id="note7"><a href="references.html#matt01" title="See full details">#</a> Mattos-Graner RO et al. (2001) Relation of oral yeast infection in Brazilian infants and use of a pacifier</li>
              <li id="note8"><a href="references.html#gome98" title="See full details">#</a> Gomez Papi A et al. (1998) Kangaroo method in the delivery room for full-term babies</li>
              <li id="note9"><a href="references.html#berg04" title="See full details">#</a> Bergman NJ et al. (2004) Randomized controlled trial of  skin-to-skin contact from birth versus conventional incubator for  physiological stabilization in 1200- to 2199-gram newborns</li>
              <li id="note10"><a href="references.html#carf05" title="See full details">#</a> Carfoot S et al. (2005) A randomised controlled trial in the north of England examining the effects of skin-to-skin care on breast feeding.</li>
              <li id="note11"><a href="references.html#fran05" title="See full details">#</a> Fransson AL et al. (2005) Temperature variation in newborn babies: importance of physical contact with the mother.</li>
              <li id="note12"><a href="references.html#viss05" title="See full details">#</a> Visscher MO et al. (2005) Vernix caseosa in neonatal adaptation.</li>
              <li id="note13"><a href="references.html#berg05" title="See full details">#</a> Bergstrom A et al. (2005) The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial.</li>
              <li id="note14"><a href="references.html#attr02" title="See full details">#</a> Attrill B (2002) The assumption of the maternal role: a developmental process</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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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        <div id="topic_4-2" class="content">
          <h1 id="top">4.2 Labor interventions</h1>
          <div>
    <p> The care a mother experiences during labor and birthing can affect breastfeeding and how she cares for her baby. Birth practices that help the mother to feel competent, in control, supported and ready to interact with her baby include: </p>
    <ul>
      <li>Emotional support during labor</li>
      <li>Freedom of movement during labor</li>
      <li>Offering light foods and fluids during labor</li>
      <li>Avoidance of unnecessary caesarean section</li>
      <li>Early mother-infant contact</li>
      <li>Facilitating the first feed</li>
    </ul>
    <p> When labor interventions are considered factor in the following information. </p>
  </div>
          <div class="section" id="Analgesia_during_labor"><h2>Analgesia during labor</h2>
    <div>
      <p> The most commonly used intrapartum analgesics are potent narcotics, all of which are known to cause sedation and respiratory depression in the mother and the baby, and also to affect behavior. </p>
      <ul>
        <li>Morphine has a short half-life (1.5 - 2 hrs) and does not have an active metabolite</li>
        <li>Butorphanol (Stadol) has a half-life of 3 - 4 hours.</li>
        <li>Nalbuphine (Nubain) has a half-life of 5 hours.<sup><a href="#note1">1</a></sup></li>
        <li>Meperidine (Pethidine/Demerol) is metabolized to the active metabolite normeperidine (norpethidine) which has a long half-life (63 hours in the neonate). Meperidine/Pethidine reaches its highest levels in the fetus 2 to 3 hours after administration, however normeperidine/norpethidine levels continue to rise the longer it is until birth. Normeperidine/norpethidine still has half the pharmacological activity of meperidine/pethidine.</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/thinker.gif" class="icon" alt="" /><h3>How long will the effects of meperidine/pethidine be experienced by the newborn baby?</h3>
      <div>
        <p>
			It takes approximately 5 half-lives for a substance to reach insignificant serum (blood) concentration. How long will it take the newborn baby to clear normeperidine and its effects from his system?
		</p>
        <p>Multiply 63 hours by 5 times; then divide by 24 to have your answer in days.</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>
    <blockquote>
      <div>
        <ol>
          <li>Shorter-acting opiates such as fentanyl are preferred. Remifentanil is potent and has rapid onset and offset but can be associated with a high incidence of maternal apnea, requiring increased monitoring. Its transfer in utero to the fetus is minimal.</li>
          <li>Meperidine/pethidine generally should not be used except in small doses less than 1 hour before anticipated delivery because of greater incidence and duration of neonatal depression, cyanosis, and bradycardia.</li>
          <li>Nalbuphine, butorphanol, and pentazocine may be used for patients with certain opioid allergies or at increased risk of difficult airway management or respiratory depression. However, these medications may interfere with fetal heart rate monitoring interpretation. Observe the mother and infant for psychotomimetic reactions (3%).</li>
          <li>Multiple doses of intravenous analgesic, and their timing of administration may lead to greater neonatal effects. For example, fentanyl administration within 1 hour of delivery or meperidine/pethidine administration between 1 and 4 hours before delivery is associated with more profound neonatal effects.<sup><a href="#note2">2</a></sup></li>
        </ol>
      </div>
    <p class="cite">From Academy of Breastfeeding Medicine, Protocol #15. Montgomery A, Hale T, et al. 2006</p></blockquote>
    <div>
      <p>
		Other forms of analgesia such as inhaled nitrous oxide, paracervical block, pudendal block and local perineal anaesthesia expose the infant to minimal quantities of medication and may be an alternative to intravenous narcotics or epidural analgesia.
	</p>
    </div>
  </div>
          <div class="section" id="Neuraxial_pain_relief_epidural_spinal_"><h2>Neuraxial pain relief (epidural/spinal)</h2>
    <div>
      <p> Anesthetics such as lignocaine and bupivacaine are commonly administered via the epidural route to mothers in labor to provide pain-free birthing. This local anesthetic is almost always combined with narcotics such as morphine, fentanyl or sufentanil, providing a rapid onset of pain relief while reducing the intensity of immobility for the mother. </p>
      <p class="listTitle">While epidurals in labor provide greater pain relief than non-epidural methods, they are also associated with:<sup><a href="#note3">3</a></sup></p>
      <ul>
        <li>longer first and second stages of labor,</li>
        <li>maternal fever<ul><li>followed by septic work-up of infant, and maternal/infant separation, and possibly antibiotic therapy</li></ul></li>
        <li>a drop in blood pressure<br /><ul><li>fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days<br /></li></ul></li>
        <li>problems passing urine</li>
        <li>an increased use of oxytocin augmentation</li>
        <li>an increased incidence of fetal malposition,</li>
        <li>an increased need for instrumental vaginal delivery</li>
        <li>the mother being unable to move for a period of time after the birth, and</li>
        <li>the possibility of a postdural puncture headache<sup><a href="#note4">4</a></sup> palliatively treated by horizontal bed rest, and usually further medical intervention.</li>
      </ul>
    </div>
    <blockquote>
      <div>Medications administered via epidural or spinal routes rapidly enter the maternal circulation, are measurable in the fetal circulation within 10 minutes<sup><a href="#note5">5</a></sup> and may persist for up to 3 days in the newborn.<sup><a href="#note6">6</a></sup> <br /></div>
    </blockquote>
    <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>Did you know?</h3>
      <div>Another side effect of epidural administration is the fall in maternal serum beta endorphins.<sup><a href="#note7">7</a></sup> <span style="font-weight: bold;">Beta-endorphins</span> are a naturally occurring opiate that, like other opiates, act as an analgesic, inducing feelings of pleasure, euphoria, and dependency or, with a partner, mutual dependency. <br /><p></p> <ul><li>levels increase throughout pregnancy; high levels at the end of pregnancy are associated with a decreased need for intrapartum analgesia.<sup><a href="#note8">8</a></sup> Such high levels help the laboring woman to transmute pain and enter the altered state of consciousness that characterizes an undisturbed birth.<sup><a href="#note9">9</a></sup></li><li>Beta-endorphins are found in colostrum; it is thought they contribute to postnatal fetal adaptation, to overcoming birth stress, to the postnatal development of several related biologic functions of breastfed infants and may persist for up to 3 days.<sup><a href="#note10">10</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note11">11</a>,</sup><sup><a href="#note12">12</a></sup></li></ul><p></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="Cesarean_caesarean_section_or_vaginal_instrumental_birth"><h2>Cesarean (caesarean) section or vaginal instrumental birth</h2>
    <div>
      <p>
		Cesarean birth is most often associated with delayed skin-to-skin contact between mother and baby and longer time to first breastfeed. Hospitals practicing Step 4 of the 10 Steps to Successful Breastfeeding are, however, diligent at ensuring a minimum disruption to this important bonding and breastfeeding step.
	</p>
      <ul>
        <li>Rowe-Murray et al (2002)<sup><a href="#note13">13</a></sup> reported a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance.</li>
        <li>Shawky &amp; Abalkhail (2003)<sup><a href="#note14">14</a></sup> found caesarean section delivery to be significantly related to earlier cessation of breastfeeding.</li>
        <li>Leung et al (2002)<sup><a href="#note15">15</a></sup> identified caesarean delivery was a risk factor for not initiating breastfeeding, for breastfeeding less than 1 month, and it remained a significant hazard against breastfeeding duration.</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/thinker.gif" class="icon" alt="" /><h3>Interesting research</h3>
      <div>An interesting study<sup><a href="#note16">16</a></sup> looked at whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency cesarean section or vaginally, and if those patterns showed any relation to the duration of breastfeeding. They found that the mothers birthing vaginally had significantly more oxytocin pulses on Day 2 than the cesarean section mothers. Furthermore, the cesarean section women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. They were able to link the oxytocin pulsatility on Day 2 to the duration of exclusive breastfeeding.</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>
		Don't forget the effects of the operation itself: an abdominal incision, pain, restricted movement, intravenous therapy, a urinary catheter, analgesics for several days, restricted oral intake and any complications arising from these interventions. Rooming-in is more difficult, at least initially.
	</p>
      <p>
		The baby has an increased risk of respiratory problems, and is subjected to suctioning of mouth and oropharynx. Some units purposely separate the post-cesarean delivered baby from its mother for "observation" for several hours and may perform routine heel prick blood tests. Due to separation and the desire of the staff to let the mother 'rest', the baby may be given formula supplements.
	</p>
      <p>
		All of these factors have the potential to limit the frequency, effectiveness and, ultimately, duration of breastfeeding.
	</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"><h3></h3>
      <div class="captionBox"><object classid="clsid:d27cdb6e-ae6d-11cf-96b8-444553540000" codebase="http://fpdownload.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=8,0,0,0" width="425" height="350"><param name="movie" value="http://www.youtube.com/v/m5RIcaK98Yg" /><param name="wmode" value="transparent" /><embed wmode="transparent" src="http://www.youtube.com/v/m5RIcaK98Yg" type="application/x-shockwave-flash" pluginspage="http://www.macromedia.com/go/getflashplayer" width="425" height="350"></embed></object><p>The Natural Caesarean. A wonderful way to support the mother and respect the baby when birth is by caesarean. This 12 minute video is from Youtube. (Some hospitals block youtube - view from a home computer) </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>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                  <img src="design/callout_04.png" width="10" height="80" alt="" />
                </td>
                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Pregnancy classes</h3>
    <div>
      <p>
			What is included about birthing interventions in the curriculum of the pregnancy classes where you work? Do all pregnant women know the effects of interventions on themselves and their baby? Do they have to give consent prior to any of these procedures? How well informed is this consent?
		</p>
      <p>
			Form a group to review the pregnancy class curriculum.
		</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="" />
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          </table>
          <div class="section" id="Assisting_a_mother_following_an_assisted_delivery"><h2>Assisting a mother following an assisted delivery</h2>
    <div>
      <ul>
        <li> Initiate skin-to-skin contact as soon as possible <ul><li>immediately following vaginal delivery if baby does not require advanced life support.</li><li>as soon as possible if caesarean section under epidural or spinal analgesia. <span class="aside">Many hospitals facilitate this while the surgeon closes the wound.</span></li><li>as soon as the mother is responsive if caesarean section under general anaesthetic. <span class="aside">Place baby in skin-to-skin contact with father or other close family until mother available.</span></li><li>If contact must be delayed initiate skin-to-skin contact at the earliest opportunity.</li></ul> </li>
        <li> Assist with breastfeeding as soon as possible. <ul><li>The mother does not need to be able to sit up, to hold her baby, or meet other mobility criteria in order to breastfeed.</li><li>It is the baby that is finding the breast and suckling.</li><li>As long as there is a support person with them, the baby can go to the breast if the mother is still sleepy from anesthesia.</li></ul> </li>
        <li>Help the mother find a comfortable position. <ul><li>Side-lying in bed. This position helps to avoid pain in the first hours and allows breastfeeding even if the mother must lie flat after spinal anesthesia.</li><li>Sitting up with a pillow over the incision or with the baby held along the side of her body with the arm closest to the breast.</li><li>Lying flat with the baby lying on top of the mother.</li></ul> </li>
        <li>Facilitate rooming-in with assistance, until mother is able to care for baby.</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/books.png" class="icon" alt="" /><h3>Workbook Activity 4.3</h3><p>Complete Activity 4.3 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>
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>What can you do?</h3>
    <div>
      <ul>
        <li>Discuss ways to cope with pain and discomfort, and their risks and benefits, during antenatal care.</li>
        <li>Provide a supportive environment for birthing - lessens need for analgesia and assisted delivery.</li>
        <li>Be prepared to allow extra time and assistance to establish breastfeeding and bonding following intrapartum medications and assisted delivery.</li>
      </ul>
    </div>
  </td>
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          </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>all interventions in labor carry a risk for both mother and infant which must be weighed against the need for the intervention</li>
          <li>that all drugs given in labor transfer to the infant and most will have a deleterious effect on the infant's ability to breastfeed, or the mother's lactation</li>
          <li>when interventions are unavoidable mother and baby both need extra help and support to establish their relationship and breastfeeding<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_h">
<script type="text/javascript">
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	new MCQ('Which of the following forms of analgesia available to a laboring mother will have the least transfer to, and therefore the least effect on her baby?', [{text:'intramuscular injection of pethidine/meperidine',feedback:'No, this drug has the potential to have far-reaching effects on the baby.',score:0},{text:'intravenous injection of fentanyl',feedback:'If given to the mother within an hour of birth the baby will be affected',score:0},{text:'morphine administered via the epidural or spinal route',feedback:'Absorption and transfer of drugs administered via this route is quite rapid, and therefore the baby will be affected',score:0},{text:'inhaled nitrous oxide',feedback:'That\'s right. This drug is poorly transferred to the fetus and has a very short half-life; its effects will wear off the baby very rapidly.',score:1}]),
	new MCQ('This potent pain suppressant, that aids the infant to overcome birth stress and contributes to postnatal fetal adaptation, is found in high levels in the colostrum of women who have not had epidural pain relief in labor.', [{text:'prolactin',feedback:'This hormone is found in breastmilk, but does not have this function.',score:0},{text:'meperidine (pethidine/demerol)',feedback:'This drug is found in breastmilk, but does not have any positive effects on the infant.',score:0},{text:'beta endorphins',feedback:'Correct. This naturally occurring opiate has many positive effects on mother and baby, but is reduced when neuraxial pain relief is used.',score:1},{text:'lignacaine or bupivacaine',feedback:'These drugs do not have this effect.',score:0}]),
	new MCQ('Epidural analgesia has been noted to have all of the following effects on breastfeeding, EXCEPT:', [{text:'increases the mothers risk of engorgement',feedback:'That\'s true. The increased fluids administered with an epidural may cause edema/oedema of the breasts; and also a baby feeding poorly often results in engorgement too. (I know this wasn\'t in your notes - even the quiz is for learning.)',score:0},{text:'babies experience more stress',feedback:'Longer labor, more risk of instrumental delivery, reduced endorphins to help them adapt ... sounds pretty stressful.',score:0},{text:'babies are less likely to breastfeed effectively in the first 24 hours',feedback:'This happens too, but not because they didn\'t want to breastfeed - they have just as many attempts as other babies, but are less able to suckle effectively.',score:0},{text:'babies are less likely to be breastfeeding at 2 months and 6 months of age.',feedback:'This has been found by some researchers.',score:0},{text:'detectable levels of the drug used is still found in breastmilk up to 24 hours after the epidual was removed',feedback:'Fortunately this is not true. The mother\'s liver and kidneys is much more efficient than the neonates and she will clear the drugs from her system, including her breastmilk, quite quickly - once the epidural is discontinued.',score:1}]),
	new MCQ('How soon after either a cesarean section or an assisted vaginal delivery should the infant be placed on the mother\'s chest in skin-to-skin contact?', [{text:'immediately',feedback:'Yes that\'s correct. Mother and baby are going to need all the help they can get to establish their relationship and begin breastfeeding following a birth that included interventions.',score:1},{text:'as soon as possible after the mother has been made comfortable',feedback:'No, this is too much delay. Both mother and baby need your support immediately.',score:0},{text:'after the initial steps or resuscitation and baby has been dried and well wrapped for warmth',feedback:'No. Resuscitation can occur in skin-to-skin contact, as can drying the infant. The mother will stabilise the baby\'s temperature.',score:0},{text:'Upon return to her room when she is able to sit up and hold her infant.',feedback:'This care is very draconian. Mother and baby need each other and should not be separated.',score:0}])
]};

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</div><script type="text/javascript">renderActivity('h');</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 id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#hale02" title="See full details">#</a> Hale TW (2002) Medications and Mothers' Milk</li>
              <li id="note2"><a href="references.html#mont06" title="See full details">#</a> Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.</li>
              <li id="note3"><a href="references.html#anim05" title="See full details">#</a> Anim-Somuah M et al. (2005) Epidural versus non-epidural or no analgesia in labour.</li>
              <li id="note4"><a href="references.html#vinc98" title="See full details">#</a> Vincent RD et al. (1998) Epidural Analgesia During Labor</li>
              <li id="note5"><a href="references.html#rose81" title="See full details">#</a> Rosenblatt DB et al. (1981) The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine</li>
              <li id="note6"><a href="references.html#sepk92" title="See full details">#</a> Sepkoski CM et al. (1992) The effects of maternal epidural anesthesia on neonatal behavior during the first month</li>
              <li id="note7"><a href="references.html#rais84" title="See full details">#</a> Raisanen I et al. (1984) Pain and plasma beta-endorphin level during labor</li>
              <li id="note8"><a href="references.html#dabo10" title="See full details">#</a> Dabo F et al. (2010) Plasma levels of beta-endorphin during pregnancy and use of labor analgesia.</li>
              <li id="note9"><a href="references.html#buck02" title="See full details">#</a> Buckley S (2002) Ecstatic Birth: The Hormonal Blueprint of Labor</li>
              <li id="note10"><a href="references.html#ombr08" title="See full details">#</a> Ombra MN et al. (2008) beta-Endorphin concentration in colostrums of Burkinabe and Sicilian women.</li>
              <li id="note11"><a href="references.html#zana01a" title="See full details">#</a> Zanardo V et al. (2001) Labor Pain Effects on Colostral Milk Beta-Endorphin Concentrations of Lactating Mothers</li>
              <li id="note12"><a href="references.html#zana01" title="See full details">#</a> Zanardo V et al. (2001) Beta Endorphin Concentrations in Human Milk</li>
              <li id="note13"><a href="references.html#rowe02" title="See full details">#</a> Rowe-Murray HJ et al. (2002) Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding</li>
              <li id="note14"><a href="references.html#shaw03" title="See full details">#</a> Shawky S et al. (2003) Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia</li>
              <li id="note15"><a href="references.html#leun02" title="See full details">#</a> Leung GM et al. (2002) Breast-feeding and its relation to smoking and mode of delivery</li>
              <li id="note16"><a href="references.html#niss96" title="See full details">#</a> Nissen E et al. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_4-3" class="content">
          <h1 id="top">4.3 Postnatal interventions</h1>
          <div class="section" id="Separation_of_mother_and_newborn"><h2>Separation of mother and newborn</h2>
    <div>
      <p>
		From an evolutionary perspective skin-to-skin care is the norm. Routine separation of the newborn from its mother soon after birth is unique to the 20th Century. At the risk of laboring the point, separating the mother and baby after birthing for any reason, other than medical emergency, is NOT applying best practice care. All indicators of infant well-being and successful extrauterine adaptation are stabilized better and faster when the newborn is in skin-to-skin contact with its mother from immediately after birth for the first few hours, or at least until after the first breastfeed.
	</p>
    </div>
    <div class="section" id="Effect_on_newborn"><h3>Effect on newborn</h3>
      <div class="columns"><div class="column" style="width: 40%">
          <div>
            <p>A researcher in behavioral neuroscience described the innate behaviors of the newborn that occur when the infant remains with his mother immediately following birth. <br />When mother and infant are separated the infant exhibits firstly distress cries, followed by what is described as "protest-despair" behavior.<sup><a href="#note1">1</a></sup> </p>
          </div>
        </div><div class="column" style="width: 60%">
          <div class="captionBox"><img width="396" height="266" src="images/newborn_weigh_trudy.jpg" alt="Note the protest response being exhibited by this newborn." /><p>Note the protest response being exhibited by this newborn. <br />Photo &copy;  T.Young, RM</p></div>
        </div></div><br style="clear: both" />
      <div class="columns"><div class="column" style="width: 40%">
          <div>
            <p> Separation distress cries have been documented in newborns. Separated newborns make 10 times more crying signals than babies in skin-to-skin care, and their cries have a completely different character.<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> During the "protest" response there is intense activity seeking the mother, followed by "despair" behavior which sees the baby withdraw with decreased heart rate and temperature, mediated by a massive rise in stress hormones.<sup><a href="#note4">4</a></sup> </p>
          </div>
        </div><div class="column" style="width: 60%">
          <div class="captionBox"><img width="394" height="428" src="images/newborn_swaddled.jpg" alt="What stage is this newborn exhibiting?" /><p>What stage is this newborn exhibiting? <br />Photo &copy;  D.Fisher, IBCLC</p></div>
        </div></div><br style="clear: both" />
    </div>
    <div class="section" id="Effect_on_oxytocin"><h3>Effect on oxytocin</h3>
      <div>
        <p>Oxytocin levels are highest around the time of birthing. Oxytocin cannot cross from the peripheral circulation into the brain; therefore it is only naturally occurring oxytocin released by the posterior pituitary gland that will have an effect on the mother's temperament, ie. not oxytocin administered to the mother. </p>
        <p></p>
        <p class="listTitle">Oxytocin causes<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a></sup></p>
        <ul>
          <li>increased uterine contraction limiting postpartum blood loss,</li>
          <li>the temperature of the mother's breast to rise, providing warmth for the infant,</li>
          <li>an anti-stress effect, reducing maternal blood pressure and cortisol levels and releasing gastrointestinal hormones,</li>
          <li>a state of calmness and social responsiveness,</li>
          <li>bonding with their infant, and enhanced maternal behaviors,</li>
          <li>milk ejection; important at this time prior to it becoming conditioned by the suckling stimulus.</li>
        </ul>
        <p>During the time the infant in skin-to-skin contact after birthing is making massage-like movements on the mother's chest and breasts the maternal serum oxytocin levels rise.<sup><a href="#note7">7</a></sup> The infant begins these hand movements soon after birth and continues until he self-attaches and suckles. </p>
        <p> The work of Michel Odent is well recognized by those involved in obstetrics. Odent's studies of the effects of oxytocin and other hormones of birthing are worthwhile following. In 2001 he wrote: </p>
        <p> </p>
      </div>
      <blockquote>
        <div>The age of cesarean sections on request, epidurals and drips of oxytocin is a turning point in the history of childbirth. Until recently women could not give birth without releasing a complex cocktail of 'love hormones'. Today, in many countries, most women have babies without releasing these specific hormones. The questions must be raised in terms of civilization. This turning point occurs at the very time when several scientific disciplines suggest that the way human beings are born has long-term consequences, particularly in terms of sociability, aggressiveness or, in other words, 'capacity to love'. <sup><a href="#note8">8</a></sup></div>
      <p class="cite">Odent, 2001</p></blockquote>
      <div>
        <p>
			With this in mind, the importance of skin-to-skin contact for mothers and babies who experience an assisted birthing appears to be even more important.
		</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"><a href="http://www.health-e-learning.com/resources/articles/34-falling-in-love" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.health-e-learning.com/resources/articles/34-falling-in-love]</span><h3><a href="http://www.health-e-learning.com/resources/articles/34-falling-in-love" target="_blank">Falling in Love</a><span class="linkDescription">[link: http://www.health-e-learning.com/resources/articles/34-falling-in-love]</span></h3>
        <div>
          <p>Click on the icon on the left and read the article.</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="Effect_on_breastfeeding"><h3>Effect on breastfeeding</h3>
      <div>
        <p> Learning is a dimension of behavior and physiology, and the human neonate has evolved to learn how to suckle when in skin-to-skin contact.<sup><a href="#note1">1</a></sup> </p>
        <p> Most babies (27 out of 34) who were separated from their mothers after 19 minutes for routine weighing procedures and then returned for feeding either refused to suckle, or demonstrated superficial nipple sucking techniques. The difference between two groups (one group remained in skin-to-skin contact) in ability to attach to the breast and suckle correctly for effective milk removal was significant (p&gt;0.001).<sup><a href="#note9">9</a></sup></p>
      </div>
    </div>
  </div>
          <div class="section" id="Washing_mother_or_newborn"><h2>Washing mother or newborn</h2>
    <div>
      <p> Washing the mother and/or baby is also to be discouraged. Infants localize the nipple by smell and have a heightened response to odor cues in the first few hours after birth. When one of the mother's breasts is washed after birthing 22 out of 30 infants preferentially self-attached to the unwashed breast.<sup><a href="#note10">10</a></sup> </p>
    </div>
    <blockquote>
      <div>
        <p> Breast odours from the mother exert a pheromone-like effect at the newborn's first attempt to locate the nipple. Newborns are generally responsive to breast odours produced by lactating women. Olfactory recognition may be implicated in the early stages of the mother-infant attachment process, when the newborns learn to recognize their own mother's unique odour signature.<sup><a href="#note11">11</a></sup> </p>
      </div>
    <p class="cite">Winberg, 1998</p></blockquote>
  </div>
          <div class="section" id="Suctioning_of_the_newborn"><h2>Suctioning of the newborn</h2>
    <div>
      <p> Oral aversion as an outcome of routine oropharyngeal or gastric suctioning or intubation is often cited by clinicians as a cause of breastfeeding difficulty, but little research is available to confirm this. <br /></p>
      <p>Fortunately routine oral and gastric suctioning is no longer recommended, it's effects proving to be harmful to more than just the infant's ability to suck.<sup><a href="#note12">12</a></sup> <br />Routine gastric suctioning, involving the passage of a tube into the neonate's stomach and aspiration of the contents has been linked to a delay in infant pre-feeding behaviours<sup><a href="#note13">13</a></sup> and an increased prevalence of functional intestinal disorders in later life.<sup><a href="#note14">14</a></sup><br /></p>
    </div>
  </div>
          <table class="callout">
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                  <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 4.4</h3>
                  <p>Complete Activity 4.4 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="" />
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            </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>Group Activity</h3>
    <div>
      <p>Form a small group to firstly compare your lists of the benefits of keeping mothers and babies together in skin-to-skin contact, then list all the interruptions to this by birthing room staff or others.</p>
      <p>Together, look at each interruption separately and develop strategies for change to prevent these separations. </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>where the normal place to care for a newborn is from immediately after birth and for several hours following</li>
          <li>the behavioural state and physiological response of the infant who is wrapped up and separated from his/her mother</li>
          <li>the baby's role in causing an oxytocin response in the mother and the effect this has on her</li>
          <li>how separation of mother and baby, even for a short time, affects his/her ability to 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="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_i">
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	new MCQ('What is the hormone that is released in the mother as the newborn infant makes hand movements and begins to move towards the breast?', [{text:'Prolactin',feedback:'No, not this one.',score:0},{text:'Oxytocin',feedback:'Yes that\'s correct. Take a moment to read over some of the many effects of oxytocin again.',score:1},{text:'Progesterone',feedback:'No, not this hormone.',score:0},{text:'Beta endorphin',feedback:'No, not this one.',score:0}]),
	new MCQ('When the practices of a birthing unit are based on best-practice principles where will the newborn infant be cared for immediately following birth?', [{text:'Taken immediately to the resuscitation area until cardiorespiratory stability achieved.',feedback:'It is not necessary to separate mother and baby for this - it occurs more quickly in skin-to-skin contact.',score:0},{text:'To the end of the birthing bed until dried, resuscitated and wrapped warmly.',feedback:'No. This reflects poor practices.',score:0},{text:'Placed in skin-to-skin contact on mother\'s chest.',feedback:'Yes, that\'s correct.',score:1},{text:'Handed to the father to hold until medical procedures, such as delivering the placenta, have been completed.',feedback:'No. The correct place for baby will see a big surge of oxytocin which helps to deliver the placenta - this is not the place.',score:0}]),
	new MCQ('When a newborn baby is separated from its mother it exhibits firstly distress cries, followed by what type of behavior?', [{text:'Quiet, alert state',feedback:'They do appear quiet, but not because they are happily alert.',score:0},{text:'Seeking the breast prior to latching.',feedback:'That would be difficult - they\'re separated.',score:0},{text:'A deep sleep.',feedback:'Part of the response could look like this.',score:0},{text:'Protest-despair behavior.',feedback:'Correct. There is a big biochemical change that is occurring in the separated infant.',score:1}]),
	new MCQ('Why is it important not to wash the mother, particularly her breasts, soon after birthing?', [{text:'Because the baby will use the smell of the breasts to locate the nipple and latch.',feedback:'Yes. It\'s pretty amazing isn\'t it.',score:1},{text:'To prevent the risk of a postpartum haemorrhage.',score:0},{text:'Because it would disturb the baby on her chest.',feedback:'It would, but that\'s not the main reason.',score:0},{text:'To save time following the birth.',score:0}])
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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>
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          <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 4 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 4.
	</p>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#albe94" title="See full details">#</a> Alberts JR (1994) Learning as adaptation of the infant.</li>
              <li id="note2"><a href="references.html#mich96" title="See full details">#</a> Michelsson K et al. (1996) Crying in separated and non-separated newborns: sound spectrographic analysis</li>
              <li id="note3"><a href="references.html#chri95" title="See full details">#</a> Christensson K et al. (1995) Separation distress call in the human neonate in the absence of maternal body contact</li>
              <li id="note4"><a href="references.html#berg03" title="See full details">#</a> Bergman N (2003) Humans and Kangaroos: A Biological Perspective</li>
              <li id="note5"><a href="references.html#matt01" title="See full details">#</a> Mattos-Graner RO et al. (2001) Relation of oral yeast infection in Brazilian infants and use of a pacifier</li>
              <li id="note6"><a href="references.html#uvna98" title="See full details">#</a> Uvnas-Moberg K (1998) Oxytocin may mediate the benefits of positive social interactions and emotions</li>
              <li id="note7"><a href="references.html#matt01a" title="See full details">#</a> Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking</li>
              <li id="note8"><a href="references.html#oden01" title="See full details">#</a> Odent M (2001) New reasons and new ways to study birth physiology</li>
              <li id="note9"><a href="references.html#righ90" title="See full details">#</a> Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed</li>
              <li id="note10"><a href="references.html#vare94" title="See full details">#</a> Varendi H et al. (1994) Does the newborn baby find the nipple by smell?</li>
              <li id="note11"><a href="references.html#winb98" title="See full details">#</a> Winberg J et al. (1998) Olfaction and human neonatal behaviour: clinical implications</li>
              <li id="note12"><a href="references.html#clif10" title="See full details">#</a> Clifford M et al. (2010) Neonatal resuscitation.</li>
              <li id="note13"><a href="references.html#wids87" title="See full details">#</a> Widstrom AM et al. (1987) Gastric suction in healthy newborn infants. Effects on circulation and developing feeding behaviour</li>
              <li id="note14"><a href="references.html#anan04" title="See full details">#</a> Anand KJ et al. (2004) Gastric suction at birth associated with long-term risk for functional intestinal disorders in later life</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_5-0" class="content">
          <h1 id="top">5.0 Breastfeeding the Baby</h1>
          <div><p> There is no knowledge or skill more important for you to possess and pass on to mothers than how to position their babies for comfortable latching and efficient milk transfer. If positioning and latching isn't correct then breastfeeding isn't working at all. When a mother is confident her baby is breastfeeding well there's very little else she needs to know to be successful. </p><p> Mothers who have the confidence to breastfeed their babies find it an empowering experience. Teaching by 'hands-off' methods will enhance the mother's confidence when her baby achieves good latch. </p><p> The best time to commence feeding an infant is when he first exhibits cues that he is ready to feed. When early cues are ignored the infant's behaviour will progressively become more agitated until he is crying, making latching more difficult. If the feed is further delayed the infant may tire quickly and feed poorly once feeding is finally offered. </p><p class="listTitle">Early feeding cues</p><ul><li>mouthing and non-nutritive sucking - the infant moves his mouth in a searching or sucking manner</li><li>subtle body movements, wriggling</li><li>rooting when face touched</li><li>hand-to-mouth movements, with or without sucking on hand</li></ul>(<span style="font-style: italic;">Note</span>: the infant may progress through these signals very quickly - immediate attention to these signals will meet the baby's needs and initiate a more effective breastfeed)<br /></div>
          <div class="captionBox">
            <img width="295" height="469" src="images/early_feeding_cue_cropped.jpg" alt="Newborn displaying early feeding cue." />
            <p>Newborn displaying early feeding cue. <br />&copy; D.Fisher, IBCLC</p>
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                <td class="body">
                  <img src="design/books.png" class="icon" alt="" />
                  <h3>Workbook Activity 5.1</h3>
                  <p>Complete Activity 5.1 in your workbook.</p>
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                <td class="body"><h3>Answering baby's cues</h3>
    <div></div><div class="activity" id="activity_j">
<script type="text/javascript">
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var jqs = {settings : {type : 'response'}, questions : [
	{ c : 'The mother can be immediately responsive to her baby\'s cues when she wears her baby on her chest or carries him in a sling/pouch. <br/>What about the baby who is laid to sleep in a bed or cot? What other suggestions could you give a mother about being alert to her baby\'s feeding cues?<br/>', r : '<ul><li>Move the baby\'s cot into the main room of the house where the mother is spending her time.</li><li>Sleep the baby in the pram (stroller) and move it from room to room as the mother continues her activites.</li><li>Use a \'baby monitor\' if the baby is sleeping in another room...........(Is it safe to sleep a baby in a room which is so far away that it can only be heard with a baby monitor?)</li><li>At night, safely bed-share or ensure the baby\'s cot is in the same room as the mother.</li></ul><br/>' }
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          <div class="section" id="It_s_a_team_effort_"><h2>It's a team effort!</h2>
    <div>
      <p>
		The team consists of the mother and the baby.  Supporters of the team include the baby's father, the mother's other relatives and friends, and her health care providers. 
	</p>
      <p>
		The mother's role is to position the baby to facilitate his breastfeeding reflexes; the baby's role is to be free to respond to the stimulation of those reflexes. If not interfered with the baby's reflexes will cause him to latch perfectly to the mother's breast and suckle effectively. The role of the health professional is to guide the mother to position the baby so that the baby's reflexes are stimulated - not to either do it for the mother and baby, nor to tell the mother how she should latch the baby.
	</p>
    </div>
    <div class="section" id="Preparing_to_guide_the_mother"><h3>Preparing to guide the mother</h3>
      <div>
        <p> Expensive teaching aids aren't necessary to demonstrate good positioning and latch. Common positioning and latching problems can be avoided by using these simple strategies. </p>
        <ul>
          <li>Demonstrate positioning using a doll. This is an effective visual aid.</li>
          <li>Ask the mother to try to swallow when her head is turned to one side, or when her head is tilted forward. This demonstrates how difficult it would be for baby to swallow if he had to turn his head or flex his neck to latch.</li>
          <li>Ask the mother suck on her own thumb. Firstly have her put her thumb midway into her mouth and suck, then move the thumb back to the junction of the soft and hard palate and suck. Ask her to compare the effort required to keep the thumb in her mouth in both positions and the different tongue action necessary in each position. This may help the mother to understand the importance of facilitating a deep latch where her nipple will move to the back of the baby's mouth to prevent undue pressure on the nipple.</li>
          <li>Show the mother a photograph of a baby who is well latched to the breast to demonstrate how wide and deep the latch should be.</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>What's your practice like?</h3>
        <div>
          <p> How do you assist a mother to position and latch her baby? How often do you achieve this being totally 'hands off'? Note the number of times the mother latches her baby well herself after your 'hands off' instructions, and the number of times you give hands-on assistance. Think about why you are needing to do it for her, or giving her significant assistance. Reflect on ways to reduce the number of times hands-on assistance is necessary. </p>
          <p> How would you feel about benchmarking your results against those of several of your colleagues? Get a small group together that you feel 'safe' with and keep your individual statistics for a month, then compare them. Explanations for unsuccessful cases can be discussed together. </p>
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  </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>Ways to teach and pass on knowledge without touching</li>
          <li>Variations of early feeding cues</li>
          <li>A baby who is crying in hunger is detrimental to breastfeeding</li>
        </ul>
        <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>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_5-1" class="content">
          <h1 id="top">5.1 Positioning Principles</h1>
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                <td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>It's fundamental!</h3>
    <div>
      <p>The mother provides the position. The baby does the latching (attaching).</p>
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          <div class="section" id="Mother_s_position"><h2>Mother's position</h2>
    <div>
      <p>Observation of experienced mothers will reveal that they adopt a myriad of positions for breastfeeding throughout the day, even walking. A breastfeed may last from a few minutes up to an hour. And the mother will repeat this many times a day for at least a year. Your guidance to her is simply to adopt a position that will avoid muscle strain and in which she is comfortable. <br /></p>
      <p>Lying positions are comfortable and facilitate rest while feeding and are particularly helpful with a newborn baby when the mother is still recovering from the birth experience.<br /></p>
      <p> Once the mother's dexterity and confidence increase most breastfeeds will probably occur sitting.</p>
    </div>
  </div>
          <div class="section" id="Baby_s_position"><h2>Baby's position</h2>
    <div>
      <p> The infant's position refers to two underlying factors:</p>
      <p> - the infant's position in relation to his mother eg. baby is lying horizontally/obliquely and mother is sitting vertically, mother and baby are both side lying on bed.<br /></p>
      <p>- the infant's own body position eg. straight back (not curved), head aligned with spine (not turned to side), slightly extended head (not flexed), prone or lateral.<br /></p>
      <p> From birth until about 3 to 4 months of age a baby's feeding behaviour is instinctive and reflexive. All actions should facilitate the baby's innate abilities rather than mother (or you) controlling the baby. </p>
      <p> When he is correctly positioned he will have control of his head and neck. In this position he is able to easily accommodate a suck/swallow/breathe sequence for several minutes at a time without distress when the milk flow is rapid. </p>
    </div>
    <div class="section" id="Principles_of_positioning"><h3>Principles of positioning</h3>
      <div><ul> </ul><ul><li><strong>Sensory input:</strong> Babies depend on smell and skin-to-skin contact to initiate their feeding behaviour. To elicit baby's instincts it is essential to stimulate these two senses. </li></ul><p> Skin-to-skin contact (ie baby and mother unrestricted by clothing from the waist up) is best in the early days or when experiencing any latching difficulties. Baby needs firm chest-to-chest contact against the mother's body to allow him to orientate and focus. Chest-to-chest contact will calm the baby and initiate his seeking behaviours. If the baby is clothed remove bulky outer clothing and blankets. </p>The unwashed breast has a unique and individual odour that stimulates prefeeding activity and delays crying in the baby.<sup><a href="#note1">1</a></sup> Only if necessary a drop of milk may be expressed and wiped over the mother's nipple and areola (the infant can smell his mother very easily so don't waste time doing this when the baby is frantically seeking to latch). <br /><br /><ul><li><strong>Positional stability:</strong> Positional stability is necessary for the baby to control his head movements. There are three aspects to this stability... </li></ul><span style="font-style: italic;">A stable base</span>: in human anatomy terms that base is provided for the head by the shoulder girdle. <br /><span style="font-style: italic;">Proximal stability</span>: infant's head and neck in alignment and supported, and<br /><span style="font-style: italic;">Midline symmetry</span>: ie. the muscles on either side of the spine are experiencing equal movement.<ul></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/books.png" class="icon" alt="" /><h3>Workbook Activity 5.2</h3><p>Complete Activity 5.2 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>
        <p> When sensory input and positional stability are achieved the baby will automatically move into the "<span style="font-style: italic;">Instinctive Position</span>". This position is described by Glover (2004)<sup><a href="#note2">2</a></sup> as the baby tilting his head back and leading with his jaw and mouth to the breast where his mouth opens wide, tongue down and over bottom gum line ready to take the breast into his mouth.</p>
      </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/tip.png" class="icon" alt="" /><h3>Applying the principles to practice</h3>
      <div><p class="listTitle">Instruct the mother to hold her baby</p><ul><li>with whole of baby's body facing and firmly supported against mother's body; <span style="font-weight: bold;">nose opposite the nipple</span>. <span class="aside">Sensory input and midline symmetry</span></li><li>a hand should be firmly placed on baby's back between the shoulder blades, stabilising the upper body against mother's body and breast. <span class="aside">Sensory input and stable base for the head</span></li><li>midline is straight from head to toe. (ie spine not twisted) <span class="aside">Midline symmetry</span></li><li>support baby's head on her forearm, pillow, bed, etc at the level of the breast. <span class="aside">Proximal stability</span></li></ul>The resultant latch will see a lot of areola/breast tissue under the nipple followed by the nipple, being taken into baby's mouth. His chin will be firmly against <span class="aside">(indenting!)</span> the breast while his nose is free to breathe, and the oro-pharynx will be wide open to allow unhindered swallowing. <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>
    <blockquote>
      <div>
        <p> For infants affected by prematurity, illness, a difficult birth, dysfunctional or poor muscle tone, positional turns, to name a few, this positioning is crucial to support and strengthen what functions and abilities they do have. Stabilized in this position, each feed has the potential to become a dynamic learning and exercise session for the infant to strengthen and coordinate muscle movement on both sides of the body. </p>
        <p> By teaching all mothers and babies this essential positioning I believe you are "treating" all sorts of "normal" anomalies before they have a chance to become a problem. When you see this transform an apparently difficult breastfeeding problem it is pure magic to behold. The simplicity will astound you." (Glover, 2004 p89-90)<sup><a href="#note2">2</a></sup></p>
      </div>
    </blockquote>
    <div class="section" id="Biological_nurturing_feeding_position"><h3>Biological nurturing feeding position</h3>
      <div>What does this mean? It is the natural, unstructured position which is adopted by mothers and babies where their own bodies provide the gravity assistance and positional stability.<br /><br />This is achieved when the mother is laid back in a semi-reclined position. The infant lies prone on top of his mother's chest. The combination of these two body positions will release the most primitive neonatal reflexes (PNR) for pre-feeding responses.<br /><br />Colson (2008)<sup><a href="#note3">3</a></sup> describes this as the<span style="font-weight: bold;"> biological nurturing position</span>. Twenty PNRs for pre-feeding have been identified. Colson's research found that mother and baby pairs who practice full biological nurturing positions released 15.9 PNR compared to only 11.6 PNR in the partial or non-biological nurturing pairs. Biological nurturing posture maximises the baby's sensory input and maintains positional stability as a result of the prone body position of the baby acting as a gravity pull towards the mother. The infant is able to use his hands to knead the breast, his feet to push off his mother's abdomen and thrust himself toward the breast, he will lift his head up into extension to allow his chin to push forward into the breast and prepare for latch.<br /><br /> All of the principles of position are achieved naturally using the mother's body and gravity to stabilize the infant on her. This is a natural position for a mother to assume after birth - semi-reclining with her baby on her chest (it is also an enforced position following a cesarean section). We now know that it is this position in particular which is the stimulus for baby self-attachment, ie. innate responses.<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/tip.png" class="icon" alt="" /><h3>Start at the beginning</h3>
        <div>Do you see some mothers who are struggling with breastfeeding - they feel awkward and unsure how to hold the baby; maybe the baby's responses seem confused?<br /><br />Rather than rush in with an intervention, suggest that the mother lie back slightly and bring her baby onto her chest. Encourage her to talk to him and hold his back, being ready for him to "bob" his head towards her breast. She can assist to free his arms or support his head if he needs guidance.<br />No interference, maximum opportunity for baby and mother to perform at their best!<br /><br />(This is best in skin-to-skin for a newborn, however, it can be very successful for the older baby who has becomes confused and is also effective when infant clothed, but not restricted by blankets.)<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>
    <div class="section" id="The_principles_are_exactly_the_same_for_ALL_positions"><h3>The principles are exactly the same for ALL positions</h3>
      <div class="columns"><div class="column" style="width: 33%">
          <div class="captionBox"><img width="240" height="231" src="images/bn_1.jpg" alt="Laid back encourages prefeeding behaviour" /><p>Laid back encourages prefeeding behaviour. <br />&copy; B.Ingle IBCLC</p></div>
        </div><div class="column" style="width: 33%">
          <div class="captionBox"><img width="240" height="231" src="images/bn_2.jpg" alt="Laid back position" /><p>Laid back position. <br />&copy; B.Ingle IBCLC</p></div>
        </div><div class="column" style="width: 33%">
          <div class="captionBox"><img width="250" height="231" src="images/bn_3.jpg" alt="Laid back position:well-latched" /><p>Laid back position:well-latched. <br />&copy; B.Ingle IBCLC</p></div>
        </div></div><br style="clear: both" />
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="225" height="221" src="images/cradle225.jpg" alt="Cradle hold" /><p>Cradle hold. <br />&copy; D.Fisher, IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div class="captionBox"><img width="225" height="221" src="images/side_lying225.jpg" alt="Side lying" /><p>Side lying. <br />&copy; D.Fisher, IBCLC</p></div>
        </div></div><br style="clear: both" />
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="225" height="331" src="images/cross-cradle225.jpg" alt="Cross cradle hold" /><p>Cross cradle hold. <br />&copy; D.Fisher, IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div class="captionBox"><img width="225" height="331" src="images/football225.jpg" alt="Underarm hold" /><p>Underarm hold. <br />&copy; D.Fisher, IBCLC</p></div>
        </div></div><br style="clear: both" />
      <div>
        <p class="listTitle">Closely examine each of the photographs above noting:</p>
        <ul>
          <li>Is there adequate sensory input? <span class="aside">chest to chest and baby held firmly against mother's body?</span></li>
          <li>Is base stabilised? <span class="aside">check for support across back and between shoulder blades</span></li>
          <li>Is there proximal stability? <span class="aside">neck and head supported</span> NB** <strong>NEVER</strong> hold the back of the baby's head at any time during positioning, latching and feeding</li>
          <li>Is there midline symmetry? <span class="aside">baby's head and neck aligned with his spine; one arm on either side of breast</span></li>
          <li>Is chin firmly applied to breast, nose free to breathe?</li>
          <li>Is mother relaxed and well supported?</li>
          <li>Is mother's arm supporting baby held comfortably, with relaxed wrist and fingers?</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/warning.png" class="icon" alt="" /><h3>When the baby's head is held....</h3>
        <div>The infant cranium is very sensitive. Pressure on the back of the head (by mother or 'helper') will cause:<br /><ul><li>the infant to push back against that force, which of course, thrusts him away from the breast</li><li>moves the infant's head into flexion (remember that slight extension is necessary for a wide gape and the tongue to come forward)</li></ul><br />Overzealous or misplaced hands can create a struggle or fight with the breast between the mother and baby. Be mindful of this and ensure that all the principles of positioning are always applied.<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"><h3>The Principles of Positioning</h3>
      <div></div><div class="activity" id="activity_k">
<script type="text/javascript">
/* <![CDATA[ */
var kqs = {settings : {type : 'response'}, questions : [
	{ c : '<p>\n				To latch and breastfeed successfully the baby must have</p><ol><li>Sensory input, and</li><li>Positional stability</li></ol><p>\n				List the TWO senses that will provide the necessary <strong>sensory input</strong> and how to stimulate them.\n			</p><p>\n				List and explain the THREE factors that make up <strong>positional stability</strong>.\n			</p>', r : '<p>Compare your response to a sample response below.</p><p><strong>Sensory Input</strong></p><ol><li>Smell. Baby should be coming to the breast from beneath it, with his nose opposite the nipple. The breast should not be washed prior to breastfeeding. A drop or two of breastmilk may be expressed to help stimulate a sleepy baby.</li><li>Touch. Firm chest-to-chest contact (especially skin-to-skin) between mother and baby will settle, orientate and focus the baby.</li></ol><p><strong>Positional stability</strong></p><ol><li>A stable base. Mother\'s hand should be placed on baby\'s back between the shoulder blades.</li><li>Proximal stability. Baby\'s head and neck supported - on mother\'s wrist/forearm, or by her fingers (cross cradle hold), or on bed, etc.</li><li>Midline symmetry. Spine is straight from head to bottom, one hand on either side of breast.</li></ol>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('k');</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="The_well-latched_baby"><h2>The well-latched baby</h2>
    <div>
      <p class="listTitle">When baby is well positioned he will assume the instinctive position:</p>
      <ul>
        <li>lifts head up,</li>
        <li>brings chin and mouth forward to make contact with the breast and nipple,</li>
        <li>initiating seeking behaviour.</li>
      </ul>
      <p> The baby's chin should have first contact with the breast, with the bottom lip placement about 3 - 4cm (1-1.5 inches) from the nipple (about the edge of the 'average-sized' areola). This light touch will stimulate the rooting reflex if baby is not already exhibiting this seeking behaviour. The rooting reflex causes the baby's mouth to open wide, mouth directed to source of stimulation. The tongue comes down and forward to grasp the breast tissue into the mouth.<br /></p>
      <p> The firm pressure maintained by the mother on baby's back ensures baby is close to her body allowing him to achieve a wide, deep latch to the breast. </p>
      <p> Some mothers need to, or prefer to, shape the breast slightly. If this is needed, simply applying some pressure near to the base of the nipple to create an indent on the side where the infant's nose is pointing, causes the nipple to tilt up at the nose. As the bottom lip is firmly planted at about the edge of the areola well under the nipple, the finger (or thumb) doing the tilting can then fold the nipple so it just brushes under baby's top lip. <span style="font-style: italic;">Refer to photograph below.</span><br /></p>
      <p> </p>
      <p>Hey presto - one beautifully latched baby, with breast tissue entirely filling his mouth! <br /></p>
      <p> This is an asymmetric latch: the mouth will NOT be centred over the nipple.<br /></p>
      <br />
    </div>
    <div class="captionBox"><img width="319" height="239" src="images/latch_video_still3.gif" alt="Note the baby is positioned below the nipple, coming up to it in the 'instinctive position' with head slightly extended, mouth wide, and tongue down and extended over the lower gum. Mother has shaped breast and tilted nipple towards baby's nose." /><p>Note the baby is positioned below the nipple, coming up to it in the 'instinctive position' with head slightly extended, mouth wide, and tongue down and extended over the lower gum. Mother has shaped breast and tilted nipple towards baby's nose. <br />&copy; Australian Breastfeeding Association</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/books.png" class="icon" alt="" /><h3>Workbook Activity 5.3</h3><p>Complete Activity 5.3 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>
          <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 importance of the mother's position in providing the basis for the baby's position.</li>
          <li>The principles of baby positioning which influence latch ability.</li>
          <li>Techniques which provide a stable base, proximal stability and midline symmetry.</li>
          <li>How to apply the same principles to all positions which the mother may use.</li>
          <li>The sequence of actions which result in correct latch.</li>
        </ul>
        <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>
          <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_l">
<p class="instructions">Click and drag the missing words below into their correct place</p><p class="missingWords">The missing words are: <strong>above</strong> <strong>alignment</strong> <strong>areola</strong> <strong>bottom</strong> <strong>chin</strong> <strong>lip</strong> <strong>odour</strong> <strong>pre-feeding</strong> <strong>prone</strong> <strong>raise</strong> <strong>reflexive</strong> <strong>shoulders</strong> <strong>smell</strong> <strong>turned</strong></p>The principles of positioning can be applied to any breastfeeding situation. The mother may adopt a variety of body positions to hold her baby. The baby's body position is designated by the relationship of his body to his mother's body and the lie of his body in relation to the ground. <br /><br />To assist the mother and baby to achieve successful breastfeeding, you will need an understanding of all the factors which facilitate the best circumstances:<br /><br /><ul><li>A newborn baby's feeding behaviour is instinctive and <span value="reflexive" class="dropper">__________</span>. </li><li>The baby's sense of <span value="smell" class="dropper">__________</span> will direct him towards the <span value="odour" class="dropper">__________</span> of his mother's breast.</li><li>When the mother reclines back, her baby will be <span value="prone" class="dropper">__________</span> on the front of her body. This natural biological nurturing position releases many primitive neonatal reflexes which stimulate <span value="pre-feeding" class="dropper">__________</span> behaviour.</li><li>The mother may support her baby's back and <span value="shoulders" class="dropper">__________</span> to provide stability.</li><li>The infant's head and neck need to be in straight <span value="alignment" class="dropper">__________</span>. The infant will not be able to latch effectively if his head is <span value="turned" class="dropper">__________</span> to the side.</li><li>Once the correct position has been achieved, the infant will <span value="raise" class="dropper">__________</span> his head and reach for the breast.</li><li>His <span value="chin" class="dropper">__________</span> will touch the breast first and make an indent in the breast.<br /></li><li>The bottom <span value="lip" class="dropper">__________</span> will make contact on the edge of the <span value="areola" class="dropper">__________</span> and remains there as he draws the breast tissue into his mouth and the nipple slips under the top lip.<br /></li><li>The end result is a latch which is asymmetrical and you will notice that more areola will be viewed <span value="above" class="dropper">__________</span> the infant's top lip than below the <span value="bottom" class="dropper">__________</span> lip.<br /></li></ul><br /><script type="text/javascript">initCloze('activity_l');</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#douc07" title="See full details">#</a> Doucet S et al. (2007) The "smellscape" of mother's breast: effects of odor masking and selective unmasking on neonatal arousal, oral, and visual responses.</li>
              <li id="note2"><a href="references.html#glov04" title="See full details">#</a> Glover R (July 14-18 2004) Lessons from Innate Feeding Abilities Transforms Breastfeed Outcomes</li>
              <li id="note3"><a href="references.html#cols08" title="See full details">#</a> Colson S et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_5-2" class="content">
          <h1 id="top">5.2 Breastmilk transfer</h1>
          <div>
    <p> Obviously the goal of breastfeeding is to achieve milk transfer from mother to baby. </p>
    <p class="listTitle">Breastmilk transfer occurs by:</p>
    <ol>
      <li>positive pressure as the milk ejection reflex (MER) forces milk from storage in the alveoli towards the nipple, and</li>
      <li>negative pressure, created in the baby's mouth, drawing the milk from the breast into the oro-pharynx.<sup><a href="#note1">1</a></sup></li>
    </ol>
  </div>
          <div class="section" id="Understanding_the_anatomy"><h2>Understanding the anatomy</h2>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="380" height="380" src="images/breast_anatomy.gif" alt="" /><p> <br />&copy; Health e-Learning</p></div>
      </div><div class="column" style="width: 50%">
        <div>
          <p>
					Imagine the functional tissue of the breast as like a large bunch of grapes. The grapes are linked by thin stalks to thicker stalks and thicker stalks again as more sections of grapes join it, until there is one thick stalk.
