Thursday, November 20, 2014

Thank you to all of my visitors over the past years. This blog will be closing in a couple of weeks but all information is available still at
I hope to see you there!

Sunday, January 5, 2014

Breast or Bottle?

We often talk about the benefits of breastfeeding but we should be referring to the disadvantages of artificially feeding – and there are MANY!

Throughout all countries of the world there is a positive correlation between artificial feeding rates and infant mortality and morbidity. The incidence of most acute illnesses increases as the proportion of breast milk intake decreases.

General Health:
Breast milk contains immunological components, such as SIgA, that provide protection for the infant and it also assists with the development of the immune system. It is because artificially fed infants are denied the unique protection of breast milk that they have been shown to have suboptimal health with conditions such as diarrhoea, respiratory tract infections, urinary tract infections and ear infections being significantly higher in formula fed babies.

Breast milk supports the establishment of a harmless anaerobic bifidus flora in the newborn’s gut which aids digestion and inhibits the growth of harmful bacteria. Artificially fed babies are colonised predominantly by enterococci and enterobacteria with Clostridia, Enterococci, Klebsiella and Escherichia coli commonly found in their digestive systems. Formula feeding is one of the key risk factors for necrotizing enterocolitis, an often fatal condition, and appears to be dose related.  

Without doubt, breastfeeding provides protection against Sudden Infant Death Syndrome (SIDS) by mitigating some of the factors implicated in the syndrome. Numerous studies have shown that artificially feeding doubles the risk of SIDS.

Chronic Disease:
Recent research suggests that the risk of chronic diseases such as type I diabetes, coeliac disease, some childhood cancers and inflammatory bowel diseases is increased by the early introduction of artificial milk. It appears that formula feeding also increases the risk of developing type II diabetes in later life. In order to reduce the risk of coeliac disease, which can more than double in artificially fed infants, it is recommended that breastfeeding continues exclusively for six months and also during the months that gluten is introduced to the diet.

Brain and CNS:
The brain of a newborn doubles its size during the first year. Unlike bovine milk, human milk is high in lactose which is needed for optimal brain development and the essential fatty acids in breast milk are proactive in the myelination process of the central nervous system. This is thought to give protection against multiple sclerosis. It has long been acknowledged that artificial feeding contributes to reduced total IQ, reduced verbal IQ and reduced performance IQ.  

Obesity is greatly influenced by the chosen feeding method and is associated with the early introduction of artificial milk, (even while breastfeeding,) and the introduction of solids before six months. Two hormones found in breastmilk, (leptin and insulin,) assist with the maintenance of normal weight.

Cow’s milk is the most common allergen affecting infants. It is the proteins in bovine milk that are the allergen and they affect the lung function of artificially fed babies leading to an increased incidence of asthma and wheezing. Allergic rhinitis and eczema are also more common in artificially fed infants.

Facial development:
Bottle feeding uses completely different facial muscles to breastfeeding and has been found to be associated with a narrowing of the palate with poor teeth spacing; reduced jaw development; altered occlusion; open bite; and posterior cross-bite. The number of dental caries is significantly lower in infants who were exclusively breastfed during the first six months of life.

Artificial milk preparations have been known to become contaminated during the manufacturing process thus exposing the infant to enteropathogens, (such as Enterobacter sakazakii,) and foreign substances. Contamination may also occur during preparation, particularly in countries or situations where potable water is not readily available.

Maternal benefits:
There are many significant maternal benefits associated with exclusive breastfeeding. These commence immediately after the birth with decreased postpartum blood loss, rapid involution of the uterus and thus a reduced risk of infection. Amenorrhea, which usually lasts for about six months, results in a reduced demand for iron and decreased total blood loss making anaemia more prevalent in women who artificially feed.

Exclusive breastfeeding provides a considerable cost saving during the first six months as personal hygiene products, contraceptives and artificial formula are not generally required. Fertility usually returns within six weeks when lactation is supressed.

Weight loss is significantly greater in women who exclusively breastfeed and occurs gradually with about twelve kilograms being shed by six months postpartum.

