<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" lang="en" xml:lang="en">
<!--Generated at Tue, 28 Feb 2012 22:38:33 +1100 HEXML processor version: 2642-->
  <head>
    <meta name="author" content="Denise Fisher" />
    <meta name="course" content="ES01" />
    <meta name="topic" content="8.1" />
    <meta http-equiv="content-type" content="text/html; charset=utf-8" />
    <meta name="copyright" content="2012 Health e-Learning" />
    <meta name="robots" content="NONE,NOARCHIVE" />
    <meta name="cache-control" content="NO-CACHE" />
    <link rel="stylesheet" href="design/hexml.pack.css?v=1330429113" type="text/css" />
    <script type="text/javascript" src="design/hexml.pack.js?v=1330429113"></script>
    <title>Engorgement</title>
  </head>
  <body>
    <div id="access">
      <a href="#access" accesskey="a">Access Keys</a>
      <a href="#menu" accesskey="m">Skip to Menu</a>
      <a href="#content" accesskey="c">Skip to Content</a>
      <a href="#footer" accesskey="f">Skip to Footer</a>
    </div>
    <div id="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>
    </td><td class="middleright" 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">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>
        </div>
      </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>
    </td><td class="middleright" 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><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>
    </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 8.1</h3>
              <p>Complete Activity 8.1 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="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>
    </td><td class="middleright" 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><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>
    </td><td class="middleright" 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 8.2</h3>
              <p>Complete Activity 8.2 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"><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>
    </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="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>
    </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/41-reverse-pressure-softening" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening" target="_blank">Read this excellent practical article</a></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> </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">
<script type="text/javascript">
/* <![CDATA[ */
var rfqs = {settings : {type : 'mcq'}, questions : [
	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}])
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('rf');</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#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"><a href="topic_8-0.html" rel="prev" class="prev">&laquo; Previous</a><a href="topic_8-2.html" rel="next" class="next">Next &raquo;</a><br style="clear: both" /><a href="#top" id="topLink">Back to top</a><a href="javascript: window.print()" id="printLink">Print this page</a><span class="noPrint"> | </span>&copy; 2012 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
    </div>
    <div id="menu">
      <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 class="current">8.1 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
      </ol>
    </div>
  </body>
</html>
    </ol>
    </div>
  </body>
</html>