				</p>
          <p>
					A grape represents an alveolus (<span class="aside">pl. alveoli</span>) which holds the breastmilk. The stalks are the ductules and lactiferous ducts through which the milk passes, and the whole bunch of grapes represents one lobe of functional breast tissue. Each breast contains about nine lobes.
				</p>
        </div>
      </div></div><br style="clear: both" />
    <div class="columns"><div class="column" style="width: 50%">
        <div>
          <p> The lactocytes, <dfn>columnar epithelial cells</dfn> that make up the alveolus, synthesise the breastmilk which is then stored in the lumen. </p>
          <p> Each alveolus is surrounded by a basket-like weave of myoepithelial cells, <dfn>muscle cells</dfn>. Contraction of the myoepithelial cells constricts the alveoli, forcing the breastmilk into the ducts and towards the nipple where the baby can remove it. </p>
        </div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="380" height="253" src="images/alveolus.gif" alt="" /><p> <br />&copy; Health e-Learning</p></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"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 5.4</h3><p>Complete Activity 5.4 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>
          <div class="section" id="Positive_pressure_transfer"><h2>Positive pressure transfer</h2>
    <div>
      <p> The hormone <strong>oxytocin</strong> causes the milk ejection reflex and the contraction of the myoepithelial cells. A surge of oxytocin is released from the posterior pituitary gland in response to stimulation of the nerves around the nipple. It travels via the blood stream to both breasts causing the myoepithelial cells surrounding the alveoli to contract. Sometimes this can be so forceful as to cause the milk to drip or even squirt from the nipple. </p>
    </div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="300" height="352" src="images/MER_graphic.gif" alt="" /><p> <br />&copy; Health e-Learning</p></div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="225" height="347" src="images/MERactive_BI.gif" alt="Note the breastmilk squirting from the unused breast while the baby suckles on the other breast." /><p>Note the breastmilk squirting from the unused breast while the baby suckles on the other breast. <br />&copy; B.Ingle, IBCLC</p></div>
      </div></div><br style="clear: both" />
    <div>
      <p class="listTitle">When the MER has been stimulated mothers may describe the sensation as</p>
      <ul>
        <li>a sharp, momentary pain in the breast, or</li>
        <li>a fullness or tightness of the breasts, or</li>
        <li>a tingling sensation inside the breast, or</li>
        <li>there may be no sensation at all.</li>
      </ul>
      <p> It can be seen to be functioning when milk drips or squirts from the breast. If the baby is suckling at the time you'll notice a change in suck pattern to a suck / swallow / breathe / suck / swallow / breathe pattern with swallows about every second. This vigorous sucking from increased milk flow may last 1.5 - 2 minutes. You may hear the baby gulping the larger volume of milk too.</p>
      <p>As the effect of oxytocin wears off the alveoli and ductal system, milk which is not removed by the infant (or by expressing) moves back up the ductal system to the alveoli once more. </p>
      <p>
        <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/warning.png" class="icon" alt="" /><h3>Take home message:</h3>
      <div>
        <p>Milk transfer is dependent on milk ejection! No MER = Hungry baby </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>
    <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>Important</h3>
      <div>
        <p> Many mothers do not feel the milk ejection at all, and rarely is it felt in the first few days postpartum despite it functioning quite well. Prior to the milk 'coming in' the change in the baby's suckling is also not noticeable. </p>
        <p> In multiparous women involution pain is felt more acutely during milk ejection. <span style="font-style: italic;">(Why?)</span><br /></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="Negative_pressure_transfer"><h2>Negative pressure transfer</h2>
    <div>
      <p> The mouth of the newborn is ideally suited to suckling at the breast. The tongue grasps the breast tissue and the lips create a seal around the areola. Negative pressure in baby's mouth draws the breast into position and maintains it there forming a teat of soft breast which completely fills the mouth. The small mandible fits closely against the breast, allowing the baby's nose to be free for breathing, while the buccal fat pads in their cheeks prevent the cheek from 'collapsing' in during suckling. </p>
      <p> Negative pressure is created in the sealed mouth when the back of the tongue drops in response to the increased milk flow at milk ejection. There is a coincident lowering of the soft palate. The intra oral vacuum is at its greatest when the tongue is fully lowered prior to swallowing. It is this negative pressure which draws the breastmilk from the nipple into the baby's mouth.</p>
    </div>
  </div>
          <table class="callout">
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                <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>
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                <td class="topleft" style="width: 10px">
                  <img src="design/callout_07.png" width="10" height="10" alt="" />
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                <td class="topcenter" style="background-image: url(design/callout_08.png);">
                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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              <tr>
                <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 5.5</h3>
                  <p>Complete Activity 5.5 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="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 two mechanisms which are required for milk transfer during breastfeeding - describe each.</li>
          <li>The hormone which stimulates the milk ejection reflex.</li>
          <li>The mechanism and function of the milk ejection reflex.</li>
          <li>The changes which occur in the mother and the infant during MER.</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_m">
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	new MCQ('How is breastmilk transferred from mother to baby during normal suckling? Choose the TWO factors involved.', [{text:'positive pressure transfer caused by the milk ejection reflex forcing the breastmilk out of storage',score:1},{text:'mechanical pressure transfer as the baby\'s tongue strips the milk from the breast',feedback:'No, this does not happen.',score:0},{text:'negative pressure transfer caused by lowering of the posterior tongue in the sealed mouth',score:1},{text:'physical pressure transfer as the baby\'s lower jaw compresses the breast against the roof of the mouth',feedback:'No. The lower jaw should always be covered by the tongue.',score:0}]),
	new MCQ('Breastmilk is made by the lactocytes. Where is it stored?', [{text:'in the lumen of the alveoli',feedback:'Yes, that\'s correct.',score:1},{text:'in the lumen of the areola',feedback:'No, the areola is the darker colored area that surrounds the nipple',score:0},{text:'in the ducts near to the base of the nipple',feedback:'No. These ducts remain empty until the milk moves out of the storage area',score:0},{text:'breastmilk is made in the breast as the baby suckles, storage is not required',feedback:'No. Minimal amounts of milk are made while the baby is suckling.',score:0}]),
	new MCQ('What is the function of the myoepithelial cells?', [{text:'they produce breastmilk',feedback:'No. That\'s not their function.',score:0},{text:'when they contract they cause the nipple to become erect facilitating latching',feedback:'No. They\'re not found near the nipple.',score:0},{text:'when they contract the alveoli is constricted forcing the breastmilk out',feedback:'Yes. That\'s right.',score:1},{text:'provide innervation to the breast',feedback:'No. These are not nerve cells.',score:0}]),
	new MCQ('Which of the following best describes the milk ejection reflex?', [{text:'stimulation of the baby\'s lips causes the baby to open the mouth wide and bring the tongue down and out seeking the breast.',feedback:'You\'re thinking of a different reflex.',score:0},{text:'stimulation of the nerves around the nipple causes prolactin to be released into the blood stream, which causes the myoepithelial cells to contract moving the milk out of the alveoli.',feedback:'No. You\'ve got the wrong hormone.',score:0},{text:'stimulation of the nipple causes the milk to be ejected from the breast',feedback:'It\'s a bit more complex than this.',score:0},{text:'stimulation of the nerves around the nipple causes oxytocin to be released into the blood stream, which causes the myoepithelial cells to contract moving the milk out of the alveoli.',feedback:'That is correct.',score:1}]),
	new MCQ('Which of the following best describes the negative pressure transfer of breastmilk to the baby?', [{text:'stimulation of the nerves around the nipple causes oxytocin to be released into the blood stream, which causes the myoepithelial cells to contract moving the milk out of the alveoli.',feedback:'This is actually positive pressure, not negative pressure.',score:0},{text:'it is created in the sealed mouth when the back of the tongue drops prior to swallowing',feedback:'Yes, that\'s right.',score:1},{text:'it is created in the baby\'s mouth as the baby\'s cheeks are sucked in prior to swallowing',feedback:'No, the cheeks should never be seen to be \'sucked in\'.',score:0},{text:'stimulation of the tip of the tongue causes a rolling movement of the tongue which removes the milk from the breast',feedback:'No. This doesn\'t happen.',score:0}])
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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>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#rams04a" title="See full details">#</a> Ramsay D et al. (2004-09-10) Ultrasound imaging of the sucking mechanics of the breastfeeding infant</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_5-3" class="content">
          <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>
      </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"><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>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="208" height="300" src="images/Annie8a.gif" alt="" /><p> <br />&copy; D.Fisher IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div class="captionBox"><img width="273" height="302" src="images/ANNIE1.GIF" alt="" /><p> <br />&copy; D.Fisher IBCLC</p></div>
        </div></div><br style="clear: both" />
    </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>
    </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_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>
    </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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                <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>
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            </thead>
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                <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="" />
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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>
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            <thead>
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                <td class="topleft" style="width: 10px">
                  <img src="design/callout_01.png" width="10" height="10" alt="" />
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_03.png" width="10" height="10" alt="" />
                </td>
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                <td class="topleft" style="width: 10px">
                  <img src="design/callout_07.png" width="10" height="10" alt="" />
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                <td class="topcenter" style="background-image: url(design/callout_08.png);">
                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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                <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="" />
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            </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"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_6-0" class="content">
          <h1 id="top">6.0 A time to learn</h1>
          <div>
    <p> Currently in developed countries, many mothers have little experience of caring for babies and children before they have their own first child. Health education is an important role for health professionals. Antenatal education and postnatal support significantly increases the incidence of breastfeeding initiation and exclusive breastfeeding to six months.<sup><a href="#note1">1</a></sup><br /></p>
  </div>
          <div class="section" id="How_to_provide_education_effectively"><h2>How to provide education effectively</h2>
    <div>
      <p>The perinatal period is filled with so many new experiences for women, and postnatal hospitalisation is short, therefore it is important to target educational interventions effectively. It is not effective to just give educational materials, either antenatally or postnatally, without a discussion with the mother of their contents.</p>
      <p> Asking people direct questions about how they learn leads towards four primary processes being involved in an overlapping way. </p>
      <p class="listTitle">These can be summarized as follows:</p>
      <ol>
        <li>wanting to learn (motivation, thirst for knowledge)</li>
        <li>learning by doing (practice, trial and error)</li>
        <li>learning from feedback (midwife/nurse's comments, seeing the results)</li>
        <li>digesting (making sense of what has been learned)</li>
      </ol>
      <p class="listTitle">Asking people further questions about where and when they learn reveals that most people consider they learn best:</p>
      <ul>
        <li>at their own pace (allow plenty of time for questions, return demonstrations, etc)</li>
        <li>at times and places of their own choosing (privacy may be important, or when less tired)</li>
        <li>often with other people around, especially fellow learners (a group of new mothers, or her partner)</li>
        <li>when they feel in control of their learning</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/books.png" class="icon" alt="" /><h3>Workbook Activity 6.1</h3><p>Complete Activity 6.1 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>
      <p class="listTitle">Individuals also have an inclination to a preferred style of learning experience.</p>
      <ul>
        <li>Auditory learners use their sense of hearing as their primary means of absorbing information eg. discussions, hearing of others' experiences, story telling.</li>
        <li>Visual learners relate to pictures, demonstrations, videos and written materials.</li>
        <li>Kinesthetic (kinaesthetic) learners like activities which involve them fully eg. practicing the skill taught, return demonstrations, etc.</li>
      </ul>
    </div>
    <div class="captionBox"><img width="500" height="432" src="images/posn_prac500SC.jpg" alt="Two pregnant woman learn about positioning using dolls." /><p>Two pregnant woman learn about positioning using dolls. <br />Photograph &copy;  S.Cox, IBCLC</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/thinker.gif" class="icon" alt="" /><h3>Clinical application</h3>
      <div>
        <p> Educational materials should be presented in a variety of formats. For example:</p>
        <p> To teach a mother how to position and latch her baby to the breast</p>
        <ul>
          <li> she may view a video with other mothers (pre/postnatal)<br /></li>
          <li> discuss a leaflet showing the technique (pre/postnatal)</li>
          <li>be given a demonstration using a doll (prenatal)<br /></li>
          <li> then (after birth of the baby), be supervised privately as she positions and latches her baby and receive feedback from the nurse as well as noting how it feels to have her baby well latched and suckling.</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="Postnatal_education"><h2>Postnatal education</h2>
    <div>
      <p> When all the information required to be covered in Step 3 and Point 3 (<a href="topic_3-0.html">see 3.0 Pregnancy Care</a>) is covered during the prenatal period, the emotion-laden postnatal period can be used more effectively for </p>
      <ul>
        <li> practical help - eg. positioning, latching, breast expression </li>
        <li> educational messages about feeding patterns, maintaining exclusive breastfeeding, baby behavior, recognizing abnormalities, and </li>
        <li> psychological support. </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/tip.png" class="icon" alt="" /><h3>Learning happens best when...</h3>
    <div>
      <ol>
        <li>the mother is needing/wanting to know</li>
        <li>the information is presented in a manner which encompasses her learning style</li>
        <li>she receives feedback that allows her to digest (or reflect) on what she has learned</li>
      </ol>
    </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>The effective learning circumstances for most people.</li>
          <li>When and where mothers are likely to prefer to learn.</li>
          <li>How to apply effective learning style to your workplace.</li>
        </ul>
        <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>
          <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_p">
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	new MCQ('When educational materials are developed for mothers, how can they be used most effectively?', [{text:'Display them in a public place for the mother to choose the ones most appropriate to her.',feedback:'She\'s unlikely to take them',score:0},{text:'Ensure every mother is given the appropriate materials in a pack after the birth of her baby.',feedback:'Busy, tired mothers are unlikely to look at them or even know that what she needs is in the pack.',score:0},{text:'Give an appropriate leaflet to a mother at the time she needs it and discuss its content with her.',feedback:'Yes. It\'s obvious really isn\'t it? Give it when it\'s needed and discuss it when you do.',score:1},{text:'Written materials are rarely effective.',feedback:'That\'s not true.',score:0}]),
	new MCQ('When a woman\'s learning style is predominantly described as kinesthetic (kinaesthetic) which of the following would be the best way for her to learn how to hand express her breastmilk?', [{text:'watch a video or another mother hand expressing breastmilk',feedback:'No. This would suit a visual learner best.',score:0},{text:'have her health professional discuss what she is doing as she hand expresses the mother',feedback:'No, not the best method for this mother.',score:0},{text:'listen to instructions given to her by her health professional',feedback:'No, this is auditory, not kinaesthetic',score:0},{text:'express her breastmilk herself with her health professional guiding her as she does it',feedback:'Yes. Kinaesthetic learners learn best by doing.',score:1}]),
	new MCQ('In order for the mother to gain maximum benefit from new information, effective education programs are characterized by being provided at a time when the mother desires to gain new knowledge and when feedback and comments are offered by the educator.With this in mind, what would best assist a new mother in hospital to effectively learn about normal breastfeeding behavior and sleep patterns during the early weeks ahead?', [{text:'Arrange for her to see the paediatrician at 4-6 weeks post partum.',feedback:'The paediatrician may be very helpful and supportive, however, the mother needs this information a lot earlier than 4-6 weeks.',score:0},{text:'Encourage her attendance at the daily discussion group morning tea for postnatal mothers to attend with their babies.',feedback:'Learning with other mothers who will be needing the same information will promote good discussion opportunities for greater understanding of infant behaviours.',score:1},{text:'Ask the mother to fill out a questionaire which measures her understanding of newborn infant feeding patterns.',feedback:'I don\'t think this will help at all and it does not provide any information to the mother. She will feel like her knowledge is being tested.',score:0},{text:'Give an information bundle to the mother for her to read when she is home and direct her to the Helpline telephone number.',feedback:'Good quality, relevant written material should be given to enhance other visual and practical learning; however, this alone would be unsatisfactory to maximise her learning experience.',score:0}])
]};

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</div><script type="text/javascript">renderActivity('p');</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 id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#sull07" title="See full details">#</a> Su LL et al. (2007) Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_6-1" class="content">
          <h1 id="top">6.1 Practical skills</h1>
          <div class="section" id="Baby_Friendly_Step_5_and_Point_4"><h2>Baby Friendly Step 5 and Point 4</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><span style="font-weight: bold;"> Step 5 </span> of the Ten Steps to Successful Breastfeeding, and <span style="font-weight: bold;"> Point 4 </span> of the Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings both require health care professionals to teach women about the maintenance of breastfeeding.</div>
      <blockquote>
        <div>
          <cite style="font-style: italic;">Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants</cite>
          <span style="font-style: italic;">.</span>
        </div>
      </blockquote>
      <blockquote>
        <div>Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). <span class="aside"> United Kingdom, Canada, New Zealand </span> <br /><br /> Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. <span class="aside"> Australia </span></div>
      </blockquote>
      <div>As well as assisting mothers to breastfeed their infant, as in the previous topic, these Points/Steps require staff to teach mothers the techniques of manual expression of breastmilk.</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="Expressing_breastmilk"><h2>Expressing breastmilk</h2>
    <div>
      <p> Some mothers may not be aware that they can remove breastmilk from their breasts for feeding to the baby later. In the case of low-birth-weight infants, breastfeeding success may depend on early and effective support with expressing breastmilk. Having the knowledge and skills to do it will encourage them to continue to provide essential breastmilk and for later, knowledge of expressing will encourage continued breastfeeding after a return to work, or during other times of separation.</p>
    </div>
    <div class="section" id="Hand_expressing"><h3>Hand expressing</h3>
      <div>
        <p class="listTitle">Many mothers prefer hand expression rather than using a pump because:</p>
        <ul>
          <li>Hands are always with you, and there are no parts to lose or break.</li>
          <li>Hand expression can be very effective and quick when the mother is experienced.</li>
          <li>Some mothers prefer the skin-to-skin stimulation from hand expression rather than the feel of plastic and sound of a pump.</li>
          <li>Hand expression is usually gentler than a pump, particularly if the mother's nipple is sore.</li>
          <li>There is less risk of cross-infection since the mother does not use equipment that may be also handled by others.</li>
        </ul>
        <p class="listTitle">Even a mother who does own a pump may have more success hand expressing</p>
        <ul>
          <li>to collect small volumes of colostrum antenatally, anticipating a postnatal medical problem, or</li>
          <li>to get just a few drops of milk to entice baby to latch, or</li>
          <li>to apply to a damaged nipple, or</li>
          <li>to remove just enough milk to allow her baby to latch to her engorged breast, or</li>
          <li>to relieve the discomfort from an engorged breast, or</li>
          <li>to clear a blocked duct, or</li>
          <li>to obtain milk for her baby who is unable to breastfeed, or</li>
          <li>to obtain milk for her baby when they are separated, or</li>
          <li>to obtain milk to pasteurize for her baby if she is HIV positive.</li>
        </ul>
        <p> Many health professionals also find hand expressing more effective and less wasteful for collecting colostrum. </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/books.png" class="icon" alt="" /><h3>Workbook Activity 6.2</h3><p>Complete Activity 6.2 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"><h3>How to hand express</h3>
        <div>
          <ul>
            <li>
              <span style="font-weight: bold;">Preparation<br /></span>
              <ul>
                <li>Mother should wash her hands;</li>
                <li>Prepare a clean wide-necked receptacle for the milk - a medicine cup, tea cup or bowl may be appropriate depending on volume expected.</li>
              </ul>
            </li>
            <li>
              <span style="font-weight: bold;">Technique</span>
              <br />
              <ul>
                <li>Mother may sit or stand comfortably - possibly where she can rest her arm or lean forward slightly over the container;</li>
                <li>Gently massage the breasts, running hands over the nipple and areola to stimulate the milk ejection reflex;</li>
                <li>Position the first finger and thumb on opposite sides of the nipple, at about the edge of the areola or about 2.5cm (1") from the base of the nipple;</li>
                <li>Push directly back towards the chest wall, then compress the breast between finger and thumb, and follow through by moving the pressure towards the nipple without sliding the fingers on the skin of the breast;</li>
                <li>It may take a minute or so to stimulate the milk ejection. Milk only flows easily during a milk ejection so continue expressing while milk flow is good for approx 2-3 minutes. Colostrum is quite viscous, so be patient;</li>
                <li>Swap breasts and repeat. The mother may like to do this on each breast several times;</li>
                <li>Stop expressing when milk flow slows to drips or the goal has been achieved (eg. areola is softened enough for infant to latch, or volume needed is achieved).</li>
              </ul>
            </li>
          </ul>
          <ul></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 class="captionBox"><img width="351" height="275" src="images/hand_expressing1_sc.gif" alt="Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb." /><p>Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb. <br />Photograph &copy;  S.Cox, IBCLC</p></div>
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<p> <br />Video &copy;  Australian Breastfeeding Association. Used with permission.</p></div>
    </div>
    <div class="section" id="Pumping_breastmilk"><h3>Pumping breastmilk</h3>
      <div>
        <p> There are many different types of breastpumps available on the market. All staff must be aware of the safety issues surrounding each pump, including adequate cleaning, and its correct use. Either get other competent staff to demonstrate its use, or ask the company representative to give a short educational session for the staff. <br /></p>
        <p>Manual and electric pumps can be equally as effective - the mother will need to consider cost and skills required to use each piece of apparatus. For example, some manual pumps can cause wrist strain which may exacerbate carpel tunnel syndrome; other mothers prefer the versatility of carrying a manual pump to work; electric pumps are very efficient for long term expressing circumstances.<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/warning.png" class="icon" alt="" /><h3>Who is best to demonstrate pump usage to mothers?</h3>
        <div>
          <p>
				The pump company representative's job is to sell more pumps and encourage as many mothers as possible to use their pumps for as long as possible. Your role is to show a mother how to safely use a pump for only as long as it is absolutely necessary.
			</p>
          <p>
				Do <strong>not</strong> ask the company representative to speak to mothers about their pump.
			</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="Storing_breastmilk_for_a_healthy_baby"><h3>Storing breastmilk for a healthy baby</h3>
      <div>
        <p> If the mother is not going to use the expressed milk within the next few hours, store it safely. Glass and plastic containers with lids are suitable for use, as are breastmilk storage bags. </p>
        <p> There should be a means of noting the time and date of expressing the breastmilk on each container. For hospital use the identity of the mother and baby should also be clearly written. </p>
        <ul>
          <li>All storage equipment will be thoroughly clean.</li>
          <li>Refrigerate milk that will not be used within the next few hours.</li>
          <li>Freeze milk that will not be used within two days.</li>
        </ul>
        <table class="grid">
          <caption> NHMRC 2003 </caption>
          <thead>
            <tr>
              <th colspan="4">Storing Breastmilk for a Healthy Baby</th>
            </tr>
          </thead>
          <thead>
            <tr>
              <th>Breastmilk status</th>
              <th>Room temperature 26°C or lower</th>
              <th>Refrigerator (4°C or lower)</th>
              <th>Freezer</th>
            </tr>
          </thead>
          <tbody>
            <tr class="row0">
              <th>Freshly expressed into container</th>
              <td>6 - 8 hours; <br />when refrigerator available store milk there</td>
              <td>3 - 5 days; <br />store at back where coldest</td>
              <td>2 weeks freezer compartment inside refrigerator; 3 months in freezer section of refrigerator with separate door; 6 - 12 months in deep freeze (-18°C or lower)</td>
            </tr>
            <tr class="row1">
              <th>Previously frozen; thawed in refrigerator, but not warmed</th>
              <td>4 hours or less; <br />that is until the next feeding</td>
              <td>24 hours</td>
              <td>Do not refreeze</td>
            </tr>
            <tr class="row0">
              <th>Thawed outside refrigerator in warm water</th>
              <td>For completion of feeding</td>
              <td>4 hours or until next feeding</td>
              <td>Do not refreeze</td>
            </tr>
            <tr class="row1">
              <th>Infant has begun feeding<br />(ie. contact with baby's mouth)<br /></th>
              <td>Only for completion of feeding</td>
              <td>Discard</td>
              <td>Discard</td>
            </tr>
          </tbody>
        </table>
        <p><span style="font-weight: bold;">Note:</span> Chilled breastmilk may be safely stored at 15°C for up to 24 hours. This is the temperature maintained in an insulated container with a freezer block, eg blue ice.<sup><a href="#note1">1</a></sup> </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></h3>
        <div>
          <p> Locate the guidelines to hand expressing and safe breastmilk storage that is provided for mothers in your Unit. Discuss this leaflet with each mother and give her a copy as she is taught this essential skill. Keep a copy of the leaflet in your Workbook.</p>
          <p><span style="font-style: italic;">There are no guidelines in your Unit for hand expressing and safe breastmilk storage</span>? Recreate the table of safe storage times and file it in your workbook; form a small group to develop a leaflet that can be presented at a Unit meeting to familiarise the staff with its content.</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>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><a href="images/competency-hand-expressing-adp.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/competency-hand-expressing-adp.pdf" target="_blank">Hand Expressing Competency</a></h3>
      <div>
        <p>
				Click on the icon on the left and print the Hand Expressing Competency. Take this to your course facilitator or mentor and ask them to observe your practice and complete the assessment.
			</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="Using_the_expressed_breastmilk"><h3>Using the expressed breastmilk</h3>
      <div>
        <p class="listTitle">The order in which to use expressed breastmilk is</p>
        <ol>
          <li>First choice: All milk expressed in the first 4 days (colostrum); <span class="aside">assures baby receives the antibody-rich colostrum as soon as possible</span></li>
          <li>Second choice: Freshly expressed milk prior to refrigeration; <span class="aside">fresh breastmilk has the most active protective properties</span></li>
          <li>Third choice: Refrigerated breastmilk, using the oldest first; <span class="aside">decreases the need to freeze milk, which has a greater effect on immunological properties</span></li>
          <li>Finally: Frozen breastmilk that has been stored the longest; <span class="aside">to reduce the need to discard milk that has passed the use-by date</span></li>
        </ol>
      </div>
    </div>
  </div>
          <div class="section" id="Supporting_mothers_who_are_separated_from_their_infants"><h2>Supporting mothers who are separated from their infants</h2>
    <div>There may be many reasons a mother is unable to be with her infant at all the times the infant requires breastfeeding. These could include:<br /><ul><li>infant or mother requiring hospitalization (eg neonatal intensive care; medical or surgical event for mother or infant)</li><li>maternal appointments (eg dentist, solicitor, etc)</li><li>maternal work commitments</li><li>or perhaps just a child-free day of leisure for the mother.</li></ul><p>Occasional separations are usually easily handled by having some breastmilk already stored in the refrigerator or freezer for the child-carer to give to the infant. <br /></p></div>
    <div class="section" id="Employment_and_breastfeeding"><h3>Employment and breastfeeding</h3>
      <div>
        <p>
	An increasing number of women spend large amounts of time away from a baby or child who is still in the age range prior to earliest age of weaning ... ie the first two years. Returning to the paid workforce is the most common reason for regular separation of mother and baby, and a common reason given for premature weaning.
</p>
        <p class="listTitle">Your role as a professional is to</p>
        <ul>
          <li>Inform the mother of her right to breastfeed, and what workplace legislation will protect her right.</li>
          <li>Educate her on the value of continuing to provide breastmilk for her baby, despite separation.</li>
          <li>Discuss the issues she will need to address to be successful.</li>
          <li>Provide her with contacts for peer-support services, to talk with other women in her situation.</li>
        </ul>
        <p class="listTitle">Leaving her baby to go to work can be a highly emotional time for the mother. Continuing to provide breastmilk can</p>
        <ul>
          <li>present many challenges,</li>
          <li>help her to maintain an emotional connection to her baby, despite her physical absence,</li>
          <li>avoid the acute and chronic illnesses associated with artificial infant formula,</li>
          <li>make breastfeeding when they are reunited a very special, and close time.</li>
        </ul>
        <p>
	Enlisting support will assist the mother to meet her breastfeeding goals. An encompassing approach including her family, the child carer, her work colleagues and employer will provide support beneficial to continuing to provide breastmilk during periods of separation.