Insulin required by type 1 diabetics decreases during the period of breastfeeding. The risk of type 2 diabetes is more common in women who did not breastfeed. The longer breastfeeding continues for each pregnancy the greater the benefits. Research conducted by Stuebe (2005) showed that “Women who did not breastfeed one child for a total of one year had a 78% increase in age-adjusted risk for diabetes.” Women with gestational diabetes double their risk of developing postpartum diabetes if they suppress and artificially feed.

Lactation is associated with a reduced risk of breast cancer. Studies of data from thirty countries found that “the longer women breast feed the more they are protected against breast cancer.” In addition, the suspension of ovulation while breastfeeding is thought to positively impact on the risk of ovarian and endometrial cancer.


Saturday, January 4, 2014

Inverted Nipples

Flat and inverted nipples vary from mild to severe and sometimes make latching difficult. Some will respond to stimulation and should not present a problem however a severely retracted nipple will remain inverted even when stimulated. If it is compressed between the thumb and forefinger just behind the base of the nipple it will retract inwards and a thick core will be felt.
Measures can be taken antenatally to improve nipple protractility. A nipple enhancer may be used to stretch the adhesions which limit the outward movement of the nipple. It is best used in the late weeks of pregnancy when the nipples are more likely to respond to stretching due to hormonal changes. The Hoffman Technique may also be utilized. It involves placing a thumb on each side and at the base of the nipple and pushing downwards and outwards to stretch the adhesions. A breast shell, which looks like a donut and applies gentle pressure around the base of the nipple, can be worn inside the bra during pregnancy and prior to breastfeeds. It has mixed success and should not be worn at night.

It is not essential to have a protractile nipple to achieve good milk transfer as the nipple merely acts as a conduit. The breast must be formed well into the baby’s mouth by the mother to achieve a good latch, bearing in mind that it is pressure on the hard palate that stimulates the baby to suck. When latching, support the breast with thumb and fingers on either side then pull back a little to assist the nipple to protrude.
Mechanical means i.e. breast pump, nipple enhancer or modified 10ml or 20ml disposable syringes can sometimes be used to draw the nipple out immediately prior to feeding.  The brief application of something cold on the nipple may also help to encourage protractility. Stimulation of the nipple by rolling it between thumb and finger or gently stroking it may also help. It is very important to initiate breastfeeding immediately after birth and to avoid the use of bottles and dummies to avoid a preference for these developing.

Nipple shields may be of some benefit once the milk supply is established but should not be used until there is a good flow of milk. Given time, many inverted nipples elongate and the adhesions loosen. Protractility improves with successive pregnancies and lactations so it is important to attempt breastfeeding even if unsuccessful previously.

Nipple Shields

Nipple shields may be used as a short term solution to damaged, flat or inverted nipples after all other options have been exhausted. Unfortunately they have the potential to reduce milk transfer, reduce breast stimulation and create a habit as the baby becomes used to the feel of the shield and becomes reluctant to breastfeed without it.
It has been shown that the use of nipple shields is associated with premature weaning. For this reason every attempt must be made to correct the underlying problems and resume direct breastfeeding as soon as possible. Expressing after feeds will protect the milk supply, should it begin to decline. Supply and demand will ensure that if you remove adequate milk for your baby at each feeding session and you feed regularly, your supply will be maintained.
The chosen shield should be made of thin silicone, not latex, and may have cut-out sections top and bottom to permit the baby’s nose and chin to come into contact with the breast. The shield should fit comfortably over your nipple to avoid chaffing while in use. They come in small 16mm, medium 20mm and large 24mm sizes. Shields with a number of holes in the tip allow milk to flow better than those with only one. Ensure that the shield is no longer than the baby’s mouth – measured from the lips to the junction of the hard and soft palates.
Moistening the areola before application of the shield may assist the shield to remain stable. Position the shield according to the chosen feeding position so that the baby’s nose and chin will sit in the cut-out areas, if applicable and centre the shield over the nipple. Stretch the shield before placing it on the nipple so that the shield pulls the nipple and some of the areola into the chamber. Fold the edges down firmly against the breast and hold them in place with your fingers. Some mothers like to express some milk into the shield so that it is readily available for the baby as soon as sucking commences.
The next, crucial step is to ensure that the baby is deeply latched over the shield to the breast. If baby is only sucking on the shaft of the nipple shield that is not breastfeeding and milk transfer will be inadequate. A wide “Special K” gape with the lower gum contacting the breast first, well away from the base of the nipple, followed by a deep latch, is essential. Look for rhythmic sucking and listen for swallowing to ensure that milk transfer is taking place. Milk should be visible in the shield when baby detaches. Be aware that the feed may take longer while using a shield.
As soon as appropriate try removing the shield once baby is sucking vigorously and then re-attach directly to the breast. If the baby refuses to suck, replace the shield and try again at the next feed. Experiment - try feeding/removing the shield when baby is sleepy, full or hungry. It is possible to feed successfully long term with a shield but deep latching is essential and some expressing may be required if the milk supply begins to wane. Ensure that baby is gaining weight as anticipated.