</p>
      </div>
      <div>
        <p class="listTitle">There are numerous challenges mothers will face, many unique to individuals. Addressing the foreseeable challenges is best begun during pregnancy.</p>
        <ul>
          <li>
            <p class="listTitle">Discuss with her employer</p>
            <ul>
              <li>working shorter hours each day, or less days per week, at least initially</li>
              <li>whether her baby could be brought to her for breastfeeding, or she could visit her baby</li>
              <li>a venue that will be suitable for her to use to pump, or breastfeed</li>
              <li>the advantages to her employer of her continuing to breastfeed, particularly that her child will suffer less illnesses, requiring her to have less absences from work</li>
              <li>If necessary, inform her employer of her legislated rights.</li>
            </ul>
          </li>
          <li>
            <p class="listTitle">Choose her potential child carer</p>
            <ul>
              <li>one whose knowledge of care of breastmilk, and importance of infants remaining exclusively breastmilk-fed for the first 6 months<br /></li>
              <li>proximity to either her home, or her place of work, with possibility of going to or having baby come to her during the period</li>
            </ul>
          </li>
          <li>
            <p class="listTitle">Will she need to pump her breastmilk?</p>
            <ul>
              <li>Begin researching pumps to find one that will suit her.</li>
              <li>Where will she keep her pumped breastmilk?</li>
            </ul>
          </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>Teaching hand expression of breastmilk is an essential part of protecting, supporting and promoting breastfeeding - even if the mother intends to use a pump.</li>
          <li>The potential circumstances that may lead to expressing of breastmilk.</li>
          <li>How to hand express and teach this skill to mothers.</li>
          <li>To complete the Hand Expressing competency.</li>
          <li>The safe storage times and temperatures for each breastmilk status.</li>
          <li>The order in which to use expressed breastmilk.</li>
          <li>How you can support mothers who must be separated from their infants.<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_rq">
<script type="text/javascript">
/* <![CDATA[ */
var rqqs = {settings : {type : 'matching', shuffle : 'both'}, questions : [
	new Matching('Hand expressing is the best technique for collecting..', 'colostrum'),
	new Matching('The technique of hand expression removes milk from the breasts by..', 'positive pressure'),
	new Matching('This event stimulates increased milk flow and enhances milk expression', 'milk ejection reflex'),
	new Matching('Breastpumps remove milk by this mechanism', 'negative pressure'),
	new Matching('Freshly expressed breastmilk may be stored like this for 6-8 hrs', 'room temperature'),
	new Matching('Freshly expressed breastmilk may be stored safely in a refrigerator for', '3-5 days'),
	new Matching('Breastmilk which has been thawed in warm water may be kept at room temperature for..', 'the completion of the feed'),
	new Matching('Breastmilk which was frozen and then thawed in a refrigerator may be safely kept in the refrigerator for..', '24hrs')
]};

/* ]]> */</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('rq');</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 id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#hamo96" title="See full details">#</a> Hamosh M et al. (1996) Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_6-2" class="content">
          <h1 id="top">6.2 Breastfeeding messages</h1>
          <div class="section" id="Baby_Friendly_Step_8"><h2>Baby Friendly Step 8</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><span style="font-weight: bold;"> Step 8 </span> of the Ten Steps to Successful Breastfeeding summarizes the basis of breastfeeding management in recognising an infant's total needs. It states:</div>
      <blockquote>
        <div>
          <span style="font-style: italic;">Encourage breastfeeding on demand.</span>
        </div>
      </blockquote>
    </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="How_often_should_my_baby_breastfeed_"><h2>How often should my baby breastfeed?</h2>
    <div class="columns"><div class="column" style="width: 50%">
        <div>
          <p class="listTitle">Teach parents to recognize and respond promptly to early feeding cues:</p>
          <ul>
            <li>Early cues
						<ul><li>wriggling, moving arms or legs</li><li>rooting, fingers to mouth</li></ul>
					</li>
            <li>Mid cues
						<ul><li>fussing, squeaky noises</li><li>restless, crying intermittently</li></ul>
					</li>
            <li>Late cues
						<ul><li>full cry, aversive screaming pitch, turns red</li></ul>
					</li>
          </ul>
        </div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="300" height="193" src="images/baby_crying_bbc_web.jpg" alt="Newborn exhibiting a late feeding cue" /><p>Newborn exhibiting a late feeding cue</p></div>
      </div></div><br style="clear: both" />
    <div><p> A mother's unique breast capacity and rate of milk synthesis dictates how much milk she has available in the breast at each feed, and infant hunger dictates how much the baby will take at each feed. Neither of these factors are amenable to manipulation. </p><p> Kent et al (2006) <sup><a href="#note1">1</a></sup> in their study of 71 thriving, exclusively breastfed babies ranging in age from 1 to 6 months, found: </p><ul><li> they averaged 11 feeds (range 6 - 18) per 24 hrs. <br /> </li><li> 10 of the babies always fed from both breasts per feed; </li><li> 19 babies always fed from one breast per feed; </li><li> the <span style="font-weight: bold;"> majority </span> of babies sometimes fed from one and sometimes fed from both breasts; </li><li> 2/3 of babies fed at night, and consumed 20% of their total daily intake at this time. <br /> </li></ul> These researchers concluded that all mothers and babies are unique and mothers should respond to their babies' cues rather than striving to be <strong>average.</strong> <br /><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/tip.png" class="icon" alt="" /><h3>What should I tell a mother?</h3>
      <div>Responding to her baby's early feeding cues will ensure baby is fed as often as necessary for her baby.</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="Is_my_baby_getting_enough_breastmilk_"><h2>Is my baby getting enough breastmilk?</h2>
    <div>
      <p> Before you can answer this question you need to know how much breastmilk is normal at the various stages of lactation. The average is as follows:<sup><a href="#note1">1</a></sup> <sup><a href="#note2">2</a></sup> <sup><a href="#note3">3</a></sup> </p>
      <table class="grid">
        <thead>
          <tr>
            <th>Age of baby</th>
            <th>24hr volume</th>
            <th>Infant intake</th>
          </tr>
        </thead>
        <tfoot>
          <tr>
            <td colspan="3">Approximate conversion: divide millitres by 30 to obtain volume in ounces</td>
          </tr>
          <tr>
            <td colspan="3">
              <span style="font-weight: bold;">Note:</span>
              <br />
              <span style="font-style: italic;">Individual breastmilk intake (and therefore production) does not significantly change from Week 4 to 6 months of age</span>
            </td>
          </tr>
        </tfoot>
        <tbody>
          <tr class="row0">
            <th>Day One</th>
            <td>37ml (7 - 123ml)</td>
            <td>few drops - 5ml/feed</td>
          </tr>
          <tr class="row1">
            <th>Day Two</th>
            <td>84ml (44 - 335ml)</td>
            <td>5 - 15ml/feed</td>
          </tr>
          <tr class="row0">
            <th>Day Three</th>
            <td>408ml (98 - 775ml)</td>
            <td>15 - 30ml/feed</td>
          </tr>
          <tr class="row1">
            <th>Day Five</th>
            <td>705ml (452 - 876ml)</td>
            <td>depends on feeding frequency, volume available and infant appetite<br /></td>
          </tr>
          <tr class="row0">
            <th>1 - 6 months</th>
            <td>780ml (500 - 1350ml)</td>
            <td>30ml - 135ml/feed (6 - 18 feeds/day)</td>
          </tr>
        </tbody>
      </table>
    </div>
    <div>
      <p> The colostrum received by the baby in the first few days contains highly concentrated immunoglobulins and other protective factors (<a href="topic_1-2.html">1.2 Breastmilk Immunology</a>). Also, babies are usually born somewhat 'waterlogged' and therefore a few days of low oral intake assists the infant to clear the excess fluids. The baby is in more need of immunological protection than nutrition in the first few days. </p>
      <p> Physiologically the newborn's stomach is not able to hold volumes larger than this. At birth the gastric wall is non-compliant and non-relaxing, which, when combined with the hypomotility of the duodenum, results in early satiety and frequent regurgitation in the first few days.<sup><a href="#note4">4</a></sup> </p>
      <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/books.png" class="icon" alt="" /><h3>Workbook Activity 6.3</h3><p>Complete Activity 6.3 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><p> In the first 3 days postpartum it can be assumed that the intake is adequate if the baby is positioned well, latches well and suckling actively. After lactogenesis II (average range of clinical onset is 50-73 hrs postpartum <sup><a href="#note5">5</a></sup> ) it is essential that mothers know how to recognize signs that their baby is feeding well. <br /> </p> Teach mothers to: <ul><li> observe the sucking pattern. Baby should be seen to move from a quick suck:suck:suck pattern <span class="aside"> (a stimulation pattern) </span> to a slower suck:swallow:breathe:suck:swallow:breathe pattern <span class="aside"> (the nutritive pattern) </span> which is sustained for 2 to 3 minutes. Baby may pause after this and repeat the pattern again. Observation of this pattern confirms milk transfer is occurring. </li><li> after most feeds the baby will appear satiated </li><li> baby's mucous membranes will be moist </li><li> urine and stool output will indicate adequate intake (If it's coming out, it must have gone in!) <strong></strong> </li></ul> <table class="grid"><thead><tr><th> Age </th><th> Urine output </th><th> Stool output </th></tr></thead><tbody><tr class="row0"><th> 0 - 24 hours </th><td> one wet nappy/diaper </td><td> one or more meconium stools </td></tr><tr class="row1"><th> 24 - 48 hours </th><td> two wet nappies/diapers </td><td> one or more meconium stools/possible transitional stool <br /> </td></tr><tr class="row0"><th> 48 - 72 hours </th><td> three wet nappies/diapers </td><td> transitional stool </td></tr><tr class="row1"><th> from Day 4 onwards </th><td> 6 - 8 thoroughly wet nappies/diapers, with clear urine </td><td> soft, yellow, curdy (at least daily until about 6 weeks) </td></tr></tbody></table> <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/tip.png" class="icon" alt="" /><h3>#1 Rule of infant output - If it's coming out it must have gone in!</h3>
      <div><span style="font-weight: bold;">It is important for parents to understand this concept</span>. Teach them that the volumes going in as intake will be reflected in output of urine and bowels. Describe the amounts that are displayed in the chart so that parents have a realistic expectation.<br /><p></p><p><span class="aside">Exception: the baby is being given fluids other than breastfeeding</span></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>
    <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>How do mothers receive this information?</h3>
      <div>
        <p> Is this information routinely given to ALL mothers? It is critical to the well-being of her baby. If you aren't able to identify when a mother has had this information discussed with her, form a group to develop a protocol to ensure this safeguard is put in place as soon as possible. </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>
    <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>Is it the same for bottle-fed babies?</h3>
      <div>Yes, on the whole it is. All babies should be fed when they cue to feed, and be allowed to finish the feed when they choose to, ie. not forced to finish all the formula or breastmilk in the bottle.<br />Urine and stool output is also an excellent guide to intake sufficiency for babies fed with a bottle, though those receiving breastmilk substitutes will have a firmer stool and be prone to constipation.<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 class="section" id="Twins_or_more_"><h3>Twins, or more!</h3>
      <div>Like most mothers, mothers of multiples choose to breastfeed because breastmilk is known to provide better nutrition and health for their babies. Prenatal counseling of mothers of multiples significantly increases the initiation and duration of breastfeeding.<sup><a href="#note6">6</a></sup> Attendance at 'mothers of multiples' support group meetings is also associated with increasing the duration of breastfeeding.</div>
      <div class="section" id="Can_mothers_produce_enough_milk_for_multiples_"><h4>Can mothers produce enough milk for multiples?</h4>
        <div>Yes. The more often and effectively breastmilk is removed from the breast, the more milk will be produced. All mothers should be taught this principle, but it is even more relevant to the mother of multiples.<br /><br />Studies<sup><a href="#note7">7</a></sup> of milk production in mothers of multiples found that the mothers of exclusively breastfed three-month-old twins were producing between 2.2 - 3.4 litres (73 - 113oz.) of breastmilk per 24 hours, while a mother of exclusively breastfed 2½ month old triplets produced 3.08 litres (~103 oz). This compares with studies of breastmilk production for singletons of 750 to 1100 ml (25 - 36oz.) per 24 hours.<sup><a href="#note8">8</a></sup><br /></div>
      </div>
      <div class="section" id="Assisting_breastfeeding"><h4>Assisting breastfeeding</h4>
        <div>
          <p> There are several issues that should be addressed, namely education about breastfeeding, working with the mother to find the positions that work for her, discussing how she will cope with fatigue and the extra workload, and increasing her food intake to maintain her health. </p>
          <ul>
            <li> Find an appropriate long couch or bed that provides space on each side of the mother for her to place essentials or place a baby down while she is attending to another baby. </li>
            <li> Use a firm pillow or foam that will not sink during feeds. </li>
            <li> The newborn may perform better with breastfeeding if the mother feeds each baby individually during the early learning phase. This allows her the opportunity to bond and learn about each baby's breastfeeding needs and abilities. </li>
            <li> When breastfeeding two babies at the same time <ul><li> initially the mother will require competent assistance to help with positioning her babies, ensuring correct latch and effectiveness of feedings </li><li> the mother can first position and attach the baby who requires the most assistance, supporting him with one hand, then assist the more competent baby to attach </li><li> should one baby have a weaker suck, the milk ejection reflex will be stimulated by the other baby </li></ul> </li>
            <li> For triplets, two babies can be fed at the same time, then the third baby feeds from both breasts. At subsequent feeds the babies are rotated. </li>
            <li> Encourage the mother to ask for and accept help from family and friends who have offered assistance so she can concentrate on her task of breastfeeding and caring for the babies, and herself. </li>
          </ul>
        </div>
      </div>
      <div class="captionBox"><img width="396" height="284" src="images/twins_blog_lge.png" alt="Breastfeeding twins" /><p>Breastfeeding twins</p></div>
    </div>
  </div>
          <div class="section" id="When_should_I_begin_giving_baby_other_foods_"><h2>When should I begin giving baby other foods?</h2>
    <div class="section" id="Baby_Friendly_Point_5"><h3>Baby Friendly Point 5</h3>
      <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><span style="font-weight: bold;">Point 5</span> of the Seven-Point Plan is concerned with maintaining <strong>exclusive</strong> breastfeeding until 6 months, and continued breastfeeding with the addition of appropriate complementary foods after 6 months of age. <br /></div>
        <blockquote>
          <div>
            <span style="font-style: italic;">Encourage exclusive and continued breastfeeding (beyond six months)(to two years), with appropriately timed introduction of (adequate and safe) complementary foods.</span>
            <br />
          </div>
        </blockquote>
      </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>The nutrient requirement of well, full term infants is met by exclusive breastfeeding for the first 6 months after birth. <p> Growth is generally not improved by complementary feeding before six months, even under optimal conditions, i.e., nutritious, microbiologically safe foods. Complementary foods introduced before six months displace the nutritionally superior breastmilk. Replacing even just some breastmilk too soon leads to nutritional deficits and growth faltering, as does not commencing appropriate complementary foods at the appropriate time for his needs. <sup><a href="#note9">9</a></sup> <br /> </p> <p> At around 6 months of age, most infant's energy needs for growth and development are beyond the provision of breastmilk alone and appropriate complementary foods will provide additional calories and nutrient for future growth. <br /> </p> <p> Also, developmental milestones also determine that the infant is not <span style="font-style: italic;"> functionally </span> ready to take complementary foods earlier than 6 months of age. At, or soon after 6 months, strengthening of the infant's musculature allows him to independently control his head and sit up. The development of fine motor coordination of more distal muscles, including the tongue and lips and their function of bringing in and manipulating more solid food in preparation for swallowing, is indicative of his ability to handle these foods at this age. <sup><a href="#note9">9</a></sup> </p> <p> Between 6 and 24 months of age is a critical time for promotion of optimal growth, health and behavioral development with longitudinal studies demonstrating this is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses. </p> <p class="listTitle"><span style="font-style: italic;"> The World Health Organisation <sup><a href="#note10">10</a></sup> </span> recommends the following guiding principles for appropriate complementary feeding to ensure nutritional wellbeing continues once complementary feeding begins: </p> <ul><li> continue frequent, on demand breastfeeding until two years old or beyond; </li><li> practise responsive feeding (e.g. feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact); </li><li> practise good hygiene and proper food handling; </li><li> start at six months with small amounts of foods and increase gradually as the child gets older; </li><li> gradually increase food consistency and variety; </li><li> increase the number of times that the child is fed, 2-3 meals per day for infants 6-8 months of age, and 3-4 meals per day for infants 9-23 months of age, with 1-2 additional snacks as required; </li><li> feed a variety of nutrient rich foods; </li><li> use fortified complementary foods or vitamin-mineral supplements, as needed; and </li><li> increase fluid intake during illness, including more breastfeeding, and offer soft, favourite foods. </li><br /> Eat daily: <ul><li> Meat, poultry, fish or eggs </li><li> Vitamin A-rich fruits and vegetables </li><li> Adequate fat content </li></ul> <p> A well-planned vegetarian diet that incorporates all macro- and micro-nutrients would be suitable. <sup><a href="#note11">11</a></sup> </p> <p> Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks. Limit the amount of juice offered to avoid displacing more nutrient-rich breastmilk. </p> <table style="width: 573px; height: 263px;" class="grid"><thead><tr><th> Age </th><th> Texture </th><th> Frequency </th><th> Amount each meal </th></tr></thead><tfoot><tr><td colspan="4"> Adapted from: WHO 2005 </td></tr></tfoot><tbody><tr class="row0"><th> From 6 months </th><td> soft porridge, well mashed vegetables, fruit, meats </td><td> 2 times/day + frequent breastfeeds </td><td> 2 - 3 tablespoonfuls </td></tr><tr class="row1"><th> 7 - 8 months </th><td> mashed foods </td><td> 3 times/day + frequent breastfeeds </td><td> Increase gradually to 2/3 of a 250ml cup each meal </td></tr><tr class="row0"><th> 9 - 11 months </th><td> finely chopped or mashed foods &amp; foods baby can pick up </td><td> 3 meals + 1 snack between meals + breastfeeds </td><td> 3/4 of 250ml cup or bowl </td></tr><tr class="row1"><th> 12 - 24 months </th><td> Family foods, mashed if necessary </td><td> 3 meals + 2 snacks + continued breastfeeding </td><td> A full 250ml cup or bowl </td></tr></tbody></table> </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>Baby-led or mother-led eating?</h3>
      <div>Developed countries approach to complementary foods tends to be in a structured fashion of food preparation (puree or mash), mother-directed using a spoon. <br />This is not possible or practical in traditional cultures - the infant is directly involved in food time with the family.<br /><br />Finger foods can be offered to babies so that they can choose their own intake according to ability and needs. This is called <span style="font-style: italic;">Baby-led weaning</span>. A recent study<sup><a href="#note12">12</a></sup> showed significantly low levels of food restriction, no association with weight and reported to possibly have a positive effect on later eating habits and weight.<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>
          <div class="section" id="When_should_I_wean_my_baby_from_the_breast_"><h2>When should I wean my baby from the breast?</h2>
    <div>
      <p> Breastfeeding and breastmilk continues to provide protection and growth factors as well as being a quality food source for as long as the child is breastfed. There is no stage of lactation where breastmilk stops having these beneficial effects. </p>
      <p> The introduction of complementary foods from 6 months of age is the beginning of the weaning process. The weaning process can take as long as the mother and baby want it to take. The American Academy of Pediatrics recommends breastfeeding continue for at least the first 12 months of life and beyond with the addition of appropriate complementary foods from 6 months.<sup><a href="#note13">13</a></sup> The World Health Organisation recommends babies continue to receive breastmilk until at least their second birthday and beyond, with the addition of appropriate complementary foods from 6 months of age.<br /></p>
      <p> Despite this knowledge, the number of babies who are being exclusively breastfed at 6 months of age, and the number of babies receiving any breastmilk at 12 months of age is much less than it should be in most countries. </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>Weaning too early</h3>
      <div>Have you thought about how you could influence mothers in your area? <p> Brainstorm some ideas with your colleagues and implement them. Examples could be a poster that simply states &ldquo;<q>Breastmilk only to 6 months; Breastmilk plus family foods to 2+ years.</q>&rdquo; Sometimes a simple statement such as that is all the mother needs to know. However, you could also address education about artificial feeding and talk to mothers about the barriers they may see to continuing to provide breastmilk. </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="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 infant feeding cues.</li>
          <li>The variation in milk production and infant intake in the first 5 days.</li>
          <li>The expected infant output which indicates adequate intake.<br /></li>
          <li>How to teach mothers to recognise milk transfer.</li>
          <li>Expectations for mothers about the frequency of breastfeeding.</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_rr">
<script type="text/javascript">
/* <![CDATA[ */
var rrqs = {settings : {type : 'mcq'}, questions : [
	new MCQ('A mother of a healthy, thriving two week old baby asks you how often her baby should be breastfeeding. Which of the following is the best response?', [{text:'Just keep doing what you\'re doing. Baby is growing well.',feedback:'While that is reassuring to the mother, she has asked you because she wants some further guidance.',score:0},{text:'Babies of this age should be breastfeeding about 8 to 10 times in 24 hours.',feedback:'Really? But that doesn\'t take into consideration her breastmilk storage capacity, or the baby\'s individual needs.',score:0},{text:'Listen to your baby. Babies will indicate a need to breastfeed by crying.',feedback:'This cue is much too late - the mother should respond before the baby gets to this stage.',score:0},{text:'Every baby and mother is different. Follow your baby\'s feeding cues, feeding him as soon as you see him wriggling or bringing his hand to his mouth.',feedback:'Yes, that encourages the mother to observe her baby, getting to know his needs. You\'d also describe normal output so that she is reassured he is getting plenty of breastmilk.',score:1}]),
	new MCQ('Several weeks later the mother tells you she must be separated from her baby for 24 hours when he is two months old. She wants to know how much breastmilk she should leave for him. What will you tell her?', [{text:'Bring baby in to the clinic just before you go away. We\'ll weigh him then work out how much he should have.',feedback:'No. This is outdated thinking. Breastfed babies don\'t significantly increase their intake of breastmilk between the first and sixth months despite gaining lots of weight in that time.',score:0},{text:'Well, if he was artificially feeding he\'d be having about 120 ml (4 ounces) 6 or 7 times a day. Use that as a guide.',feedback:'This suggestion is unhelpful and probably harmful.',score:0},{text:'Breastfed babies average about 800ml (27 ounces) in 24 hours. Aim for that amount and a little extra. If you can express another 30 - 60ml (ounce or two) it should be plenty.',feedback:'That\'s correct. And it\'s only for one day, so it\'s not critical that she gets it exactly right.',score:1},{text:'Express as much milk as you can between now and then. We don\'t know how much breastfed babies take, so have some artificial infant formula for back-up.',feedback:'This suggestion is unhelpful and portrays health provider approval of artificial feeding which is likely to influence her long-term breastfeeding intention.',score:0}]),
	new MCQ('Many mothers are concerned they don\'t know if their baby is getting enough breastmilk. Which one of the following points is likely to hinder a mother\'s confidence and knowledge about her baby\'s adequate intake?', [{text:'bringing the baby to the clinic to be weighed frequently',feedback:'Frequent weighing is more likely to worry the mother than reassure her; and only tells her in retrospect if baby is receiving enough breastmilk and doesn\'t teach her about making her own observations.',score:1},{text:'watching the baby\'s feeding pattern move from a quick suck/suck to the slower sucking and swallowing which is sustained for a couple of minutes every breastfeed',feedback:'This is a good point. The mother can see and hear that the baby is swallowing breastmilk.',score:0},{text:'the infant will appear settled, with moist mucous membranes after most breastfeeds',feedback:'Infants who have breastfed well appear calm and sleep well. Moist mucous membranes is good to look for but if they\'re not it\'s a late sign that breastfeeding is not going well.',score:0},{text:'the infant\'s output will be plentiful - nappies/diapers soaked with clear urine, frequent copious stool output.',feedback:'You\'ll definitely discuss this. This sign is evident at every nappy/diaper change (...what comes out, must have gone in). A deviation away from this is the first sign that intake is inadequate.',score:0}]),
	new MCQ('The father of a 3-month old breastfed baby mentions he\'s looking forward to being able to feed the baby too and asks when he can start. How will you respond?', [{text:'Your baby is not old enough for food yet. You could help by changing diapers/nappies or giving him a bath.',feedback:'Perhaps not an exciting proposition for him and perhaps this comment indicated that he may not be capable of participating in the feeding.',score:0},{text:'Yes it is fun to give the baby other foods. You could do it now if you like, but he\'ll only push the food out with his tongue as he isn\'t ready yet.',feedback:'This advice is wrong and dangerous as it could cause the baby to aspirate food.',score:0},{text:'Yes that\'s a great way for you to help by being involved in the feeding, and you will also have fun with your baby. At around 6 months, he\'ll be able to sit well and be developed enough to be ready for foods.',feedback:'This is the best of the responses, but you could probably think of better ways to phrase it to maintain the father\'s enthusiasm.',score:1},{text:'Babies shouldn\'t be started on solids until they are 6 months old. How would you feel about giving your baby a bottle of breastmilk to let his mother sleep longer some nights?',feedback:'While this suggestion does maintain the desired exclusive breastfeeding until 6 months, the unnecessary introduction of a bottle could cause some babies suck confusion, and the mother will still need to wake up to pump her milk to prevent engorgement. Other ways for the father to be involved in baby care are preferred.',score:0}]),
	new MCQ('For how long is the mother\'s breastmilk of benefit to her child? How long will you recommend that mothers continue to breastfeed their baby?', [{text:'Breastmilk no longer meets an infant\'s needs after 6 months and weaning can occur any time after that.',feedback:'No, that\'s wrong. Breastmilk will provide nutritional and immunological protection to the baby for as long as he receives it, and he needs it until at least his second birthday.',score:0},{text:'Breastmilk continues to provide nutritional and immunological protection to the baby for as long as he receives it. Breastfeeding should continue with the addition of complementary foods from 6 months until at least the end of baby\'s second year.',feedback:'Yes, that\'s correct. The timing of weaning is recommended by the World Health Organisation.',score:1},{text:'The first 3 months of breastfeeding is the most important, but even to encourage the mother to give colostrum is better than nothing.',feedback:'Breastmilk NEVER becomes unimportant, or \'less\' important. The breastfed child should be in a nutritionally and immunologically sound position by two years of age and healthy enough to maintain his condition without breastmilk.',score:0},{text:'Breastmilk is the best milk for babies. The duration of breastfeeding is a decision she should make according to how it fits into her lifestyle.',feedback:'Does the baby have any rights in this decision? It\'s the baby\'s health that will be MOST affected by the mother\'s decision. Most mothers want to do what is best for their babies and therefore you should discuss with her the effects of premature weaning.',score:0}])
]};

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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
              <li id="note2"><a href="references.html#rior05" title="See full details">#</a> Riordan J (2005) Breastfeeding and Human Lactation</li>
              <li id="note3"><a href="references.html#sain84" title="See full details">#</a> Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum</li>
              <li id="note4"><a href="references.html#zang01" title="See full details">#</a> Zangen S et al. (2001) Rapid maturation of gastric relaxation in newborn infants</li>
              <li id="note5"><a href="references.html#pere01" title="See full details">#</a> Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview</li>
              <li id="note6"><a href="references.html#frie04a" title="See full details">#</a> Friedman S et al. (2004) The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants.</li>
              <li id="note7"><a href="references.html#sain86" title="See full details">#</a> Saint L et al. (1986) Yield and nutrient content of milk in eight women breast-feeding twins and one-woman breast-feeding triplet.</li>
              <li id="note8"><a href="references.html#kent04" title="See full details">#</a> Kent JC et al. (2004) Frequency, volume and fat content of breastfeeds of exclusively breastfed babies</li>
              <li id="note9"><a href="references.html#whor01" title="See full details">#</a> World Health Organization (2001) Report of the expert consultation of the optimal duration of exclusive breastfeeding</li>
              <li id="note10"><a href="references.html#who10" title="See full details">#</a> World Health Organisation (2010) Infant and young child feeding - Fact sheet N,.342</li>
              <li id="note11"><a href="references.html#amit10" title="See full details">#</a> Amit M (2010) Vegetarian diets in children and adolescents.</li>
              <li id="note12"><a href="references.html#brow10" title="See full details">#</a> Brown A et al. (2010) Maternal Control of Child Feeding During the Weaning Period: Differences Between Mothers Following a Baby-led or Standard Weaning Approach.</li>
              <li id="note13"><a href="references.html#aapp05" title="See full details">#</a> AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_6-3" class="content">
          <h1 id="top">6.3 Normal growth</h1>
          <div>
    <p> Physical growth is measured by weight, length (height) and head circumference. A 2002 World Health Organization (WHO) survey revealed that regular weighing is part of most Western well-baby care systems and that growth charts are used universally in pediatric care.<sup><a href="#note1">1</a></sup> Growth charts are used to plot the expected growth in each of these parameters. </p>
    <p> Growth charts plot a curve of the median (50% of children will be equal to and below this curve; likewise 50% of children will be equal to and above this curve), then plot the highest and lowest curves of normal growth on either side. Many growth charts use percentile curves. The 3<sup>rd</sup> percentile reflects that 3% of children are at and below this line. The 97<sup>th</sup> percentile indicates that 97% of children will be at and below that line. The 50<sup>th</sup> percentile is the median. </p>
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Look at the movie not the photo</h3>
    <div>
      <p> Plotting of a child's data on one occasion in time has limited value. The important information is what happens to that child's data over time - is the child's data continuing to cross through curves?; is the child's data following an upward curve, even if it is the 3rd percentile? </p>
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          <div class="section" id="Weighing_of_babies_is_not_an_innocuous_procedure"><h2>Weighing of babies is not an innocuous procedure</h2>
    <div>
      <p> Sachs (2006) <sup><a href="#note2">2</a></sup> found that clinic visits focussed around the weighing of the baby with little attention being given to discussing other child care matters. She also noted that the interpretation of an acceptable weight gain was reduced to the expectation that the plotted weight should mirror one of the curves on the growth chart. Mothers in this study, and others, <sup><a href="#note3">3</a></sup> were found to change their feeding practices at the expense of breastfeeding to increase weight gain to stay on or exceed a growth curve. </p>
      <p>&ldquo;<q> ... the routine of weighing risks becoming a ritual practice with potential to undermine infant nutrition rather than a supportive means to encourage the best care possible for individual babies. </q>&rdquo; (p94) <sup><a href="#note2">2</a></sup> </p>
      <p class="listTitle"> Before weighing a baby: </p>
      <ul>
        <li> ask the mother if she has any concerns about her baby. </li>
        <li> discuss the baby's breastfeeding behavior and intake of complementary foods (if age appropriate) <br /> </li>
        <li> ask about the baby's output - urine and stooling. </li>
        <li> observe the achievement of age-appropriate developmental skills. </li>
        <li> observe the baby's general condition: skin turgor, color, adipose distribution (particularly as the mother takes the baby's clothes off in preparation for weighing). </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>Surprised?</h3>
      <div>
        <p> Absolutely NOT!!! <br /> The weight readout on the scale should not come as a surprise to you. </p>
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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"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 6.4</h3><p>Complete Activity 6.4 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="captionBox"><img width="450" height="338" src="images/PNG_motherbaby.jpg" alt="Before weighing this exclusively breastfed Papua New Guinean baby would you anticipate having any concerns?" /><p>Before weighing this exclusively breastfed Papua New Guinean baby would you anticipate having any concerns? <br />Photograph &copy;  D.Fisher, IBCLC</p></div>
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          <div class="section" id="What_influences_movement_through_growth_curves_"><h2>What influences movement through growth curves?</h2>
    <div>
      <p> A variation from a growth curve is only one observation. Further history-taking, other observations, investigations or time may be required before a definitive explanation can be given. </p>
      <p class="listTitle"> Reasons data may fluctuate: </p>
      <ul>
        <li> Data is plotted on a growth chart based predominantly on artificially-fed children. (Ensure you are using the WHO growth charts) <span class="aside"> Artificially-fed babies have a markedly different, and therefore abnormal, growth trajectory. </span> </li>
        <li> Child was born large, but is genetically determined to be slighter - or vice versa. </li>
        <li> Child has had a temporary illness, losing weight which will be quickly regained when healthy again. </li>
        <li> Inadequate nutritional sustenance to support growth; or excessive, but poor quality foods causing obesity. </li>
        <li> Chronic illness that prevents normal growth. </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"><h3>WHO Child Growth Standards</h3>
      <div>The WHO Multicentre Growth Reference Study (MGRS) as undertaken between 1997 and 2003 to generate new growth curves for assessing the growth and development of infants and young children around the world.<br /><br />The MGRS collected primary growth data and related information from approximately 8500 children from widely different ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA).<br /><br />These growth curves provide a single international standard that represents the best description of physiological growth for <span style="font-weight: bold;">all</span> children from birth to five years of age and <span style="font-style: italic;">establish the breastfed infant as the normative model for growth and development</span>. <br /><br />Print a copy of the percentile charts <img alt="PDF" src="design/page_white_acrobat.png" /><a href="http://www.who.int/entity/childgrowth/standards/cht_wfa_boys_p_0_6.pdf">BOYS weight-for-age</a><span class="linkDescription">[link: http://www.who.int/entity/childgrowth/standards/cht_wfa_boys_p_0_6.pdf]</span> and <img alt="PDF" src="design/page_white_acrobat.png" /><a href="http://www.who.int/entity/childgrowth/standards/cht_wfa_girls_p_0_6.pdf">GIRLS weight-for-age</a><span class="linkDescription">[link: http://www.who.int/entity/childgrowth/standards/cht_wfa_girls_p_0_6.pdf]</span>. File in your workbook.<br /></div>
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          <div class="section" id="Accurately_weighing_an_infant"><h2>Accurately weighing an infant</h2>
    <div>
      <p> In comparing balance, spring and electronic scales most studies found greatest accuracy using electronic scales, with newer scales being more accurate than older scales. Scales should be regularly re-calibrated. </p>
      <p class="listTitle">For greatest accuracy:</p>
      <ul>
        <li>weigh the infant on the same set of scales each time</li>
        <li>weighing procedure to be performed by the same person at each visit, using their usual technique</li>
        <li>weigh the baby at approximately the same time of day</li>
        <li>weigh the baby at the same time in relation to a feed, eg. straight after feeding</li>
        <li>weigh the baby naked. Weighing baby with a diaper/nappy or clothed results in larger discrepancies.</li>
        <li>take time to concentrate on accurately plotting the weight. One study<sup><a href="#note4">4</a></sup> found &gt;28% of points were plotted inaccurately.</li>
      </ul>
    </div>
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          <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>Normal infant growth occurs within a range.</li>
          <li>Artificially fed infants have an abnormal growth pattern.<br /></li>
          <li>All infant measurements should be plotted using the WHO Child Growth Standards.<br /></li>
          <li>Consider weight as one useful measurement of progress.</li>
          <li>The important techniques which make weighing as accurate as possible.</li>
        </ul>
      </div>
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          <div class="section" id="Self-test_Quiz"><h2>Self-test Quiz</h2>
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	{ c : '<p>\n				Janie comes to your clinic with her four-week old baby girl. She says to you: <em>I\'m here to have my baby weighed.</em> Write down how you would continue the clinic visit with Janie.\n			</p>', r : '<p> There are many ways you could have responded. I hope none of them involved you saying something like, \"OK. Take her clothes off and put her on the scale.\" </p><p> Here\'s one example of how the conversation may have gone. </p><p> Health Worker (HW): It\'s good to see you again Janie, and isn\'t your baby looking beautiful. Do you have some worries about her weight?<br/><br/> Mother (M): Well I don\'t know if she\'s getting enough breastmilk so I thought I\'d better get her weighed.<br/><br/> HW: Not knowing exactly how much breastmilk a baby is having can be worrying; but there are other ways for you to know so you won\'t have to wait until you see me.<br/><br/> M: I thought the best way to tell was to make sure she gained weight every week.<br/><br/> HW: Weight gain is one way to show she is growing, but if she isn\'t getting enough breastmilk you don\'t want to wait until her next clinic visit before you know that.<br/><br/> M: Oh no! I\'d want to know straight away. I wouldn\'t want her to go hungry for even one day.<br/><br/> HW: Exactly! Could you tell me about how you decide when baby needs a breastfeed? </p><p> The remainder of the conversation should give you information on how well the baby is breastfeeding, and is an ideal opportunity to discuss normal breastfeeding patterns and the signs of good milk transfer and adequate intake that Janie can be aware of. <br/>Finally, after Janie feels she can confidently predict the progress of her baby, you would weigh her. </p>' }
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#deon04" title="See full details">#</a> de Onis M et al. (2004) Worldwide practices in child growth monitoring</li>
              <li id="note2"><a href="references.html#sach06" title="See full details">#</a> Sachs M (2006) Routine weighing of babies: does it improve feeding and care?</li>
              <li id="note3"><a href="references.html#beha93" title="See full details">#</a> Behague D (1993) Growth monitoring and the promotion of breastfeeding.</li>
              <li id="note4"><a href="references.html#coon94" title="See full details">#</a> Cooney K et al. (1994) Infant growth charts</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_6-4" class="content">
          <h1 id="top">6.4 Sleep</h1>
          <div class="section" id="Rooming-in_in_Hospital"><h2>Rooming-in in Hospital</h2>
    <div class="section" id="Baby_Friendly_Step_7"><h3>Baby Friendly Step 7</h3>
      <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>Step 7 of the Ten Steps to Successful Breastfeeding states:</div>
        <blockquote>
          <div>
            <span style="font-style: italic;">Practice rooming in - allow mothers and infants to remain together 24 hrs/day.</span>
            <br />
          </div>
        </blockquote>
      </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>
      <p> In their research to support the inclusion of this Step, UNICEF<sup><a href="#note1">1</a></sup> found that when mothers and infants were separated, infants breastfed less frequently, lactogenesis II was evident later and clinical jaundice was more common. Weight gain per day was also statistically less. </p>
      <p>Babies cared for in nurseries had more crying episodes (and were therefore more stressed) and were responded to less frequently. <br /></p>
      <p>24-hr rooming in resulted in mothers experiencing the same number of hours total sleep as the separated dyads, infants spent 33% of the time in quiet sleep compared with only 25% in the nursery group and there was no difference in daytime alertness in the two groups.</p>
      <p> This suggests that rooming-in does not greatly alter maternal sleep and it improves infants' sleep. </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/books.png" class="icon" alt="" /><h3>Workbook Activity 6.5</h3><p>Complete Activity 6.5 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>
          <div class="section" id="How_long_should_my_baby_sleep_"><h2>How long should my baby sleep?</h2>
    <div>
      <p> Initially wakefulness and feeding are closely related. During the first 24 hours the newborn spends the first 2 hours awake and alert, and breastfeeding.</p>
      <p> After the initial few days most babies will sleep about 16 hours a day, slowly decreasing to 14-15 hours by 3 months and 13-14 hours by 6 months of age.<sup><a href="#note2">2</a></sup> </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/thinker.gif" class="icon" alt="" /><h3>Interesting</h3>
      <div>
        <p> By 3 weeks of age the average length of the longest sleep is about 3.5 hours. By 6 weeks of age some babies are having up to 6 hrs in one sleep.<sup><a href="#note2">2</a></sup> </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>
      <p> Neonates will often fall asleep directly in an 'active sleep' or REM (rapid eye movement) stage. It's during the active sleep stage that an infant is most easily roused. Neonates have a 50:50 relationship between active and quiet sleep, with sleep cycles lasting about 50 minutes.<sup><a href="#note2">2</a></sup> </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/thinker.gif" class="icon" alt="" /><h3>How can I use this knowledge to help parents?</h3>
      <div>
        <p>
			Knowledge of what is normal behaviour is reassuring to parents. Discuss normal breastfeeding and sleep patterns with expectant or new parents. When putting a baby down to sleep suggest they stay with the baby until he moves from the rapid eye movement stage from which he is easily roused, into the deep sleep stage where he is more likely to stay asleep regardless of movement and noises around him.
		</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>
      <p> The natural course of settling seems to proceed over the first 6 months, but even after that age increased waking occurs in up to 42% of children who have already shown the capacity to sleep through the night.<sup><a href="#note2">2</a></sup> Two thirds of babies breastfeed at night, and have their biggest feed at this time consuming 20% of their total daily intake.<sup><a href="#note3">3</a></sup> For these reasons implementing behavioral therapy for infant and toddler night-waking before 18 months of age is ill-advised. </p>
    </div>
  </div>
          <div class="section" id="Where_should_my_baby_sleep_"><h2>Where should my baby sleep?</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>Definitions</h3>
      <div>
        <p><dfn>Co-sleeping<sup><a href="#note4">4</a></sup></dfn> encompasses various sleeping situations with &ldquo;<q>having a responsive adult within proximity of the infant</q>&rdquo; (ie same room) being paramount. </p>
        <p><dfn>Bedsharing</dfn> is sleeping in the same bed. </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>
      <p>Where the infant should sleep is a contentious issue. Prior to the 20<sup>th</sup> Century and the application of rules and regulations to childcare in the Western world, infants and mothers slept together, and still do in countries not influenced by Western customs. A recent UK study found that 72% of breastfeeding mothers consistently co-slept during the first 12 weeks of life.<sup><a href="#note5">5</a></sup> Bedsharing and breastfeeding are mutually reinforcing - breastfeeding couples are more likely to bedshare, and bedsharing babies are more likely to breastfeed successfully.<sup><a href="#note4">4</a></sup><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/thinker.gif" class="icon" alt="" /><h3>Now that's significant!</h3>
      <div>
        <p>
			Perhaps of even more significance to mothers is the finding of Quillin &amp; Glenn (2004)<sup><a href="#note6">6</a></sup> that breastfeeding mothers who co-sleep get more total sleep than bottle feeding mothers or breastfeeding mothers who slept apart from 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>
    <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>Research Findings</h3>
      <div>
        <p>
			The results of fascinating research by McKenna &amp; Mosko (1994)<sup><a href="#note7">7</a></sup> suggest that co-sleeping is associated with enhanced infant arousals and striking temporal overlap (synchronicity) in infant and maternal arousals, and that, possibly as a result, co-sleeping mothers and infants spend more time in the same sleep stage or awake condition. This synchronicity assists mothers to cope with broken sleep - the infant isn't rousing them at a time when they are in their quiet sleep phase.
		</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>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><a href="images/UKbedsharingpolicy.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/UKbedsharingpolicy.pdf" target="_blank">Do you have a bed-sharing policy?</a></h3>
      <div>
        <p> Click on the icon to be taken to a sample bedsharing policy produced by UK Baby Friendly. Print the article, read it and file it with your notes from this course. <br /></p>
        <p>Also read this <a href="Guideline%20for%20Co-sleeping%20and%20Breastfeeding">Guideline for Co-sleeping and Breastfeeding</a> from the Academy of Breastfeeding Medicine.<br /></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="columns"><div class="column" style="width: 50%">
        <div>
          <p> As it appears that breastfeeding mothers are likely to bedshare with their babies it is important to discuss how to do so safely. <br /></p>
          <p>Note this mother and her baby are on a firm mattress, she is turned toward her baby, her lower arm is not restricting infant movement. The bed linen is not covering the infant and he is sleeping safely on his back. This mother will respond immediately to her baby's cues to feed, and he can be easily rolled towards her to breastfeed.<br /></p>
        </div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="220" height="220" src="images/James_newborn.jpg" alt="Safe bedsharing with baby includes a firm mattress, supine sleep position and a breastfeeding mother." /><p>Safe bedsharing with baby includes a firm mattress, supine sleep position and a breastfeeding mother. <br />Photograph &copy;  D.Fisher, IBCLC</p></div>
      </div></div><br style="clear: both" />
    <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>Your Hospital Policy on Bedsharing</h3>
      <div>You have a legal responsibility to adhere to your hospital policy on bedsharing and ensure that the mother is aware of this for her hospital stay.<br /><br />Now that you have read the research about safe bedsharing and co-sleeping, you may feel more confident about the many benefits and even infant safety advantages.<br />If your hospital does not allow bedsharing, you may like to form a group to gather research and present it to the hospital administrators. <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/group.png" class="icon" alt="" /><h3>What do you tell mothers about bedsharing?</h3>
      <div>
        <p>You need to inform mothers about your hospital policy on bedsharing. However, it is also important for mothers to be given accurate information on safe bedsharing and co-sleeping at home with their baby.<br /> </p>
        <p>Does your Unit have a leaflet you can discuss with mothers about safe bedsharing? If you don't have one, or it requires updating, form a small group to research the issue, share their findings with other staff, then create a leaflet for the purpose of educating mothers about this important aspect of parenting. </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="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 maternal and infant benefits of rooming-in.</li>
          <li>The deleterious effects of keeping infants in newborn nurseries.</li>
          <li>How normal sleep patterns progress from birth to older infant.</li>
          <li>Safe bed-sharing techniques.</li>
        </ul>
        <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>
          <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_rt">
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	new MCQ('Choose all the contraindications to co-sleeping in the list below.', [{text:'mother is a smoker',score:1},{text:'baby is less than 24 hours old',feedback:'As long as mother doesn\'t have any contraindications the best place for a baby this age is in skin-to-skin contact with his mother.',score:0},{text:'father, who is co-sleeping with mother and baby, is affected by alcohol',score:1},{text:'they are sleeping on a sofa',score:1},{text:'mother is artificially feeding',score:1},{text:'mother is very obese',score:1},{text:'baby is sick',score:1},{text:'baby has physiological jaundice',feedback:'Jaundice is not a contraindication to cosleeping - in fact it will encourage more breastfeeding, resolving the jaundice faster.',score:0}])
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  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#chil98" title="See full details">#</a> Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding</li>
              <li id="note2"><a href="references.html#dewe03" title="See full details">#</a> de Weerd AW et al. (2003) The development of sleep during the first months of life</li>
              <li id="note3"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
              <li id="note4"><a href="references.html#mcke04" title="See full details">#</a> McKenna JJ (2004, July) Examining Sudden Infant Death and Co-sleeping</li>
              <li id="note5"><a href="references.html#ball03" title="See full details">#</a> Ball HL (2003) Breastfeeding, bed-sharing, and infant sleep</li>
              <li id="note6"><a href="references.html#quil04" title="See full details">#</a> Quillin SI et al. (2004) Interaction between feeding method and co-sleeping on maternal-newborn sleep</li>
              <li id="note7"><a href="references.html#mcke94" title="See full details">#</a> McKenna JJ et al. (1994) Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_6-5" class="content">
          <h1 id="top">6.5 Psychological support</h1>
          <div>
    <p> Many clinicians will tell you that breastfeeding is a confidence game. <br />Prof Hartmann in his studies of breast growth and development from preconception to weaning noted one woman in their study had no breast changes during her pregnancy. She went on to successfully breastfeed her baby. Prof Hartmann commented that she was successful because no one at any time suggested to her that she might have a problem. <br />Similarly a woman who exclusively breastfed her triplets for 6 months said that she did it because no one told her she might not be able to, and that had it been suggested she probably wouldn't have had the confidence to even try. </p>
  </div>
          <div class="section" id="Maternal_self-confidence_and_self-efficacy"><h2>Maternal self-confidence and self-efficacy</h2>
    <div>
      <p> Researchers confirm self-confidence and self-efficacy to be major predictors of breastfeeding success. Women studied in Denmark,<sup><a href="#note1">1</a></sup> USA,<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> Australia,<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup> New Zealand<sup><a href="#note6">6</a></sup> and Canada<sup><a href="#note7">7</a></sup> have all found mothers who have confidence in their ability to breastfeed and mothers with high breastfeeding self-efficacy significantly more likely to breastfeed. </p>
    </div>
  </div>
          <div class="section" id="Influencing_self-confidence_and_self-efficacy"><h2>Influencing self-confidence and self-efficacy</h2>
    <div>
      <p> A lack of education about breastfeeding was identified by several of the researchers mentioned above. </p>
      <p class="listTitle">Breastfeeding education needs to be included as a part of</p>
      <ul foot="to ensure mothers have an excellent understanding of all the relevant factors.">
        <li>community awareness programs,</li>
        <li>prenatal classes,</li>
        <li>prenatal health care provider visits, and</li>
        <li>postnatally</li>
      </ul>
      <p> Health professional attitudes and actions in regard to breastfeeding significantly influences mothers. At 12 weeks postpartum mothers are much more likely to be breastfeeding if they reported having received encouragement from their clinician to breastfeed<sup><a href="#note2">2</a></sup>. Health care professionals can also have a negative influence if their lack of knowledge results in inaccurate or inconsistent advice. Some hospital routines are also potentially detrimental to breastfeeding<sup><a href="#note7">7</a></sup>. Blyth et al (2002)<sup><a href="#note5">5</a></sup> recommend integrating self-efficacy enhancing strategies, improving the quality of healthcare delivered and increasing a new mother's confidence in her ability to breastfeed. </p>
      <p> Support from the mother's partner or a nonprofessional greatly increases the likelihood of positive breastfeeding behaviors<sup><a href="#note7">7</a></sup>. </p>
    </div>
    <div class="captionBox"><img width="418" height="534" src="images/WIC_Father_support_poster.jpg" alt="Never underestimate the role of the father in supporting breastfeeding." /><p>Never underestimate the role of the father in supporting breastfeeding. <br />&copy; WIC program, USA</p></div>
  </div>
          <div>
    <p>
			Be aware at all times of how your seemingly innocent comments and actions can affect maternal confidence. For example: mothers have reported losing self-confidence to breastfeed from staff commenting about their 'flat' nipples, or small breasts, or red hair, or fair skin, or ability to hold the baby. Impatience is another factor identified by mothers trying to learn a new skill. Taking the baby from the mother and having him/her settle immediately demonstrates to a mother her lack of skill, and perhaps to an anxious mother, that the baby may 'prefer' someone else.
		</p>
    <p>
			With such short hospital stays it's important for the mother to assume all care of her infant as soon as she is physically able to, with nurses or midwives available to coach her when needed, providing positive feedback at every opportunity.
		</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="" />
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                <td class="topcenter" style="background-image: url(design/callout_08.png);">
                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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              <tr>
                <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>Think positive. Sound positive.</h3>
    <div>
      <p>It's the little things that count.</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="" />
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            </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>Never say 'never'</li>
          <li>Health professional encourgement is vital to maternal self-confidence</li>
          <li>Include the father or mother's support people in education</li>
          <li>Encourage independence in baby care, with help when required</li>
        </ul>
      </div>
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          <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_ru">
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  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kron04" title="See full details">#</a> Kronborg H et al. (2004) The influence of psychosocial factors on the duration of breastfeeding</li>
              <li id="note2"><a href="references.html#tave03" title="See full details">#</a> Taveras EM et al. (2003) Clinician support and psychosocial risk factors associated with breastfeeding discontinuation</li>
              <li id="note3"><a href="references.html#chez03" title="See full details">#</a> Chezem J et al. (2003) Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices</li>
              <li id="note4"><a href="references.html#cree03" title="See full details">#</a> Creedy DK et al. (2003) Psychometric characteristics of the breastfeeding self-efficacy scale: data from an Australian sample</li>
              <li id="note5"><a href="references.html#blyt02" title="See full details">#</a> Blyth R et al. (2002) Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory</li>
              <li id="note6"><a href="references.html#voge99" title="See full details">#</a> Vogel A et al. (1999) Factors associated with the duration of breastfeeding</li>
              <li id="note7"><a href="references.html#denn02" title="See full details">#</a> Dennis CL (2002) Breastfeeding initiation and duration: a 1990-2000 literature review</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_6-6" class="content">
          <h1 id="top">6.6 Discharge planning</h1>
          <div><p class="listTitle">The goal of discharge planning is two-fold</p><ul><li>to prevent common problems, and</li><li>to enhance maternal self-esteem and self-confidence<sup><a href="#note1">1</a></sup></li></ul><br />It is the duty of care of the health professionals caring for the mother-baby dyad to ensure that all mothers, particularly those who have not had prenatal education, know how to recognise wellness in their baby and adequate transfer of milk and to react quickly when anything abnormal occurs.</div>
          <div class="section" id="Preventing_common_problems"><h2>Preventing common problems</h2>
    <div class="section" id="Timing_of_follow-up"><h3>Timing of follow-up</h3>
      <div>
        <p>
			Routine follow-up with a qualified health care provider must be confirmed with the parents prior to discharge. A Clinical Practice Guideline recommends the following appointment schedule (AAP Subcommittee on Hyperbilirubinemia, 2004).
		</p>
        <table class="grid">
          <thead>
            <tr>
              <th>Age of infant at discharge</th>
              <th>Should be seen by</th>
            </tr>
          </thead>
          <tbody>
            <tr class="row0">
              <td>Before 24hr old</td>
              <td>72 hrs (3 days)</td>
            </tr>
            <tr class="row1">
              <td>From 24 - &lt;48 hrs</td>
              <td>96 hrs (4 days)</td>
            </tr>
            <tr class="row0">
              <td>From 48 - 72 hrs</td>
              <td>120 hrs (5 days)</td>
            </tr>
            <tr class="row1">
              <td colspan="2">For some newborns discharged before 48 hours, 2 follow-up visits may be required, the first visit between 24 and 72 hours and the second between 72 and 120 hours.</td>
            </tr>
          </tbody>
        </table>
      </div>
    </div>
    <div class="section" id="Critical_warning_signs"><h3>Critical warning signs</h3>
      <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 class="warning"></h3>
        <div><h3>The 3 Red Flags!</h3>Optimal birth circumstances and good post natal breastfeeding care will significantly reduce the incidence of infant problems. Each of these signs is an indicator that there may be a breastfeeding problem or something more serious.<br />Any of these signs need immediate medical attention.<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>
        <h3> #1. Baby's output is less than expected. </h3>
        <p> Review the table <a href="topic_6-2.html">6.2 Breastfeeding Messages</a> </p>
        <p><span class="aside"> Do all mothers have a copy of that table to take home? </span> . <br /> </p>
        <p> Output is a direct indicator of intake - ensure that you can accurately describe normal urine and stool output of the breastfed infant. Ask about the pinkish/rusty stain on a nappy/diaper which is urates in urine. This is normal <strong>until</strong> baby is 72 hours old (3 completed days). Secretion of urates in urine is a direct function of the serum uric acid concentration (ie blood levels). It is normal to see urates on a nappy/diaper with a scant volume of urine until Day 4. As the milk intake increases on Day 4 urates should no longer be seen. </p>
        <p> A note of caution to health professionals who provide only telephone consultations ... your image of a wet nappy/diaper, or a reasonable bowel action may not match the mother's impression. Urine should be clear and each nappy/diaper heavy. Although not a pleasant image, it is helpful to describe a 'handful' size as being a good volume of stooling. This is a very clear picture and will help the mother understand that scant frequent stainings are inadequate. <br /> </p>
        <p> If there is any doubt at all you must organize for the baby to have medical review urgently. </p>
        <h3>#2. Breastfeeding is painful. </h3>
        <p> Breastfeeding should not be painful. </p>
        <p> Pain during feeding, misshapen or damaged nipples or pain continuing after the feeding are all indicators that baby is poorly latched and milk transfer will be compromised. A hot or inflamed painful breast is a sign of severe engorgement, or mastitis with reduced milk transfer as a result. Painful breastfeeding is abnormal! </p>
        <p> Immediately seek help from an expert in breastfeeding. </p>
        <h3>#3. Increasing jaundice </h3>
        <p> Jaundice is a physiological state and is an expected developmental state for the majority of breastfed babies. Jaundice peaks at about Day 3 then gradually fades over the next few weeks. Jaundice should not be seen below the level of the umbilicus. <br /> </p>
        <p> However, increasing jaundice causes sleepiness and poor feeding; conversely, poor feeding causes increased jaundice. <br /> </p>
        <p> Teach parents to check for jaundice by observing their baby in natural daylight and putting finger pressure on their baby's forehead, upper chest, arms, abdomen, upper legs and watching for blanching. <br /> </p>
        <p> Instruct parents that jaundice below the umbilicus is to be reported immediately to their baby's health professional. </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/warning.png" class="icon" alt="" /><h3>Return for immediate assessment</h3>
        <div>
          <ul>
            <li>Urine and stool output less than normal or urates persist after the 3rd completed day </li>
            <li>Nipple damage, pain; painful or inflamed breasts</li>
            <li>Jaundice below the level of the umbilicus</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 6.6</h3><p>Complete Activity 6.6 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>
      <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></h3>
        <div><p> These symptoms are the most important for the parents to remember and seek help with if they develop. <br /></p>Some instructions tell parents to count a minimum number of feeds per day, or to be concerned about sleepy babies, etc, however, if these markers become a problem then one or more of the above symptoms will also be occurring. <br />Succinct instructions will more likely be remembered by parents. Ensure they know to seek <span style="font-weight: bold;">urgent</span> review by their health care provider whenever any of those points are abnormal.</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="Contraception"><h3>Contraception</h3>
      <div class="columns"><div class="column" style="width: 50%">
          <div>
            <p> Preventing an unwanted pregnancy is important to women, and adequate child-spacing is important to the mother's health and the health of the new baby. Breastfeeding is also of paramount importance to the health of both mother and baby. <br /></p>
            <p>It is preferable for the mother to recover her nutritional status following the demands of pregnancy and lactation. Recovery of these stores prior to a subsequent pregnancy is important for her health - a recuperative period of less than 6 months between the end of breastfeeding and the next pregnancy is associated with depletion of maternal nutrient stores.<sup><a href="#note2">2</a></sup><br /></p>
            <p> Mothers therefore require counselling on selection of a contraceptive method that is <br /></p>
            <ul>
              <li>highly effective in preventing pregnancy, and <br /></li>
              <li>does not interfere with breastfeeding. </li>
            </ul>
            <p> The Lactational Amenorrhea Method (LAM) of contraception has been extensively studied and found to be more effective than the progestin-only contraceptive pill. Additionally all forms of hormonal contraceptive have the potential to adversely affect breastfeeding. </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"><a href="http://www.waba.org.my/resources/lam/FBPF.htm" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.waba.org.my/resources/lam/FBPF.htm]</span><h3><a href="http://www.waba.org.my/resources/lam/FBPF.htm" target="_blank">Contraception for breastfeeding mothers</a><span class="linkDescription">[link: http://www.waba.org.my/resources/lam/FBPF.htm]</span></h3>
            <div>
              <p> To read more about other contraceptive methods during lactation click on the icon on the left, print the page and file it with your course notes. From this page you'll find further links and references. </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="column" style="width: 50%">
          <div class="captionBox"><img width="400" height="478" src="images/algorithm.jpg" alt="Using the Lactational Amenorrhea Method of contraception" /><p>Using the Lactational Amenorrhea Method of contraception. <br />Graphic &copy;  Health e-Learning</p></div>
        </div></div><br style="clear: both" />
      <div>
        <p> The quality of contraceptive/fertility counselling given to a woman significantly influences its effectiveness. When giving advice about any contraception ensure you understand it completely. </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/books.png" class="icon" alt="" /><h3>Workbook Activity 6.7</h3><p>Complete Activity 6.7 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>
    </div>
  </div>
          <div class="section" id="Consolidating_learning"><h2>Consolidating learning</h2>
    <div>
      <p class="listTitle">Practical skills should be reinforced by educational materials which must be</p>
      <ul>
        <li>accurate,</li>
        <li>consistent within themselves and with previous verbal teaching,</li>
        <li>written at an appropriate reading-age, and</li>
        <li>free from commercial advertising.</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>Resource materials for mothers</h3>
      <div>
        <p> Form a group to look at ALL the materials that are given to mothers. Each one should be discussed and explained to the mother as it is given. Are all the materials necessary? Are all staff familiar with the materials? </p>
        <p>"The critical warning signs" handout is the most important - does it stand out from the brochures? Perhaps you could start a working group to design/update this vital parent information page?<br /></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>
      <p> Discharge packs DO influence actions, particularly in regard to breastfeeding. Artificial formula company sponsored packs reduce the likelihood of exclusive breastfeeding<sup><a href="#note3">3</a></sup> and therefore for the health and safety of mother and baby they should not be distributed by any health care facilities. </p>
    </div>
    <div class="section" id="Referral_to_mother-to-mother_support_network"><h3>Referral to mother-to-mother support network</h3>
      <div class="section" id="Baby_Friendly_Step_10_and_Point_7"><h4>Baby Friendly Step 10 and Point 7</h4>
        <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><span style="font-weight: bold;">Step 10</span> of the Ten Steps to Successful Breastfeeding, and <span style="font-weight: bold;">Point 7</span> of the Seven-point Plan for Sustaining Breastfeeding in the Community state:</div>
          <blockquote>
            <div><span style="font-weight: bold;">Step 10</span>:<span style="font-style: italic;"> Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.</span></div>
          </blockquote>
          <blockquote>
            <div><span style="font-weight: bold;">Point 7</span>:<span style="font-style: italic;"> Promote co-operation between health care staff, breastfeeding support groups and the local community. </span></div>
          </blockquote>
        </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>
        <p>Attendance at mother-to-mother support groups or follow-up by peer counselors has demonstrated significant increases in maintaining exclusive breastfeeding. <sup><a href="#note4">4</a></sup> Strategies that depend mainly on face-to-face support appear more effective than those that rely primarily on telephone contact. <sup><a href="#note5">5</a></sup> Parents should be given information about the location and availability of these services with encouragement to use the services. </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>How is the information provided?</h3>
        <div>Does your Unit have a list of all the available breastfeeding support groups and networks in your area? Is it up-to-date with current phone numbers and meeting places and dates? Are representatives from these groups welcome to meet with mothers in your Unit? <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>
  </div>
          <div class="captionBox">
            <img width="450" height="653" src="images/ABA_support_poster450.jpg" alt="" />
            <p> <br />&copy; Australian Breastfeeding Association</p>
          </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 3 critical warning signs that indicate potential infant danger.</li>
          <li>The consequences of these warning signs if left unattended.</li>
          <li>The contraceptive choices and actions which can be offered safely for breastfeeding mothers.</li>
          <li>How to contact your local mother-to-mother support group.</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_rv">
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	new MCQ('To prevent problems and ensure that mothers know when to make an urgent appointment with their health professional you would discuss all of the following, EXCEPT:', [{text:'baby must be breastfeeding 8 - 10 times per day',feedback:'Some babies will thrive on 6 breastfeeds a day, and others will be feeding INEFFECTIVELY 10 times per day. Therefore this is not an adequate guide that the baby is doing well.',score:1},{text:'after Day 4 baby should be having at least 6 - 8 thoroughly wet, with clear urine, diapers/nappies per day.',feedback:'This is an excellent guide to adequate intake, when baby is exclusively breastfed and something you would definitely discuss.',score:0},{text:'the mother has comfortable breasts and no nipple damage',feedback:'Painful breasts and/or damaged nipples are a sign that latching is poor, and therefore milk transfer will be ineffective.',score:0},{text:'how to tell the degree of jaundice in the baby',feedback:'You would discuss this, and that they should seek urgent review if it extends below the umbilicus.',score:0}]),
	new MCQ('Following the birth of her first infant, a mother tells you she wants to use the most effective contraceptive that is safe while breastfeeding. Which of the following would be the BEST choice for her?', [{text:'diaphragm use combined with a spermicide',feedback:'No. The mother will have a 16% chance of getting pregnant using this method (as commonly used).',score:0},{text:'male condom',feedback:'with common usage there is a 15% chance of pregnancy with this method',score:0},{text:'lactational amenorrhea method',feedback:'This is the best choice. With common usage there is a 2% chance of pregnancy.',score:1},{text:'progestin-only oral contraceptive pills',feedback:'No. In common usage this has a failure rate of 8% and some mothers report a reduced milk supply following commencement of this method.',score:0}]),
	new MCQ('36 hours after birthing a mother decides to go home from the hospital. As a part of her discharge education you would make an appointment for her and her baby to be seen by a health professional by what age, at the latest?', [{text:'2 days',feedback:'No, they should both be OK for at least the 12 hours after you last see them.',score:0},{text:'3 days',feedback:'While you may organise to see them at this time, you could leave it a little longer if necessary.',score:0},{text:'4 days',feedback:'Yes. It\'s important mother and baby are both assessed again by this age, or earlier if she has noted any of the critical warning signs prior to this.',score:1},{text:'7 days',feedback:'This is too late. Early problems may have developed into a near-disaster by now. They should be seen again prior to this.',score:0}]),
	new MCQ('To assist the mother\'s transition to motherhood, give her confidence in her mothering ability and increase the chance of her breastfeeding for longer you would...', [{text:'suggest she attend peer-support meetings.',feedback:'That\'s correct. Mother-to-mother support offers mothers a dimension to parenthood that health professionals cannot provide.',score:1},{text:'offer frequent phone follow-up from your clinic.',feedback:'This is helpful in problem-solving, but there is a more effective way.',score:0},{text:'give her the contact for her community-based health care organisation.',feedback:'You would do this too, but to meet the criteria in the question this is less likely to be effective.',score:0},{text:'include the mother\'s mother in educational sessions.',feedback:'This is an excellent idea, if she is available, and the mother would like it. But discussion with her peers is the most effective method of support for mothers.',score:0}])
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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>
  </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 6 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 6.
	</p>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#frie04" title="See full details">#</a> Friedman MA et al. (2004) Discharge criteria for the term newborn.</li>
              <li id="note2"><a href="references.html#merc90" title="See full details">#</a> Merchant K et al. (1990) Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals.</li>
              <li id="note3"><a href="references.html#donn04" title="See full details">#</a> Donnelly A et al. (2004) Commercial hospital discharge packs for breastfeeding women</li>
              <li id="note4"><a href="references.html#hodd06" title="See full details">#</a> Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland</li>
              <li id="note5"><a href="references.html#siko04" title="See full details">#</a> Sikorski J et al. (2004) Support for breastfeeding mothers</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-0" class="content">
          <h1 id="top">7.0 Infant Challenges</h1>
          <div>
    <p> A knowledge of what conditions or events are linked with decreased initiation or duration of breastfeeding will help you to focus your breastfeeding assistance and education activities to those in most need. </p>
    <p class="listTitle">Infant Risk Factors</p>
    <ul>
      <li>birth trauma</li>
      <li>intrapartum analgesics or anaesthetics</li>
      <li>the 'late preterm' (34 to 38 weeks gestation)</li>
      <li>inconsistent ability to latch on</li>
      <li>sleepiness or irritability</li>
      <li>hyperbilirubinemia</li>
      <li>hypoglycemia</li>
      <li>either small (intrauterine growth retardation) or large for gestational age baby</li>
      <li>ankyloglossia (tight lingual frenulum or tongue-tie)</li>
      <li>multiples (twins, triplets or more)</li>
      <li>neuromotor problems (eg Down Syndrome)</li>
      <li>oral abnormalities (ie cleft of lip and/or palate)</li>
      <li>acute or chronic illness</li>
    </ul>
    <p> In this course we will only cover the most commonly presenting problems. For some conditions, such as neuromotor problems and oral abnormalities, the mother and baby will require a practitioner with a lot of experience and advanced skills. Early referral to a Lactation Consultant is recommended for these babies and others where the usual management strategies aren't quickly producing the expected results. </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/warning.png" class="icon" alt="" /><h3></h3>
    <div>Don't endanger breastfeeding by delaying referral.<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 id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-1" class="content">
          <h1 id="top">7.1 Late preterm infant; Non-latching</h1>
          <div class="section" id="The_late_preterm_baby"><h2>The 'late preterm' baby</h2>
    <div>
      <p> Infants born 34 weeks 0 days to 36 weeks 6 days gestational age are categorised as 'late preterm'.<sup><a href="#note1">1</a></sup> <br /> </p>
      <p> Late preterm infants with no significant respiratory problems or other problems of prematurity are often cared for on the postnatal ward, with the temptation to treat them as you would a term baby. Often called 'the great pretenders', these infants may present with subtle immaturity that requires a trained eye to detect, and proactive management to prevent subsequent problems. </p>
      <p class="listTitle"> Some problems these infants may encounter: </p>
      <ul>
        <li> respiratory instability and interrupted lung development<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> <ul><li> poor ability to clear normal lung fluid (particularly if delivered by elective, pre-labour caesarean section) </li><li> increased incidence of apnoea </li><li> little respiratory reserve </li></ul> </li>
        <li> temperature instability<sup><a href="#note2">2</a></sup> <br /> </li>
        <li> less glycogen and brown fat stores available to protect against hypoglycaemia<sup><a href="#note4">4</a></sup> </li>
        <li> reduced ability to conjugate and excrete bilirubin, increasing need for phototherapy to treat jaundice<sup><a href="#note2">2</a></sup> </li>
        <li> neurological immaturity <br /> <ul><li> poor state regulation - may go from hyper-alert to deep sleep without intervening stages </li><li> easily overstimulated, then exhausted - may fall asleep before full breastfeed taken </li></ul> </li>
        <li> lower tone <br /> </li>
        <li> reduced immunological competence.<sup><a href="#note2">2</a></sup> Very important not to separate baby from mother - avoiding nosocomial infections and ensuring extra breastmilk feedings for the immunological protection this gives </li>
        <li> poor breastfeeding establishment and breastfeeding-associated rehospitalisation<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup> <br /> </li>
        <li> higher mortality throughout infancy<sup><a href="#note8">8</a></sup> <br /> </li>
        <li> higher incidence of mental and physical developmental delay at 24 months<sup><a href="#note9">9</a>,</sup><sup><a href="#note2">2</a></sup> <br /> </li>
      </ul>
    </div>
    <div class="section" id="Postpartum_care"><h3>Postpartum care</h3>
      <div>
        <p class="listTitle">Initial treatment should be no different from any other infant:</p>
        <ul>
          <li>Skin-to-skin contact immediately after birth - drying and observations occuring on mother's chest</li>
          <li>Leave in skin-to-skin contact until after the first breastfeed <p class="listTitle">Skin-to-skin care will provide</p><ul foot="all of which, in these circumstances, are even more important to be achieved quickly"><li>optimal physiological stability</li><li>temperature stability</li><li>improved oxygen saturation and gas exchange</li><li>enhanced immune protection (colonization with mother's normal flora; maternal antibody development targeted to baby's needs) </li><li>decreased crying</li><li>increased opportunities to breastfeed<br /></li><li>improved breastmilk production</li><li>enhanced maternal-infant bonding</li><li>longer exclusive and total breastfeeding<br /></li></ul>all of which are even more important to be achieved quickly for these infants.</li>
          <li>Delay all routine procedures (eg. vit K injection, eye prophylaxis, hepatitis B vaccine, weighing) until baby stable, settled and had first breastfeed as these procedures increase crying which depletes metabolic reserves and disrupts breastfeeding behaviours. <span class="aside">Most can be carried out while skin-to-skin with mother if hospital routine is not flexible.</span></li>
        </ul>
      </div>
    </div>
    <div class="section" id="Lactation_Management"><h3>Lactation Management</h3>
      <div>
        <p>The importance of breastfeeding for a preterm infant is even more significant than for full term infants. Yet it is the very nature of the immaturity of the preterm and late preterm that creates breastfeeding challenges. Poor stamina, low tone, difficulty with latch and suck all contribute. Each infant needs to be assessed on individual needs and abilities and a tailor-made breastfeeding support plan can be established.<sup><a href="#note10">10</a>,</sup><sup><a href="#note7">7</a>,</sup><sup><a href="#note11">11</a></sup><br /></p>
        <p>The mother of the late preterm infant should be instructed to respond immediately to early feeding cues, leaving nappy/diaper changing until after feeding due to baby's low energy reserves. Due to the possibility of poor milk transfer associated with low energy reserves and low tone, encourage mothers to express after every breastfeeding attempt to ensure adequate drainage, or 2-3 hourly, unless baby breastfed vigorously. Small frequent feeds accommodate small stomach capacity and lessen chance of overdistension. A maximum length of 2-3 hours between breastfeeds may need to be set as these babies are sleepier and may not wake for feeds.<br /></p>
        <p> Involve experienced lactation support. </p>
        <p class="listTitle">A lactation consultant can determine the need for additional lactation support such as:</p>
        <ul>
          <li>special positioning in view of maturity deficits</li>
          <li>jaw support while breastfeeding, if hypotonia present</li>
          <li>breast compression/massage</li>
          <li>determine whether a lactation aid is indicated, eg. nipple shield after lactogenesis II, or tube-feeding device at breast</li>
        </ul>
        <p class="listTitle">Note special attention to:</p>
        <ul>
          <li>output - both urine and stool</li>
          <li>weight gain/loss</li>
          <li>level of jaundice</li>
          <li>essential early post-discharge follow-up <br /></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/tip.png" class="icon" alt="" /><h3>Don't be complacent</h3>
      <div>
        <p> These babies are NOT term babies. They may initially appear to cope well (remember 'the great pretenders'), but exhibit decreasing stamina and ability after several days so need to be watched carefully. </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_"><h3>What should I remember?</h3>
      <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>Near-term is not full term even if appearing to be well. </li>
            <li>Be observant of all aspects of baby's condition and progress.</li>
            <li>Skin-to-skin is highly significant to enhancing stablization of all body systems.</li>
            <li>Breastfeeding management which minimises energy usage and protects milk supply.</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"><h3>Self-test quiz</h3>
      <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_rw">
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	new MCQ('Baby Jack was born following a normal labour at 36 weeks gestation. His condition at birth was very good, permitting him to stay with his mother in the postnatal ward. You have identified him as a potential risk for problems of immaturity but you are LEAST LIKELY to observe: ', [{text:'poor milk transfer at each breastfeed',feedback:'There is a high risk of this. Supervise all feeds.',score:0},{text:'few breastfeeding cues',feedback:'This baby may be excessively sleepy, not rousing sufficiently to cue for feeds.',score:0},{text:'hypothermia or hypoglycaemia',feedback:'This is a risk with \'near-term\' babies.',score:0},{text:'absence of the sucking reflex',feedback:'That\'s right. At 36 weeks gestation the sucking reflex should be well established and not a concern.',score:1}]),
	new MCQ('To prevent problems developing for this infant, the staff will follow a procedure manual for their care of baby Jack that will include: (choose ALL correct answers)', [{text:'Assist Jack\'s mother to express breastmilk after each breastfeed, or 3rd hourly to give to Jack.',feedback:'Yes. This is helpful to provide good stimulation and drainage for the mother\'s breasts, and the additional milk ensures baby is well fed.',score:1},{text:'Encourage the mother to spend extended periods of skin-to-skin contact with Jack, particularly prior to breastfeeding.',feedback:'Yes.This provides many benefits for the baby promoting a problem-free postnatal adaptation',score:1},{text:'Perform test weighing (weighing pre- and post-feed to check volume consumed) at each feed.',feedback:'No.This is unnecessary, delays feeding, stresses baby and is not accurate for the small intake volume expected in the first few days.',score:0},{text:'Observation of all, or most breastfeeds.',feedback:'Yes. Early problems can be identified and strategies enacted before the baby\'s condition suffers.',score:1}]),
	new MCQ('Baby Jack is discharged home with his mother when he is 2 and a half days old. When should she and the baby be next seen by a health professional?', [{text:'Suggest she makes an appointment as soon as the clinic can fit her in.',feedback:'The clinic doesn\'t know this baby\'s special circumstances and may not book her for another week.',score:0},{text:'Within one week of discharge.',feedback:'This could be too long.',score:0},{text:'In two days time.',feedback:'Yes. Mother\'s milk is not yet in, jaundice levels are yet to peak, and near-term babies may deteriorate after initially doing well. Early follow-up is essential.',score:1},{text:'The next day.',feedback:'This is too soon to ask her to take her baby out again. However, if a home visiting service is available this would be ideal.',score:0}])
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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>
    </div>
  </div>
          <div class="section" id="The_Non-latching_Baby"><h2>The Non-latching Baby</h2>
    <div>
      <p class="listTitle">There are many reasons for a newborn not to latch or latch poorly and breastfeed ineffectively. The following have been associated with sub-optimal breastfeeding behaviors on Day 3 postpartum:</p>
      <ul>
        <li>condition at birth compromised (trauma, intrapartum drugs, resuscitation required)</li>
        <li>pacifier/dummy use</li>
        <li>flat or inverted nipples</li>
        <li>breastfeeding delayed for up to 48 hours, and </li>
        <li>primiparous mothers.<sup><a href="#note12">12</a></sup></li>
      </ul>
      <p> It has been demonstrated that forcing the baby to the breast can abolish the rooting reflex and disturb placement of the tongue. A healthy baby should have the opportunity of showing hunger and optimal reflexes, and attach to its mother's breast by itself.<sup><a href="#note13">13</a></sup><br /></p>
      <p> Read this <img alt="External" src="design/external.gif" /><a href="http://www.health-e-learning.com/resources/articles/37-when-the-back-of-the-babys-head-is-held-to-attach-the-baby-to-the-breast" target="_blank" title="External link">short article</a><span class="linkDescription">[link: http://www.health-e-learning.com/resources/articles/37-when-the-back-of-the-babys-head-is-held-to-attach-the-baby-to-the-breast]</span> that describes the detrimental effects of a hand placed on the back of the baby's head during latching. </p>
    </div>
    <div class="section" id="Your_first_responsibility"><h3>Your first responsibility</h3>
      <div>
        <p>
          <strong>A newborn who shows no inclination to breastfeed is abnormal until proven otherwise.</strong>
        </p>
        <p> The most important concern when a baby is not exhibiting this expected reflex is to rule out infant morbidity. Observe the infant's vital signs and organize a pediatric review if any abnormality is detected. Conditions such as unexpected respiratory distress syndrome, Group B strep infection, sepsis, hypoglycaemia, etc may first present as a baby not exhibiting the normal feeding reflexes. We also know that it could be as a result of intrapartum drugs or the birthing experience, and the baby just needs more time, but don't assume that until you have eliminated the more sinister causes. </p>
      </div>
    </div>
    <div class="section" id="Principles_of_management"><h3>Principles of management</h3>
      <div>
        <p class="listTitle"> The aim of your plan is to: </p>
        <ol foot="until such time as baby is suckling well.">
          <li>
            <strong>protect the baby:</strong>
            <span class="aside"> this not only means to ensure the physical well-being of the infant (nutrition and warmth), but includes protecting the baby from unnecessary supplementation before it is indicated. </span>
          </li>
          <li>
            <strong>protect the lactation: <span class="aside">until such time as baby is suckling well</span></strong>
          </li>
        </ol>
        <p> Re-establish skin-to-skin care on mother's chest if this had been interrupted. This baby should have A LOT of time in this position. Encourage the mother to adopt the laid back position of Biological Nurturing to stimulate pre-feeding behaviours.</p>
        <p>Avoid stressful events/procedures and handle the baby with care ie. definitely don't hold the infant's head in an attempt to hasten latching.<br /> </p>
        <p> Encourage the mother to respond <strong>immediately</strong> to baby's earliest feeding cues and instinctive behaviours. </p>
        <p> Trickle small amounts of breastmilk into the corner of the infant's mouth as he lies near the breast. <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/books.png" class="icon" alt="" /><h3>Workbook Activity 7.1</h3><p>Complete Activity 7.1 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="The_Action_Plan"><h4>The Action Plan</h4>
        <div>
          <p class="listTitle">From 0 to 24 hours old</p>
          <ul>
            <li>initiate and maintain skin-to-skin contact with the mother. Utilizing the baby's instinctual reflexes is very important.</li>
            <li>teach the mother about the early feeding cues, ie. wriggling, bringing hand to mouth, rooting; ensure she knows to facilitate feeding immediately the baby shows these cues</li>
            <li>continue to observe the baby's vital signs regularly and observe for symptoms of hypoglycemia (blood testing not indicated if asymptomatic). Initiate pediatric review if outside the range of normal.</li>
            <li>be patient and reassure the mother, providing the baby's condition is satisfactory.</li>
            <li>hand express breastmilk each time baby tries unsuccessfully to breastfeed. Finger-feed, spoon feed or slowly trickle the tiny volumes into the corner of the baby's mouth from a syringe if the baby is swallowing OK.</li>
            <li>hand expressing should have commenced within 6 hours of birthing <span class="aside">(preferably earlier)</span> and regularly at least 3 hourly thereafter (up to 5 hour break overnight).<sup><a href="#note14">14</a></sup> While the baby's condition should not deteriorate due to lack of feeding in this first 24 hours, giving the baby the expressed milk makes common sense.</li>
          </ul>
          <p class="listTitle">From 24 to 48 hours old</p>
          <ul>
            <li>continue in skin-to-skin care</li>
            <li>continue regular observations of vital signs and for signs of hypoglycemia.</li>
            <li>attempt to rouse and interest baby in breastfeeding every 3 hours. If unsuccessful ...</li>
            <li><strong>Feed the baby!</strong> Average breastmilk volume taken during the second 24 hours is 5 - 15ml per feed with a 24 hour volume of 84ml. This should be your goal.<br /><ul><li>cup, finger or spoon feed the breastmilk to the baby. Giving more than 2 supplements using a bottle can lead to discontinuation of exclusive, and any, breastfeeding.<sup><a href="#note15">15</a></sup></li><li>continue regular hand expressing or pumping at least 8 times per 24 hours.</li><li>refer mother and baby to a Lactation Consultant for evaluation.</li></ul></li>
          </ul>
          <p class="listTitle">From 48 to 72 hours old</p>
          <ul>
            <li>Continue all strategies as above</li>
            <li>Average volume of breastmilk taken is 400ml (13.5oz) per day, or about 8 feeds of 50ml/feed - or less volume more frequently depending on the volume the mother is able to express each time.</li>
          </ul>
          <p class="listTitle">After 72 hours</p>
          <ul>
            <li>Lactogenesis II should have occurred by now</li>
            <li>Continue all strategies as above</li>
            <li>Average daily volume of breastmilk consumed from Day 5 is 700ml (~24oz). Some babies may settle and thrive on less, some may require more.</li>
          </ul>
          <p> </p>
          <span class="aside">(The recommended daily volumes are taken from the average volume taken at the breast by the well, full-term baby. Refer to the table in <a href="topic_6-2.html">topic 6.2</a>.)</span>
          <p></p>
          <span style="font-weight: bold; font-style: italic;">Note: Never underestimate the significance of skin-to-skin contact to trigger instinctive reflexes and enhance recovery.<br /></span>
        </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>Does your Unit have a policy on the non-latching baby?</h3>
        <div>
          <p>
				Review the policy. Is it current, using up-to-date research to support the recommendations? If not, form a small group to research the topic then draft a policy that you present to your colleagues (midwifery, nursing and medical). Ensure all staff are familiar with the policy to avoid conflicting information and management strategies.
			</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="Breast_refusal_in_the_older_baby"><h3>Breast refusal in the older baby</h3>
      <div>
        <p> Babies may be fussy at the breast and refuse to breastfeed for a period of time. Before 12 months of age this is rarely due to the infant choosing to wean. </p>
        <p> Determine that it actually is breast refusal. Mothers sometimes misinterpret an older baby's quicker more efficient feeding, or a decreased need for breastmilk when complementary foods are introduced, as breast refusal. During very hot weather baby may not feed during the heat of the day, but will feed well in the evening or during the night. Other reasons may be pain, forceful MER/low supply, flavour changes and sucking confusion. <br /> </p>
        <p class="listTitle"> Management strategies for the older baby </p>
        <ul>
          <li> Record a comprehensive history, including specifics on breastfeeding behavior and urine and stool output prior to this episode. Record the change in behavior and baby's current output. </li>
          <li> Do an assessment of the baby including weight, length, head circumference, attainment of appropriate developmental milestones, observation of alertness and general health. If there are signs of delayed growth or ill health, refer the baby to a doctor. </li>
          <li> Observe a breastfeed, or attempted breastfeed. (Review <a href="topic_5-2.html">Topic 5.2 Assessing Breastfeeding</a>) <br /> </li>
          <li>
            <p class="listTitle"> If refusal persists for more than one or two missed feeds </p>
            <ul>
              <li> the mother should express her milk to maintain her milk supply, and </li>
              <li> use the expressed milk to feed baby, preferably using a cup. In the absence of donor breastmilk, artificial infant formula will be required if mother's milk volumes are inadequate or baby refuses the breastmilk. </li>
              <li> a medical review of the baby is indicated if baby won't feed at all. </li>
            </ul>
          </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/thinker.gif" class="icon" alt="" /><h3>Detective work is needed!</h3>
        <div>
          <p>
				This is a distressing time for the mother, who may be feeling variously angry, rejected, worried, disappointed and bewildered. Good counseling skills will help you to empathise with the mother and work together through a comprehensive history-taking to find a reason for the baby's behaviour. If you can determine the cause you can then direct your management strategies more effectively.
			</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>
        <p class="listTitle">General guidelines include:</p>
        <ul>
          <li>patience; avoid trying to force the baby to breastfeed or displaying anxiety or anger during attempts</li>
          <li>encourage lots of skin-to-skin time in bed together or sharing a bath. Don't expect the baby to breastfeed ... but it just might happen</li>
          <li>observe the environment - avoid distractions such as other children, toys, television, etc. Choose a dimly lit room and play some relaxation music.</li>
          <li>attempt breastfeeding when baby is nearly asleep or just beginning to wake up</li>
          <li>offer the breast instead of pacifier/dummy, and when infant starts thumb sucking</li>
          <li>suggest baby be cup fed rather than bottle fed when separated from the mother</li>
          <li>suggest the use of a tube feeding device at the breast if supplements were being given</li>
          <li>give written instructions and supervise the mother using alternative feeding methods until she feels confident doing it herself.</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/books.png" class="icon" alt="" /><h3>Workbook Activity 7.2</h3><p>Complete Activity 7.2 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>
    <div class="section" id="What_should_I_remember_"><h3>What should I remember?</h3>
      <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>Protect the baby. Protect the lactation.</li>
            <li>Be a detective to determine possible cause of non-latch or refusal.</li>
            <li>Know the protocol to follow for a non-latching infant in the first 24 hrs after birth and for each day until secretory activation.<br /></li>
            <li>Encourage patience.<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"><h3>Self-test quiz</h3>
      <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>Give your response</h3>
        <div></div><div class="activity" id="activity_rx">
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	{ c : 'An older baby can suddenly refuse to breastfeed or gradually develop refusal behaviour over a period of time.<br/><br/>List the subjects relevant to the baby\'s breast refusal that you will ask the mother during your history taking.<br/>', r : 'Compare the following suggestions on your list: (additional points can be discussed with your tutor and colleagues in the forum)<br/><ul><li>age and recent health of the baby</li><li>weight and developmental progress</li><li>is the baby exclusively breastfed/solids (how much, how often)/supplements of artificial infant formula (how much, how often, since when?)</li><li>does the infant sleep through the night? is the infant sleeping in the same room/bed as the mother?</li><li>what is the timing of the refusal - since commencing complementary feeding? following sickness? on holidays?</li><li>are there any flavour changes that may have contributed? mother on a new medication or hormonal contraceptive?</li><li>could the infant have a sore mouth? teething? candida overgrowth? throat infection?</li><li>what is happening with mother\'s milk supply - could any of the above situations cause decreased supply?</li></ul><br/>Depending on your detective work, you will suggest a management plan that may include increasing supply, removing new taste, treating sore mouth.<br/>Other helpful suggestions include using baby sling/carrier, sleeping with baby so he will search for breast as he is waking up, bathing with baby.<br/>Avoid distress surrounding breastfeed attempts.<br/>' }
]};

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</div><script type="text/javascript">renderActivity('rx');</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>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#engl06" title="See full details">#</a> Engle WA (2006) A recommendation for the definition of "late preterm" (near-term) and the birth weight-gestational age classification system.</li>
              <li id="note2"><a href="references.html#baum11" title="See full details">#</a> Baumert M et al. (2011) [Late preterm infants--complications during the early period of adaptation].</li>
              <li id="note3"><a href="references.html#resc11" title="See full details">#</a> Resch B et al. (2011) Are late preterm infants as susceptible to RSV infection as full term infants?</li>
              <li id="note4"><a href="references.html#aap" title="See full details">#</a> AAp Committee on Fetus and Newborn (2011) Postnatal glucose homeostasis in lat preterm and term infants</li>
              <li id="note5"><a href="references.html#radt11" title="See full details">#</a> Radtke JV (2011) The paradox of breastfeeding-associated morbidity among late preterm infants.</li>
              <li id="note6"><a href="references.html#vess10" title="See full details">#</a> Vessière-Varigny M et al. (2010) [Breastfeeding in a population of preterm infants: a prospective study in a university-affiliated hospital].</li>
              <li id="note7"><a href="references.html#clea10" title="See full details">#</a> Cleaveland K (2010) Feeding challenges in the late preterm infant.</li>
              <li id="note8"><a href="references.html#toma07" title="See full details">#</a> Tomashek KM et al. (2007) Differences in mortality between late-preterm and term singleton infants in the United States, 1995-2002.</li>
              <li id="note9"><a href="references.html#woyt11" title="See full details">#</a> Woythaler MA et al. (2011) Late preterm infants have worse 24-month neurodevelopmental outcomes than term infants.</li>
              <li id="note10"><a href="references.html#ahme10" title="See full details">#</a> Ahmed AH (2010) Role of the pediatric nurse practitioner in promoting breastfeeding for late preterm infants in primary care settings.</li>
              <li id="note11"><a href="references.html#walk08" title="See full details">#</a> Walker M (2008) Breastfeeding the late preterm infant.</li>
              <li id="note12"><a href="references.html#dewe03a" title="See full details">#</a> Dewey K (2003) Guiding Principles for Complementary Feeding of the Breastfed Child</li>
              <li id="note13"><a href="references.html#wids93" title="See full details">#</a> Widstrom AM et al. (1993) The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle</li>
              <li id="note14"><a href="references.html#furm02" title="See full details">#</a> Furman L et al. (2002) Correlates of lactation in mothers of very low birth weight infants</li>
              <li id="note15"><a href="references.html#howa03" title="See full details">#</a> Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-2" class="content">
          <h1 id="top">7.2 Hypoglycemia; Jaundice</h1>
          <div class="section" id="Pathologic_Neonatal_Hypoglycemia"><h2>Pathologic Neonatal Hypoglycemia</h2>
    <div class="section" id="Physiology"><h3>Physiology</h3>
      <div>The term <span class="term"> hypoglycemia </span> refers to low blood glucose concentration. The body, and particularly the brain, requires a source of energy to function. Glucose is an important source of energy. <br /> <br /> There are two times of crisis in the neonates life regarding energy (glucose) needs. Both crises are managed by <span style="font-weight: bold;">normal metabolic adaptation</span> which provides alternative fuel sources for the neonate. <br /> <ol><li> The first crisis occurs when the cord is cut and the maternal supply of glucose to the newborn is abruptly discontinued.<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup> <br /> <ul><li> blood glucose concentration reaches its nadir in the first 1 - 2 hours <br /> </li><li> blood glucose concentration then rises to a steady state within 2 - 3 hours </li><li> feeding the infant may cause small transient rises in blood glucose concentration, but it is not feeding that maintains euglycemia </li></ul> </li><li> The second crisis will occur if lactation is delayed.<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup><br /><ul><li>Fat breakdown occurs, releasing ketone bodies that provide glucose-sparing fuel to the neonatal brain, protecting neurologic function.</li></ul></li></ol></div>
      <blockquote>
        <div>Transient hypoglycemia in the early neonatal period is a common adaptive phenomenon as the newborn changes from the fetal state of continuous transplacental glucose consumption to intermittent nutrient supply following cessation of maternal nutrition at birth. <br />Research has demonstrated that in the term, healthy newborn, this dynamic process is self-limiting and is not considered pathologic.<sup><a href="#note6">6</a></sup></div>
      </blockquote>
      <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>Do not screen normal, full term neonates.</h3>
        <div>
          <p><br />Clinically significant (ie pathologic) hypoglycemia does NOT occur in well, full term babies. The baby's physiology protects him against this by using metabolic processes to maintain steady-state glucose concentration. <sup><a href="#note2">2</a></sup></p>
          <p> Unnecessary routine screening results in the <span style="font-weight: bold;">misidentification</span> of neonates captured while experiencing the normal, self-correcting physiologic blood glucose nadir, who are then diagnosed with pathologic neonatal hypoglycemia. <br />Subsequent to this misdiagnosis, further surveillance and unnecessary, aggressive treatment interventions will follow that are potentially harmful to the successful establishment of positive maternal-infant interactions and the breastfeeding experience. </p>
          <p> Research studies indicate that routine hypoglycemia screens, treatments, and interventions in the healthy infant are not evidence-based and result in a serious disruption of the initiation process and duration patterns of lactation.<sup><a href="#note6">6</a></sup> </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="Diagnosing_pathologic_neonatal_hypoglycemia"><h3>Diagnosing pathologic neonatal hypoglycemia</h3>
      <div>Prolonged hypoglycaemia, sufficiently severe to cause neurological signs, is called pathologic neonatal hypoglycemia.<br />Diagnosis is made when <br /><ul><li>neurological signs are present, and <br /></li><li>blood glucose concentration is low.<sup><a href="#note7">7</a></sup> </li></ul></div>
      <div class="section" id="Clinical_signs_to_observe_for_"><h4>Clinical signs to observe for:</h4>
        <div>
          <p> The first observation to make, and the most important, is the infant's <span style="font-weight: bold;"> level of consciousness</span>. Pick up the infant, talk to him, wake him up. A limp infant you cannot wake is a bad sign. </p>
          <p class="listTitle"> Other clinical manifestations </p>
          <ul>
            <li> irritability, tremors, jitters </li>
            <li> exaggerated Moro reflex </li>
            <li> high-pitched cry </li>
            <li> lethargy, limpness, hypotonia </li>
            <li> apnea or irregular breathing </li>
            <li> cyanosis </li>
            <li> hypothermia, temperature instability </li>
            <li> poor or inadequate sucking reflex </li>
            <li> vasomotor instability </li>
            <li> seizures </li>
          </ul>
        </div>
      </div>
      <div class="section" id="Which_infants_are_at_risk_"><h4>Which infants are at risk?</h4>
        <div>Think about which infant's may have metabolic stressor's or immaturity that could affect the normal release of glucose in the first hours following birth, or ketone body metabolism later.<br /><br />Infants at risk of symptomatic hypoglycemia include:<sup><a href="#note8">8</a></sup><br /><ol><li>Infants of diabetic mothers - hyperinsulinemia as a result of poor maternal control during pregnancy will cause hypoglycemia until stabilised.</li><li>Infants who are preterm or late preterm with metabolic immaturity.</li><li>Infants who have few fat reserves, eg small for gestational age infants</li></ol>Infants in these categories require frequent observation for neurological signs and blood screening for glucose concentration at intervals according to evidence-based medical policies.<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/books.png" class="icon" alt="" /><h3>Workbook Activity 7.3</h3><p>Complete Activity 7.3 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>
    <div class="section" id="Preventing_pathologic_hypoglycemia"><h3>Preventing pathologic hypoglycemia</h3>
      <div><ul> </ul>Placing <span style="font-weight: bold;">ALL</span> newborns in skin-to-skin care with their mother from immediately after birth, and for as long as possible, preferably at least the first day of life, will:<br /><ul><li>stabilise the infant's temperature (no requirement to burn fat for heat)<br /></li><li>stabilise the infant's cardio-respiratory system<br /></li><li>stimulate metabolic adaptation</li><li>initiate the first phase of the enteric nervous system (facilitating intestinal function)<br /></li><li>reduce stress (release of cortisol initially causes a surge in blood glucose concentration, then a fall)</li><li>facilitate early and frequent breastfeeding, preventing a delay in lactation</li><li>and prevent other factors, such as nosocomial infections and hypothermia that cause hypoglycemia.<br /></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/thinker.gif" class="icon" alt="" /><h3>This is really important!</h3>
        <div>It's worthwhile repeating: The <span style="font-weight: bold;"> BEST </span> way for you to prevent hypoglycaemia in the infants you care for is by placing baby in skin-to-skin contact with his mother immediately after birth, and for as long as possible. <br /> <p> Share your thoughts in the forum about how this simple, no-cost practice helps prevent hypoglycemia. <br /> </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_about_early_feeding_"><h4>What about early feeding?</h4>
        <div>Facilitation of early and frequent breastfeeding is strongly encouraged. However, sources of exogenous glucose, such as from colostrum, are not essential to maintain <span style="font-weight: bold;">normal glucose concentration</span> in the first 24 hours. <p> Healthy, full-term infants do not develop symptomatic hypoglycemia in the first 24 hours simply as a result of underfeeding.<sup><a href="#note9">9</a></sup> </p>Frequent, effective breastfeeding will, however, be protective after the first 24 hours. Beginning breastfeeding soon after birthing will ensure the infant is breastfeeding well and maternal lactation is becoming established by the time the infant is dependent on this source of energy.<br /><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/books.png" class="icon" alt="" /><h3>Workbook Activity 7.4</h3><p>Complete Activity 7.4 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>
    <div class="section" id="Clinical_management_of_pathologic_hypoglycaemia"><h3>Clinical management of pathologic hypoglycaemia</h3>
      <div>
        <p> Inadequately treated symptomatic hypoglycemia has such a serious outcome that pediatricians agree that <br /> &ldquo;<q> the clinician <span style="font-weight: bold;">should not rely on oral feeding</span> (eg breastmilk or infant formula) for the correction of symptomatic hypoglycemia </q>&rdquo; <sup><a href="#note9">9</a></sup> and &ldquo;<q> symptomatic hypoglycemia should <span style="font-weight: bold;">always be treated with a continuous infusion of parenteral dextrose</span>. </q>&rdquo; <sup><a href="#note8">8</a></sup> <br /> </p>
        <p>However, during this medical management, breastfeeding should continue uninterrupted. The goal is to have an infant who suckles effectively at the breast and a mother's milk supply that is able to meet his needs when IV therapy is discontinued. <br /></p>
        <ul>
          <li> continue breastfeeding, and skin-to-skin contact during treatment<br /></li>
          <li><span style="font-weight: bold;"> do not give </span> water, glucose water or formula to the breastfed infant </li>
          <li> continue breastfeeding while weaning baby from IV glucose, monitoring carefully </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/article.png" class="icon" alt="" /><h3>Extend your knowledge</h3>
      <div>Go to the <img alt="PDF" src="design/page_white_acrobat.png" /><a href="http://www.bfmed.org/Media/Files/Protocols/hypoglycemia.pdf">Academy of Breastfeeding Medicine</a><span class="linkDescription">[link: http://www.bfmed.org/Media/Files/Protocols/hypoglycemia.pdf]</span> and read this protocol on Hypoglycemia. File it in your workbook.<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/group.png" class="icon" alt="" /><h3>Unit Activity</h3>
      <div>Access your Unit policy on the management of hypoglycemia. Compare it to the literature published in peer-reviewed journals. Is it up-to-date and evidence-based? If not, form a working group to review it, present it at a Unit meeting and implement it.</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_"><h3>What should I remember?</h3>
      <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>How euglycemia is maintained, regardless of oral intake.<br /></li>
            <li>The effect of unnecessary blood glucose monitoring on the full-term infant.</li>
            <li>The infants who are 'at-risk' of pathologic neonatal hypoglycemia.</li>
            <li>How to recognise signs of pathologic hypoglycemia.</li>
            <li>The best practice management to prevent symptomatic hypoglycemia for all infants.</li>
            <li>How to support breastfeeding during medical management of pathologic hypoglycemia.<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"><h3>Self-test quiz</h3>
      <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_ry">
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	{ c : 'Baby Freddy was born at 38 weeks 6 days gestation weighing 2.6kg (5lb 11oz). Following an examination by the pediatrician at which time he was noted to be healthy, he was transferred to the postnatal ward with his mother.<br/><br/>A junior nurse/midwife is assigned to care for mother and baby. She has asked you if there is any additional care or considerations in their postnatal recovery.<br/><br/>Discuss the important issues you\'d discuss with the nurse.<br/><br/>', r : 'Compare your response to these sample points:<br/><br/><ul><li>Gestation. Not really significant as infant is quite close to term. Feeding ability should be unaffected.</li><li>Weight. This is significant. Plot the weight on a weight percentile. This infant falls in the small-for-gestational-age range.<br/>Discuss the possibility of pathologic hypoglycemia developing. Is it likely to occur in the first few hours? Why not?</li></ul>Due to low fat reserves baby Freddy is at most risk if he needs to burn fat for energy. To ensure this isn\'t necessary he should be cared for in skin-to-skin contact with his mother (or father or grandmother when mother showering, etc). The infant will be physiologically stabilised rapidly, stress reduced, temperature maintained and breastfeeding established early. <br/><br/>Due to his weight the doctor may have requested a blood screen for hypoglycemia. However, of more importance is regular observations for the signs associated with hypoglycemia. A symptomatic infant requires immediate medical attention.<br/><br/>If baby Freddy is not breastfeeding regularly, assist his mother to hand express her colostrum. The goal being to ensure an early, problem-free establishment of lactogenesis. The colostrum can be fed to baby Freddy, though this won\'t prevent hypoglycemia, but could encourage him to breastfeed.<br/><br/>Provide support for the mother and a safe sleeping environment for her and her baby.<br/>Offer frequent drinks and nutritious foods to the mother.<br/><br/>' }
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</div><script type="text/javascript">renderActivity('ry');</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>
          <div class="section" id="Jaundice"><h2>Jaundice</h2>
    <div>
      <p>
		The most common paediatric condition encountered in the first week is hyperbilirubinaemia. It is so common that it is termed "Physiological Jaundice" and reflects the normal physiological changes that occur as the neonate adapts to extrauterine life.
	</p>
    </div>
    <div class="section" id="Normal_serum_bilirubin_levels"><h3>Normal serum bilirubin levels</h3>
      <div>
        <p class="listTitle">The neonate is more susceptible to high serum bilirubin levels because</p>
        <ol>
          <li>there is increased breakdown of fetal erythrocytes. This is the result of the shortened lifespan of fetal erythrocytes and the greater number of erythrocytes in neonates.</li>
          <li>liver excretory ability is low because of the relative immaturity of the liver.</li>
        </ol>
        <p> </p>
        <p>At birth neonates have a low serum bilirubin. The normal pattern is for a rise to a peak by the third day of life, followed by a plateau and drop in levels, or, for ⅔ of babies, a gradual rise to another peak on about the 10th day. After this the levels gradually drop until about the third week of life. (An exception to this is found in babies of Asian origin whose Day 3 levels peak nearly twice as high as found in non-Asian babies). </p>
        <p> In some mothers, unidentified factors present in her breastmilk may contribute to increased enterohepatic circulation of bilirubin with harmless jaundice persisting for many weeks. This is an extension of physiologic jaundice known as breastmilk jaundice. No special treatment is required and continued breastfeeding is recommended.<sup><a href="#note10">10</a></sup> </p>
        <br />
      </div>
      <div class="captionBox"><img width="475" height="342" src="images/se_bilirubin_graph.gif" alt="" /><p> <br />Diagram &copy;  Health e-Learning</p></div>
      <div>
        <p>
			An explanation of why newborns have elevated bilirubin levels could be that the antioxidant effects of bilirubin compensate for the relative deficiency of endogenous antioxidants in newborns. It is another protective effect denied the artificially fed infant.
		</p>
      </div>
    </div>
    <div class="section" id="Causes_of_abnormal_bilirubin_levels"><h3>Causes of abnormal bilirubin levels</h3>
      <div>
        <ul>
          <li><span style="font-weight: bold;"> Abnormal weight loss </span> : A weight loss of more than 7% in both artificially fed and breastfed infants is associated with higher serum bilirubin concentrations. Inadequate intake causes <br /> <ul><li> retention of meconium and reabsorption of previously excreted bilirubin back into the blood stream. </li></ul> The cycle is then likely to continue as raised serum bilirubin causes sleepiness and poor feeding, decreased intake and further reabsorption of bilirubin. </li>
          <br />
          <li><span style="font-weight: bold;"> Hemolytic processes </span> : Blood group incompatibilities (Rh, ABO, and others) may increase bilirubin production through increased haemolysis. Nonimmune haemolytic disorders (spherocytosis, G-6-PD deficiency) also may cause increased jaundice through increased haemolysis. </li>
          <br />
          <li><span style="font-weight: bold;"> Non-hemolytic processes </span> : A number of other nonhaemolytic processes can increase serum bilirubin levels. Accumulation of blood in extravascular compartments (cephalhaematomas, bruising, occult bleeding) may increase bilirubin production as the blood is absorbed and degraded. Increased bilirubin production also is seen in infants with polycythemia and in infants of mothers with diabetes. Increased reabsorption of bilirubin from the bowel leading to elevated bilirubin levels is seen in infants with bowel obstruction or ileus. </li>
        </ul>
      </div>
    </div>
    <div class="section" id="Physical_appearance"><h3>Physical appearance</h3>
      <div>
        <p> Jaundice has a cephalocaudal (or cephalopedal) <span class="aside"> ie head to toe </span> progression; it is evident first in the face, gradually becoming visible on the trunk. Jaundice seen below the level of the umbilicus and on the extremities reflects increasingly higher serum bilirubin levels. Jaundice disappears in the opposite direction. <br /> Daylight on a clear day provides the best lighting for evaluation. Pressure applied on the skin using the finger pad will blanch the skin revealing the underlying colour. <br /> </p>
        <p> Non-invasive transcutaneous measurement of bilirubin is a reliable screening method for identifying infants who need additional work-up.<sup><a href="#note11">11</a></sup> Laboratory measurement of bilirubin is indicated if jaundice involves the lower body and extremities.<sup><a href="#note10">10</a></sup> </p>
      </div>
    </div>
    <div class="section" id="Management_of_hyperbilirubinemia"><h3>Management of hyperbilirubinemia</h3>
      <div><p><span style="font-weight: bold;"> Prevention </span> of hyperbilirubinemia due to inadequate intake involves early recognition of risk factors, good teaching and supervision of breastfeeding, and mothers who are able to recognize that good transfer of breastmilk to the infant is occurring. </p><p class="listTitle"> Low serum bilirubin concentrations in the first 5 days are characterised by optimal breastfeeding behaviours: <sup><a href="#note10">10</a></sup> </p><ul><li> initiation of breastfeeding in the first hour after birth </li><li> continuous rooming-in with unlimited access to the breast </li><li> a breastfeeding frequency of 10 to 12 times per day </li><li> prompt responses to early hunger cues, and </li><li> absence of all supplementation. </li></ul><p><span style="font-weight: bold;"> Ensure adequate intake for the infant: </span></p><ul><li> assess breastfeeding effectiveness </li><li> stimulate and support an adequate milk supply </li><li> frequent breastfeeds; 8-12 per 24 hrs </li><li> offer supplemental feeds of expressed breastmilk </li><li> artificial infant formula is given only in the absence of adequate breastmilk volumes </li></ul> Phototherapy treatment may be required to heighten elimination of bilirubin. If the infant is under phototherapy lights: <br /> <ul><li> continue all of the above </li><li> offer emotional support to the mother while her baby is receiving treatment </li><li> Contraindicated: water supplementation </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/books.png" class="icon" alt="" /><h3>Workbook Activity 7.5</h3><p>Complete Activity 7.5 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>
    <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/article.png" class="icon" alt="" /><h3>Extend your knowledge</h3>
      <div>
        <p>Read and print the <img alt="External" src="design/external.gif" /><a href="http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/297" title="External link" target="_blank">AAP Clinical Practice Guidelines for the management of hyperbilirubinemia</a><span class="linkDescription">[link: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/297]</span>. Note the recommendations regarding breastfeeding and supplements. </p>
        <p class="listTitle">Note that the first two recommendations are to:</p>
        <ol>
          <li>promote and support successful breastfeeding, and</li>
          <li>harm is associated with supplementing breastfed infants with water or dextrose water.</li>
        </ol>
      </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/group.png" class="icon" alt="" /><h3>Unit activity</h3>
      <div>
        <p>
			What is your Unit's policy on recognition, prevention and management of jaundice? Discuss the Unit policy with your colleagues, comparing it to the AAP recommendations and other evidence-based articles. Would the algorithm in the AAP guidelines be useful to reproduce for your Unit?