Monday, August 19, 2013


Mastitis is a fairly common but preventable complication of lactation. It is an inflammatory process that usually occurs in the first two to four weeks postpartum or due to sudden weaning. It can progress to the development of abscesses requiring needle aspiration or surgical intervention; the need for antibiotics; and often, early weaning due to the associated pain. The most common causative organism is Staphylococcus aureus which can enter through broken skin.
The common signs and symptoms include:
  • Decreases in milk volume due to diminished lactose levels 
  • Breast refusal due to increased sodium and chloride levels in the milk 
  • A break in the skin i.e. nipple damage
  • Stinging pain in the nipple when feeding and afterwards
  • A nipple wound that won’t heal with crusting yellow to red exudate
  • The breast will appear swollen, red, warm and sore
  • Flu-like symptoms including chills, headache and a rapid pulse
  • Fever above 38 degrees
  • Red streaks extending towards the axilla
The causes include:
  • Milk stasis due to severe, prolonged engorgement
  • Infrequent or inadequate emptying of breasts 
  • Practice early, frequent breast feeding
  • Ensure that baby has a deep latch and is removing milk efficiently
  • Empty one breast before offering the second
  • Follow twenty-four hour rooming together to promote frequent feeding
  • Clear blocked ducts by heat, massage and breast compression during feeding/expressing
  • Express regularly if baby not feeding effectively
  • Ensure that milk continues to be removed while breasts are engorged
  • Avoid the use of dummies
  • Watch for early indications of mastitis
  • Avoid sudden weaning
  • Seek assistance with breastfeeding if early signs of mastitis appear
  • Practice good hand hygiene before handling breasts
  • Broken skin may be cleaned with a saline solution
  • Continue to breast feed from both breasts
  • Begin each feed on the affected side 
  • Ensure that the latch is deep and efficient
  • Warm water immersion for comfort prior to feeding
  • Feeding in the hands-and-knees position
  • Analgesics and anti-inflammatories
  • Cold packs after feeds for about twenty minutes
  • If no improvement after twenty-four hours antibiotics will probably be required
Breast abscesses:
Breast abscesses may result as a complication of poorly managed mastitis. A well defined and usually painful area of swelling will be observed at the site of the abscess. It is important that regular and effective breastfeeding or expressing for the baby continue. Weaning at this time should be avoided and the milk is quite safe to feed.  Your doctor will arrange for needle aspiration or surgical drainage of the abscess  and prescribe appropriate antibiotics.



Saturday, June 1, 2013


Hypoplasia is the term used to describe restricted breast development. The majority of women with hypoplasia report no breast growth during pregnancy and experience primary lactation insufficiency. The breasts may appear tubular and have areolar enlargement. The deformity may be asymmetrical. A wide inter-mammary space (3.75cm or greater between the breasts) is indicative of hypoplasia. There are four types:

Type 1: Round breasts, normal lower medial and lower lateral quadrants
Type 2: Hypoplasia of the lower medial quadrant
Type 3: Hypoplasia of the lower medial and lower lateral quadrants
Type 4: Severe constrictions, minimal breast base

Almost all women with hypoplasia will have inadequate milk supply for their infant during the first week postpartum. Many are unable to produce sufficient milk to meet their infants' needs by the end of the first month. This is particularly so with type 3 and 4 breasts.
The delayed onset of milk production may be stimulated by the use of a galactagogue and by ensuring complete breast drainage by expressing after each feed. This may be required for an extended period of time i.e. a month or more. Milk supplements may be required and close follow-up after discharge will be essential to ensure baby gains weight and is well hydrated. The signs and symptoms of neonatal dehydration should be clearly understood and assistance sought if output is insufficient (refer to Input and Output of the Newborn). Emotional support will also be beneficial as feelings of inadequacy are common.