		</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_"><h3>What should I remember?</h3>
      <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>Jaundice is a normal physiological process in the well full-term baby (physiological jaundice)</li>
            <li>The potential risk factors for problematic jaundice</li>
            <li>The optimal management that prevents an abnormal pattern of jaundice</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"><h3>Self-test quiz</h3>
      <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_rz">
<p class="instructions">Click and drag the missing words below into their correct place</p><p class="missingWords">The missing words are: <strong>breastfeeding</strong> <strong>breastmilk</strong> <strong>physiological</strong> <strong>supplementation</strong> <strong>tenth</strong> <strong>third</strong></p><span value="physiological" class="dropper">__________</span> jaundice is normal in most newborns. Bilirubin rises to a peak on the <span value="third" class="dropper">__________</span> day of life, followed by a further rise until the <span value="tenth" class="dropper">__________</span> day for most breastfed infants. A harmless form of jaundice that persists for many weeks is termed <span value="breastmilk" class="dropper">__________</span> jaundice.<br />Prevention of hyperbilirubinemia is focused on frequent, effective <span value="breastfeeding" class="dropper">__________</span> and the absence of all <span value="supplementation" class="dropper">__________</span>.<br /><script type="text/javascript">initCloze('activity_rz');</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>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#hawd10" title="See full details">#</a> Hawdon JM (2010) Best practice guidelines: Neonatal hypoglycaemia.</li>
              <li id="note2"><a href="references.html#corn00" title="See full details">#</a> Cornblath M et al. (2000) Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds</li>
              <li id="note3"><a href="references.html#hawd92" title="See full details">#</a> Hawdon JM et al. (1992) Patterns of metabolic adaptation for preterm and term infants in the first neonatal week.</li>
              <li id="note4"><a href="references.html#edmo85" title="See full details">#</a> Edmond J et al. (1985) Ketone body metabolism in the neonate: development and the effect of diet.</li>
              <li id="note5"><a href="references.html#cott11" title="See full details">#</a> Cotter DG et al. (2011) Obligate role for ketone body oxidation in neonatal metabolic homeostasis.</li>
              <li id="note6"><a href="references.html#hani01" title="See full details">#</a> Haninger NC et al. (2001) Screening for hypoglycemia in healthy term neonates: effects on breastfeeding</li>
              <li id="note7"><a href="references.html#hawd99" title="See full details">#</a> Hawdon JM (1999) Hypoglycaemia and the neonatal brain.</li>
              <li id="note8"><a href="references.html#jain10" title="See full details">#</a> Jain A et al. (2010) Hypoglycemia in the newborn.</li>
              <li id="note9"><a href="references.html#eide01" title="See full details">#</a> Eidelman AI (2001) Hypoglycemia and the breastfed neonate</li>
              <li id="note10"><a href="references.html#gart01" title="See full details">#</a> Gartner LM (2001) Breastfeeding and jaundice</li>
              <li id="note11"><a href="references.html#panb10" title="See full details">#</a> Panburana J et al. (2010) Accuracy of transcutaneous bilirubinometry compare to total serum bilirubin measurement.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-3" class="content">
          <h1 id="top">7.3 Supplementation</h1>
          <div class="section" id="Exclusive_breastfeeding"><h2>Exclusive breastfeeding</h2>
    <div class="section" id="Baby_Friendly_Point_5_and_Step_6"><h3>Baby Friendly Point 5 and Step 6</h3>
      <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><span style="font-weight: bold;">Step 6</span> of the Ten Steps to Successful Breastfeeding, and <span style="font-weight: bold;">Point 5</span> of the Seven-point Plan for Sustaining Breastfeeding in the Community state:</div>
        <blockquote>
          <div>
            <span style="font-style: italic;"><span style="font-weight: bold;">Step 6:</span> Give newborn infants no food or drink other than breastmilk, unless medically indicated.</span>
            <br />
          </div>
        </blockquote>
        <blockquote>
          <div><span style="font-weight: bold;"> Point 5: </span> Encourage exclusive and continued breastfeeding (beyond six months) (to two years or more), with appropriately-timed introduction of (adequate and safe) complementary foods.</div>
        </blockquote>
      </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>
          <div class="section" id="Pre-lacteal_feeds"><h2>Pre-lacteal feeds</h2>
    <div>
      <p> Pre-lacteal feeds are any feeds given to the newborn before breastfeeding is established and the milk 'comes in', often within 0-2 hrs of birth. Honey, teas, pastes and herbal preparations are cultural and religious choices.<sup><a href="#note1">1</a></sup> Water, glucose water, milk-based substitutes are common pre-lacteal feeds given in hospital.<sup><a href="#note2">2</a></sup> <sup><a href="#note3">3</a></sup> <br /> </p>
      <p> Prelacteal feeds have been given in some cultures since ancient times in the belief that colostrum is harmful to infant, stale, and that it is not considered to be 'true breastmilk'.<sup><a href="#note4">4</a></sup> Colostrum may be expressed and discarded or replaced with the prelacteals.<sup><a href="#note5">5</a></sup> The prelacteals are believed to moisten the mouth and cleanse the gastrointestinal tract and aid expulsion of the meconium.<sup><a href="#note4">4</a></sup> </p>
    </div>
    <div class="section" id="Effect_on_mother_and_infant"><h3>Effect on mother and infant</h3>
      <div>Colostrum is essential for gut protection, growth and repair as well as the establishment of the bifidobacterium environment. Colostrum aids the expulsion of meconium which reduces enterohepatic circulation of bilirubin. Prelacteal feeding impairs these processes. Water provides no nutrition and fills the infant's stomach lessening the urge to breastfeed. As a result, breastmilk intake is minimal ...<br /><ul><li>increasing diarrhea and infections,<sup><a href="#note6">6</a></sup> <br /></li><li>increasing breastfeeding problems,<sup><a href="#note7">7</a></sup> <br /></li><li>decreases exclusive breastfeeding and duration of breastfeeding,<sup><a href="#note7">7</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note8">8</a>,</sup><sup><a href="#note3">3</a></sup> and <br /></li><li>the cycle of delayed initiation of lactation has the propensity to cause further use of prelacteal feedings.<sup><a href="#note9">9</a></sup></li></ul> <br />The practice of giving pre-lacteal feeds is a key determinant of early cessation of full breastfeeding.<sup><a href="#note3">3</a></sup>With education and support for breastfeeding, the acceptance of exclusive breastfeeding from birth has become more widespread.<br /></div>
    </div>
  </div>
          <div class="section" id="Supplementation"><h2>Supplementation</h2>
    <div>
      <p> Even more common than giving pre-lacteal feeds has been the routine giving of post-breastfeed supplements, or additional bottles of water, glucose water or artificial infant milk. </p>
      <p class="listTitle">The reasons sometimes given for this practice include:</p>
      <ul>
        <li>to give the mother a rest</li>
        <li>because the mother doesn't have her milk 'in' yet</li>
        <li>to calm a crying infant<br /></li>
        <li>to prevent hypoglycemia</li>
        <li>to prevent or reduce jaundice</li>
      </ul>
      <p> None of these reasons are indications for giving supplements, with some having the opposite effect to the result desired. </p>
    </div>
    <div class="section" id="Medical_indications_for_supplementation"><h3>Medical indications for supplementation</h3>
      <div>
        <p> The World Health Organization states that there are few medical indications that may require individual infants to be given fluids or food in addition to, or in place of, breastmilk. Whenever stopping breastfeeding is considered, the risks of infant formula feeding and the benefits of breastfeeding should be weighed against the risks posed by the presence of the specific condition listed. The following circumstances may be considered: <br /> </p>
        <p> Infant conditions: </p>
        <ul>
          <li> These infants should receive only specialized infant formula: <ul><li>an infant with certain inborn errors of metabolism; eg classic galactosemia, maple syrup urine disease, phenyloketonuria (some breastfeeding possible with careful monitoring)</li></ul> </li>
          <li>These infants should continue to receive breastmilk, but may require other food in addition for a limited time: <ul><li>infants with very low birth weight (&lt;1500g) or who are born preterm (before 32 weeks gestational age)</li><li>infants with potentially severe hypoglycemia, or who require therapy for hypoglycemia, and who do not improve through increased breastfeeding or by being given breastmilk.</li></ul> </li>
        </ul>
        <p>Maternal conditions:</p>
        <ul>
          <li>HIV infection. Individualized assessment required that includes the availability of counseling and support, and that infant formula feeding will be acceptable, feasible, affordable, sustainable and safe (AFASS). Antiretroviral therapy and exclusive breastfeeding for 6 months must be supported if the mother breastfeeds.</li>
          <li>Temporary infant formula feeding may be necessary when <ul><li>the mother is taking medication which is contraindicated when breastfeeding, and for which there is no safe alternative. Rarely are there no safe alternatives, however cytotoxic chemotherapy is one.</li><li>the mother abuses drugs such as heroin, cocaine, amphetamines, cannabis, alcohol etc. Seek individual counseling for mothers in these instances to assess their dependency and the needs of their infant.</li></ul> </li>
        </ul>
        <p> Adapted from WHO/UNICEF: <span style="font-style: italic;"> Baby-Friendly Hospital Initiative. Hospital level Implementation 1992. </span> </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/tip.png" class="icon" alt="" /><h3>Protect breastfeeding</h3>
        <div>While breastfeeding is temporarily delayed or interrupted for any reason, the mother should be given instructions to maintain her milk supply (or increase it as the case may be) by regular expression of milk.<br />Encourage the mother to be with her baby as much as possible. Explain to her about the importance of her breastmilk for her baby and discuss strategies for the infant's return to breastfeeding.<br /><br />Review the literature which you can give to the mother about expressing, storage of breastmilk and maintaining milk supply.<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 class="section" id="Supplements_in_order_of_preference"><h4>Supplements in order of preference</h4>
        <div>When the baby cannot be breastfed, the World Health Organisation sets a feeding preference in this order:<sup><a href="#note10">10</a></sup> <br /> <ul><li> The mother's own expressed breastmilk </li><li> Donor breastmilk - from another healthy mother or human milk bank </li><li> Infant formula. The type chosen requires careful consideration of maternal preference and family history of allergies. A pediatrician should guide the choice according to infant need.<br /></li></ul> The WHO strategy states that infants who are not breastfed should receive special attention from health systems as they constitute a group at risk for growth and health problems. <br /></div>
      </div>
    </div>
    <div class="section" id="Effect_on_infant_health"><h3>Effect on infant health</h3>
      <div>
        <p class="listTitle"> As mentioned earlier, prelacteal feeds and supplements change the normal flora of the intestine, decreases gut mobility, increases jaundice, etc. Artificial infant milk can be contaminated during manufacture and preparation, and the feeding implements can introduce another source of infection. Protective properties such as lactoferrin are inactivated by artificial infant milk.<sup><a href="#note11">11</a></sup> </p>
      </div>
    </div>
    <div class="section" id="Effect_on_breastfeeding"><h3>Effect on breastfeeding</h3>
      <div>
        <p>
			As with pre-lacteal feeds, researchers using randomized, controlled trials and prospective studies found the use of supplements during the hospital stay (and afterwards) is associated with </p>
      </div>
      <blockquote>
        <div>earlier cessation of exclusive breastfeeding and earlier weaning.</div>
      </blockquote>
      <div>
        <p></p>
        <p> Breastfeeding is negatively affected when formula is used, even in hospitals where educational materials, counseling, support and policies are generally favorable to breastfeeding. Research was conducted in a unit where nursing staff's attitudes regarding breastfeeding were very positive with more than 80% reporting discussing the advantages of breastfeeding routinely with mothers.<sup><a href="#note12">12</a></sup> However, 77% of mothers had started bottle-feeding 2 to 3 weeks after birth, the majority (93%) remembered which brand of formula was used to supplement their baby in hospital and most were using that brand.</p>
        <p>
          <span style="font-style: italic;">Parents may interpret the use of formula as an endorsement by hospital staff, despite clear verbal messages promoting breastfeeding. </span>
        </p>
      </div>
    </div>
    <div class="section" id="Effect_on_the_mother"><h3>Effect on the mother</h3>
      <div><p class="listTitle">The reduced breast stimulation and reduced milk removal that occurs as a result of the infant being given supplements results in</p><ul><li>an increased incidence of breast engorgement, and</li><li>more severe engorgement, which can cause breast involution and the failure of adequate lactation. Early, frequent milk removal is pivotal to the success of breastfeeding in the coming weeks.</li><li>shorter duration of lactational amenorrhoea<sup><a href="#note13">13</a></sup></li></ul>Giving supplements when a medical indication does not exist causes a loss of maternal self-confidence.<sup><a href="#note14">14</a></sup><p> </p></div>
    </div>
    <div class="section" id="Effect_on_infant_serum_glucose_levels"><h3>Effect on infant serum glucose levels</h3>
      <div>
        <p> Serum glucose levels normally drop to their lowest levels at about 2 hours of age, then rise to remain normal for up to 24 hours, irrespective of feeding.<sup><a href="#note15">15</a></sup> Giving babies glucose water or artificial infant formula only serves to interfere with this normal physiological process and is poor clinical practice. </p>
      </div>
    </div>
    <div class="section" id="Effect_on_hyperbilirubinemia"><h3>Effect on hyperbilirubinemia</h3>
      <div>
        <p> Likewise the pathophysiology of hyperbilirubinemia does NOT respond to giving water. Reduced breastfeeding frequency and supplementation with water or glucose water have been associated with increased serum bilirubin concentrations in the first 5 days of life.<sup><a href="#note16">16</a></sup> Lack of early feeding delays passage of meconium and increases enterohepatic re-absorption of bilirubin. </p>
        <p> Increased breastfeeding is the best way to treat the additional insensible water loss that is caused when phototherapy is instituted.<sup><a href="#note17">17</a></sup> </p>
      </div>
    </div>
    <div class="section" id="Effect_on_atopic_disease"><h3>Effect on atopic disease</h3>
      <div>
        <p> Even just one or two artificial baby milk feeds at this time may result in the development of cow's milk intolerance or cow's milk allergy, which will become symptomatic later in infancy.<sup><a href="#note18">18</a>,</sup><sup><a href="#note19">19</a></sup> </p>
      </div>
    </div>
    <div class="section" id="Effect_on_infant_digestion_and_absorption"><h3>Effect on infant digestion and absorption</h3>
      <div>
        <p class="listTitle">Artificial infant formula is poorly digested and absorbed compared to breastmilk as</p>
        <ul>
          <li>there is a normal immaturity of digestion and absorption at birth</li>
          <li>breastmilk contains enzymes to aid digestion (eg lipase)</li>
          <li>breastmilk macronutrients are in easily digested form</li>
          <li>absorption of minerals is enhanced by breastmilk 'transporters'</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/group.png" class="icon" alt="" /><h3>Let's solve this problem...</h3>
      <div>
        <p>
			Lack of understanding of normal newborn behavior and maternal fatigue appear to be the major reasons mothers give their infants supplements. Time for some brainstorming!
		</p>
        <p>
			Brainstorm with your colleagues ways of supporting a tired mother in hospital who has requested a supplement, or who, in the community setting, is wanting to give supplements to change her baby's behavior.
		</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="Human_Immunodeficiency_Virus_HIV_"><h3>Human Immunodeficiency Virus (HIV)</h3>
      <div>
        <ul>
          <li> Exclusive breastfeeding, combined with antiretroviral therapy has a low risk of mother-to-child transfer of HIV. <sup><a href="#note20">20</a></sup> <sup><a href="#note21">21</a></sup> <sup><a href="#note22">22</a></sup> <br /> </li>
          <li> Mixed feeding (ie breastfeeding and giving supplements) significantly increases the risk of mother-to-child (MTC) transfer of HIV. <br /> </li>
        </ul>
        <p> Exposure to cow's milk protein and other foods damages the permeable infant gut allowing transfer of the HIV virus. <sup><a href="#note23">23</a></sup> Unless it is known, <span style="font-weight: bold;"> without doubt</span>, that a mother is HIV negative then there is a likelihood the baby may suffer serious morbidity and eventual mortality from giving a breastfed infant just one supplementary bottle.</p>
      </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 7.6</h3><p>Complete Activity 7.6 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="Legal_implications"><h3>Legal implications</h3>
      <div>
        <p> The effects discussed above are just a few of the many detrimental effects of infant formula on babies. The knowledge of these detrimental effects has been available in mainstream medical, nursing and midwifery literature for many years. </p>
        <p> Consider the liability of introducing an inferior product (ie artificial infant formula) to an infant, particularly as it is known to cause breastfeeding failure and acute and chronic illness for infants. Should the parents, or affected child, take legal action it would be very difficult to defend. <br /></p>
      </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>Unit Activity</h3>
      <div>
        <p> Review your Unit's policy on supplementation AND common practices of the staff. Ensure that there are very clear policy guidelines for when a supplement is medically indicated. Discuss with your colleagues the implications for them, the mother and the baby should they not follow this policy. <br /></p>
        <p>Do you have an "Informed Consent" form to ensure mothers are aware of the dangers of infant formula? </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_"><h3>What should I remember?</h3>
      <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>Exclusive breastfeeding, initiated immediately after birth provides the best opportunity for optimal health.</li>
            <li>Any food or liquid other than breastmilk is foreign and harmful to an infant and breastfeeding.</li>
            <li>The effects of pre-lacteals and supplementation on the infant, mother and breastfeeding.</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"><h3>Self-test quiz</h3>
      <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_ra">
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	new CWWord('prelacteal', 'Feeds given as first feeding or before milk \'comes in\'.', 6, 7, 0),
	new CWWord('bifidobacterium', 'This environment in the gut is disturbed when any supplement is introduced.', 1, 3, 1),
	new CWWord('honey', 'A commonly-used cultural prelacteal feed.', 8, 12, 0),
	new CWWord('water', 'It is dangerous to give this to infants because it has no nutritional value and it fills their stomach and suppresses their urge to breastfeed.', 5, 15, 1),
	new CWWord('supplement', 'Additional feeding given to the infant whilst continuing breastfeeding.', 0, 4, 0),
	new CWWord('contamination', 'This effect of infant formula supplementation causes direct exposure of the infant to infection.', 10, 0, 0),
	new CWWord('lactoferrin', 'Artificial infant formula deactivates this breastmilk immune component.', 6, 1, 1),
	new CWWord('engorgement', 'First noticeable effect on mother\'s lactation when pre-lacteal and supplements given.', 0, 9, 1),
	new CWWord('lowsupply', 'Ongoing effect on mother\'s lactation when supplements given to infant. (2 words together)', 3, 8, 0),
	new CWWord('bilirubin', 'Water supplementation of the infant causes this increased serum levels.', 9, 6, 1),
	new CWWord('atopic', 'The risk of these diseases increase with supplementation of cow\'s milk based artificial infant formulas and become evident later in life.', 10, 8, 1),
	new CWWord('HIV', 'The virus will transfer through the permeable gut when artificial infant formula damages gut lining.', 16, 5, 0)
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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>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#laro06" title="See full details">#</a> Laroia N et al. (2006) The religious and cultural bases for breastfeeding practices among the Hindus.</li>
              <li id="note2"><a href="references.html#akus02" title="See full details">#</a> Akuse RM et al. (2002) Why healthcare workers give prelacteal feeds.</li>
              <li id="note3"><a href="references.html#laka10" title="See full details">#</a> Lakati AS et al. (2010) The effect of pre-lacteal feeding on full breastfeeding in Nairobi, Kenya.</li>
              <li id="note4"><a href="references.html#ingr03" title="See full details">#</a> Ingram J et al. (2003) South Asian grandmothers' influence on breast feeding in Bristol.</li>
              <li id="note5"><a href="references.html#roge11" title="See full details">#</a> Rogers NL et al. (2011) Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in rural Northern Ethiopia.</li>
              <li id="note6"><a href="references.html#hoss92" title="See full details">#</a> Hossain MM et al. (1992) Prelacteal infant feeding practices in rural Egypt.</li>
              <li id="note7"><a href="references.html#isen87" title="See full details">#</a> Isenalumhe AE et al. (1987) Prelacteal feeds and breast-feeding problems.</li>
              <li id="note8"><a href="references.html#prez96" title="See full details">#</a> Pérez-Escamilla R et al. (1996) Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras.</li>
              <li id="note9"><a href="references.html#ahme96" title="See full details">#</a> Ahmed FU et al. (1996) Prelacteal feeding: influencing factors and relation to establishment of lactation.</li>
              <li id="note10"><a href="references.html#who03a" title="See full details">#</a> World Health Organisation (2003) Global Strategy for Infant and Young Child feeding</li>
              <li id="note11"><a href="references.html#whar94" title="See full details">#</a> Wharton BA et al. (1994) Faecal flora in the newborn. Effect of lactoferrin and related nutrients</li>
              <li id="note12"><a href="references.html#reif85" title="See full details">#</a> Reiff MI et al. (1985) Hospital influences on early infant-feeding practices.</li>
              <li id="note13"><a href="references.html#mcne01" title="See full details">#</a> McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women</li>
              <li id="note14"><a href="references.html#gagn05" title="See full details">#</a> Gagnon AJ et al. (2005) In-hospital formula supplementation of healthy breastfeeding newborns</li>
              <li id="note15"><a href="references.html#eide01" title="See full details">#</a> Eidelman AI (2001) Hypoglycemia and the breastfed neonate</li>
              <li id="note16"><a href="references.html#gart01" title="See full details">#</a> Gartner LM (2001) Breastfeeding and jaundice</li>
              <li id="note17"><a href="references.html#deca81" title="See full details">#</a> de Carvalho M et al. (1981) Effects of water supplementation on physiological jaundice in breast-fed babies</li>
              <li id="note18"><a href="references.html#wegi06" title="See full details">#</a> Wegienka G et al. (2006) Breastfeeding history and childhood allergic status in a prospective birth cohort</li>
              <li id="note19"><a href="references.html#maci10" title="See full details">#</a> MacIntyre EA et al. (2010) Early-life otitis media and incident atopic disease at school age in a birth cohort.</li>
              <li id="note20"><a href="references.html#horv09" title="See full details">#</a> Horvath T et al. (2009) Interventions for preventing late postnatal mother-to-child transmission of HIV.</li>
              <li id="note21"><a href="references.html#ilif05" title="See full details">#</a> Iliff PJ et al. (2005) Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival.</li>
              <li id="note22"><a href="references.html#coov07" title="See full details">#</a> Coovadia HM et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.</li>
              <li id="note23"><a href="references.html#smit00" title="See full details">#</a> Smith MM et al. (2000) Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1?</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-4" class="content">
          <h1 id="top">7.4 Crying baby</h1>
          <div class="section" id="My_baby_cries_a_lot._What_should_I_do_"><h2>My baby cries a lot. What should I do?</h2>
    <div>
      <p> Babies cry to express a need, and the cry of the baby causes the parent to respond. <br /> </p>
      <p> Breastfeeding is often the first thing that is blamed when the baby is perceived to have problems. Babies who cry frequently are at higher risk of being given foods and drinks inappropriately <sup><a href="#note1">1</a></sup> or a pacifier/dummy and infants who are perceived as 'fussy' are more likely to be fed solid foods before 4 months. <sup><a href="#note2">2</a></sup> <br /> </p>
      <p> Using counseling skills techniques, listen to what the mother is saying, and try to determine a cause. Observe her interaction with her baby and what settling techniques she is using. Watch the baby breastfeeding and examine the baby. If necessary, refer to a doctor for further assessment. </p>
      <p class="listTitle"> Build the mother's confidence </p>
      <ul>
        <li> Listen and accept the mother's feelings </li>
        <li> Reinforce what the mother and baby are doing right; what is normal </li>
        <li> Give information relevant to this mother </li>
        <li> Give practical help </li>
      </ul>
      <p class="listTitle"> Some suggestions that may help </p>
      <ul>
        <li> Hold her baby skin-to-skin against her chest; her warmth, smell and heartbeat will help to soothe him. </li>
        <li> Offer her breast to her baby: he may be hungry, thirsty or in need of suckling for a sense of security; some babies will settle quickly when offered a 'nearly-empty' breast when not hungry. </li>
        <li> Attend to baby's comfort: change nappy/diaper; check baby is not too warm not too cold; etc </li>
        <li> Talk to, sing, rock the baby while holding close. Gently swinging the baby sideways (ie from ear to ear) helps settle quicker than backwards and forwards movement. <br /> </li>
        <li> Stroking or baby massage with oil may help. </li>
        <li> Involve the mother's support people in the discussion so they understand that supplements aren't the solution to this problem. </li>
        <li> Suggest use of a baby sling/pouch for the mother to be able to continue other tasks or ask that someone else carry and comfort the baby for some time, giving the mother a break. </li>
        <li> Encourage the involvement in a mother-to-mother support group for the mother to share experiences and concerns. </li>
        <li> Investigate the mother's intake of caffeinated drinks and smoking - both of which are associated with crying and unsettled babies. </li>
        <li> Suggest a 24-48 hr diary of the infant's behaviour - this may help you determine a link to a time of day or activity and help the mother's perception of the crying. <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/thinker.gif" class="icon" alt="" /><h3>To Swaddle or not to swaddle?</h3>
      <div>A crying baby needs comfort and reassurance - do you like to be ignored when you are upset? <br /> Some cultures use swaddling methods and this practice has disseminated into many modern parenting styles. The adult observes that the infant becomes calm, quiet and less likely to disturb themselves with jerky movements. <br /> <ul><li> Swaddling increases intrathoracic pressure which, in turn, decreases pulmonary functional residual capacity. <sup><a href="#note3">3</a></sup> <br /> </li><li> It also decreases spontaneous cortical arousals and autonomic control in newly swaddled sleeping infants - similar responses are observed in victims of sudden infant death. <sup><a href="#note4">4</a></sup> </li></ul> <p> Be cautious not to look for a quick fix. A 'good' baby is not a sleeping baby. Be a detective to help determine the existence of an underlying organic cause of the unsettled behaviour and reassure the mother. </p> <p> Some babies may benefit from gentle swaddling. Carefully explain the correct application of this technique to ensure it isn't used as a first method of settling or used inappropriately. </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>
    <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>Be alert!</h3>
      <div>
        <p>A crying baby causes strong emotional responses in people so be alert to the mother's state of mind and ability to cope. This may be a desperate plea for more professional help, not just settling tips. </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="Pacifiers_Dummies"><h2>Pacifiers/Dummies</h2>
    <div class="section" id="Baby_Friendly_Step_9_and_Point_4"><h3>Baby Friendly Step 9 and Point 4</h3>
      <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><span style="font-weight: bold;">Step 9</span> of the Ten Steps to Successful Breastfeeding, and <span style="font-weight: bold;">Point 4</span> of the Seven-point Plan for Sustaining Breastfeeding in the Community state:</div>
        <blockquote>
          <div><span style="font-weight: bold;"> Point 4: </span><br /> Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). <span class="aside"> United Kingdom, Canada, New Zealand </span> <p> Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. <span class="aside"> Australia </span> </p></div>
        </blockquote>
        <blockquote>
          <div>
            <span style="font-style: italic;"><span style="font-weight: bold;">Step 9:</span> Give no artificial nipples/teats or dummies/pacifiers to breastfeeding infants. </span>
          </div>
        </blockquote>
      </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="Sucking_and_breastfeeding"><h3>Sucking and breastfeeding</h3>
      <div>
        <ul>
          <li> The suckling technique used during breastfeeding is completely different to the action of sucking used on a bottle teat or non-nutritive sucking on a pacifier/dummy. <br /> Babies are thought to 'imprint' latching and suckling skills from their earliest experiences.<sup><a href="#note5">5</a></sup> When artificial teats/dummies are their predominant feeding experience, learning to latch and use a correct sucking technique is difficult. </li>
          <br />
          <li> Pacifiers/dummies stifle early feeding cues and are often used to delay breastfeeding and reduce the time spent at the breast. This will have a significant impact on the control of milk synthesis and potential to decrease milk supply. <br /> Studies of full term newborns and preterm infants demonstrate reduced duration of exclusive breastfeeding when pacifiers are used extensively and/or more than a few supplements are given using bottles.<sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup> </li>
          <br />
          <li>Teats and pacifiers are reservoirs for infection which adheres easily to the surface.<sup><a href="#note8">8</a>,</sup><sup><a href="#note9">9</a></sup> <br /></li>
          <li>Pacifiers are associated with an increase in otitis media and dental malocclusion.</li>
          <br />
          <li> Some studies recommend the use of pacifiers for the prevention of sudden infant death syndrome (SIDS).<sup><a href="#note10">10</a></sup> The explanation offered, that an infant sucking on a pacifier during the night has more spontaneous arousals, has been shown not to occur.<sup><a href="#note11">11</a></sup> However, breastfeeding and co-sleeping have been shown to reduce the risk of SIDS, and pacifier use reduces the incidence of breastfeeding. <br /></li>
        </ul>
        <p> Should a mother wish to use a pacifier it's use should be guided by ...<br /></p>
        <ul>
          <li>do not commence use until breastfeeding well established, eg 4 - 6 weeks or longer</li>
          <li>only use it at the time the infant is put down to sleep - if rejected by infant do not force</li>
          <li>when the pacifier falls out during the infant's sleep it is not to be reinserted.<br /> </li>
        </ul>
      </div>
    </div>
  </div>
          <div class="section" id="When_crying_is_excessive"><h2>When crying is excessive</h2>
    <div>
      <p class="listTitle">The most common causes of excessive crying are</p>
      <ul>
        <li>immaturity in the first 7-8 weeks of life</li>
        <li>lactose malabsorption,</li>
        <li>colic, and</li>
        <li>gastroesophageal reflux disease</li>
      </ul>
    </div>
    <div class="section" id="Lactose_malabsorption_overload"><h3>Lactose malabsorption/overload</h3>
      <div>This is primarily a condition of overload of large volumes of breastmilk in the gut which exceeds the ability of lactase to split it. Undigested lactose osmotically draws in fluid from the abdominal cavity where it ferments in the presence of the gut bacteria.</div>
      <div class="section" id="Presentation"><h4>Presentation</h4>
        <div>
          <p> Onset is usually in the first few weeks of life, but could present later if mother changes her feeding style. </p>
          <dl> </dl>
          <ul>
            <li> Baby <br /> <ul><li> usually thriving baby, putting on weight very well </li><li> frequently distressed and has inconsolable crying </li><li> short sleeps followed by waking in pain <br /> </li><li> frequently sucking fist for comfort </li><li> draws knees up to chest while crying </li><li> flatulence ++ </li><li> many nappies/diapers per day soaked with clear urine </li><li> frequent, watery, copious, green-ish and/or frothy stools </li></ul> </li>
          </ul>
          <ul>
            <li> Mother <br /> <ul><li> has a copious breastmilk supply and a large breastmilk storage capacity </li><li> offers baby both breasts at most breastfeeds, taking baby off first breast after a measured amount of time, rather than when it feels 'drained' </li><li> may feel the baby's 'fist sucking' indicates hunger and breastfeeds baby again; usually from breast not (or least) suckled at the previous feed </li><li> may feel she has an inadequate supply because of his frequent feeding and crying </li><li> may be concerned baby has a gastrointestinal infection because of the unusual stool appearance </li></ul> </li>
          </ul>
        </div>
      </div>
      <div class="section" id="Management"><h4>Management</h4>
        <div>
          <ul>
            <li>Reassure mother of the volume and suitability of her breastmilk for her baby.</li>
            <li>Discuss with her the signs that indicate the infant is in good health.</li>
            <li> Encourage breastfeeding from only one breast over a period of time, determined individually. eg. One mother may repeatedly breastfeed from only her left breast for a 2-4 hours time period. Every time baby indicates a need to suckle during that time he will be put to the left breast and receive breastmilk that has an increasing fat content as that breast is progressively drained. This will slow the gastric emptying, and usually the infant will take less breastmilk when the breast is less full; both factors resulting in less lactose being transferred rapidly into the small intestine. For the next 2-4 hour block of time, the infant may only feed from the right breast, and so on until the problem is resolved. Mothers will be able to determine by trial and error the most appropriate time period for each breast. </li>
            <li> Frequency of breastfeeding is not restricted. All feeding cues during the set time period are responded to with the same breast. </li>
            <li> Care of the breast not being suckled may involve gentle expressing or releasing enough milk for comfort and applying ice packs to prevent engorgement. This can be done while the infant is feeding on the other breast. <br /></li>
            <li>Resolution of the infant's symptoms is usually rapid - within 48 hours, although it could take up to a week.</li>
            <li> A return to two-sided breastfeeding may be indicated in time as milk volume settles and gut maturity improves, either for most feeds or perhaps only evening feeds. </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/books.png" class="icon" alt="" /><h3>Workbook Activity 7.7</h3><p>Complete Activity 7.7 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>
      </div>
    </div>
    <div class="section" id="Colic"><h3>Colic</h3>
      <div>
        <p> One study<sup><a href="#note12">12</a></sup> noted that infants who have colic cry excessively without an identifiable need. They are difficult to console and provoke much parental anxiety. Sleep is interrupted for both infant and caregiver, and mothers experience increased risks of breastfeeding failure, postpartum depression, and marital conflict. When infants cry excessively, they are at a much greater risk of child abuse. Parents become desperate for resolution and accept advice and therapies from a wide variety of resources. The authors estimate that between 16% and 26% of all infants experience colic. </p>
        <p> Reviews of the research<sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup> examining pharmaceutical, naturopathic and behavioral techniques for their effectiveness in reducing colic are only able to recommend a low-allergen maternal diet as having any effect on the breastfed baby. Only one pharmaceutical agent (dicyclomine) was found to be any more effective than a placebo, and due to serious side effects it is no longer recommended. </p>
        <p> A tea containing camomile and other herbs had a degree of effectiveness, however the volume required to be given to the infant to obtain this effect was excessive and therefore not recommended. </p>
        <p> A pilot study<sup><a href="#note15">15</a></sup> found a significant decrease in crying and increase in sleeping in colicky infants receiving cranial osteopathic manipulation. Larger studies are required to confirm the effectiveness of this intervention. </p>
        <p> Eglash<sup><a href="#note13">13</a></sup> considers pure colic to be a patterned daily behavior of crying that a parent can predict will occur and stop at certain times, and the baby is fine at other times of day. This health care provider does not expect a change in maternal diet to help, the condition being self-limiting by about age 3 months. </p>
      </div>
      <div class="section" id="Management"><h4>Management</h4>
        <div>
          <ol>
            <li>Refer for medical review to exclude pathology</li>
            <li>Low-allergen diet for the mother may result in some improvement</li>
            <li>Infant and parent support measures</li>
          </ol>
        </div>
      </div>
    </div>
    <div class="section" id="Gastroesophageal_Reflux"><h3>Gastroesophageal Reflux</h3>
      <div>
        <p>
			Gastroesophageal reflux occurs when stomach contents reflux into the esophagus/oesophagus and out the mouth, resulting in regurgitation, or spitting up, and vomiting. This condition is very common and is caused by the sphincter at the top of the infant's stomach having not yet become efficient at retaining the stomach contents. Most babies with this condition are happy and continue to thrive, outgrowing the worst of it around 6 months of age.
		</p>
      </div>
      <div class="section" id="Gastroesophageal_Reflux_Disease"><h4>Gastroesophageal Reflux Disease</h4>
        <div>
          <p> Gastroesophageal Reflux Disease (GERD, GORD) occurs when the constant refluxing of stomach contents causes burning and ulceration of the esophagus and sometimes aspirates into the lungs. This medical condition will be diagnosed and treated by the infant's doctor. </p>
        </div>
      </div>
      <div class="section" id="Breastfeeding_Management"><h4>Breastfeeding Management</h4>
        <div>
          <ul>
            <li>Breastfeed the infant in an upright position, at least 30<sup>o</sup> elevation of the head above the stomach.</li>
            <li>Some babies will want to breastfeed very frequently, as the breastmilk eases the pain by neutralizing stomach acid.<br /></li>
            <li>Cow milk protein allergy is frequently associated with GERD. A trial of maternal low-allergen diet is recommended.<sup><a href="#note16">16</a></sup></li>
          </ul>
        </div>
      </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>Crying is an expression of a need.</li>
          <li>Some practical suggestions to settle the infant's crying.</li>
          <li>The possible underlying causes of excessive crying.</li>
          <li>The breastfeeding management strategies which may assist lactose overload symptoms.</li>
          <li>Excessive crying not relieved by practical suggestions is a marker requiring medical review.</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_rb">
<script type="text/javascript">
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var rbqs = {settings : {type : 'response'}, questions : [
	{ c : 'A mother of a 7 week old baby is very upset - she is tired and in despair because her baby cries lot and she doesn\'t know why or how to stop the crying.<br/>Babies cry for many reasons. Use the headings Detective work, Practical suggestions, Breastfeeding management, Emotional support to discuss how you would address this situation.<br/>', r : '<span style=\"font-weight: bold;\">Detective work:</span><br/>Take a history - maternal health, pregnancy and birth history<br/>Infant health - breastfeeding progress <br/>Examination of the baby - weight check and progress<br/>Observe a breastfeed<br/><br/><span style=\"font-weight: bold;\">Practical Suggestions:</span><br/>Suggest a sling/pouch<br/>Encourage skin-to-skin cuddles of mother and baby<br/>Teach baby massage<br/>Suggest lying down breastfeeding to get extra rest and minimising unnecessary tasks<br/>Suggest a diary as a means of pin-pointing the cause<br/>Ask about sharing baby cares with another support person<br/>Arrange a medical review of the infant if suggestions don\'t ease the symptoms<br/><br style=\"font-weight: bold;\"/><span style=\"font-weight: bold;\">Breastfeeding Management:</span><br/>Ensure crying is not from inadequate intake<br/>Suggest block feeding on one breast at a time to ensure adequate drainage of fat portion of feed<br/>Encourage squeeze off or gentle express of engorged breasts<br/>Suckling at the breast relieves pain <br/>Some modification of maternal diet may assist<br/><br/><span style=\"font-weight: bold;\">Emotional Support:</span><br/>Reassure the mother of the baby\'s good health<br/>Congratulate her on her care of her baby.<br/>Support her when she recognises strategies which help<br/>Acknowledge her distress<br/>Offer contact details for mother-to-mother support group<br/><br/><br/><br/><br/>' }
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</div><script type="text/javascript">renderActivity('rb');</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 id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kara07" title="See full details">#</a> Karacam Z (2007) Factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community-based study of Turkish women</li>
              <li id="note2"><a href="references.html#wass11" title="See full details">#</a> Wasser H et al. (2011) Infants perceived as fussy are more likely to receive complementary foods before 4 months.</li>
              <li id="note3"><a href="references.html#thac09" title="See full details">#</a> Thach BT (2009) Does swaddling decrease or increase the risk for sudden infant death syndrome?</li>
              <li id="note4"><a href="references.html#rich10" title="See full details">#</a> Richardson HL et al. (2010) Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants.</li>
              <li id="note5"><a href="references.html#wool86" title="See full details">#</a> Woolridge MW (1986) The 'anatomy' of infant sucking.</li>
              <li id="note6"><a href="references.html#howa03" title="See full details">#</a> Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding</li>
              <li id="note7"><a href="references.html#coll04" title="See full details">#</a> Collins CT et al. (2004) Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial</li>
              <li id="note8"><a href="references.html#comi06" title="See full details">#</a> Comina E et al. (2006) Pacifiers: a microbial reservoir</li>
              <li id="note9"><a href="references.html#dasi09" title="See full details">#</a> da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.</li>
              <li id="note10"><a href="references.html#hauc05" title="See full details">#</a> Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis</li>
              <li id="note11"><a href="references.html#hanz09" title="See full details">#</a> Hanzer M et al. (2009) Pacifier use does not alter the frequency or duration of spontaneous arousals in sleeping infants.</li>
              <li id="note12"><a href="references.html#fire06" title="See full details">#</a> Fireman L et al. (2006) Colic</li>
              <li id="note13"><a href="references.html#crot06" title="See full details">#</a> Crotteau CA et al. (2006) Clinical inquiries. What is the best treatment for infants with colic?</li>
              <li id="note14"><a href="references.html#garr00" title="See full details">#</a> Garrison MM et al. (2000) A Systematic Review of Treatments for Infant Colic</li>
              <li id="note15"><a href="references.html#hayd06" title="See full details">#</a> Hayden C et al. (2006) A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic</li>
              <li id="note16"><a href="references.html#hein06" title="See full details">#</a> Heine RG (2006) Gastroesophageal reflux disease, colic and constipation in infants with food allergy</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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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        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-5" class="content">
          <h1 id="top">7.5 Inadequate weight gain</h1>
          <div>
    <p>
	Inadequate weight gain, or failure to thrive (FTT) is a sign of poor health that is caused by other factors. It's not a condition in its own right.
</p>
  </div>
          <div class="section" id="Definition_of_failure_to_thrive_FTT_"><h2>Definition of failure to thrive (FTT)</h2>
    <div>
      <p> In the younger baby weight loss of &gt;7 - 10% of birthweight, or failure to regain birthweight by the second week is considered abnormal. </p>
      <p class="listTitle">In the older baby it may be defined in several ways</p>
      <ul>
        <li>an infant whose weight or height for age is less than the 3<sup>rd</sup> or 5<sup>th</sup> percentile</li>
        <li>an infant whose weight for age falls through 2 major percentile curves on their growth chart</li>
        <li>weight less than 80% of ideal body weight for age</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></h3>
      <div>Review the WHO Child Growth Standards as covered in <a href="topic_6-3.html">Topic 6.3</a> . It is important to have a good understanding of normal growth and to be competent to recognise sub-optimal growth patterns. <br /> All infant measurements should be plotted on these charts only.</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="Cause_of_failure_to_thrive"><h2>Cause of failure to thrive</h2>
    <div>
      <ul>
        <li>poor absorption and/or the inability to use absorbed nutrients, or</li>
        <li>increased metabolic demands, (eg heart disease, undiagnosed infection, etc) or</li>
        <li>
          <p class="listTitle">inadequate energy intake from</p>
          <ul>
            <li>an insufficient supply of breastmilk, or</li>
            <li>regulation of breastfeeding such that the baby is unable to take sufficient breastmilk, or</li>
            <li>inability of the baby to suckle effectively at the breast.</li>
          </ul>
        </li>
      </ul>
    </div>
  </div>
          <div class="section" id="What_to_do_when_you_suspect_FTT"><h2>What to do when you suspect FTT</h2>
    <div class="section" id="Record_a_thorough_history"><h3>Record a thorough history</h3>
      <div>
        <p>
			Your routine history intake form should allow you to identify issues that may be significant, eg. gestational age at birth, weight at birth, weight at hospital discharge, interventions in birthing, early postnatal breastfeeding history, jaundice, ill health since birth, maternal medical, surgical, obstetric and lactation history, etc. <span class="aside">[Discuss in the forums or with your colleagues why each of these could be significant.]</span>
		</p>
        <ul>
          <li>
				If the mother has been concerned about her baby's growth, ask her what actions she has taken to date; eg. doctor review, pumping additional breastmilk, using breast compression, taking a galactagogue, giving supplements, etc.
			</li>
          <li>
				Ask the mother to describe typical breastfeeding behavior.
				<p class="listTitle">If necessary prompt the mother to include:</p><ul><li>type of feeding cues and her response to them,</li><li>describe when the baby feeds, not just how many times per day or night,</li><li>baby's behavior before, during and after breastfeeds,</li><li>the mother's active involvement, eg. waking baby to feed, delaying feeding to fit a schedule or her busy lifestyle, stimulating baby to continue to breastfeed, stopping baby after a time-limit, etc. </li></ul>
			</li>
          <li>
				Ask the mother about complementary foods, or other fluids given to baby, or the use of a pacifier - How much? How often? Why? ...
			</li>
          <li>
				Ask her to describe her baby's urine and stool output in a typical day. It would be an advantage if you could see a wet and a dirty diaper/nappy.
			</li>
          <li>
				Ask her to describe her baby's temperament. If crying behavior sounds excessive, ask for a more detailed description of frequency and type.
			</li>
          <li>Ask her about her baby's recent state of health.</li>
          <li>Does she give the baby any medications (prescription or non-prescription), vitamins, 'tonics', etc?</li>
          <li>
				If you don't already have it, plot as many weight and length measurements onto the WHO Growth Chart as the mother is able to provide you with. From this you will be able to determine a trend.
			</li>
          <li>
				Ask about her recent state of health, medications (prescription and non-prescription) and postpartum recovery, particularly her lochia. <span class="aside">[Why ask about lochia?]</span>
			</li>
          <li>
				Ask her about the growth patterns of her other children, if applicable. If they followed a similar growth pattern did she do anything to try to influence it? Was it successful?
			</li>
          <li>
				Social issues could be significant: if appropriate, ask about the family structure, their living conditions, stressors, other children. Observe the interaction between mother and baby during your consultation - also other relationships if someone else has accompanied the mother.
			</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Examination_of_the_baby"><h3>Examination of the baby</h3>
      <div><p style="font-weight: bold;"> Observe the baby naked. </p><p> Ask the mother to lie the infant down and undress him/her (reducing chance of distress caused by unfamiliarity). Observation should include the infant lying flat on his back (if tolerated), turned gently from one side to the other, and laid prone with head turned to face both sides. </p><ul><li> Behavioral state, and transition between states. Reaction to being undressed, laid down flat, picked up and cuddled/soothed by mother. </li><li> Muscle tone and position that the infant assumes (well flexed, partially flexed, extended, hyperextended, head turned one particular direction exclusively) </li><li> Shape of the infant's head particularly noting presence of forceps or vacuum marks (first few weeks), cephalhaematoma, asymmetry. </li><li> Skin: turgor, subcutaneous fat, rashes, integrity, bruises; color - jaundice (extent); pale; mottled; cyanosis - where, what precipitated it </li><li> Mucous membranes: color, moisture, inflammation, integrity, infection </li><li> Respiratory effort, presence of sweating; response to exertion </li><li> Does the infant feel hot (febrile), or unusually cool to touch? </li><li> If you have received instruction on how to assess for intact cranial nerves, note your findings. Note facial movement and symmetry. </li><li> Weigh the infant. (Review the information in <a href="topic_6-3.html"> Topic 6.3</a> ) - Length and head circumference could also be recorded if you have an accurate means of doing so. <br /> </li></ul><span style="font-weight: bold;"> Oral assessment </span><ul><li> Response to stimulation of rooting reflex </li><li> Visual examination - size, shape of tongue; uvula (bifid or not); intact palate, labial and lingual frenulum, condition of mucous membranes (moist/dry; candida; etc) </li><li> Suck assessment - (only perform after instruction and supervision by experienced practitioner) feeling for intact palate (hard and soft), notches on palate, shape of palate, grooving of tongue, tongue action during sucking (or preventing sucking) </li></ul><span style="font-weight: bold;"> Observe a breastfeed </span> - if the infant is not in immediate danger, observation of a breastfeed is essential. (Review <a href="topic_5-2.html">Topic 5.2</a> ) <br /> <ul><li> Note position adopted by mother and how she holds her baby </li><li> Note sucking pattern and ability - <span style="font-style: italic;"> Note: Sucking will be sub-optimal and with notable non-nutritive sucking. Observing the feeding process will help determine whether poor sucking caused the failure to thrive or whether the failure to thrive is the end result of another cause. </span> <span style="font-style: italic;"> Milk supply is usually compromised too due to the poor feeding, so this needs to be assessed and addressed. </span> </li></ul> <br /> As the mother prepares to breastfeed ask permission to examine her breasts, looking for marked differences in size, hypoplasia, state of health of the breasts and nipples and surgical scars. <br /> <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>Modelling observational skills</h3>
        <div>
          <p>By following the flow of the consultation above, (until you assessed the cranial nerves or performed the oral assessment) you were modelling to the parents good general observational skills. <br /> If you also talked with the parents as you made each observation you will be giving them the confidence to be objective in their observations of their baby too, preventing unnecessary anxiety but ensuring prompt attention is sought when needed.</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>
      <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 class="warning">RED FLAG</h3>
        <div>
          <p> If the infant appears ill (pale, lethargic, sunken fontanelle, poor skin turgor, minimal urine output, hot or cool to touch) organise for the infant to be seen by a doctor urgently or for immediate transfer to hospital. </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>
      <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 7.8</h3><p>Complete Activity 7.8 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="Test_weighing"><h4>Test weighing</h4>
        <div><p> Some practitioners find test weighing a baby to determine the volume of breastmilk received at a single breastfeed to be beneficial, while other practitioners do not. </p><p class="listTitle">This procedure must be used sensitively and its limitations explained to the mother:<br /></p><ul><li>From one test weigh it is not possible to conclude how much milk the baby is consuming in a 24-hour period,<br /></li><li>nor how much milk is available for the baby in the breast either at this feed or for the 24-hour period.<br /></li></ul>Accurate test weighing requires quality, digital scales that are sensitive to within 2g and are re-calibrated regularly. The infant is weighed immediately before and again after breastfeeding without removing any of the clothing or wraps the baby was in at the first weighing. The difference between the second weight and the first weight is an indication of how much breastmilk the baby consumed. <p>Accuracy is dependent on attention to weighing technique.</p></div>
      </div>
      <div class="section" id="What_do_you_see_"><h4>What do you see?</h4>
        <div class="captionBox"><img width="302" height="400" src="images/FTT_bi.jpg" alt="" /><p> <br />&copy; B.Ingle, IBCLC</p></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>
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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>
    </div>
  </div>
          <div class="section" id="Management"><h2>Management</h2>
    <div>
      <p>
		Management of failure to thrive in a breastfed baby requires a multidisciplinary team approach. The ultimate goal is to have baby exclusively breastfeeding and gaining weight normally.