Saturday, April 20, 2013

Informed Consent and Induction of Labour

It is freely acknowledged that the rate of intervention in childbirth is on the rise. The so-called “Intervention Cascade” commences with the decision to consent to the induction of labour but is it always informed consent? In Queensland, in 2010, only 27.1% of women who were induced reported having made an informed decision.[i]

While induction is appropriate in some cases it is very often resorted to in order to overcome time constraints, staffing limitations overnight and for social reasons. Induction usually involves the use of Dinoprostone to soften the cervix, artificial rupture of the membranes (amniotomy) and an oxytocic infusion to stimulate contractions. These are serious interventions and should never be assented to without a sound understanding of the possible consequences for mother and baby.

Information regarding induction must be offered in such a way as not to exploit the woman’s vulnerability or take advantage of the power imbalance represented in the health care provider/client relationship. It must never be assumed that consent will be given but when given it must be given voluntarily and founded on evidence based information, presented thoroughly and empathetically. Opportunity must always be given for questions to be asked and when appropriate, other options must be offered. Time should be given for decision-making. Plans must be put in place for management should the induction fail. Once made, the woman’s decision should be supported by the entire medical team.

Information concerning induction must be tailored to each woman’s needs. It must be culturally appropriate, objective and address both the benefits and the disadvantages of the intervention. It is not sufficient to say “this will speed your labour” without also mentioning other effects:

·         There will be a need for intravenous infusion and continuous monitoring

·         The ability to mobilise freely will be lost

·         There will be little amniotic fluid to buffer the baby during contractions

·         Labour will usually be more painful than spontaneous labour

·         An epidural may be required

·         If an epidural is required a urinary catheter will be inserted

·         Due to the epidural, assisted delivery will be more likely

·         Surgical delivery will be more probable

·         Breastfeeding initiation may be impaired

Indications for induction:

·         Pregnancy at 41 completed weeks

·         Diabetes

·         Hypertension

·         Intra Uterine Growth Restriction

·         Maternal or fetal ill health

·         Cholestasis of pregnancy

·         Premature rupture of membranes after 34 weeks

·         Rupture of membranes at term (>37 weeks) and after 24 hours

·         Maternal request at or after 40 weeks (NICE guidelines)

Prior to offering induction it is essential to confirm dates. An irregular cycle (other than 28 days) may distort the calculation of the due date.  All available data should be reassessed. A vaginal examination should be performed and a Bishop’s Score calculated as a guide to determine the success or otherwise of an induction. A score over eight suggests that spontaneous labour is probable while a score under five indicates that the cervix is unfavourable. Induction should not be performed unless the score is seven or higher.

Surgical Intervention:
As indicated above, induction of labour is more likely to lead to assisted or surgical delivery than spontaneous labour. Should the labour fail to progress a Lower Uterine Segment Caesarean Section would usually be performed. Adverse effects associated with operative delivery include:

·         Infection of the wound, pelvis, infusion site or urinary tract

·         Uncontrolled bleeding at the surgical site requiring return to theatre

·         Deep vein thrombosis

·         Excessive vaginal bleeding

·         Adhesions requiring later surgery

·         Heart and lung complications

·         Confined to bed following surgery

·         Poor breast feeding initiation

·         Need for opioid and other analgesia

·         Delayed return to normal role

A spinal anaesthetic is usually administered prior to surgery. The common side effects of this form of anaesthetic include:

·         Nausea, vomiting, itching and shivering

·         Hypotension

·         Post spinal headache

·         Pain and/or bruising at the injection site

·         Ineffective spinal anaesthetic requiring a general anaesthetic

·         Dysuria

Further information on consent is available on the Queensland Health web site:





[i] Miller Y, Thompson R, Porter J, Prosser S. Findings from the having a baby in Queensland survey, 2010. Queensland Centre for Mothers and Babies, the University of Queensland. 2011.