	</p>
    </div>
    <div class="section" id="Parent_education_and_counseling"><h3>Parent education and counseling</h3>
      <div>
        <p>
			While the management below is focussed on clinical issues, your communication skill and care and understanding for the parents is as important an aspect of the consultation as getting nutrients into the baby. You must build trust and understanding between you and the parents.
		</p>
      </div>
    </div>
    <div class="section" id="Step_1"><h3>Step 1</h3>
      <div>
        <p> The <strong>first action</strong> you will take is to discuss with the mother the importance of having her baby reviewed by the baby's doctor. This is important, even if you think it is a feeding problem that you can resolve that has caused the problem. The infant has been compromised and needs a medical review. </p>
      </div>
    </div>
    <div class="section" id="Step_2"><h3>Step 2</h3>
      <div>
        <p> Next, <strong>feed the baby!</strong> The normal range of daily intake of breastmilk by healthy infants aged from 1 month to 6 months is 500ml - 1350ml (17oz - 44oz), with the average being 780ml (26oz) irrespective of the infant's weight or age. This volume is consumed over 11 feeds a day (range 6-18). Infants generally consume significantly more breastmilk during the morning and nighttime breastfeeds than during the day and evening breastfeeds.<sup><a href="#note1">1</a></sup> </p>
        <p> The baby will need supplementation. Determining how much milk to supplement will depend firstly on the infant's condition, and secondly on how much is required to produce a normal urine and stool output and consistent weight gain. <br /></p>
        <p>The infant's stomach will be unaccustomed to large volumes of milk. Introducing frequent small volumes of supplement will prevent overdistention and possible vomiting. Bear in mind the very wide range of normal - being pedantic about a set volume to be consumed at a predetermined number of feeds without considering what is normal is not helpful to the mother or baby. Individualize your care! <br /></p>
        <p style="font-weight: bold;">Be very careful that you don't jeopardise breastfeeding completely with a management plan that doesn't take normal breastfeeding physiology into consideration. </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/thinker.gif" class="icon" alt="" /><h3>A quick calculation</h3>
        <div>Let's look at that from a practical viewpoint.<br /><br />Total daily intake = approx 800ml<br />8 feeds/24 hrs = 100ml/feed<br />11 feeds/24 hrs = 70ml/feed<br />12 feeds/24 hrs = 65ml/feed<br /><br />The volume of supplement will be a<span style="font-style: italic;"> portion</span> of these total feed amounts. Some babies wake frequently because they are hungry. Other babies have no energy reserves so they are very difficult to rouse and will feed poorly when woken.<br /><br />The supplement is to enhance the infant's current intake, not to act as a total replacement feed.<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 class="section" id="What_supplement_shall_I_use_"><h4>What supplement shall I use?</h4>
        <div>
          <p> The aim is for the infant to have as much of his mother's breastmilk as is available, while ensuring the infant receives sufficient nutrition to correct the deficit and permit normal growth. Sometimes the mother's milk supply is still adequate to meet her baby's needs - correcting poor positioning may be all that is required. </p>
          <p class="listTitle"> In order of preference: <sup><a href="#note2">2</a></sup> </p>
          <ul>
            <li> mother's own expressed breastmilk </li>
            <li> donor breastmilk from a trusted, infection-free source, eg a milk bank <br /> If neither of those are available: </li>
            <li> artificial infant formula. Discuss with the mother whether a regular or a hypoallergenic formulation is required. </li>
            <li><strong>ONLY</strong> if baby is &gt;6 months - commence complementary foods, replacing nutrient-poor foods with nutrient-dense, high calorie foods if necessary. </li>
          </ul>
        </div>
      </div>
      <div class="section" id="How_will_the_supplement_be_given_to_the_infant_"><h4>How will the supplement be given to the infant?</h4>
        <div>
          <p class="listTitle">Different circumstances dictate different methods of supplementation. (<span style="font-style: italic;">Click on supplement feeding method below for additional information and technique</span>)<br /></p>
          <ul>
            <li>A <strong><a href="topic_7-5-1.html">tube-feeding device at the breast</a></strong> is the method of choice when the infant is willing and able to suck at the breast - he has good underlying sucking ability but the suck may be weak and/or the mother has insufficient milk supply. <br /></li>
            <li><strong><a href="topic_7-5-2.html">Cup-feeding</a></strong> is the preferred choice for an alert baby who cannot suckle for any reason (absence of mother, suck abnormality, etc)</li>
            <li><strong><a href="topic_7-5-3.html">Finger-feeding</a></strong> is a useful technique to help teach an infant to suck. When small quantities are to be given (ie colostrum) using this technique with just a syringe containing the milk is convenient.</li>
            <li><strong><a href="topic_7-5-4.html">Bottle feeding</a></strong> is the least preferred method, but may be the method of choice of the parents. Bottle feeding should not be used for infants while still in the hospital setting.</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/books.png" class="icon" alt="" /><h3>Workbook Activity 7.9</h3><p>Complete Activity 7.9 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>
      <div class="section" id="When_to_supplement"><h4>When to supplement</h4>
        <div>
          <p> With the information you have gained during your history-taking and clinical examination you should be able to decide whether the baby needs supplementing after all breastfeeds, or only from the afternoon, or even just the evening feeds as most mothers have fuller breasts in the morning. </p>
        </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/remember.png" class="icon" alt="" /><h3>Individualise your care</h3>
        <div>
          <p>
				No two babies will be in the same situation therefore every strategy you and the parents devise will be unique. Don't look for a 'solution' you can apply in every situation.
			</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="Step_3"><h3>Step 3</h3>
      <div>
        <p> You must also <strong>determine and treat the cause</strong>, if possible. Is the cause maternal or infant in origin? <br /> </p>
        <ul>
          <li><span style="font-style: italic;"> Protect the milk supply </span> - insufficient breastmilk supply is addressed in <a href="topic_8-4.html">Topic 8.4</a> </li>
          <li> Inability of the infant to suckle effectively at the breast could be caused by poor positioning and poor latching, or by ineffective suckling. Positioning and latch is well within your area of expertise, however you may need to refer the infant with poor suckling ability to a lactation consultant, pediatric speech therapist or other appropriate specialist. </li>
          <li> Restrictive scheduling of breastfeeding, excessive non-nutritive sucking (pacifier or dummy use), denial of night-feeding, etc is addressed by education and discussion of normal behavior with the parents. Encourage the mother to join mother-to-mother support groups. </li>
          <li> The management of the infant with poor absorption of nutrients or increased metabolic demands will be managed by a medical specialist. </li>
        </ul>
      </div>
    </div>
    <div class="section" id="Step_4"><h3>Step 4</h3>
      <div>
        <p><strong>Follow-up</strong>. It is absolutely essential that the parents are competent, and feel confident, to observe their infant, recognise a problem early and seek assistance at any time.</p>
        <p class="listTitle">To this end you will discuss with them ...</p>
        <ul>
          <li> Observation of infant's output. Baby must have at least 5 thoroughly wet with clear urine nappies (diapers) per day; stooling should be regular and copious. Keeping a feeding and output diary will provide them and you with accurate information on which to base changes to the management plan. </li>
          <li>Observation of infant's appearance. Baby should be bright-eyed and alert, and skin should not be pale.</li>
          <li> Observation of infant's behavior. Baby should be active, alert and happy for some time each day, waking for feeds and feeding enthusiastically. </li>
        </ul>
        <p> How soon and frequently you follow-up will depend on the baby's condition. Daily phone follow-up could be indicated to get reports on feeding and output, with a weight check again in two or three days if output was satisfactory until then. Revise the plan as necessary with the ultimate goal to have the baby fully breastfed and thriving.</p>
      </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>The signs of failure to thrive.</li>
          <li>The possible underlying causes of poor weight gain.</li>
          <li>The significant history information which will help to identify the cause of the problem.</li>
          <li>The steps to appropriate management of failure to thrive.</li>
          <li>The indications for choosing the method of supplementation.</li>
          <li>How to teach safe preparation and storage of breastmilk substitutes, when necessary.<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_rd">
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	new MCQ('At your breastfeeding clinic you meet a mother who is exclusively breastfeeding her one month old infant. He takes 5 - 6 sleepy feeds per day, sleeps well between feeds and has infrequent bowel motions and 5 moderate wet nappies per day. He appears of reasonable health, but has minimal subcutaneous fat. The scales reveal he has just regained his birth weight of 3.7kg (8lb 2oz).After your examination of the infant and taking a thorough history of events, what feeding management strategies will you implement for this mother and infant?', [{text:'Perform a breastfeeding assessment, assisting the mother to correct a poor latch. Ask the mother to wake baby to breastfeed at least 8 - 10 feeds per 24 hours, and to express any remaining milk after most feeds to give to her baby.',feedback:'Correcting the poor latch will result in increased drainage of the breast which will stimulate milk production. This infant needs to be fed more frequently and expressing is also another way to increase milk volume.',score:1},{text:'Suggest small supplements of artificial infant formula to be given by cup after each breastfeed.',feedback:'It is good to try using a cup for supplements. However, there is no indication that this baby is in immediate danger and regular supplements of infant formula will compromise the mother\'s milk supply.',score:0},{text:'Suggest that the mother totally express for 24 hours and bottlefeed the expressed milk to her baby so that she can see exactly how much milk she is producing.',feedback:'Hmm, the total expressing may actually stimulate the breast compared to the infant\'s current ability, however, the bottle will be harmful to breastfeeding and the emphasis here needs to be on frequent effective drainage preferably by the baby.',score:0},{text:'Recommend a galactogogue for her to commence after consultation with her doctor.',feedback:'A galactogogue will not work by itself - although a galactogogue may be a good additional strategy, frequent effective drainage is the most important factor in milk production.',score:0}]),
	new MCQ('The mother implements your suggested feeding plan and calls you the following day to report that the infant now has very wet nappies (diapers) with every feed and he is waking up easily and wanting to feed each time. Based on this report, what is the most obvious reason for this change in the infant?', [{text:'The mother now has an adequate milk supply.',feedback:'hmm, probably not after 24 hours but if this plan continues well, the milk supply will increase.',score:0},{text:'The infant may have been sleepy from breastmilk jaundice.',feedback:'Breastmilk jaundice is an extension of physiological jaundice in some breastfed infants - it should not cause an infant to fail to thrive.',score:0},{text:'The mother\'s milk supply now has a higher water content.',feedback:'How does this happen?',score:0},{text:'The increased number of feeds and expressing has increased breast drainage and milk synthesis.',feedback:'Yes, this is the most important basic breastfeeding management to attend to.',score:1}]),
	new MCQ('The mother and infant return to see you another 24 hours later. The mother has continued with the plan and reports the same as the day before. The infant still has passed only one small bowel motion each day for the past 24 hours. The infant\'s weight has not increased when you weigh him again. What is the best explanation for you to give to the mother about the situation and your plan for her baby?', [{text:'I am very happy about the increased wet nappies and that he is now waking and feeding willingly. Based on that, I don\'t want you to worry about his weight, keep up the good work and bring him back next week for another weight check.',feedback:'It is very good to encourage the mother, but he hasn\'t made enough progress and his lack of weight is an indicator of possible other problems.',score:0},{text:'That is not good. He should have gained at least 30grams per day since we started this plan. I don\'t think your milk supply is adequate.',feedback:'no! This is very demoralising for this mother. It appears that her milk supply is still low and further attention is necessary in a caring way.',score:0},{text:'It is concerning that your baby still hasn\'t gained weight. We\'ve waited for your milk supply, but now it\'s important to give him infant formula for him to grow adequately.',feedback:'It is true that the lack of weight gain is concerning, but dismissing her breastfeeding and implying that infant formula is the only solution is wrong.',score:0},{text:'We can see signs that your supply has started to increase and it will continue to increase the more often that your baby feeds well. His lack of weight gain indicates that he needs a bit more assistance. Let\'s discuss other forms of supplementation for him to help his progress.',feedback:'Yes. This acknowledges the efforts and results so far and is setting a future plan which will not compromise breastfeeding.',score:1}]),
	new MCQ('After consultation with the infant\'s doctor, you discuss the need for additional supplementation of the infant. If all methods were available, what would be the first choice of supplement and method?', [{text:'Donor breastmilk or hypoallergenic artificial infant formula via a feeding line at the breast.',feedback:'Good choice - always donor milk if available. This infant is still willing to feed at the breast, so a feeding line will optimise breastfeeding ability.',score:1},{text:'Artificial infant milk by bottle after each breastfeed.',feedback:'No, not first choice.',score:0},{text:'Artificial infant milk via feeding line at the breast.',feedback:'Feeding line is good, artificial infant milk only if donor milk not available.',score:0},{text:'Cup feeding donor breastmilk.',feedback:'Donor milk is great, cup feed if feeding line not available.',score:0}])
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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>
  </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 7 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 7.
	</p>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
              <li id="note2"><a href="references.html#who03a" title="See full details">#</a> World Health Organisation (2003) Global Strategy for Infant and Young Child feeding</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-5-1" class="content">
          <h1 id="top">7.5.1 Feeding-line device at the breast</h1>
          <div>
    <p> There are various types of feeding-line devices commercially available; they can also be improvised. The supplemental milk is contained in a soft pouch or bottle, and a length of fine, soft tubing reaches from the milk receptacle to the breast at the nipple/areolar complex. </p>
    <p> As the baby suckles at the breast, milk is removed from both the breast and the feeding-line device. This is an excellent method of providing supplemental milk. It avoids any possibility of suck confusion, stimulates the mother's breastmilk production, enhances the infant's suck vigor by creating a steady milk flow and lessens the likelihood of breast refusal when supplementation becomes necessary. <br /></p>
    <p>Unlike any other form of supplemental feeding method, the at-breast supplementer will never compromise the mother's milk supply and in most circumstances, it will enhace milk supply or stimulate supply to achieve the highest possible production in the individual mother.<br /></p>
  </div>
          <div class="section" id="When_to_choose_an_at-breast_feed_line"><h2>When to choose an at-breast feed line</h2>
    <div>An at-breast supplemental feed line provides a constant flow of milk to the infant while he suckles on the breast. The infant will draw milk from the breast and the supplementer at the same time. It may be very useful for:<br /><ul><li>newborn requiring supplementation for medical reasons<br /></li><li>mothers with a chronic low supply (ie. due to infant poor feeding or conditions such as hypoplasia)</li><li>failing to thrive infants who are still willing to breastfeed</li><li>infants with low tone (primary hypotonia or secondary due to underfeeding)</li><li>some cases of breast refusal in the older infant who is frustrated with a slow milk flow</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/tip.png" class="icon" alt="" /><h3>Clinical tip</h3>
      <div>Insufficient milk flow will very quickly cause the infant to lapse into non-nutritive sucking or display breast refusal behaviour. <br />Newborns imprint that the breast is the place which provides all their needs. An at-breast feed line can rescue a breastfeeding relationship which is threatened by poor infant-breast association. Consider a feed line as a first choice rather than a last resort. Become proficient with it's use so that you can confidently assist mothers.<br /><br />Does your unit use any feed lines? Practice with a 'home-made' version using a syringe and naso-gastric feedling tube and organise to purchase a demonstartion kit which mothers would use at home for longer term supplementing.<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>
          <div class="section" id="Equipment"><h2>Equipment</h2>
    <div>
      <ul>
        <li>the feeding line device, ready-to-use</li>
        <li>hypoallergenic tape</li>
      </ul>
      <span style="font-style: italic;">Note: an improvised feedline can be may with a 10/20ml syringe and a premature infant naso-gastric tube. Cut off the diffusion holes at the end so milk flows only out of one hole. The tube may be placed alongside the nipple as usual with kit feeding line.</span>
      <br />
    </div>
  </div>
          <div class="section" id="Preparation"><h2>Preparation</h2>
    <div>
      <ul>
        <li>Warm the milk to be used as a supplement.</li>
        <li>Prime the tubing with the supplement milk, either by gravity or by vacuum (suction). </li>
        <li>Tape the distal end of the tubing to lie alongside the mother's nipple, with tape away from where baby will latch. The tubing is best placed on the breast to be just above the corner of the infant's mouth, not in the middle of the top lip.<br /></li>
      </ul>
    </div>
  </div>
          <div class="section" id="Technique"><h2>Technique</h2>
    <div>
      <ul>
        <li>Latch the baby as usual, ensuring the soft tubing passes into baby's mouth as he latches to the breast. (Instruct the mother to visualise that the tubing will be running alongside the length of the nipple so it sits in the groove of the tongue during sucking.<br /></li>
        <li>Breastfeed as usual.</li>
        <li>
          <p class="listTitle">Milk flow can be controlled by</p>
          <ul>
            <li>raising the milk container; the flow of the supplement is easier to initiate and requires less suction to maintain flow, </li>
            <li>lowering the milk container; the flow will be slower, requiring greater suction from the baby, or</li>
            <li>clamping the tubing off initially, encouraging baby to remove as much breastmilk from the breast as possible before unclamping the supplement.</li>
          </ul>
        </li>
      </ul>
    </div>
    <div class="captionBox"><img width="455" height="341" src="images/sns_BI.jpg" alt="At-breast supplemental feeding line." /><p>At-breast supplemental feeding line. <br />&copy; B.Ingle IBCLC</p></div>
  </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-5-2" class="content">
          <h1 id="top">7.5.2 Cup feeding</h1>
          <div>Cup feeding is easy to perform by parents or health professionals. During cupfeeding, premature infants are more physiologically stable than when bottlefeeding with lower heart rates and higher oxygen saturations. <sup><a href="#note1">1</a></sup>Infants quickly learn to lap the milk and feeding by this method causes minimal exhaustion. <br /></div>
          <div class="section" id="When_to_choose_cup_feeding"><h2>When to choose cup feeding</h2>
    <div>Cup feeding would be the first choice for any infant who was not able to achieve suckling at the breast or for a newborn not yet established at breastfeeding who is separated from his mother.<br /></div>
  </div>
          <div class="section" id="Equipment"><h2>Equipment</h2>
    <div>
      <ul>
        <li>A small cup with a smooth edge</li>
        <li>a plastic cup can be shaped slightly during feeding</li>
        <li>a small glass, eg. a sherry glass, is also quite suitable</li>
        <li>cups for the purpose of cup-feeding babies are available commercially</li>
      </ul>
    </div>
  </div>
          <div class="section" id="Preparation"><h2>Preparation</h2>
    <div>
      <ul>
        <li>Two thirds fill cup with slightly warmed breastmilk or artificial infant formula</li>
        <li>Baby must be alert and showing an interest in feeding</li>
        <li>Wrap baby well to prevent cup being knocked by his hands</li>
        <li>Sit baby comfortably upright on your lap</li>
      </ul>
    </div>
  </div>
          <div class="section" id="Technique"><h2>Technique</h2>
    <div>
      <ul>
        <li>Rest the rim of cup on baby's bottom gum</li>
        <li>Tip the cup until milk just reaches rim of cup</li>
        <li>DO NOT pour milk into baby's mouth</li>
        <li>Leave cup in position when baby pauses and is not drinking</li>
        <li>Continue to tip cup to keep milk at rim of cup</li>
      </ul>
      <p>Baby will quickly learn to sip or lap milk from the cup.</p>
    </div>
    <div class="captionBox"><img width="370" height="285" src="images/cup_feed_bi.jpg" alt="Infant supported for cup feeding" /><p>Infant supported for cup feeding. <br />&copy; B.Ingle IBCLC</p></div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#mari01" title="See full details">#</a> Marinelli KA et al. (2001) A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-5-3" class="content">
          <h1 id="top">7.5.3 Finger Feeding</h1>
          <div>Finger feeding is an alternative feeding method when an infant is unable to breastfeed. It can also be used for modification of inappropriate sucking technique.<br /><br />Finger feeding may be used by the health professional and parents can very ably continue at home. It is seen as an alternative to cup feeding<sup><a href="#note1">1</a></sup> and a hospital study in Australia used finger feeding to substitute bottlefeeding in preterm infants who displayed faulty sucking techniques and found that it increased breastfeeding rates at discharge by 30% to 71%.<sup><a href="#note2">2</a></sup> <br /></div>
          <div class="section" id="When_to_consider_finger_feeding"><h2>When to consider finger feeding</h2>
    <div>Finger feeding may be considered:<br /><ul><li>the infant is unable to grasp the breast - affected by maternal medications during birth, trauma impairing cranial nerve function, tongue-tie, low tone conditions</li><li>the infant is refusing the breast<br /></li><li>mother has severely damaged nipples requiring rest during healing process - this is helpful to the mother and may also serve as a suck therapy for the infant during this time</li><li>as a 'pre-breastfeed' enticer for infants suffering from confusion or dysfunctional suck problems.<br /></li></ul>Finger feeding avoids the complications of bottlefeeding for a breastfed infant.<br />The feeder is able to feel the tongue action and respond with milk flow accordingly or stimulate the palate or tongue as required. The infant should be able to efficiently coordinate breathing and sucking if using this method.</div>
  </div>
          <div class="section" id="Preparation"><h2>Preparation</h2>
    <div>Infant to be ready for a feed<br />Infant supported on a pillow or on the lap of the feeder person.<br /></div>
  </div>
          <div class="section" id="Equipment"><h2>Equipment</h2>
    <div>
      <ul>
        <li>Syringe - regular or periodontal curved-tip OR soft feeding bag and feed line<br /></li>
        <li>Breastmilk or substitute at room temperature</li>
        <li>Pillow or towel roll</li>
        <li>Gloves (for all except infant's own parents)<br /></li>
      </ul>
    </div>
  </div>
          <div class="section" id="Finger_feeding_technique"><h2>Finger feeding technique</h2>
    <div>The feeder controls the flow of milk according to the infant's sucking. The tip of the syringe is placed next to the feeder's finger, not pushing on the baby's mouth.<br /><br /> Be consistent in the technique used for finger placement, and utilize the same positioning principles as used when feeding at the breast: <br /> <ul><li> Infant well supported down the back </li><li> Infant's body in alignment with his head; neck slightly extended </li></ul> <br />The feeder washes hands -<span style="font-weight: bold;"> Note: health professionals to use a gloved finger</span>:<br /><ul><li>The feeder uses their finger with nail-side down and soft pad of finger to the palate.</li><li>The feeder's finger begins curled and uses the knuckle to stimulate the top lip and encourage tongue extension and gap. </li><li>Uncurl the finger under the top lip and introduce it along the palate.</li><li>Keep finger directly down midline during feeding.</li><li>Once sucking has commenced, insert syringe in corner of infant's mouth against the feeder's finger. Push very small aliquots of milk (approx 0.5ml) into infant's mouth to stimulate continued sucking.</li><li>Follow infant's lead with sucking bursts - only push milk in when infant is sucking, or stimulate suck recommencement by massaging the palate.</li></ul><span style="font-style: italic;">Note: if using soft feeding bag with feed line, place bag in palm of feeder's hand and tape tubing alongside gloved finger.</span><br /><ul> </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>Important tip!</h3>
      <div>The infant oral cavity is very sensitive. Fingers come in all different shapes and sizes so to avoid confusion and desensitization of the infant, limit the number of different people who perform this procedure. Parents are very capable of taking on this task and teaching them will give them confidence.<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/group.png" class="icon" alt="" /><h3>Finger feeding instruction sheet</h3>
      <div>Click on this <img alt="PDF" src="design/page_white_acrobat.png" /><a href="http://www.saskatoonhealthregion.ca/pdf/bcs_finger_ffeeding_oral_syringe.pdf"> hospital information page</a><span class="linkDescription">[link: http://www.saskatoonhealthregion.ca/pdf/bcs_finger_ffeeding_oral_syringe.pdf]</span> for parents on finger feeding. <br />Does your unit or practice have an information sheet like this? If not, research the topic further and produce your own.<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 class="section" id="Teach_finger_feeding"><h3>Teach finger feeding</h3>
      <div id="slideshow_0" class="slideshow">
        <div class="captionBox"><img width="454" height="461" src="images/gape_response_crop.jpg" alt="Step 1 - Stimulate gape and uncurl finger onto tongue." /><p>Step 1 - Stimulate gape and uncurl finger onto tongue. <br />&copy; B.Ingle IBCLC</p></div>
        <div class="captionBox"><img width="455" height="341" src="images/finger_feed_crop_BI.jpg" alt="Step 2 - Introduce syringe tip alongside finger keeping finger down midline of palate and infant's head slightly extended." /><p>Step 2 - Introduce syringe tip alongside finger keeping finger down midline of palate and infant's head slightly extended. <br />&copy; B.Ingle IBCLC</p></div>
      </div>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#marm00" title="See full details">#</a> Marmet C et al. (2000) Assessing infant suck dysfunction: case management.</li>
              <li id="note2"><a href="references.html#oddy03b" title="See full details">#</a> Oddy WH et al. (2003) Implementing the Baby Friendly Hospital Initiative: the role of finger feeding.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_7-5-4" class="content">
          <h1 id="top">7.5.4 Bottle feeding</h1>
          <div>Bottle feeding is a last choice for a breastfed infant. It is only a feeding method, unlike breastfeeding which is a complete physiological, psychological and nutritional experience. Bottle feeding undermines breastfeeding success.<br />The physical act of bottle feeding is very different to the normal action which occurs during breastfeeding. Artificial nipples/teats are less elastic than a mother's breast. The infant's tongue works in an up-and-down piston motion during bottlefeeding<sup><a href="#note1">1</a></sup> and overuses the buccinator and orbicularis muscles.<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> Bottle feeding creates repeated airway closure during swallowing. Rapid milk flow results in more frequent swallowing and less opportunities for breathing.<sup><a href="#note4">4</a></sup> <br /></div>
          <div class="section" id="When_to_use_bottle_feeding"><h2>When to use bottle feeding</h2>
    <div>Bottle feeding may be considered when the mother: <br /> <ul><li> is unable to breastfeed for medical reasons or her infant's medical condition precludes breastfeeding ability. </li><li> chooses to use a bottle for supplementation - with adequate education about impact on breastfeeding and health risks associated with bottle use. </li><li> weans her infant when milk is still a major part of the diet. </li></ul></div>
  </div>
          <div class="section" id="Considerations_when_bottlefeeding_a_breastfed_infant"><h2>Considerations when bottlefeeding a breastfed infant</h2>
    <div>
      <ul>
        <li> Use a straight bottle rather than a bent bottle. </li>
        <li> Choosing a teat/artificial nipple: <br /> <ul><li> Use a long teat/artificial nipple, with a rounded end and a medium-wide base. <sup><a href="#note5">5</a></sup> </li><li> Use a slow-flow artificial nipple/teat. This requires the baby to suck well to obtain the milk. A full feed, bottle-fed, should take about 15 - 20 minutes. Babies with low tone who take longer than this to be fed may require a medium-flow artificial nipple. </li><li> Choose a soft artificial nipple/teat if possible. </li><li><span style="font-weight: bold;"> Rationale </span> : <ul><li> When the artificial nipple is taken into the baby's mouth the tip of the artificial nipple is well back in the mouth, close to the junction of the hard and soft palate. The baby is reminded that something is always supposed to be towards the back of his mouth as he feeds, as occurs during breastfeeding. </li><li> The medium-wide base, up to the screw cap, causes the baby to have a wide mouth when he makes a seal around the base of the artificial nipple, similarly to how he holds his mouth for breastfeeding. </li><li> Don't use artificial nipples that have a short, narrow shaft and a very wide base. They force the baby to make a tight mouth around the narrow shaft. This short shaft is forward in the baby's mouth changing the tongue position and action. </li></ul> </li></ul> </li>
      </ul>
    </div>
  </div>
          <div class="section" id="Bottle_feeding_technique"><h2>Bottle feeding technique</h2>
    <div>
      <ul>
        <li> Position the baby so that he is sitting upright. Support the baby's back, neck and base of head with the forearm and hand. Hold the bottle horizontally removing the pressure from gravity. Without gravity helping to pour milk into the baby's mouth, baby will have better control of the volume taken at each mouthful and will suck a little harder. Kassing (2002) <sup><a href="#note6">6</a></sup> cautions against the mother and/or caregiver using an arm or the crook of an elbow to support the baby's neck, because there is a greater tendency for the baby to lean back a bit rather than remaining upright. </li>
        <li> Using the tip of the artificial nipple brush the baby's lips gently, stimulating the rooting reflex. When baby opens his mouth very wide slide the tip of the teat under the top lip, wait for the baby to grasp and draw the entire artificial nipple into his mouth right up to the cap. By stimulating the rooting reflex and waiting for a wide gape, you are simulating what will occur when breastfeeding. </li>
        <li> Keeping baby upright, tilt the bottle just enough to keep the artificial nipple filled with milk. As the bottle empties take care not to hyper-extend the baby's neck. </li>
        <li> Closely observe baby for full duration of the feeding. Slow the feed, or pause it if the baby is showing early signs of distress. These signs can be very subtle: frowning, wide-eyed, fist clenching, etc. Baby should not get to the stage where he is gulping, or not pausing to take a breath, or becoming cyanosed. </li>
      </ul>
      <br />
    </div>
    <div class="section" id="Assess_a_bottle_feed"><h3>Assess a bottle feed</h3>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="250" height="188" src="images/britton_bottle_003_250.jpg" alt="" /><p> <br />&copy; B.Ash, IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div class="captionBox"><img width="250" height="188" src="images/britton_bottle_009_250.jpg" alt="" /><p> <br />&copy; B.Ash, IBCLC</p></div>
        </div></div><br style="clear: both" />
      <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>What is the difference?</h3>
        <div></div><div class="activity" id="activity_re">
<script type="text/javascript">
/* <![CDATA[ */
var reqs = {settings : {type : 'response'}, questions : [
	{ c : 'Look closely at the two photos above. Compare and contrast the artificial nipple position in the baby\'s mouth, the gape used by the baby, the tilt of the bottle, the body position of the baby and briefly explain the significance of each of these.<br/>', r : '<span style=\"font-weight: bold;\"> Photo on left </span><br/><span style=\"font-style: italic;\"> Infant\'s lips are tight </span> - this indicates overuse, whereas lips would be more relaxed when properly positioned. <br/> <span style=\"font-style: italic;\"> Gape is narrow </span> - tongue can\'t come down and forward if gape is not wide. <br/> <span style=\"font-style: italic;\"> Infant is recumbent </span>- this causes the tongue to retract and makes swallowing difficult; <br/> <span style=\"font-style: italic;\"> Teat is only partially in infant\'s mouth </span> - the teat is only half filling the oral cavity so the milk is being delivered too far forward in the mouth causing the posterior tongue to lift. <br/> <span style=\"font-style: italic;\"> The tilt of the bottle indicates that the tip of the teat will be applying pressure on the back of the infant\'s tongue </span> - stimulation should be along the palate except when using special suck modification techniques. Milk flow will be fast with gravity forcing it, another reason the infant will retract tongue, lifting the posterior tongue in an attempt to control flow. <br/> <br/> <span style=\"font-weight: bold;\"> Photo on Right </span> <br/> <span style=\"font-style: italic;\"> Artificial teat is fully in infant\'s mouth </span> - this encourages maximum filling of the oral cavity. <br/> <span style=\"font-style: italic;\"> Gape is more relaxed and fairly wide </span> - indicating that the oral cavity is well-filled. <br/> <span style=\"font-style: italic;\"> The tilt of the bottle </span> indicates that the tip of the teat is along the palate - the mother\'s naturally pliable breast would fill the oral cavity and touch most of the palate. It does not create any downward pressure on the infant\'s tongue. Milk flow is much easier to control in this position. Infant is less likely to become distressed from a fast, uncontrollable flow.<br/> It is difficult to see, however it appears that the infant could be positioned for better head extension. <br/> <span style=\"font-style: italic;\"> </span>' }
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('re');</script>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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  </div>
          <div class="section" id="Good_bottle_feeding_practices_are_essential"><h2>Good bottle feeding practices are essential</h2>
    <div>A sound nutritional foundation for growth of the child is laid down during the first two years. A critical aspect of care to ensure bottle-fed infants receive appropriate nutrition during this time is to ensure the infant's caregivers receive education on the importance of proper feeding.<br />Positive nurturing and infant feeding are closely aligned. Encourage the bottle feeding mother to make the feeding experience an enjoyable one for her infant by responding to feeding cues promptly, holding her infant during feeding, using an appropriate nipple/teat for milk flow and not forcing the infant to consume more than he wants. Discuss observations the mother can make that indicate:<br /><ul><li>early feeding cues, <br /></li><li>infant pleasure (or stress) during the feed, <br /></li><li>adequate intake such as <br /><ul><li>signs of satiety <br /></li><li>normal bowel actions, <br /></li><li>expected urine output, and <br /></li><li>appropriate weight gain (neither excessive, nor inadequate).<br /></li></ul></li></ul></div>
    <div class="section" id="Preventable_dangers"><h3>Preventable dangers</h3>
      <div>
        <p>In a 2008 study <sup><a href="#note7">7</a></sup> more than 3/4 of mothers reported they did not receive instruction on artificial formula preparation from a health professional. Consequently many mothers did not follow safe practices when preparing their infant's formula feeds. </p>
        <ul>
          <li> Dangers of incorrect preparation <ul><li> gastrointestinal infection, serious illness and death from: <ul><li> contamination from unhygienic practices contaminating feeding implements </li><li> contamination from bacteria found in the powdered formula when purchased (eg enterobacter sakazakii)<br /></li><li> contaminated water supply. </li></ul> </li></ul> </li>
          <li> Incorrect reconstitution - a commonly found error: <ul><li> over-dilution causes poor weight gain and inadequate intake of calories and nutrients </li><li> under-dilution causes hypernatremic dehydration, diarrhea and excessive intake of calories. </li></ul> </li>
          <li> Over-feeding and under-feeding by caregivers must also be addressed. <br />Volume of intake guidelines are available from various sources, however parents should be encouraged to use these as only a guide. Encourage feeding to be initiated when the infant cues and ended by the infant when satiety is indicated. A responsive caregiver is able to observe the infant's behavior so that the infant remains comfortable. The focus is on reading the infant's needs rather than consuming a predetermined volume of milk. <ul><li> Over-feeding causes 'food battles' and obesity, </li><li> under-feeding causes poor growth and development </li><li> both under- and over-feeding cause failure to thrive and malnutrition </li></ul> </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"><a href="images/formula_prep_DOH_UK_2011.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/formula_prep_DOH_UK_2011.pdf" target="_blank">Preparing breastmilk substitutes safely</a></h3>
      <div>Click on the title above. This links to a leaflet produced by the Department of Health in the UK for mothers that describes, with very good graphics, how to safely prepare breastmilk substitutes. Read this leaflet, print it out and file it in your Workbook.<br />Go through this leaflet, or a similar one that your hospital or clinic may use, as you demonstrate to a mother how to prepare the formula. Then, most importantly, ask her to show you how she would do it by making up another bottle of formula, confirming that she understands each step of the process.<br /></div>
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                <td class="body"><img src="design/remember.png" class="icon" alt="" /><h3>What should I remember?</h3>
    <div>
      <ul>
        <li>the different oral actions that occur during bottle feeding and breastfeeding</li>
        <li>the type of bottle and teat/artificial nipple to use when a breastfed infant is being bottle fed</li>
        <li>how to teach a safe bottle-feeding technique that encourages positive parenting skills</li>
        <li>the preventable dangers inherent in bottle feeding</li>
        <li>how to effectively and clearly teach safe preparation of breastmilk substitutes and safe bottle-feeding techniques to caregivers<br /></li>
      </ul>
    </div>
  </td>
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          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#webe86" title="See full details">#</a> Weber F et al. (1986) An ultrasonographic study of the organisation of sucking and swallowing by newborn infants.</li>
              <li id="note2"><a href="references.html#inou95" title="See full details">#</a> Inoue N et al. (1995) Reduction of masseter muscle activity in bottle-fed babies.</li>
              <li id="note3"><a href="references.html#gome06" title="See full details">#</a> Gomes CF et al. (2006) Surface electromyography of facial muscles during natural and artificial feeding of infants</li>
              <li id="note4"><a href="references.html#math91" title="See full details">#</a> Mathew OP (1991) Breathing patterns of preterm infants during bottle feeding: role of milk flow.</li>
              <li id="note5"><a href="references.html#nobl97" title="See full details">#</a> Noble R et al. (1997) Therapeutic teat use for babies who breastfeed poorly</li>
              <li id="note6"><a href="references.html#kass02" title="See full details">#</a> Kassing D (2002) Bottle-Feeding as a Tool to Reinforce Breastfeeding</li>
              <li id="note7"><a href="references.html#labi08" title="See full details">#</a> Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_8-0" class="content">
          <h1 id="top">8.0 Maternal Challenges</h1>
          <div><p> A knowledge of the conditions or events which are linked with decreased initiation or duration of breastfeeding will help you to focus your breastfeeding assistance and education activities to those in most need. </p><p class="listTitle"> Maternal Risk Factors <br /> </p><ul><li> acute or chronic disease </li><li> maternal obesity </li><li> hypertension during pregnancy </li><li> intrapartum analgesics or anaesthetics </li><li> assisted or surgical delivery of baby </li><li> breast or nipple abnormality </li><li> history of breast surgery or trauma </li><li> previous breastfeeding difficulty </li><li> persistent breast pain </li><li> severe engorgement </li><li> cracked/bleeding nipples </li></ul> Risk factors such as intrapartum sedation and assisted birthing use the same management techniques as for the baby affected by these factors. <p> Mothers with persistent breast pain, acute or chronic disease and previous breast surgery will require ongoing management and should receive an early referral to a lactation consultant who can continue care in the community. <br /> </p></div>
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    <div>Don't endanger breastfeeding by delaying referral.<br /></div>
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          <div>This module will only cover the more common occurring problems.<br /></div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_8-1" class="content">
          <h1 id="top">8.1 Engorgement</h1>
          <div class="section" id="Breast_fullness"><h2>Breast fullness</h2>
    <div>
      <p> Secretory activation (lactogenesis II) occurs biochemically at about 30 - 40 hours postpartum.<sup><a href="#note1">1</a></sup> The clinical onset is heralded by the maternal experience of 'the milk coming-in' and the breasts making a copious volume of milk. Across studies the average timing of this is reported to be 50 to 73 hours postpartum, with wide individual variation <span class="aside"> (1hr to 148 hrs)</span>.<sup><a href="#note2">2</a></sup> </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"><h3>Why does this happen?</h3>
      <div>Several hormonal and biochemical changes occur which contribute to copious milk production: <sup><a href="#note3">3</a></sup> <br /> <ul><li> progesterone levels fall with removal of the placenta no longer inhibiting milk secretion </li><li> prolactin levels remain high to initiate milk production </li><li> lactose concentration in colostrum rises osmotically drawing in water to increase milk volume <sup><a href="#note4">4</a></sup> </li></ul> There is also a marked increase in mammary blood flow. These changes will occur regardless of type of birth or whether breastfeeding is initiated or not. <br /> <br /> Review this in <a href="topic_4-0.html"><span style="font-style: italic;">Topic 4.0</span></a><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 class="section" id="Signs_and_Symptoms"><h3>Signs and Symptoms</h3>
      <div><p class="listTitle">Women report knowing their milk is 'in' by the following cues:</p><ol><li>breast fullness <br /></li><li>milk leakage</li><li>physical appearance of the milk</li><li>breast tingling</li><li>change in infant cues.<br /></li></ol>These are all <span style="font-style: italic;">normal and manageable events</span>. Diligent attention to the breasts with continued frequent milk removal will make this transition uneventful and serve to meet the changing needs of the infant.<br /></div>
    </div>
  </div>
          <div class="section" id="Engorgement"><h2>Engorgement</h2>
    <blockquote>
      <div>...the swelling and distension of the breast, usually in the early days of initiation of lactation, caused by vascular dilatation as well as the arrival of the early milk.<sup><a href="#note5">5</a>,</sup><br /></div>
    </blockquote>
    <blockquote>
      <div>Breast engorgement is not an inevitable part of early lactation.</div>
    </blockquote>
    <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>Why does this happen?</h3>
      <div>Hormonal and biochemical changes combine to create a 'traffic jam' in the breast. <br />There is a combination of<br /><ul><li>increased venous congestion (blood) </li><li>tissue oedema (fluid) and </li><li>increasing milk volume which is inadequately drained (milk stasis). </li></ul>These three events occur within the confines of the breast. Individually, each is a notable factor, yet combined, they impact each other and continue the cause and effect cycle.<br /></div>
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    <div>
      <p class="listTitle">If normal breast fullness <span style="font-style: italic;">progresses to engorgement</span> the signs and symptoms include:</p>
      <ul>
        <li>swollen breasts; tight, shiny skin</li>
        <li>generalized redness of both breasts</li>
        <li>mild to severe pain</li>
        <li>increased heat of both breasts</li>
        <li>difficulty latching baby effectively and achieving milk removal</li>
        <li>mild pyrexia (fever)</li>
      </ul>
    </div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="section" id="Predisposing_factors"><h3>Predisposing factors</h3>
          <div>
            <ul>
              <li> Milk stasis, as a result of inadequate milk removal <ul><li> poorly latched infant, or ineffective suckling </li><li> infrequent breastfeeding<sup><a href="#note6">6</a></sup> </li><li> 'skipping' feeds, particularly night feeds </li><li> not expressing the breasts when baby not breastfeeding at all or effectively</li><li>cesarean delivery when early feeding is delayed<sup><a href="#note7">7</a></sup><br /></li></ul> </li>
              <li> Overhydration during labor <sup><a href="#note8">8</a>,</sup><sup><a href="#note9">9</a></sup> </li>
              <li> Low serum albumin<sup><a href="#note10">10</a></sup> </li>
            </ul>
          </div>
        </div>
      </div><div class="column" style="width: 50%">
        <div class="section" id="Prevention"><h3>Prevention</h3>
          <div>In the majority of women engorgement is a condition simply prevented by encouraging ideal breastfeeding practices. <ul><li> early initiation of breastfeeding - more breastfeeding in the first 48 hrs is associated with less engorgement <sup><a href="#note11">11</a>,</sup><sup><a href="#note12">12</a></sup> </li><li> baby well latched to the breast </li><li> frequent feeds day and night </li><li> fully draining of one breast at a time each feed <sup><a href="#note13">13</a></sup> <br /> </li><li> express frequently if baby not feeding </li></ul></div>
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      </div></div><br style="clear: both" />
    <div class="captionBox"><img width="350" height="276" src="images/engorgement350SC.jpg" alt="Engorgement" /><p>Engorgement. <br />&copy; S.Cox, IBCLC</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/warning.png" class="icon" alt="" /><h3>Don't be fooled</h3>
      <div><br />Breast fullness is normal. Engorgement is a warning sign.<br />Engorged, large breasts are not a sign of a good milk supply. It indicates that breastfeeding practices are suboptimal and proactive management is required to retrieve normality.<br /><br /><span style="font-weight: bold;">Breast engorgement is preventable in most cases.</span><br /></div>
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    <div>
      <p><span style="font-weight: bold;">Milk engorgement </span>can occur at any point in the<span style="font-weight: bold;"> </span>progression of breastfeeding. The cause is milk stasis from oversupply, inadequate drainage and long gaps between feeds rather than reasons of interstitial odema, and increased venous congestion.</p>
      <p>Unresolved or repeated episodes of engorgement risks blocked ducts, mastitis and low supply.<br /></p>
      <p>Severe engorgement (initial or with established lactation) begins the process of involution of the breast due to poor milk drainage. The mother will progress from painful engorgement with perceived adequate/excessive amounts of milk, to an inadequate supply. Poor milk supply and nipple damage have been identified by mothers as reasons for premature weaning of their babies.<sup><a href="#note14">14</a></sup> </p>
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                  <h3>Workbook Activity 8.1</h3>
                  <p>Complete Activity 8.1 in your workbook.</p>
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          <div class="section" id="Clinical_Management"><h2>Clinical Management</h2>
    <div>This temporarily uncomfortable condition can be resolved with diligent attention to: <br /> <ul><li><p class="listTitle"><span style="font-style: italic; font-weight: bold;"> Frequent, effective removal of milk </span> from the breast until it is comfortable is the mainstay of management. </p><ul foot="Because lactogenesis II is caused by hormonal activity and engorgement is caused by inadequate early breastmilk removal, milk removal above the infant's current needs will not necessarily continue to cause oversupply."><li> Encourage the mother to breastfeed her baby often. If baby feeding well, but breasts still uncomfortably tight, expressing enough to maintain comfort is essential. This can be done after and between feeds as often as is necessary. </li><li> Ensure baby is latched on to breast well. If breasts are very firm but there is no areolar edema, hand expressing for a few minutes to soften the nipple/areola area may be required. Re-latching the baby after suckling for several minutes will result in an even deeper latch. </li><li> Allow the baby to feed as long as he will on one side to optimize drainage. Firm, but gentle massage of lumpy areas while baby feeds helps drainage. Allow the other breast to drip freely. If baby doesn't want the second side, express enough milk to make that breast comfortable. Repeat this process each feed. <br /> </li><li> When breasts are particularly full it can be effective to stimulate a milk ejection by soft massage or short-time application of a warm compress. Then apply gentle compression anywhere on the breast with the palm of the hand - this gentle pressure may help the milk flow freely from the nipple without having to hand express or use a pump which may be too uncomfortable. </li></ul></li></ul><p> </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/thinker.gif" class="icon" alt="" /><h3>Will expressing increase milk supply?</h3>
      <div>The emphasis is on frequent removal of milk to prevent milk stasis. <br /><br />Milk volume is increasing daily until peak milk volume between 2-3 weeks post-partum. Extra expressing and breastfeeding will promote better breast drainage but it will not increase milk volume further.<br /><br />Reassure the mother that this management will assist faster resolution of her engorgement. Failure to diligently attend to these strategies will prolong the discomfort, initiate involution and risk a resultant low supply.<br /></div>
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    <div><ul><li><span style="font-style: italic;"><span style="font-weight: bold;"> Reduce tissue swelling </span></span><br /><ul><li> A Cochrane Review of management of breast engorgement <sup><a href="#note15">15</a></sup> examined trials of breast engorgement treatments: <br /> <ul><li> There is no difference between treatment with cold packs or cabbage leaves. Both were equally effective in relieving pain but there was no strong evidence that interventions resolved symptoms faster than with no treatment. </li><li> Acupuncture gave greater improvement in symptoms in the days immediately after the treatment. </li></ul> </li><li> The underlying principle is the use of cold to initiate vasoconstriction to decrease venous congestion and help reduce interstitial oedema. <br /> <ul><li> Depending on degree of engorgement, the cold compresses may need to be replaced frequently (e.g. 20 mins on, 20 mins off and repeat several times) </li><li> Apply cold compresses to both breasts immediately after breastfeeding. </li></ul> </li><li> Certain non-steroidal anti-inflammatory drugs are very effective. <sup><a href="#note15">15</a></sup> </li></ul></li></ul> Therapeutic ultrasound was found to be of no benefit in a randomized, controlled, double-blind trial. <sup><a href="#note16">16</a></sup>  <br /> <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/tip.png" class="icon" alt="" /><h3>Heat or cold?</h3>
      <div>Heat increases blood flow to the breast and movement of fluid into the tissues to further exacerbate the engorgement.<sup><a href="#note17">17</a></sup> Avoid standing under a hot shower or soaking the breasts in warm water during this period of engorgement.<br /><br />Mothers usually prefer the feeling of cold on their hot breasts, but it is important to individualise your management and be responsive if a mother finds this to be unpleasant.<br /></div>
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                  <h3>Workbook Activity 8.2</h3>
                  <p>Complete Activity 8.2 in your workbook.</p>
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                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Unit Activity</h3>
    <div>
      <p>
		Revise your unit's policy on the management of engorgement. Develop a teaching plan for a 15-minute educational session you could lead on the prevention and management of engorgement for your colleagues.
	</p>
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          <div class="section" id="Areolar_oedema_edema"><h2>Areolar oedema/edema</h2>
    <div>
      <p> When areolar edema is present latching the baby onto the breast for effective breastfeeding is impossible. Methods have been described to assist the movement of this interstitial fluid to make latching possible. <sup><a href="#note10">10</a>,</sup><sup><a href="#note8">8</a></sup> </p>
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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"><a href="http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]</span><h3><a href="http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening" target="_blank">Read this excellent practical article</a><span class="linkDescription">[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]</span></h3>
      <div>
        <p> Click on the icon on the left to be taken to a description of Reverse Pressure Softening for the treatment of areolar edema. Print the paper for filing in your Workbook. </p>
        <p> Share this paper with your colleagues who may be working with women experiencing this type of engorgement. Ask the mothers about their feelings of the usefulness of this technique. When you are proficient at it you will be able to describe its application over the phone to mothers in difficulty at home. <br /> <img alt="External" src="design/external.gif" /><a href="http://health-e-learning.com/resources/articles/41-reverse-pressure-softening" title="External link" target="_blank">http://health-e-learning.com/resources/articles/41-reverse-pressure-softening</a><span class="linkDescription">[link: http://health-e-learning.com/resources/articles/41-reverse-pressure-softening]</span> </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>
      <p class="listTitle"> Additional strategies include </p>
      <ul>
        <li> lie mother on her back and massage the breast away from the nipple, towards the axilla; <span class="aside"> aiding lymphatic drainage </span> </li>
        <li> baby has to be ready to feed immediately after massage because the fluid will return very quickly </li>
        <li> hand express if baby not available to suckle. DO NOT use a breast pump ... this increases the edema. </li>
      </ul>
    </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>Breast fullness with 'milk-in' is normal - engorgement is abnormal.</li>
          <li>The difference between normal breast fullness and breast engorgement.</li>
          <li>Breastfeeding practices which reduce likelihood of engorgement.</li>
          <li>Management to assist the resolution of engorgement.</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_rf">
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	new MCQ('Choose the hormonal and biochemical changes which occur with Secretory Activation (lactogenesis II).', [{text:'fall in progesterone levels, stable high prolactin, increase in lactose in colostrum',feedback:'With birth of the placenta, the progesterone breaks are removed which allows the high pregnancy prolactin to take over milk synthesis. Increased lactose in colostrum osmotically draws water in to increase milk volume.',score:1},{text:'increase in progesterone, increase in prolactin, increase in lactose in colostrum',feedback:'almost right',score:0},{text:'fall in progesterone, increase in prolactin, increase in lactose in colostrum',feedback:'almost correct',score:0},{text:'fall in progesterone, stable prolactin, increase in protein',feedback:'protein in breastmilk lowers as milk volume increases',score:0}]),
	new MCQ('Choose the normal symptoms that characterise the onset of secretory activation.', [{text:'swollen breasts with tight shiny skin',feedback:'This is serious and painful',score:0},{text:'milk leakage',feedback:'This is as a result of increased volume',score:1},{text:'audible infant swallowing or gulping during breastfeeding',feedback:'It\'s easier for the baby to feed when the milk \'comes-in\'',score:1},{text:'infant difficulty latching effectively',feedback:'This is a risk factor for engorgement and forms part of the cause/effect cycle',score:0},{text:'breast tingling',feedback:'The symptoms reflect normal physiological changes and should be minimally bothersome to the mother and her baby. No severe symptoms should be present with secretory activation.',score:1},{text:'generalised redness of both breasts',feedback:'Redness would be an alert',score:0},{text:'mild to severe pain',feedback:'Slight discomfort may be normal but pain would be a reason to review the situation',score:0}]),
	new MCQ('You arrive at work today in a busy postnatal ward. There have been four new mothers admitted since you were at work 2 days ago. As you assist them, you realise that three of the new mothers have risk factors for developing engorgement. Which mother is more likely to experience a normal onset of secretory activation?', [{text:'The infant of this mother is poorly latched at the breast.',feedback:'Poor latch means poor breast drainage',score:0},{text:'This mother\'s baby has been contentedly sleeping for up to 6 hours between feeds for the past 36 hours.',feedback:'hmm, this infant has only breastfed 5 times since birth!',score:0},{text:'This mother is comfortably breastfeeding her baby and tells you that she is well rested due to a long sleep overnight while her baby was attended by staff in the nursery.',feedback:'It is good that the breastfeed is comfortable, however the mother may be awake all night tonight with engorgement!',score:0},{text:'This mother\'s baby has not latched since birth 24 hours ago. She has been hand expressing only 3-5ml of breastmilk every 2-3 hours.',feedback:'Long gaps between feeds or lack of expressing if baby is not removing milk and poor drainage of the breast are risk factors for engorgement.',score:1}]),
	new MCQ('Which of the following is the basis of helpful management of engorgement?', [{text:'frequent removal of milk and reduce interstitial swelling',feedback:'Remember the reasons for engorgement? Each factor needs to be addressed to break the cause/effect cycle.',score:1},{text:'removal of minimal amounts of milk, warmth for pain relief',feedback:'Small amounts of milk removal may not prevent milk stasis. Warm increase blood flow...',score:0},{text:'ultrasound and cold packs',feedback:'Whilst there is some comfort merit to these treatments, the basic management is more important.',score:0},{text:'regular anti-inflammatory medication',feedback:'Anti-inflammatory medication will reduce inflammation but not attend to the other physiological processes.',score:0}])
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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>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#coxd99" title="See full details">#</a> Cox DB et al. (1999) Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships</li>
              <li id="note2"><a href="references.html#pere01" title="See full details">#</a> Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview</li>
              <li id="note3"><a href="references.html#pang07" title="See full details">#</a> Pang WW et al. (2007) Initiation of human lactation: secretory differentiation and secretory activation.</li>
              <li id="note4"><a href="references.html#nevi91" title="See full details">#</a> Neville MC et al. (1991) Studies in human lactation: Milk volume and nutrient composition during weaning and lactogenesis</li>
              <li id="note5"><a href="references.html#lawr10" title="See full details">#</a> Lawrence R (2010) A Breastfeeding guide for the Medical Profession</li>
              <li id="note6"><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="note7"><a href="references.html#dewe03b" title="See full details">#</a> Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss</li>
              <li id="note8"><a href="references.html#mill04" title="See full details">#</a> Miller V et al. (2004) Treating Postpartum Breast Edema With Areolar Compression</li>
              <li id="note9"><a href="references.html#hunt04" title="See full details">#</a> Hunter D (2004) Oedema and its impact on breastfeeding outcome: Assessment and management of the mother and her breastfeeding baby during the postpartum period.</li>
              <li id="note10"><a href="references.html#cott04" title="See full details">#</a> Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement</li>
              <li id="note11"><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="note12"><a href="references.html#abm20" title="See full details">#</a> Academy of Breastfeeding Medicine (2009) Clinical Protocol #20: Engorgement</li>
              <li id="note13"><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="note14"><a href="references.html#wigh01" title="See full details">#</a> Wight NE (2001) Management of common breastfeeding issues</li>
              <li id="note15"><a href="references.html#mang10" title="See full details">#</a> Mangesi L et al. (2010) Treatments for breast engorgement during lactation.</li>
              <li id="note16"><a href="references.html#mcla93" title="See full details">#</a> McLachlan Z et al. (1993) Ultrasound treatment for breast engorgement: A randomised, double-blind trial</li>
              <li id="note17"><a href="references.html#robs90" title="See full details">#</a> Robson BA (1990) Breast engorgement in breastfeeding women</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_8-2" class="content">
          <h1 id="top">8.2 Nipple Pain</h1>
          <div>
    <p> Nipple pain is a common early postpartum concern. </p>
    <p class="listTitle"> It causes mothers </p>
    <ul>
      <li> to wean early <sup><a href="#note1">1</a></sup> <sup><a href="#note2">2</a></sup> <sup><a href="#note3">3</a></sup> <sup><a href="#note4">4</a></sup> <span class="aside"> (is a reason given by one third of mothers who wean prior to 6 weeks postpartum) </span> </li>
      <li> emotional distress <sup><a href="#note1">1</a></sup> <span class="aside"> (women with nipple pain experience high levels of emotional distress, which resolves once the pain resolves) </span> </li>
    </ul>
    <p class="listTitle"> Nipple pain can be caused by several factors: </p>
    <ul>
      <div class="columns"><div class="column" style="width: 50%">
          <li> Technical issues: <ul><li> poorly latched baby </li><li> baby with incorrect sucking technique </li><li> incorrect use of lactation aids, eg. a breast pump, nipple shields, breast shells, etc. </li></ul> </li>
          <li> Maternal anatomy issues <ul><li> non-protractile nipples - not always resulting in nipple pain/damage </li><li> firm, dense breast tissue </li></ul> </li>
          <li> Dermatological conditions of the nipple <ul><li> dermatitis (atopic and contact) </li><li> psoriasis, and other skin conditions </li></ul> </li>
        </div><div class="column" style="width: 50%">
          <li> Infections <ul><li> fungal overgrowth, eg. candidiasis </li><li> bacterial infections, eg. staph aureus </li><li> viral infections, eg. herpes simplex </li></ul> </li>
          <li> Neurovascular conditions <ul><li> vasospasm of the nipple </li><li> Raynaud's phenomenon </li><li> nerve response to damaged nipples </li></ul> </li>
          <li> Infant anatomy issues <ul><li> high arched palate or a bubble palate </li><li> short lingual frenulum<br /></li><li> receding/small mandible </li><li> teething <br /> </li></ul> </li>
        </div></div><br style="clear: both" />
    </ul>
    <p> Transient nipple pain is common during the first week postpartum, peaking at day 3 and decreasing by day 7. <sup><a href="#note5">5</a></sup> There is no damage evident and the pain disappears within a short time of commencing the feed (ie, about 30 seconds). </p>
  </div>
          <div class="section" id="Technique_factors"><h2>Technique factors</h2>
    <div>
      <p> Historically, an intervention to try to prevent nipple damage was to limit the number of feeds and length of time on the breast. A Cochrane Review <sup><a href="#note6">6</a></sup> concluded that this practice was associated with an <strong>increased</strong> incidence of sore nipples, engorgement and the need to give additional (formula) feeds, and is therefore not recommended. <br /> </p>
      <p> One study noted that 94% of women with breastfeeding problems had babies who had a "superficial, nipple-sucking" technique. <sup><a href="#note7">7</a></sup> <br /> </p>
      <p> Many authors implicate a poorly latched baby as being the major culprit of nipple damage. <sup><a href="#note8">8</a></sup> <sup><a href="#note9">9</a></sup> <sup><a href="#note10">10</a></sup> </p>
      <p> It has also been noted that there is a correlation between the early use of bottles and/or pacifiers and a disorganized suck and nipple damage. <sup><a href="#note7">7</a></sup> <sup><a href="#note11">11</a></sup> </p>
      <p class="listTitle"> From this body of work it is clear that <strong>the most common cause</strong> of nipple pain and nipple damage is preventable by: </p>
      <ul>
        <li><strong>teaching correct positioning and latching techniques,</strong> and </li>
        <li>
          <strong>avoiding artificial nipples (teats/pacifiers/dummies) during the learning period.</strong>
        </li>
      </ul>
      <p> </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/tip.png" class="icon" alt="" /><h3>Back to basics</h3>
      <div>Poor latch (whether from maternal technique or infant ability) may exist in the presence of other factors mentioned above.<br />In assisting the mother, go back to basic principles of position and latch FIRST to obtain a clearer picture of the other factors.<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/group.png" class="icon" alt="" /><h3>Quality assurance activity</h3>
      <div>Would you and a small group of colleagues be able to organize an audit of all cases of nipple damage on discharge from your maternity unit over a one-month period? <br /> It may be as simple as just an incident report, though trying to determine a cause for each would be useful. You may like to discuss with your colleagues the significance of this data once collected. Together you could work on ways to reduce the incidence before surveying again.</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="Maternal_anatomy_issues"><h2>Maternal anatomy issues</h2>
    <div>
      <p class="listTitle">General tips:</p>
      <ul>
        <li>Always start any 'difficulty latching' attempt to breastfeed with a well positioned baby in skin-to-skin contact with mother.</li>
        <li>Gentle touch or massage, or a cold cloth over the nipple will stimulate the erectile tissue.</li>
        <li>Compress the breast to hold the shape, ensuring the compression points on the breast coincide with where the baby's bottom and top jaws will be. Some mothers find it helpful to maintain this hold for a minute or two until sucking well established.</li>
        <li>While the breast is still soft prior to lactogenesis II is the best time for the baby to learn to breastfeed from his mother's breasts. If an artificial teat, whether it be a bottle nipple or a nipple shield, is introduced before giving the baby this opportunity the baby is more likely to require the 'super' stimulation of a formed shape at the posterior hard palate to stimulate sucking for all future feeds.</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/books.png" class="icon" alt="" /><h3>Workbook Activity 8.3</h3><p>Complete Activity 8.3 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="Inverted_or_non-protractile_nipples"><h3>Inverted or non-protractile nipples</h3>
      <div>Non-protractile or inverted nipples are difficult to draw out. Attempt to shape the breast well and hold that shape until infant is well established on the breast.<br /><br />Some devices may assist:<br /></div>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="200" height="300" src="images/modified_syringe.gif" alt="Syringe on right modified for mother to gently draw out non-protractile or inverted nipple." /><p>Syringe on right modified for mother to gently draw out non-protractile or inverted nipple. <br />Photograph &copy;  Health e-Learning</p></div>
        </div><div class="column" style="width: 50%">
          <div>
            <p> Devices such as the modified syringe, or commercially available devices have assisted mothers to draw their nipples out to enhance baby's ability to latch. Using a hand pump for a minute or so can also draw out the nipple. Some mothers may find it more comfortable if her partner is able to suck the breast/nipple into a teat shape immediately before feeding the baby. <br /></p>
            <p>These techniques are not always necessary though as many babies latch well to the breast regardless of nipple protractility. <br /></p>
            <p>
              <span style="font-style: italic;">Remember it is breastfeeding, not nipple feeding.</span>
            </p>
          </div>
        </div></div><br style="clear: both" />
    </div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="225" height="338" src="images/feed_with_shield.jpg" alt="Infant well-latched to nipple shield." /><p>Infant well-latched to nipple shield. <br />&copy; B. Wilson-Clay IBCLC</p></div>
      </div><div class="column" style="width: 50%">
        <div>
          <p> Sometimes a nipple shield may be successful. A risk:benefit assessment needs to be thoroughly explored first. Short-term benefits may lead to long-term complications for the breastfeeding dyad. In the past, nipple shields have been associated with decreased milk transfer, infant weight loss and decreased milk supply.<sup><a href="#note12">12</a></sup> <sup><a href="#note13">13</a></sup> <sup><a href="#note14">14</a></sup> Even with modern, thin nipple shields their use has been associated with premature weaning<sup><a href="#note15">15</a></sup> yet one study of preterm infants showed increased milk transfer over two consecutive feeds.<sup><a href="#note16">16</a></sup><br /></p>
          <p>Milk transfer via a shield, before lactogenesis II, will be negligible and therefore shields are <strong>not started</strong> until mother has established a good milk supply. <br /></p>
          <p>
            <span style="font-style: italic;">Note: Once a nipple shield has been introduced, observe for a good deep latch and nutritive sucking pattern. Follow-up assessment of infant condition and maternal milk supply is very important with the aim to weaning off the shield when the initial problem has resolved.</span>
            <br />
          </p>
          <p>
            <br />
          </p>
          <p>
            <br />
          </p>
        </div>
      </div></div><br style="clear: both" />
  </div>
          <div class="section" id="Infant_anatomy_issues"><h2>Infant anatomy issues</h2>
    <div class="section" id="Ankyloglossia_tongue_tie_"><h3>Ankyloglossia (tongue tie)</h3>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="300" height="206" src="images/tongue-tie1.JPG" alt="Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue." /><p>Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue. <br />&copy; Dr E. Jain</p></div>
        </div><div class="column" style="width: 50%">
          <div>
            <p> Ankyloglossia is a membranous attachment between the inferior aspect of the tongue and the anterior floor of the mouth, just beneath or directly onto the posterior alveolar ridge. This short or tight lingual frenulum may prevent the baby from extending the tongue over the bottom gum line or elevating the tongue (a very essential action for breastfeeding). </p>
          </div>
        </div></div><br style="clear: both" />
      <div class="section" id="Presentation"><h4>Presentation</h4>
        <div>
          <p> 80% of cases of poor latch as a result of ankyloglossia presented at 2 days postpartum; whereas 60% of women with nipple pain from ankyloglossia presented after day 2.<sup><a href="#note17">17</a></sup> </p>
          <p class="listTitle"> If not treated the most common outcomes include: </p>
          <ul>
            <li> poor latch </li>
            <li> nipple pain </li>
            <li> severe nipple damage </li>
            <li> constantly feeding </li>
            <li> infant failure to thrive (inadequate milk transfer) <br /> </li>
          </ul>
        </div>
      </div>
      <div class="section" id="Treatment"><h4>Treatment</h4>
        <div>Several factors need to be considered. Adequate tongue movement and function is essential for breastfeeding. Mild anomalies may have minimal effect on tongue function. However, when tongue-tie is noted, it must always be considered as causative of any breastfeeding problems until proven otherwise. <br /> <br style="font-weight: bold;" /> <span style="font-weight: bold;"> Frenotomy </span> <br /> This is a simple surgical procedure to release the restriction and provide greater movement. <br /> <br /> The following outcomes of frenotomy have been achieved: <br /><ul><li> Where poor latch was their major complaint, 100% of women found latch was improved.<sup><a href="#note17">17</a></sup> <br /></li><li>Of those presenting with nipple pain, mean pain score reduced from 6.9 to 1.2 immediately after the procedure.<sup><a href="#note17">17</a></sup></li><li> A significant decrease in nipple pain score reported after frenotomy compared to after sham procedure.<sup><a href="#note18">18</a></sup></li><li>Ultrasound post-frenotomy demonstrated less nipple compression by the tongue and was associated with "better attachment, increased milk transfer and less maternal pain".<sup><a href="#note19">19</a></sup></li></ul></div>
      </div>
    </div>
  </div>
          <div class="section" id="Nipple_infections"><h2>Nipple infections</h2>
    <div class="section" id="Fungal_overgrowth_candidiasis_thrush_yeast_"><h3>Fungal overgrowth (candidiasis, thrush, yeast)</h3>
      <div><p><dfn> Candida albicans </dfn> is a fungus (a form of yeast), which exists normally on the mucous membranes of the gut and vagina and usually presents no problems to a healthy individual. Factors that cause an imbalance of the normal flora of the body often result in candidiasis - the condition caused by an overgrowth and change in form of the fungus as it infects the host tissue. </p><p class="listTitle"> Factors often associated with nipple candidiasis are: </p><ul><li> presence of vaginal candidiasis - up to 25% of women are affected by end of pregnancy <sup><a href="#note20">20</a></sup> </li><li> use of antibiotics <sup><a href="#note1">1</a></sup> </li><li> break in skin integrity of nipple </li><li> infant who has oral candidiasis (acquired during birthing or being introduced on fingers, etc) </li><li> infant use of pacifiers/dummies <sup><a href="#note21">21</a></sup> <sup><a href="#note22">22</a></sup> - may also contribute to persistence of infant oral infection </li><li> use of bottles - 23% of lactating women who used bottles tested positive for <dfn> Candida </dfn> and 20% had nipple candidiasis. A risk factor for colonization of the mother was bottle use in the first 2 weeks postpartum. Of these women 57% had weaned by 9 weeks postpartum, compared to 31% who were negative for <dfn> Candida </dfn> . <sup><a href="#note23">23</a></sup> </li></ul> Amongst women who reported breastfeeding associated pain, C.albicans is the most commonly cultured organism. <sup><a href="#note24">24</a></sup> <br /></div>
      <div class="section" id="Presentation"><h4>Presentation</h4>
        <div>
          <p class="listTitle">Nipple candidiasis commonly presents with the following signs and symptoms</p>
          <ul>
            <li>acute breast/nipple pain after a period of pain-free feeding</li>
            <li>deep shooting, burning, or stabbing pain in the breast</li>
            <li>burning nipple pain, during and for some time after a breastfeed</li>
            <li>nipple and/or areola may be red, shiny or flakey; though may show no changes</li>
            <li><dfn>Candida</dfn> may be obvious in the baby's mouth</li>
          </ul>
        </div>
      </div>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="250" height="245" src="images/flakey_thrush_400_BI.jpg" alt="Note the dry, flakey area at base of nipple." /><p>Note the dry, flakey area at base of nipple. <br />&copy; B.Ingle IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div class="captionBox"><img width="296" height="293" src="images/thrush2_BI.jpg" alt="Note the shiny, red areola." /><p>Note the shiny, red areola. <br />&copy; B. Ingle, IBCLC</p></div>
        </div></div><br style="clear: both" />
      <div class="section" id="Management"><h4>Management</h4>
        <div><p> Observe a breastfeed to ensure latch is optimal, preventing further nipple damage. <br /> </p><p><span style="font-style: italic;"> Candida </span> branches and multiples rapidly and exists in many different stages at the same time. Management is aimed at eradicating the pathogen and preventing re-infection. The mother's doctor will confirm the diagnosis and may prescribe a pharmaceutical antifungal agent. <br /> </p><p><span style="font-weight: bold;"> Antifungal agents </span> that have been found to be effective in treating nipple candidiasis include: </p><ul><li> Gentian violet - painted on the nipples. This purple dye kills <dfn> Candida </dfn> on contact. <span class="aside"> (not readily available in some countries) </span> </li><li> Pure coconut oil - rubbed into nipples and ingested for candida in other sites. 100% effective against candida albicans <sup><a href="#note25">25</a></sup> </li><li> Miconazole - cream applied sparingly to nipples, oral gel, and powder. Effective in 99% of cases. <sup><a href="#note26">26</a></sup> </li><li> Fluconazole - systemic agent, usually administered orally. </li><li> Nystatin cream, tablets and pessaries. Not usually the drug of first choice. Resistance has developed to this drug, only being effective in 54% of cases. <sup><a href="#note26">26</a></sup> </li></ul><p class="listTitle"> Educate the mother about the following <span style="font-weight: bold;"> supportive strategies </span> that will enhance the antifungal treatment and prevent re-infection. </p><ul><li> Meticulous attention to hygiene. <br /> <ul><li> wash hands in warm, running soapy water before and after breastfeeding and any time when potentially infected areas have been touched, drying hands on a paper towel. </li><li> discard reusable gel breast pads if they were being used and don't recommence until infection is cured, and preferably not at all. </li><li> wash bras and cloth nursing pads daily and dry in direct sunlight if possible. </li><li> boil pacifiers or artificial teats/nipples daily and replaced frequently. <br /> </li><li> wash and thoroughly dry all toys, etc the baby puts in his mouth. </li></ul> </li><li> Rinse the nipples in a bicarbonate of soda solution to create an alkaline skin environment. Nipples may respond differently to traditional vaginal thrush soothing treatments.</li><li> Consider and treat all possible sources of recurring infection <br /> <ul><li> trim the baby's finger nails to prevent <span style="font-style: italic;"> Candida </span> being harbored under the nail and transferred to the mouth. </li><li>the moist fold under the breasts of large breasted women<br /></li><li> other children, maternal vaginal infection, sexual partner, a pet </li></ul> </li><li> Some women have reported faster resolution of symptoms when they eliminate simple sugars and yeasts from their diet and consume pure coconut oil, acidophillus and/or bacillo bifidus either in yoghurt form or in a commercially prepared capsule. </li></ul><span style="font-weight: bold;"> Treatment of the infant </span><br /> The infant may be a source of a re-infection cycle. Check the infant's mouth mucosa carefully. It may be necessary to treat the mouth with an appropriate infant preparation such as miconazole gel. <br /> <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/books.png" class="icon" alt="" /><h3>Workbook Activity 8.5</h3><p>Complete Activity 8.5 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>
    </div>
    <div class="section" id="Bacterial_infection"><h3>Bacterial infection</h3>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="288" height="295" src="images/staph_sm_BI.jpg" alt="Look closely at the nipple, noting the exudate." /><p>Look closely at the nipple, noting the exudate. <br />&copy; B.Ingle IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div><dfn></dfn> Whenever nipple skin integrity is broken the risk of colonization with bacterial <strong>and</strong> fungal pathogens is significantly increased. <br /><dfn>Staphylococcus aureus</dfn> is the most common causative organism of bacterial infections on the nipple, though streptococcus may also be implicated.<br /><br /><p class="listTitle"><span style="font-weight: bold;">Diagnosis</span> is usually made following careful history taking:</p> <ul><li>pain described as stinging,</li><li>observation of nipple damage,</li><li>presence of an exudate that could be yellow to red and crusting,</li><li>a delay in wound healing</li></ul><br /></div>
        </div></div><br style="clear: both" />
      <div>
        <span style="font-weight: bold;"> Management: </span>
        <ul>
          <li> Treat the original cause of the break in nipple skin integrity. </li>
          <li> Clean the nipple wound in a saline solution. </li>
          <li> Apply antibiotic ointment as ordered by the doctor. A compound many find useful is a combination of betamethasone ointment, mupirocin ointment and miconazole powder making an anti-inflammatory, antibiotic and antifungal ointment. <sup><a href="#note27">27</a></sup> A doctor may prescribe this and a compounding pharmacy supply it. </li>
          <li> It has been suggested that prophylactic oral antibiotics when nipple bacterial infection is diagnosed will prevent subsequent mastitis. <sup><a href="#note28">28</a></sup> However, in an unsuccessful attempt to replicate that study, the authors reported a significant number of women reluctant to take antibiotics prophylactically.<sup><a href="#note29">29</a></sup> </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/warning.png" class="icon" alt="" /><h3>Be vigilant</h3>
        <div>A bacterial nipple infection is a strong risk factor for the development of infective mastitis.<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>
  </div>
          <div class="section" id="Treatment_of_nipple_damage"><h2>Treatment of nipple damage</h2>
    <blockquote>
      <div>There is nothing to be achieved by treating sore or damaged nipples if you don't simultaneously treat the cause.</div>
    </blockquote>
    <div><p> After identifying the cause and initiating an appropriate action plan, the mother may also benefit from some other supportive measures to give added relief.</p>Breastmilk contains anti-infective agents and epidermal growth factor to prevent infections and heal any damage, as well as the hindmilk being high in fat to soothe the nipple. When you remove the cause of the damage, the nipple will heal quickly even while the mother continues to breastfeed on the affected breast. <p class="listTitle">After performing a meta-analysis<sup><a href="#note30">30</a></sup> on the available research on treatment methods for nipple damage best practice is to</p><ol><li>apply warm water compresses <span style="font-style: italic;">to relieve pain</span>, and</li><li>apply breastmilk <span style="font-style: italic;">to hasten healing</span> of cracked nipples.</li></ol><p> None of the following are recommended: lanolin, ointments, aerosol sprays, film dressing and hydrogel dressings.</p><p>You can read the whole Best Practice information sheet on <img alt="External" src="design/external.gif" /><a href="http://www.jbiconnectplus.org/ViewSourceFile.aspx?0=500" title="External link" target="_blank"><span style="font-style: italic;">Management of nipple pain and/or trauma associated with breastfeeding.</span></a><span class="linkDescription">[link: http://www.jbiconnectplus.org/ViewSourceFile.aspx?0=500]</span><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/warning.png" class="icon" alt="" /><h3>What about resting the nipple?</h3>
      <div>Severely damaged nipples may need to be rested for 24 hours or longer for initial healing to occur. During this time regular expressing of breastmilk will be required. <br /><br />We live in a time of technology and gadgets. A breast pump (electric or manual) is often the only option considered for milk removal. Just as infants who exert a stronger baseline peak and pause vacuum will cause more pain for their mothers compared to infants with vacuum within normal range<sup><a href="#note31">31</a></sup> so too the vacuum of breast pumps has been associated with increased nipple pain and damage.<sup><a href="#note32">32</a></sup> If a pump is to be used careful instruction to mothers about the correct use will prevent a bad situation becoming worse.<br /><br />Hand expressing breastmilk may be a better option for many mothers.<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/group.png" class="icon" alt="" /><h3>Group Activity</h3>
      <div>
        <p>
			Review your unit's Breastfeeding Policy for the management of nipple damage. Is it up-to-date and evidence-based? Is this the procedure all your colleagues follow?
		</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="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> Nipple pain threatens breastfeeding continuance. </li>
          <li> The many causes of nipple pain. </li>
          <li> The most important basic principle to address nipple pain. </li>
          <li> How to assist mothers with non-protractile nipples. </li>
          <li> Identification of ankyloglossia and impact on breastfeeding dyad. </li>
          <li> How to recognise nipple infections such as candidiasis and Staph aureus. </li>
          <li> Treatment choices for nipple candidiasis and Staph aureus. </li>
          <li> Supportive management for damaged nipples. </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">
<script type="text/javascript">
/* <![CDATA[ */
var rgqs = {settings : {type : 'matching', shuffle : 'both'}, questions : [
	new Matching('This is the organism most commonly cultured in mothers reporting nipple pain.', 'Candida albicans'),
	new Matching('Nipple infections by this organism significantly increase the risk of mastitis.', 'Staph. aureus'),
	new Matching('Candida albicans is often harbored in these implements, causing infection and re-infection.', 'pacifiers and teats'),
	new Matching('Staph aureus infection of the nipple has a characteristic feature.', 'yellow exudate'),
	new Matching('This is the pharmacological treatment required for Candida albicans.', 'antifungal'),
	new Matching('Treatment with this increases the risk of candidiasis.', 'antibiotics'),
	new Matching('If untreated this could result in the infant failing to thrive.', 'ankyloglossia')
]};

/* ]]> */</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('rg');</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 id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#amir96" title="See full details">#</a> Amir LH et al. (1996) Candida albicans: is it associated with nipple pain in lactating women?</li>
              <li id="note2"><a href="references.html#schw02" title="See full details">#</a> Schwartz K et al. (2002) Factors associated with weaning in the first 3 months postpartum.</li>
              <li id="note3"><a href="references.html#lewa06" title="See full details">#</a> Lewallen LP et al. (2006) Breastfeeding support and early cessation.</li>
              <li id="note4"><a href="references.html#amir05a" title="See full details">#</a> Amir LH et al. (2005) Why do women stop breastfeeding? A closer look at not enough milk among Israeli women in the Negev Region.</li>
              <li id="note5"><a href="references.html#morl05" title="See full details">#</a> Morland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review.</li>
              <li id="note6"><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="note7"><a href="references.html#righ98" title="See full details">#</a> Righard L (1998) Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles?</li>
              <li id="note8"><a href="references.html#gunt45" title="See full details">#</a> Gunther M (1945) Sore Nipples: Causes and Prevention</li>
              <li id="note9"><a href="references.html#prac02" title="See full details">#</a> Prachniak GK (2002) Common breastfeeding problems</li>
              <li id="note10"><a href="references.html#wigh01" title="See full details">#</a> Wight NE (2001) Management of common breastfeeding issues</li>
              <li id="note11"><a href="references.html#cent99" title="See full details">#</a> Centuori S et al. (1999) Nipple care, sore nipples, and breastfeeding: a randomized trial</li>
              <li id="note12"><a href="references.html#wool80" title="See full details">#</a> Woolridge MW et al. (1980) Effect of a traditional and of a new nipple shield on sucking patterns and milk flow.</li>
              <li id="note13"><a href="references.html#jack87" title="See full details">#</a> Jackson DA et al. (1987) The automatic sampling shield: a device for sampling suckled breast milk.</li>
              <li id="note14"><a href="references.html#auer90" title="See full details">#</a> Auerbach KG (1990) The effect of nipple shields on maternal milk volume.</li>
              <li id="note15"><a href="references.html#pinc08" title="See full details">#</a> Pincombe J et al. (2008) Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.</li>
              <li id="note16"><a href="references.html#meie00" title="See full details">#</a> Meier PP et al. (2000) Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding.</li>
              <li id="note17"><a href="references.html#ball02" title="See full details">#</a> Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad</li>
              <li id="note18"><a href="references.html#grif04" title="See full details">#</a> Griffiths DM (2004) Do Tongue Ties Affect Breastfeeding?</li>
              <li id="note19"><a href="references.html#gedd08a" title="See full details">#</a> Geddes DT et al. (2008) Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound.</li>
              <li id="note20"><a href="references.html#cotc98" title="See full details">#</a> Cotch MF et al. (1998) Epidemiology and outcomes associated with moderate to heavy Candida colonization during pregnancy</li>
              <li id="note21"><a href="references.html#comi06" title="See full details">#</a> Comina E et al. (2006) Pacifiers: a microbial reservoir</li>
              <li id="note22"><a href="references.html#dasi09" title="See full details">#</a> da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.</li>
              <li id="note23"><a href="references.html#morr05" title="See full details">#</a> Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women</li>
              <li id="note24"><a href="references.html#andr07" title="See full details">#</a> Andrews JI et al. (2007) The yeast connection: is Candida linked to breastfeeding associated pain?</li>
              <li id="note25"><a href="references.html#ogbo07" title="See full details">#</a> Ogbolu DO et al. (2007) In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.</li>
              <li id="note26"><a href="references.html#hopp96" title="See full details">#</a> Hoppe JE et al. (1996) Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group</li>
              <li id="note27"><a href="references.html#newm05" title="See full details">#</a> Newman J et al. (2005) Dr Jack Newman's Guide to Breastfeeding (The Ultimate Breastfeeding Book of Answers)</li>
              <li id="note28"><a href="references.html#livi99" title="See full details">#</a> Livingstone V et al. (1999) The treatment of staphylococcus aureus infected sore nipples: a randomized comparative study</li>
              <li id="note29"><a href="references.html#amir04" title="See full details">#</a> Amir LH et al. (2004) A failed RCT to determine if antibiotics prevent mastitis: Cracked nipples colonized with Staphylococcus aureus: A randomized treatment trial</li>
              <li id="note30"><a href="references.html#jbi09" title="See full details">#</a> Johanna Briggs Institute et al. (2009) The management of nipple pain and/or trauma associated with breastfeeding.</li>
              <li id="note31"><a href="references.html#mccl08" title="See full details">#</a> McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums</li>
              <li id="note32"><a href="references.html#clem10" title="See full details">#</a> Clemons SN et al. (2010) Breastfeeding womens experience of expressing: a descriptive study.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_8-3" class="content">
          <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="275" height="184" src="images/mastitis2.jpg" alt="" /><p> <br />&copy; B.Ingle, IBCLC</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_rh">
<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_rh');</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>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_8-4" class="content">
          <h1 id="top">8.4 Insufficient breastmilk</h1>
          <div class="section" id="Perceived_breastmilk_insufficiency"><h2>Perceived breastmilk insufficiency</h2>
    <div>
      <p> Along with nipple pain, this is the most common breastfeeding problem which women experience and a reason mothers give for introducing artificial infant formula and weaning prematurely. "Not enough milk" is reported by women, but usually their perception does not match reality.<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup><br /></p>
      <p>Education about normal infant behavior, normal infant breastfeeding frequency, good latch and normal infant output will prevent this misunderstanding and unfortunate outcome. </p>
      <p> Output is the most obvious and reassuring way for a mother to know her baby is being well fed. Remind the mother: <strong>If it's coming out, it must have gone in!</strong> </p>
    </div>
  </div>
          <div class="section" id="How_is_breastmilk_production_regulated_"><h2>How is breastmilk production regulated?</h2>
    <div>
      <p class="listTitle">You will recall</p>
      <dl>
        <dt>Secretory differentiation (Lactogenesis I)</dt>
      </dl>
      <ul>
        <li>commences during pregnancy</li>
        <li>regulates production of colostrum</li>
        <li>is an endocrine function <dfn> dependent on hormonal control</dfn></li>
      </ul>
      <dl>
        <dt>Secretory activation (Lactogenesis II)</dt>
      </dl>
      <ul>
        <li>commences soon after birthing, when serum prolactin is high and progesterone is suddenly removed</li>
        <li>is seen clinically as a copious production of breastmilk</li>
        <li>is an endocrine function</li>
      </ul>
      <dl> </dl>
    </div>
    <div class="section" id="Lactogenesis_III"><h3>Lactogenesis III</h3>
      <div>
        <p> Lactogenesis III is the <dfn> maintenance of milk synthesis </dfn> . </p>
        <p> This is an <span style="font-weight: bold;"> autocrine </span> function, meaning the control is under local control at the breast. Simply explained, <dfn> milk must be removed from the breast for more milk to be made. </dfn> Each breast is independent of the other in regards to milk production. <br /></p>
        <p class="listTitle"> Researchers have described the following mechanisms, which both work together. </p>
        <ol>
          <li>
            <p>
              <strong>Feedback Inhibitor of Lactation (FIL)</strong>
            </p>
            <p> FIL is a small whey protein that is found in breastmilk. It works on an inhibitory basis. The more milk present in the breast, the more FIL is present to be absorbed and exert its inhibitory effect on milk production. Conversely, as the breastmilk volume in the breast drops there is less inhibitory protein and production of breastmilk is more rapid. </p>
          </li>
          <li><p><strong>Prolactin receptors:</strong></p><p> </p>Prolactin is necessary to form the substrate of breastmilk, therefore the amount of prolactin in the milk is more important to milk production than serum (blood) prolactin. Prolactin must pass from the bloodstream through the alveolus and into the milk.<br />Prolactin receptors on the alveolus control how much prolactin can move into the milk. <span class="aside">(Imagine the prolactin receptors to be like keyholes, and prolactin is the key. The keyhole must be the perfect shape to allow the key to fit into it.)</span> As the alveoli become increasingly distended, such as occurs as the breast is filling, less prolactin is found in the alveolus so milk production slows.<sup><a href="#note3">3</a></sup> As the alveolus empties of milk, the cells flatten allowing prolactin to bind to the receptors, pass through them and into the milk increasing the rate of milk production again.<sup><a href="#note4">4</a></sup> <sup><a href="#note5">5</a></sup><br /><br /></li>
        </ol>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>What was that again?</h3>
        <div>
          <p> Simply put: </p>
          <p>full breast = lots of milk in alveoli = lots of FIL = slow breastmilk production </p>
          <p>full breast = distorted receptors = slow passage of prolactin = slow breastmilk production</p>
          <p> Two very good reasons to ensure <strong>frequent, effective milk removal</strong> for adequate milk production.<br /></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>
      <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 8.8</h3><p>Complete Activity 8.8 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="Breast_storage_capacity_and_rate_of_breastmilk_production"><h4>Breast storage capacity and rate of breastmilk production</h4>
        <div>
          <p> Breastmilk storage capacity is unique to each mother, and each breast.</p>
          <ul>
            <li>A mother who has a small storage capacity will find that her baby feeds frequently, removing most milk at each breastfeed. This mother's rate of breastmilk production will be high most of the time. It would be inappropriate to suggest that her baby should be feeding less frequently, or expect him to sleep through the night, as this is most likely to result in failure to thrive and an insufficient milk supply. </li>
            <li> A mother with a large storage capacity will have higher degree of breast fullness for longer. Her infant made need only one breast per feed or may feed less frequently. Breastmilk production during this time will be slow, increasing as the available milk is removed. </li>
          </ul>
          <p> Over a 24-hour period both babies may take very similar amounts of milk, but one baby may have to breastfeed many more times per day to achieve it. </p>
        </div>
      </div>
    </div>
  </div>
          <div class="section" id="Insufficient_breastmilk"><h2>Insufficient breastmilk</h2>
    <div class="section" id="Diagnosis"><h3>Diagnosis</h3>
      <div>
        <p> Diagnosis of insufficient breastmilk supply is generally made by observing the condition of the baby. As mentioned in <a href="topic_7-2.html">Topic 7.2</a> , it may not be low supply that has caused failure to thrive, which is why a pediatric review is always indicated. <br /> </p>
        <p> Your thorough history-taking and excellent assessment and observational skills may reveal the reason for insufficient milk. These can be summarised as: </p>
        <p style="font-weight: bold;">
          <span style="font-weight: normal;">Maternal: </span>
        </p>
        <ul>
          <li> medical conditions such as polycystic ovary syndrome, retained placenta, obesity, diabetes, large blood loss </li>
          <li> breast conditions - surgery (reduction mammoplasty, augmentation), hypoplasia </li>
          <li> other - contraceptive pill, subsequent pregnancy </li>
        </ul>
        <p style="font-weight: bold;">
          <span style="font-weight: normal;">Infant: </span>
        </p>
        <p> any medical condition or temporary circumstance which prevents adequate sucking strength and drainage of the breast. <br /> </p>
      </div>
      <div class="section" id="Delayed_onset"><h4>Delayed onset</h4>
        <div>The absence of noticeable fullness/heaviness of the breasts within 72 hours is considered delayed onset of lactogenesis.<sup><a href="#note6">6</a></sup> <br /><br />The infant's needs are increasing daily, so without adequate milk volume, the infant is at risk of dehydration, weight loss, hyperbilirubinemia, loss of energy and breast refusal.<br /><br /><span style="font-style: italic;"></span>Refer back to your notes about the biochemical changes which occur after birth to initiate secretory activation. Progesterone drops, prolactin remains high, lactose increases in colostrum. Insulin, thyroxine and glucocorticoids are also involved, but the role is uncertain.<br />Medical conditions which impair any of the chemical and hormonal changes are associated with delay of secretory activation. Your further study in <a href="topic_8-5.html">Topic 8.5</a> will assist your further understanding of the potential impact on delayed onset of secretory activation.<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"><h3>Being proactive</h3>
          <div>What measures will you take when you are caring for a mother-to-be/new mother who falls into one of these risk categories?<br /><br />How can you help to reduce the impact of her risk on delayed secretory activation?<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>
    </div>
    <div class="section" id="Management"><h3>Management</h3>
      <div>
        <p> A team approach may be required depending on the cause. Insufficient milk may be temporary of permanent, however, your role will be to guide the mother and assist her to effectively and regularly remove breastmilk to encourage rapid breastmilk production. </p>
        <ol>
          <li>
            <p class="listTitle"><span style="font-style: italic;"> The breastfeed </span> - be a detective, examine the infant and assess a breastfeed as discussed in <a href="topic_5-3.html">Topic 5.3</a><br /> </p>
            <ul>
              <li> Observe for good positioning, deep latch, effective suckling, swallowing. <span class="aside"> Believe it or not this very first step is one often neglected, particularly by health professionals whose specialty is not breastfeeding. </span> </li>
              <li> Correcting a poor latch may be all that's required to solve the mother's lactation insufficiency. </li>
              <li> Breast compression during breastfeeding increases milk transfer. Breast compression involves holding the breast in the hand and gently squeezing it. Hold the compression until the baby's sucking pattern changes then release. Repeat. </li>
              <li> Switch feeding can also be effective. When the infant stops nutritive sucking on the first breast, swap to the other breast. Repeat this on each breast to encourage infant's interest and promote milk synthesis. <br /> </li>
              <li> Use a tube-feeding device at the breast for supplements. If possible commence the breastfeed without the supplement flowing to encourage good drainage of the breast first. When nutritive sucking stops allow the supplemental milk to flow. Review <a href="topic_7-5-1.html">Topic 7.5.1</a> <br /> </li>
            </ul>
          </li>
          <li>
            <p style="font-style: italic;" class="listTitle"> Breastfeeding frequency </p>
            <ul>
              <li> Unfortunately many mothers are told they must feed 'X' number of times per day for 'X' number of minutes. They believe that long gaps between the feeds are a sign of a good baby and that frequent feeding will spoil the baby or create 'bad' habits, etc. </li>
              <li> Educate the mother about milk synthesis and breast storage capacity so that she can feel confident about the optimal breastfeeding practices to promote her milk supply. <br /> </li>
              <li> Frequent and effective breastmilk removal from the breast at each feed, by a well-latched baby or breast expression, will produce more milk in each breast. <br /> </li>
            </ul>
          </li>
          <li>
            <p class="listTitle"><span style="font-style: italic;"> Additional stimulation </span> - milk removal between breastfeeds </p>
            <ul>
              <li> Fact: The more frequently milk is removed from the breast the more rapidly the breast will produce breastmilk. The fuller the breast, the slower the breast will make breastmilk. </li>
              <li> Additional milk removal between breastfeeds will increase total breastmilk produced in that period. Use this milk as a supplement later. </li>
              <li> Express immediately after breastfeeding <strong>IF</strong> the baby does not remove all breastmilk from the breast each breastfeed, as may happen in the mornings when volume contained in the breast is greater, or the baby has an ineffectual suck. (And pump again in another hour) <br /> </li>
            </ul>
          </li>
          <li>
            <p class="listTitle"><span style="font-style: italic;"> Galactagogues </span> - discuss the pros/cons and types available <br /> </p>
            <ul>
              <li> A galactagogue is a substance that increases the volume of breastmilk produced. </li>
              <li> Effective galactagogues include domperidone and metoclopramide, as well as the herbals fenugreek, blessed thistle and goat rue. </li>
              <li>Galactogogues will only be successful if combined with clinical measures that ensure frequent, effective milk removal.<br /></li>
            </ul>
          </li>
          <li>
            <p class="listTitle"><span style="font-style: italic;"> Counselling the mother </span> - sensitivity and caring will be needed to assist this mother. </p>
            <ul>
              <li> Reassure her that your recommendations won't be detrimental to the baby <span class="aside"> (and make sure they aren't - ensure the baby receives adequate nutrition, which may include artificial infant formula.) </span> . </li>
              <li> Educate the mother about how milk production is controlled in her breast. This knowledge can be very empowering, particularly if mother had been limiting feeds based on erroneous advice.<span class="aside"></span> </li>
              <li> Be sensitive to her feelings; some people have probably criticised her decision to breastfeed, and she may see this problem as justification of their criticism. </li>
              <li> Be careful that she doesn't perceive you to be unapproachable if she does decide to artificially feed. She's still going to need lots of support to help her through possible emotional and guilt reactions. </li>
            </ul>
          </li>
        </ol>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>When is the best time to express?</h3>
        <div>
          <p> Assume a mother has an insufficient milk supply. Her baby latches effectively and drains both breasts well each breastfeed. When will you tell her to pump? </p>
          <p><strong>Immediately after breastfeeding??</strong> This is what is frequently advised. Mother breastfeeds, then pumps and gets only a few mls, or maybe nothing. That's understandable: the baby had just breastfed effectively. Mother feels disheartened - it proves her inability to provide for her baby. Breastmilk production will not be enhanced because the breast was already as empty as possible. </p>
          <p><strong>However, if she waits for an hour then pumps</strong>, breastmilk production would have been at maximum for the majority of that time, beginning to slow now as more milk accumulates in the breast. Pumping may produce 30ml (1 ounce) from each breast (depends on individual rate of milk production). The breast will be emptied again, milk production will be back to maximum rate once again enhancing overall volume produced, and the mother will feel positive about her ability to produce breastmilk. </p>
          <p> This is an example of applying your knowledge of physiology to a problem. </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>
      <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 8.9</h3><p>Complete Activity 8.9 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>
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                <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Did you know?</h3>
    <div>
      <p>
		Women are able to relactate <span class="aside">having prematurely weaned their baby</span>, and also induce lactation, <span class="aside">if they did not previously go through pregnancy</span>. Always offer this as an option for mothers who weaned prematurely or are adopting a baby.
	</p>
    </div>
  </td>
                <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
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          </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>That lactogenesis III is the maintenance of milk secretion.</li>
          <li>The more breastmilk removed from the breast the more rapidly more breastmilk will be made. </li>
          <li>Be able to describe the 2 mechanisms of autocrine control of milk synthesis at the breast level.</li>
          <li>Understand how milk storage capacity impacts on breastfeeding frequency.<br /></li>
          <li>How to maximise a mother's ability to produce an adequate milk supply.</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_ri">
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	{ c : 'Mary, the first-time mother of a 6 week old infant, tells you that she is concerned about her milk supply. <br/> <br/> Her baby Max, feeds about 6 times per day taking one breast per feed and often seems fussy in between feeds. She has large breasts so her friend told her that she would have enough milk in one breast per feed.<br/> Max regained his birthweight at 16 days and has gained 190g, 180g, 170g and 170g respectively each week since then. (30g = 1oz)<br/><br/>Is this weight gain adequate? (refer <a href=\"6.3\">Topic 6.3</a> for assistance)<br/>Discuss what further information you need to obtain from Mary.<br/>What observations will you make?<br/>What specific education points will you discuss with Mary?<br/>What management will you out into place for Mary and Max?<br/>', r : '<span style=\"font-weight: bold;\">Weight Gain:<br/></span>Weight gain is not poor, but it is slowing which may indicate that milk supply is slowing due to reduced stimulation.<span style=\"font-weight: bold;\"><br/><br/>Further information:</span><br/>This is a large breasted women - is she obese, does she/did she have diabetes?<br/>You will need to ask a full history of general health, pregnancy and birth - does she take any medications, has she commenced the contraceptive pill, did she have hypertension during pregnancy, ?full term birth, ?vaginal birth/Cesarean section, blood loss, was the infant held in uninterrupted skin-to-skin?<br/>Milk supply - when did she notice breast fullness?<br/>Breastfeeding - does she have any nipple soreness or any breast lumps, what is the length of each feed, describe the baby\'s behaviour at the breast during feeds.<br/>Infant well-being - wet and dirty nappy count<br/><br/><br/><span style=\"font-weight: bold;\">Observations:</span> (Review <a href=\"5.3\">Topic 5.3</a>)<br/>Examination of the infant for general well-being - colour, skin turgor, fat deposits. Oral examination for obvious issues such as oral thrush or tongue-tie (if you are more experienced, you may perform a sucking assessment too)<br/>Observe a breastfeed - watch the feed from positioning to first latch and through some of the feed - observe quality of gape and signs of milk transfer, note baby\'s participation in the breastfeed.<br/><br/><span style=\"font-weight: bold;\"><br/>Education points:<br/></span>Describe breast storage capacity - large breasts don\'t necessary have large storage capacity or greater milk production<br/>Milk production<span style=\"font-weight: bold;\"> </span>is dependent on effective frequent milk removal - if milk is removed infrequently, production will slow down, increased removal of milk will increase production.<br/>Discuss about listening and responding to her baby\'s cues - the baby is probably wanting more breastfeeds<span style=\"font-weight: bold;\"><br/></span><span style=\"font-weight: bold;\"><br/><br/>Management:</span><br/>Increase number of breastfeeds per day - perhaps offer both breasts to see if baby is interested or not, otherwise give breastfeeds when baby is fussy.<br/>If the baby tends to be a sleepy feeder, suggest that the mother swap the baby from one breast to the next and back again to promote better quality of feeding and more effective drainage of milk.<br/>If baby is asleep, mother could express for a short time to stimulate milk supply - this milk could be offered back to baby at a later stage by cup or spoon or stored in the freezer for 3 months.<br/>Suggest a follow-up appointment next week - if there is no improvement, you might then suggest galactogogues. If the weight gain had been poor (eg, 100g per week), then introduction of galactogogues would be judicious immediately to enhance other breastfeeding practice suggestions.<br/><br/><br/><br/><br/>' }
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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>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#amir06b" title="See full details">#</a> Amir LH (2006) Breastfeeding--managing supply difficulties.</li>
              <li id="note2"><a href="references.html#lamo08" title="See full details">#</a> Lamontagne C et al. (2008) The breastfeeding experience of women with major difficulties who use the services of a breastfeeding clinic: a descriptive study.</li>
              <li id="note3"><a href="references.html#creg02" title="See full details">#</a> Cregan MD et al. (2002, March) Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period</li>
              <li id="note4"><a href="references.html#deca83" title="See full details">#</a> DeCarvalho MD (1983) Effect of frequent breastfeeding on early milk production and infant weight gain</li>
              <li id="note5"><a href="references.html#zapp88" title="See full details">#</a> Zappa AA (1988) Relationship between maternal parity, basal prolactin levels and neonatal breast milk intake</li>
              <li id="note6"><a href="references.html#nomm10" title="See full details">#</a> Nommsen-Rivers LA et al. (2010) Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_8-5" class="content">
          <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>
    </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="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>
    </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="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>
  </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="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_03.png" width="10" height="10" alt="" />
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            </thead>
            <tfoot>
              <tr class="decoRow">
                <td class="topleft" style="width: 10px">
                  <img src="design/callout_07.png" width="10" height="10" alt="" />
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                <td class="topcenter" style="background-image: url(design/callout_08.png);">
                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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                <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 8.10</h3>
                  <p>Complete Activity 8.10 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="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><span class="linkDescription">[link: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT]</span> . 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">
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	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%'),
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	new Matching('Drug levels up to this amount are considered safe to continue breastfeeding', '10%')
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<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"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_9-0" class="content">
          <h1 id="top">9.0 Promotion, Protection and Support</h1>
          <div>
    <p> You may wonder how this module is relevant for your practice. An understanding of the history of artificial infant formula promotion and the impact it has had on breastfeeding will help you to understand how your values, the values of the mothers you assist and the community in which you live have been formed. </p>
    <p> Artificial infant formula manufacturers are businesses, large businesses with shareholders whose concern is profit. Even though a LOT of evidence exists that artificial infant formula causes serious acute and chronic diseases and developmental and neurological insult to babies and children, and that in developing countries it is deadly, it is still marketed unethically to those who don't need it with the aim being to limit breastfeeding and increase profits, at the expense of the World's children. The World's first international code that regulates the practices of trans-national corporations had to be developed specifically to curb the marketing practices of artificial formula manufacturers. </p>
    <p> The formula industry puts corporate profits before child health by subtle and less subtle marketing to parents, wooing of health professionals and disregard for national and international conventions. Artificial infant formula does have a role to play in infant feeding, but a professional will acquire the knowledge needed from unbiased published research, not from salesmen or saleswomen. Mothers who need to use infant formula can receive accurate, unbiased information from their health professional. </p>
    <p> When you are aware of their practices you will realise that free lunches, pens, diaries or other give-aways are only given to you for one purpose - so that you will promote their product - and it works! A similar problem exists with pharmaceutical companies and the medical profession. Evidence is very clear that accepting their give-aways does influence the medical and nursing professional even when they don't think it does.<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> </p>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#erle08" title="See full details">#</a> Erlen JA (2008) Conflict of interest: nurses at risk!</li>
              <li id="note2"><a href="references.html#civa08" title="See full details">#</a> Civaner M (2008) [A proposal for the prevention of ethical problems related to drug promotion: a national network for drug information].</li>
              <li id="note3"><a href="references.html#sari09" title="See full details">#</a> Sarikaya O et al. (2009) Exposure of medical students to pharmaceutical marketing in primary care settings: frequent and influential.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_9-1" class="content">
          <h1 id="top">9.1 The International Code of Marketing of Breastmilk Substitutes</h1>
          <div>In 1981, the World Health Assembly adopted the <span style="font-style: italic;">International Code of Marketing of Breastmilk Substitutes</span> (the WHO Code). This document was prepared jointly by the World Health Organisation and UNICEF. The original document has continued to be developed as more resolutions have been passed by the World Health Assembly to see the WHO Code refined into the working document which we know today.<br /></div>
          <div class="section" id="Aim_of_the_WHO_Code"><h2>Aim of the WHO Code</h2>
    <div class="section" id="The_safe_and_adequate_nutrition_of_all_infants."><h3>The safe and adequate nutrition of all infants.</h3>
      <blockquote>
        <div>The WHO Code aims <span style="font-style: italic;"> to contribute to the provision of safe and adequate nutrition for infants</span> by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.</div>
      </blockquote>
    </div>
    <div>To achieve this aim <ul><li> Protect, promote and support breastfeeding. </li><li> Ensure that breastmilk substitutes are used properly when they are necessary. </li><li> Provide adequate information about infant feeding </li><li> Prohibit the advertising or any other form of promotion of breastmilk substitutes. </li></ul> The WHO Code does not aim to compel women to breastfeed against their will. It protects artificially fed infants by ensuring that the choice of products is impartial, scientific and protects these children's health. The WHO Code ensures that labels carry warnings and the correct instructions for preparation, so they are prepared in a safe manner if they are used. <p> The WHO Code is clear that the manufacture and availability of safe and appropriate products is not prohibited, but <span style="font-style: italic;"> promoting </span> them in the way most consumer products are marketed is unacceptable. </p></div>
  </div>
          <table class="callout">
            <thead>
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                <td class="topleft" style="width: 10px">
                  <img src="design/callout_01.png" width="10" height="10" alt="" />
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                <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="" />
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            </thead>
            <tfoot>
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                <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="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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                  <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 9.1</h3>
                  <p>Complete Activity 9.1 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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          </table>
          <div class="section" id="What_s_covered_by_the_WHO_Code_"><h2>What's covered by the WHO Code?</h2>
    <div class="section" id="Breastmilk_substitute"><h3>Breastmilk substitute</h3>
      <div>......is any food being marketed or otherwise presented as a partial or total replacement for breastmilk, whether or not suitable for that purpose.<br /><br /></div>
    </div>
    <div>The WHO Code applies to: <br /> <ul><li> breastmilk substitutes, including bona fide artificial infant formula </li><li> other milk products, foods (cereals) and beverages (teas and juices for babies), when marketed or otherwise represented to be suitable for use as a partial or total replacement of breastmilk before 6 months </li><li> anything that replaces the milk part of the child's diet after 6 months, which would ideally be fulfilled by breastmilk, is a breastmilk substitute, for example 'follow-on' milks or cereals promoted to be offered by bottle </li><li> feeding bottles and teats/artificial nipples </li><li> the quality of these, the availability and information concerning their use <br /> </li></ul> <p class="listTitle"> The scope of the WHO Code does not include any food, solid or semi-solid intended to be given to infants after 6 months. Such foods are complementary or weaning foods and can not be considered breastmilk substitutes. </p></div>
  </div>
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                  <img src="design/callout_02.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_03.png" width="10" height="10" alt="" />
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="topright" style="width: 10px">
                  <img src="design/callout_09.png" width="10" height="10" alt="" />
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                  <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 9.2</h3>
                  <p>Complete Activity 9.2 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="" />
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          <div class="section" id="Promotion_and_product_information"><h2>Promotion and product information</h2>
    <div>
      <ul>
        <li>Product labels must clearly state their inferiority to breastfeeding, the need for the advice of a health care worker, and a warning about health hazards. They may not show pictures of babies, or other pictures or text idealising the use of infant formula.</li>
        <li>Advertising of breastmilk substitutes to the public is not permitted.</li>
        <li>Companies can provide necessary information to health workers on the ingredients and use of their products. This information must be scientific and factual, not marketing materials. This product information should not be given to mothers.</li>
        <li>No financial or material inducements (pens, lunches) which promote products within the WHO Code should be provided for health workers or accepted by health workers.<br /></li>
      </ul>
    </div>
  </div>
          <div class="section" id="Free_samples"><h2>Free samples</h2>
    <div>
      <ul>
        <li>No free or low-cost breastmilk substitutes can be supplied in any part of the health care system.</li>
        <li>The small amount of infant formula needed for any babies who are not breastfeeding should be bought through regular purchasing channels. <br /></li>
        <li>Free samples should not be given to mothers, their families or health care workers. Small samples of artificial formula may not be given to mothers either from hospital or in the community, as these are samples to encourage mothers to use those products.</li>
        <li>Supplies of breastmilk substitutes to be given by the institution for free or at a reduced price to mothers or caregivers for social welfare purposes must continue to be provided for each baby for as long as the baby needs them. (ie, the responsibility of continued cost)<br /></li>
      </ul>
    </div>
  </div>
          <div class="section" id="What_can_you_do_"><h2>What can you do?</h2>
    <div>
      <ul>
        <li>Remove posters that advertise formula, teas, juices or baby cereal, as well as any that advertise bottles and teats and refuse any new posters.</li>
        <li>Refuse to accept free gifts from companies.</li>
        <li>Refuse to allow free samples, gifts, or leaflets to be given to mothers.</li>
        <li>Give individual private teaching of artificial infant formula use postnatally when a baby has a need for it. Do not allow group teaching of artificial formula preparation to pregnant women. <br /></li>
        <li>Accept only product information from companies that is scientific and factual, not marketing materials.</li>
        <li>Report breaches of the Code to the appropriate authorities.</li>
      </ul>
      <p> As a health care worker who cares about the health of mothers and babies it is up to each individual to uphold the WHO Code, regardless of your country's commitment to it. If your hospital intends to seek Baby Friendly accreditation it must comply with the WHO Code in its entirety, including the WHA Resolutions. </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/books.png" class="icon" alt="" /><h3>Workbook Activity 9.3</h3><p>Complete Activity 9.3 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"><a href="http://www.ibfan.org/code_watch-monitoring.html" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.ibfan.org/code_watch-monitoring.html]</span><h3><a href="http://www.ibfan.org/code_watch-monitoring.html" target="_blank">Violation spotting</a><span class="linkDescription">[link: http://www.ibfan.org/code_watch-monitoring.html]</span></h3>
      <div>
        <p>
				Click on the icon to be taken to the IBFAN site, which gives you a quick and easy summary called <img alt="External" src="design/external.gif" /><a href="http://www.ibfan.org/code-brief_guide.html" title="External link" target="_blank">"A brief guide to spotting a violation"</a><span class="linkDescription">[link: http://www.ibfan.org/code-brief_guide.html]</span>. Print this out to keep, and also put a copy on the staff notice boards at your place of work.
			</p>
        <p>Alternative download: <img alt="PDF" src="design/page_white_acrobat.png" /><a href="images/IBFAN_Brief%20guide%20to%20spotting%20a%20violation.pdf" title="PDF file">download the PDF here</a></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="captionBox">
            <img width="300" height="420" src="images/WHO_Code_lge.jpg" alt="The WHO Code" />
            <p>The WHO Code</p>
          </div>
          <table class="callout">
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                <td class="body"><a href="http://www.who.int/nutrition/publications/code_english.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.who.int/nutrition/publications/code_english.pdf]</span><h3><a href="http://www.who.int/nutrition/publications/code_english.pdf" target="_blank">A copy of the WHO Code</a><span class="linkDescription">[link: http://www.who.int/nutrition/publications/code_english.pdf]</span></h3>
    <div>
      <p> Click on the icon above to be taken to a site where you can download and print a copy of the International Code of Marketing of Breastmilk Substitutes <span class="aside">(it's a .pdf document which will open your Acrobat Reader)</span>. If that website is 'down' it's also available at the <img alt="External" src="design/external.gif" /><a href="http://www.ibfan.org/issue-international_code.html" title="External link" target="_blank">IBFAN</a><span class="linkDescription">[link: http://www.ibfan.org/issue-international_code.html]</span> website, which has all the WHA Resolutions listed for you to read and print also. </p>
      <p> Your workplace should have a copy (or several copies) of this document. It can be purchased inexpensively. <img alt="External" src="design/external.gif" /><a href="http://www.who.int/bookorders/anglais/detart1.jsp?amp;sesslan=1&amp;codlan=1&amp;codcol=15&amp;codcch=94" title="External link" target="_blank">CLICK HERE</a><span class="linkDescription">[link: http://www.who.int/bookorders/anglais/detart1.jsp?amp;sesslan=1&amp;codlan=1&amp;codcol=15&amp;codcch=94]</span> to open the Order Form. </p>
    </div>
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          <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>What is the WHO Code</li>
          <li>The purpose of the WHO code</li>
          <li>What company products and marketing tactics are included in the scope of the Code</li>
          <li>How to identify and report breaches of the WHO Code</li>
          <li>My responsibilities as a health care worker<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>
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          <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_rk">
<script type="text/javascript">
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	new MCQ('Under the scope of the International Code of Marketing of Breastmilk substitutes, a health worker may give a sample of infant formula to a mother whose 3 month old infant is gaining weight slowly on the 5th percentile.', [{text:'True',score:0},{text:'False',score:1}]),
	new MCQ('The WHO code covers all breastmilk substitutes including infant formula.', [{text:'True',score:1},{text:'False',score:0}]),
	new MCQ('The scope of the WHO Code excludes infants who are being formula fed.', [{text:'True',score:0},{text:'False',score:1}]),
	new MCQ('Under the provisions of the Code, it is acceptable for a health worker to take promotional gifts such as pens and notepads from infant formula manufacturers but the health worker must not show these products to a mother.', [{text:'True',score:0},{text:'False',score:1}]),
	new MCQ('Follow-on formulas, intended for infants older than 6 months are covered in the scope of the WHO Code.', [{text:'True',score:1},{text:'False',score:0}])
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</div><script type="text/javascript">renderActivity('rk');</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 id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_9-2" class="content">
          <h1 id="top">9.2 The Baby Friendly Initiative</h1>
          <div class="section" id="Innocenti_Declaration"><h2>Innocenti Declaration</h2>
    <div>
      <p> Some 10 years after the WHO Code was first signed a group of high-level policy-makers convened; the outcome was the release of the <span style="font-style: italic;">Innocenti Declaration</span>. The <span style="font-style: italic;">Innocenti Declaration</span> was endorsed by the World Health Assembly in 1991, giving it world-wide status and acceptance. <span style="font-weight: bold;">It is the most concise international statement on breastfeeding and covers all three facets of protection, promotion and support.</span><br /></p>
      <p class="listTitle">The <span style="font-style: italic;">Innocenti Declaration</span> set 4 targets for all governments:<span style="font-style: italic;"></span></p>
      <ol>
        <li>To appoint a national breastfeeding coordinator and a multi-sectoral national breastfeeding promotion committee. This target put accountability directly in the hands of each nations' government. </li>
        <li>That governments would have taken action to implement the International Code of Marketing of Breastmilk Substitutes. </li>
        <li>That maternity facilities should practice the recently published Ten Steps to Successful Breastfeeding. This came at just the right time historically. The launching of the Baby Friendly Hospital Initiative has been the most important and powerful step ever taken on behalf of breastfeeding. It has put breastfeeding on the health policy map in almost every country in the world. </li>
        <li>To enact imaginative legislation to protect the breastfeeding rights of working women. </li>
      </ol>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Reaching the targets</h3>
      <div>In 2005, 15 years after setting the original goals, a celebration was held to evaluate progress and re-affirm commitment to the targets.<br />The targets were ambitious and although they were not fully achieved by the projected date, great progress was made:<br /><ul><li>80 countries formed national breastfeeding authorities</li><li>19,000 hospitals became designated Baby-Friendly</li><li>80 countries had laws implementing the WHO Code on Marketing of Breastmilk Substitutes</li><li>declining breastfeeding rates were reversed and exclusive breastfeeding rates increase 15% worldwide.</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="The_Baby_Friendly_Initiative"><h2>The Baby Friendly Initiative</h2>
    <div>You may be working in an accredited Baby Friendly facility already or your hospital/institution may be working towards that now.<br />The thought process began more than 20 years ago to set targets and implement steps to increase world breastfeeding trends.<span style="font-weight: bold;"></span><br /></div>
    <div class="section" id="Baby_Friendly_hospitals"><h3>Baby Friendly hospitals</h3>
      <div class="columns"><div class="column" style="width: 40%">
          <div><span style="font-weight: bold;">The Baby Friendly Hospital Initiative (BFHI)</span> was launched by WHO and UNICEF in June 1991 at a meeting of the International Pediatric Association. The goal is to promote the adoption of the <span style="font-style: italic;">Ten Steps to Successful Breastfeeding </span>in hospitals worldwide by the designation of a Baby-Friendly Hospital Initiative award. It is designed to remove hospital barriers to breastfeeding by creating a supportive environment with trained and knowledgeable health workers.</div>
        </div><div class="column" style="width: 60%">
          <div class="captionBox"><img width="300" height="199" src="images/baby_friendly_billboard.jpg" alt="A proud hospital!" /><p>A proud hospital!</p></div>
        </div></div><br style="clear: both" />
      <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/article.png" class="icon" alt="" /><h3>Ten Steps to Successful Breastfeeding</h3>
        <div><p>Every facility providing maternity services and care for newborn infants should:</p><ol><li>Have a written breastfeeding policy that is routinely communicated to all health care staff.</li><li>Train all health care staff in skills necessary to implement this policy. </li><li>Inform all pregnant women about the benefits and management of breastfeeding. </li><li>(Help mothers initiate breastfeeding within a half-hour of birth.) Place babies in skin-to-skin contact with their mothers immediately following birth for at last an hour and encourage mothers to recognize when their babies are ready to breastfeeding, offering help if needed. </li><li>Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.</li><li>Give newborn infants no food or drink other than breastmilk unless medically indicated. </li><li>Practise rooming-in - allow mothers and infants to remain together - 24 hours a day. </li><li>Encourage breastfeeding on demand. </li><li>Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.</li><li>Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.</li></ol>Source: <span style="font-style: italic;">1989 WHO/UNICEF</span><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>
    <div class="section" id="Baby_Friendly_communities"><h3>Baby Friendly communities</h3>
      <div>To continue the best practices initiated in the hospital situation, and to provide supportive care to the mother, UNICEF/BFI United Kingdom developed best practice standards for the community. The <span style="font-style: italic;">Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Services </span>follows the same principles as the Ten Steps to Successful Breastfeeding. The emphasis is to ensure consistency of advice for mothers and continuity of care when care is passed from maternity to community services.<span style="font-style: italic;"><br />Community facilities who acquire the Seven-Point Plan Award are often referred to a "mother-child friendly" or "breastfeeding-friendly".<br /></span></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/article.png" class="icon" alt="" /><h3>Seven-Point Plan</h3>
        <div>The 7 points in summary are:<br /><br />1. Have a written breastfeeding policy that is routinely communicated to all health-care staff.<br />2. Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy.<br />3. Inform all pregnant women about the benefits and management of breastfeeding.<br />4. Support mothers to initiate and maintain breastfeeding.<br />5. Encourage exclusive and continued breastfeeding, with appropriately-timed introduction of complementary foods.<br />6. Provide a welcoming atmosphere for breastfeeding families.<br />7. Promote cooperation between health-care staff, breastfeeding support groups and the local community.<br /><br />Source: 2001 UNICEF/BFI UK<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>
    <div class="section" id="Does_Baby_Friendly_Work_"><h3>Does Baby Friendly Work?</h3>
      <div>
        <ul>
          <li> UNICEF, in 1999, reported widespread increases in rates of breastfeeding in urban areas, reductions in respiratory infections and diarrhea in infants, and savings in terms of both costs and staff time when BFHI is implemented. </li>
          <li>USA - Baby-Friendly designated hospitals have elevated rates of breastfeeding initiation and exclusivity. Elevated rates persist regardless of demographic factors that are traditionally linked with low breastfeeding rates. <sup><a href="#note1">1</a></sup> </li>
          <li>China - after 2 years of implementation of the Ten Steps, exclusive breastfeeding rates doubled in rural areas and improved from 10% to 47% in urban areas. </li>
          <li>Cuba - exclusive breastfeeding rates increased from 25% in 1990 to 72% in 1996. <sup><a href="#note2">2</a></sup> </li>
          <li>Scotland - babies born in a Baby-Friendly accredited hospital were 28% more likely to be exclusively breastfed at 7 days of postnatal age than those born in other maternity units. <sup><a href="#note3">3</a></sup> </li>
          <li> UK - in a 2 year period of mandatory BFI training of health visitors and nursery nurses resulted in a 1.57 times increased likelihood of an infant being breastfed at 8 weeks. <sup><a href="#note4">4</a></sup> <br /> </li>
        </ul>
      </div>
    </div>
    <div class="section" id="Becoming_accredited"><h3>Becoming accredited</h3>
      <div>To receive the Baby Friendly designation a hospital or community health unit will have fully embraced all of the Steps or Points, as well as adhere to the International Code on the Marketing of Breastmilk Substitutes. Achievement of the criteria will be assessed by a team of trained assessors who will make observations, view charts and feeding records and speak with mothers and the unit's staff.<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/books.png" class="icon" alt="" /><h3>Workbook Activity 9.4</h3><p>Complete Activity 9.4 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>Poster Promotion</h3>
      <div>Gather a small working group to collect appropriate photos (or obtain permission from mothers to photograph them and their babies) which could be made into a poster for each of the Ten Steps or each of the Seven Points.<br /><br />Display the posters in strategic areas in your workplace.<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>
          <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 significance of the landmark Innocenti Declaration on the protection, promotion and support of breastfeeding.</li>
          <li>An understanding of the purpose of the Baby-Friendly Initiative.</li>
          <li>The application of each of the Ten Steps or Seven Points to my work practice.</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_rl">
<script type="text/javascript">
/* <![CDATA[ */
var rlqs = {settings : {type : 'crossword'}, questions : [
	new CWWord('pacifier', 'Step 9 states that breastfeeding infants should not be given this form of artificial sucking.', 8, 1, 0),
	new CWWord('policy', 'Step 1 and Point 1 both state that this important breastfeeding document is the basis of breastfeeding support in their working environment.', 2, 5, 0),
	new CWWord('expressing', 'Step 5 states that hospital staff will \"Show mothers how to...maintain lactation if they are separated from their babies.\" What is the process being referred to?', 4, 7, 1),
	new CWWord('roomingin', 'Step 7 states the importance of keeping mothers and babies together in hospital by this practice. (2 words together)', 6, 14, 1),
	new CWWord('tensteps', 'The goal of the Baby-Friendly hospital initiative is for hospital practices to adopt these. (2 words together)', 6, 1, 0),
	new CWWord('initiation', 'Baby-Friendly designated hospital practices have increased ___________ and exclusivity of breastfeeding.', 11, 5, 0),
	new CWWord('support', 'The Baby-Friendly Initiative and the Seven-Point Plan encourage healthcare facilities and staff to work co-operatively with and refer mothers to these special breastfeeding groups.', 0, 5, 1),
	new CWWord('coordinator', 'One target of the Innocenti Declaration is for governments to appoint this national breastfeeding position.', 4, 10, 1),
	new CWWord('rights', 'A target of the Innocenti Declaration protects the breastfeeding _________ of working women.', 0, 0, 0),
	new CWWord('exclusive', 'What rates of breastfeeding have been shown to increase in areas with BFHI accredited hospitals?', 5, 12, 1)
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('rl');</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 id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#mere05" title="See full details">#</a> Merewood A et al. (2005) Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey</li>
              <li id="note2"><a href="references.html#phil04" title="See full details">#</a> Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.</li>
              <li id="note3"><a href="references.html#broa05" title="See full details">#</a> Broadfoot M (2005) The Baby Friendly Hospital Initiative and breast feeding rates in Scotland</li>
              <li id="note4"><a href="references.html#ingr11" title="See full details">#</a> Ingram J et al. (2011) The effects of baby-friendly iniatiative training on breastfeeding rates and the breastfeeding attitudes, knowledge and self-efficacy of community health care staff.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_9-3" class="content">
          <h1 id="top">9.3 Young Child Feeding</h1>
          <div><p><span style="font-style: italic;">The Global Strategy for Infant and Young Child Feeding</span> was endorsed by the World Health Assembly in 2002. The aim of this strategy is to improve, through optimal feeding, the nutritional status, growth and development, health, and thus the survival of infants and young children. <br /></p><p>"Malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths, which are often associated with inappropriate feeding practices, occur during the first year of life.....malnourished children who survive are more frequently sick and suffer the life-long consequences of impaired development."</p><p class="listTitle">The strategy's specific objectives are:</p><ul><li>to raise awareness of the main problems affecting infant and young child feeding, identify approaches to their solution, and provide a framework of essential interventions;</li><li>to increase the commitment of governments, international organisations and other concerned parties for optimal feeding practices for infants and young children;</li><li>to create an environment that will enable mothers, families and other caregivers in all circumstances to make, and implement, informed choices about optimal feeding practices for infants and young children.</li></ul>The document acknowledges these important background principles:<br /><ul><li>Inappropriate feeding practices and their consequences are major obstacles to sustainable socioeconomic development and poverty reduction.</li><li>Mothers and babies form an inseparable biological and social unit; the health and nutrition of one group cannot be divorced from the health and nutrition of the other.</li><li>Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; infants should be exclusively breastfed for the first 6 months to achieve optimal growth, development and health.</li><li>Infants are vulnerable during the transition period when complementary feeding begins. Nutritional status needs to be maintained by complementary foods which are timely, safe, adequate and properly-fed.</li><li>Infants and children are among the most vulnerable victims in natural and human-induced emergencies. Interrupted breastfeeding and inappropriate complementary feeding heighten the risk of malnutrition.</li></ul>Note also that this document also states the hierarchy of feeding options as you have learned in Topic 7.3 and 7.5.<br /><br />Source: <span style="font-style: italic;">Global Strategy for Infant and Young Child Feeding, WHO 2003</span><br /></div>
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                <td class="body"><a href="http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&amp;codlan=1&amp;codcol=15&amp;codcch=510" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&amp;codlan=1&amp;codcol=15&amp;codcch=510]</span><h3><a href="http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&amp;codlan=1&amp;codcol=15&amp;codcch=510" target="_blank">Does your Unit have a copy of this document?</a><span class="linkDescription">[link: http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&amp;codlan=1&amp;codcol=15&amp;codcch=510]</span></h3>
    <div>
      <p>
			If your Unit does not have a copy of this document it can be obtained, for a small cost, from the World Health Organisation website. Click on the icon to be taken to the order form. While at the website order <cite>Implementing the Global Strategy for Infant and Young Child Feeding</cite> at the same time - it is a free publication.
		</p>
      <p>
			Alternatively, you could download the Strategy for no cost from <img alt="PDF" src="design/page_white_acrobat.png" /><a href="http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf" title="Global Strategy booklet" target="_blank">the World Health Organisation website.</a><span class="linkDescription">[link: http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf]</span>
		</p>
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            <img width="384" height="550" src="images/global_strategy.jpg" alt="Global Strategy for Infant and Young Child Feeding" />
            <p>Global Strategy for Infant and Young Child Feeding</p>
          </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>To ensure my workplace has a copy of the Global Strategy for Infant and Young child feeding.</li>
          <li>Exclusive breastfeeding is the cornerstone of the health of infants, young children, children and adults and socioeconomic stability of communities.</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 id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_9-4" class="content">
          <h1 id="top">9.4 Local initiatives</h1>
          <div class="section" id="Breastfeeding_in_public"><h2>Breastfeeding in public</h2>
    <div class="section" id="Baby_Friendly_Point_6"><h3>Baby Friendly Point 6</h3>
      <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><span style="font-weight: bold;">Point 6</span> of the Seven-point Plan for Sustaining Breastfeeding in the Community states:</div>
        <blockquote>
          <div>
            <span style="font-style: italic;">Provide a welcoming atmosphere for breastfeeding families</span>
          </div>
        </blockquote>
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    <div>
      <p>
		   The health care facility should welcome breastfeeding in all public areas and this should be indicated by appropriately worded signs. Suitable facilities should be available for mothers who prefer to feed in privacy.
		 </p>
      <p>
		 	Reception staff should be aware that mothers are welcome to breastfeed in all public areas and be able to describe how they would advise a mother who wished to feed in privacy.
		 </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/thinker.gif" class="icon" alt="" /><h3>The normal act of breastfeeding seen in public</h3>
      <div>
        <p>Australia now has a law passed in Federal Parliament under the Sex Discrimination Act which makes it illegal for anyone to discriminate against breastfeeding mothers!</p>
        <p>Does your community health unit make it explicitly clear that breastfeeding is welcomed in all public areas? Do you have an area set aside should a mother prefer to breastfeed in privacy? </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="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="208" height="298" src="images/breastfeeding_welcome.jpg" alt="" /><p> <br />&copy; Australian Breastfeeding Association</p></div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="276" height="415" src="images/bfiUKwelcome_sm.jpg" alt="" /><p> <br />&copy; BFI UK Breastfeeding Welcome</p></div>
      </div></div><br style="clear: both" />
  </div>
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                  <img src="design/callout_03.png" width="10" height="10" alt="" />
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                  <img src="design/callout_07.png" width="10" height="10" alt="" />
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                  <img src="design/callout_08.png" width="59" height="10" alt="" />
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                  <img src="design/callout_04.png" width="10" height="80" alt="" />
                </td>
                <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Take a walk</h3>
    <div>
      <p>
			Go for a walk around your hospital or community health centre. Are there obvious signs in all the public areas making it clear that mothers may breastfeed in any them, AND referring her to a private area should she prefer it?
		</p>
      <p>
			If not design your own signs and display them until the organisation develops 'official' signs.
		</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="" />
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          </table>
          <div class="section" id="Supporting_mothers_in_the_community"><h2>Supporting mothers in the community</h2>
    <div class="section" id="Baby_Friendly_Step_10_and_Point_7"><h3>Baby Friendly Step 10 and Point 7</h3>
      <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><span style="font-weight: bold;">Step 10</span> of the Ten Steps to Successful Breastfeeding, and <span style="font-weight: bold;">Point 7</span> of the Seven-point Plan for Sustaining Breastfeeding in the Community state:</div>
        <blockquote>
          <div><span style="font-weight: bold;">Step 10</span>:<span style="font-style: italic;"> Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.</span></div>
        </blockquote>
        <blockquote>
          <div><span style="font-weight: bold;">Point 7</span>:<span style="font-style: italic;"> Promote co-operation between health care staff, breastfeeding support groups and the local community. </span></div>
        </blockquote>
      </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>
      <p> A Cochrane database systematic review <sup><a href="#note1">1</a></sup> on the effect of lay health workers in the community found them to be "promising" in breastfeeding promotion. Attendance at mother-to-mother support groups or follow-up by peer counsellors has demonstrated significant increases in maintaining exclusive breastfeeding. <sup><a href="#note2">2</a></sup> The peer counsellor role is unique from a health professional role in that it brings a mother together with another mother - the experienced can share with the new, the new can be supported and learn from the experienced. <br /> </p>
      <p> A report on the effects of implementation of the Baby Friendly Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates indicated an increase in breastfeeding initiation to one month of age in the BFHI group compared to the control.<sup><a href="#note3">3</a></sup> However, once breastfeeding support groups activity increased, breastfeeding at 6 months and 12 months was significantly increased. They concluded that activities aiming to promote breastfeeding in maternity hospitals had limited success on long-term breastfeeding. For far-reaching effect postnatal support is also required. </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/books.png" class="icon" alt="" /><h3>Workbook Activity 9.5 </h3><p>Complete Activity 9.5  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>
      <p class="listTitle">UK Baby Friendly requires Community Health Units to address each of the following to meet the requirements of this point.</p>
      <ul>
        <li>All breastfeeding mothers should know which professional(s) to contact for breastfeeding support and how to access this help.</li>
        <li>All breastfeeding mothers should know how to contact a breastfeeding counsellor or support group for help with breastfeeding.</li>
        <li>All breastfeeding mothers should know how to access help with breastfeeding outside surgery/office hours.</li>
        <li>Relevant staff should be able to describe a procedure which ensures that information on the progress of breastfeeding is passed on during the handover of care between midwife and health visitor.</li>
        <li>Mothers should demonstrate an awareness that such a procedure exists.</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>What procedures does your unit have in place to meet this standard?</h3>
      <div>
        <p>
					How is the availability of professional support <strong>and</strong> peer support communicated to mothers? Do you have a method of recording that mothers have received this information? How does your Unit encourage mothers to attend peer support organisations? If you are unsure of this could you form a group to look at what is done now, improve the procedure if necessary, and ensure the procedure is communicated to all staff at your Unit?
				</p>
        <p>
					If applicable, what handover procedures are in place between the birthing service and the community service?
				</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>
    <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>Peer support in unusual circumstances</h3>
      <div>
        <p> 
				As a sign of the changing times Gribble (2001)<sup><a href="#note4">4</a></sup> found that Internet breastfeeding support groups can provide mother-to-mother support to those breastfeeding in unusual circumstances.
			</p>
        <p>
				Consider forming a small group to research online support groups with the goal being to produce reference material for staff when counselling a mother whose situation may be unique (eg. adoptive breastfeeding, breastfeeding after reduction mammaplasty, etc). Contacting the facilitator of the group to determine their goals and the way the group functions would help to determine if their goals are consistent with those of your organisation.
			</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>
    <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>You can't do it alone!</h3>
      <div>
        <p>
				Peer support offers mothers a different type of support to what she receives from health professionals. Both are needed by mothers and, working together, both will help her to give her baby the healthiest start in life.
			</p>
        <p>
				Engage the peer breastfeeding support organisations in your community.
			</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="Engaging_the_Community"><h2>Engaging the Community</h2>
    <div>
      <p> Each year the World Alliance for Breastfeeding Action (WABA) promotes World Breastfeeding Week. World Breastfeeding Week (WBW) is the greatest outreach vehicle for the breastfeeding movement, being celebrated in over 120 countries. Officially it is celebrated from 1-7 August. However, groups may choose other dates to make it a more successful event in their countries. </p>
      <p> Each year a theme is chosen and WABA produces resource materials to assist groups and individuals to celebrate this event, raising community and media awareness of breastfeeding. This is an ideal opportunity for your Unit to celebrate breastfeeding and use the occasion to educate your community about breastfeeding. <br /></p>
      <p>You will be able to get ideas and download resources from their website when they become available: <img alt="External" src="design/external.gif" /><a href="http://worldbreastfeedingweek.org/" target="_blank" title="External link">WABA World Breastfeeding Week</a><span class="linkDescription">[link: http://worldbreastfeedingweek.org/]</span>. <br /></p>
      <p>
        <br />
      </p>
    </div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="216" height="360" src="images/WBWlogo07.png" alt="Logo for WBW 2007" /><p>Logo for WBW 2007</p></div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="304" height="240" src="images/wbw2010logo_sm.jpg" alt="Logo for WBW 2010" /><p>Logo for WBW 2010</p></div>
      </div></div><br style="clear: both" />
  </div>
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                  <img src="design/callout_07.png" width="10" height="10" alt="" />
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                  <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="" />
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            <tbody>
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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/group.png" class="icon" alt="" /><h3>Have fun this year!</h3>
    <div>
      <p> Start now! Get a group together to plan activities and promotions (of breastfeeding and your wonderful unit!) during Breastfeeding Awareness Week. The theme for this year is very modern and topical.<br /></p>
      <p>There are lots of resources available on the Internet and you could think up many others. Don't forget to involve the media in your celebrations. </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="" />
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            </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>Breastfeeding is a normal act which needs to be seen by everyone.</li>
          <li>The importance of welcoming breastfeeding mothers in public areas.</li>
          <li>How breastfeeding support groups play a vital role in continued support for breastfeeding mothers.</li>
          <li>That there are opportunities to become involved in breastfeeding promotion on a personal and professional level.</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_rm">
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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>
  </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 9 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 9.
	</p>
    </div>
  </div>
          <div id="footnotes">
            <h3>Notes</h3>
            <ol>
              <li id="note1"><a href="references.html#lewi05" title="See full details">#</a> Lewin SA et al. (2005) Lay health workers in primary and community health care.</li>
              <li id="note2"><a href="references.html#hodd06" title="See full details">#</a> Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland</li>
              <li id="note3"><a href="references.html#bosn04" title="See full details">#</a> Bosnjak AP et al. (2004) The effect of baby friendly hospital initiative and postnatal support on breastfeeding rates - Croatian experience</li>
              <li id="note4"><a href="references.html#grib01" title="See full details">#</a> Gribble KD (2001) Mother-to-mother support for women breastfeeding in unusual circumstances: a new method for an old model.</li>
            </ol>
          </div>
          <div id="footer"><br style="clear: both" /><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>
        </div>
        <script type="text/javascript">/* <![CDATA[ */ topicLoaded(); /* ]]> */</script>
        <div id="topic_9-5" class="content">
          <h1 id="top">9.5 Infant feeding in emergencies</h1>
          <div class="section" id="The_problem"><h2>The problem</h2>
    <div>In a nutshell the problem is to provide ongoing food security for everyone involved.<br /><br />Some emergency nutrition situations can be anticipated, eg famine and war; however, the majority can not. Earthquakes, floods, tsunami, fire, cyclones, hurricanes and tornadoes happen quickly and with little warning or time to prepare. During or following such an event there may be:<br /><ul><li>no clean drinking water</li><li>no clean area for food preparation</li><li>no supplies to clean or sterilize feeding utensils</li><li>no refrigeration<br /></li></ul><p>Donations of baby foods and breastmilk substitutes in situations such as this is dangerous and can do more harm to the infants than good.<br /></p></div>
  </div>
          <div class="section" id="The_solution_for_the_breastfed_infant"><h2>The solution for the breastfed infant</h2>
    <div>Providing food to the mothers of infants less than a year old, and giving them support to breastfeed their infant is the best way to protect the infant from malnutrition and diseases, and ease the trauma they have experienced.<br /></div>
    <div class="section" id="Some_frequently_asked_questions"><h3>Some frequently asked questions</h3>
      <div>
        <table class="dialogue"><tbody><tr class="speaker0"><th>Question:</th><td> Does a mother lose her milk supply when she is in a stressful situation? </td></tr><tr class="speaker1"><th>Answer:</th><td> Stress will not stop the mother producing milk; however it may delay her milk ejection. If a quiet area can be set aside for mothers to breastfeed, with reassurance and support offered, the suckling of the infant will elicit the milk ejection. </td></tr><tr class="speaker0"><th>Question:</th><td> Won't stress or trauma cause the mother's milk to be unsuitable?</td></tr><tr class="speaker1"><th>Answer:</th><td>The composition of a mother's milk will always be perfect - it is not possible to make 'weak' or 'spoiled' breastmilk.</td></tr><tr class="speaker0"><th>Question:</th><td>Could a mother's milk become contaminated?</td></tr><tr class="speaker1"><th>Answer:</th><td>If the infant is suckling directly from the breast there will be no contamination from infectious organisms in the environment. Even if the mother has diarrhea or other infections acquired as a result of the emergency situation these will not be passed via breastfeeding to her infant.</td></tr></tbody></table>
      </div>
    </div>
  </div>
          <div class="section" id="The_solution_for_the_artificially_fed_infant"><h2>The solution for the artificially fed infant</h2>
    <div>Artificial feeding in these situations is difficult and increases the risk of malnutrition, disease and infant death. The resources required to provide safe nutrition to artificially fed infants may be scarce. They include:<br /><ul><li>an ongoing source of a safe breastmilk substitute, and safe storage for it</li><li>utensils for the preparation of the infant formula, and bottles and teats for feeding<br /></li><li>an ongoing source of clean drinking water</li><li>fuel to heat the water to a safe temperature for formula preparation</li><li>the ability to thoroughly clean all the preparation and feeding utensils</li></ul><p>In crisis affected areas where an imminent end is not in sight, assisting mothers to relactate could be the only solution.<br /></p></div>
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          <div class="section" id="What_can_you_do_to_help_"><h2>What can you do to help?</h2>
    <div>
      <ul>
        <li> Protect, promote and support breastfeeding for all infants for at least the first two years of life, with the addition of suitable complementary foods from six months of age. <span style="font-style: italic;"> Breastfed infants are in a much more secure situation should an emergency strike. <br /> <br /> </span> </li>
        <li> Discourage the public from donating infant formula at these times as it is likely to cause more morbidity than it prevents.<br /><br /></li>
        <li>If you are in a position to, volunteer your services to provide support, encouragement and information to the breastfeeding mothers caught in the emergency; and education to the other relief workers.<br /><br /></li>
        <li>Know how to assist a mother to relactate should it become necessary.<br /><br /></li>
        <li>Discuss with ALL parents emergency preparedness for themselves and their children. Encourage them to have an emergency plan and kit always ready.<br /></li>
      </ul>
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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"><a href="http://www.internationalbreastfeedingjournal.com/content/6/1/16" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><span class="linkDescription">[link: http://www.internationalbreastfeedingjournal.com/content/6/1/16]</span><h3><a href="http://www.internationalbreastfeedingjournal.com/content/6/1/16" target="_blank">Emergency preparations parents can make</a><span class="linkDescription">[link: http://www.internationalbreastfeedingjournal.com/content/6/1/16]</span></h3>
      <div>Click on the icon, save and print the paper, <span style="font-style: italic;">"Emergency preparedness for those who care for infants in developed country contexts"</span>. <br />Read the paper, provide copies of it for your colleagues at your place of work, and discuss how you can ensure that this very important message is given to all parents who access your care.<br /></div>
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                <td class="body"><img src="design/remember.png" class="icon" alt="" /><h3>What should I remember?</h3>
    <div>
      <ul>
        <li>emergency situations are usually unexpected, with little or no time for preparation</li>
        <li>breastfeeding provides the best food security for infants</li>
        <li>artificially fed infants require a lot of care and resources to ensure their safety</li>
        <li>parents are unlikely to be prepared for an emergency if there is not a procedure in place to educate them<br /></li>
      </ul>
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          <div id="footer"><br style="clear: both" /><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 id="top">10.0 Closing session</h1>
          <div>
    <p> Thank you for participating in Breastfeeding Essentials. We hope you have found it thought provoking and interesting, and that it has revitalised your desire to provide the best care for mothers and babies. </p>
    <p class="listTitle">The key points of the course are</p>
    <ul>
      <li>Breastfeeding is important for mother and baby.</li>
      <li>Most mothers and babies can breastfeed.</li>
      <li>Mothers and babies who are not breastfeeding need extra care to be healthy.</li>
      <li>Hospital and community health practices can help <span class="aside">(or hinder)</span> the success of breastfeeding.</li>
      <li>Implementing the Ten Steps to Successful Breastfeeding or the Seven Point Plan to Protect, Promote and Support Breastfeeding helps good practices to happen.</li>
    </ul>
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                <td class="body"><img src="design/remember.png" class="icon" alt="" /><h3>Your certificate.</h3>
    <div>
      <p>
			Have you passed the Assessment Quizzes yet? If you have &ldquo;<q>Congratulations!</q>&rdquo; You can now collect your Certificate and display it at your place of work.
		</p>
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          <div id="footer"><br style="clear: both" /><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>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>
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