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15 minute on breastfeeding

Fifteen-minute consultation on the
healthy child: breast feeding
F Cleugh,1 A Langseth2
Paediatric Emergency
Department, St Mary’s Hospital,
Imperial College NHS Healthcare
Trust, London, UK
Department of Paediatrics,
Imperial College Healthcare NHS
Trust, London, UK
Correspondence to
Dr F Cleugh, Paediatric
Emergency Department, St
Mary’s Hospital, Imperial College
NHS Healthcare Trust, Praed
Street, London W2 1NY, UK;
[email protected]
Received 23 June 2016
Revised 4 July 2016
Accepted 5 July 2016
Published Online First
28 July 2016
Despite extensive evidence about the benefits of
breast feeding for both infants and mothers,
breastfeeding rates in the UK remain low. Most
infants presenting with feeding issues are
otherwise well but are often over diagnosed with
clinical conditions such as maternal milk
insufficiency, cow’s milk intolerance or reflux.
With simple advice and troubleshooting common
problems, all child health professionals can
support mothers to establish and continue breast
feeding exclusively for longer.
A 6-day-old term infant is brought to accident and emergency department (A&E). His
mother reports he is unsettled, crying a lot
and is struggling to breast feed. She is concerned that he has lost weight and is
finding the situation stressful. She is keen
to breast feed but is finding it difficult.
How will you manage this family? What
is the best advice to give them about
feeding and what symptom and signs
should alert you to underlying conditions
that need investigation or treatment?
Breast feeding can be a challenging skill
to learn at a time when many mothers
are vulnerable and exhausted in the post
delivery period. In short, what nature
intended can be surprisingly difficult to
achieve. The most recent UK survey
showed though 69% of mothers initiated
exclusive breast feeding, by 1 week this
had fallen to less than a half and less than
a quarter by 6 weeks, and only 1% at 6
months.1 In this article, we consider the
environmental, maternal and infant
factors that can have an impact on establishing successful breast feeding, and
what we as clinicians need to know to
support breastfeeding mothers.
To cite: Cleugh F,
Langseth A. Arch Dis Child
Educ Pract Ed 2017;102:8–
First time mothers and mothers with
no previous experience can find the
technique and pattern of breast feeding
difficult to establish. Evidence shows
early skin-to-skin contact facilitates successful breast feeding by allowing the
baby to root and latch and stimulating
maternal oxytocin release. Maternal oxytocin causes breast myoepithelial cells to
contract, causing milk to be ejected
towards the nipple in the ‘let down’
reflex.2 3 Anything that causes the
mother to be separated from the baby in
those early days including admission to
the postnatal unit can impede this early
process. Sometimes separation is unavoidable but we should be cognisant of
the importance of maternal contact and
that we as clinicians do our best to facilitate it.
Breastfed infants are fed by their
mothers responsively, that is, the mother
responds to her infant’s needs for food
exhibited by signs such as fist sucking,
tongue protrusion and moving their head
from side to side. This was previously
described as ‘on demand’. Each infant
will have a varying pattern. If this is the
mother’s first baby, she may be letting
him sleep through the night because she
is not aware that she should wake him to
feed. In fact, her prolactin levels, the
hormone responsible for milk production
within the alveoli of the breast, are
highest at night, making night feeds an
important part of establishing breast
feeding by optimising milk production.3
This early period is also the ideal time
to advise on the basics of breast feeding
and trouble shoot any potential problems
with regard to latch as outlined in box 1.
A useful tool is UNICEF breastfeeding
assessment tool.4 5 In a recent study, physicians were found to give both scant and
contradictory advice regarding breast
feeding6 and, in this type of environment, it is easy for breastfeeding myths to
take hold. Below, we highlight some of
the more common ones.
Cleugh F, Langseth A. Arch Dis Child Educ Pract Ed 2017;102:8–13. doi:10.1136/archdischild-2016-311456
Best practice
Box 1 Breastfeeding basics—A useful guide with helpful images that you can download for yourself and the
family is UNICEF UK ‘Off to the Best Start’7
Correct mode of attachment
1. Position infant nose to nipple with their head in line with their body.
2. Support the infant’s head but allow room for them to tilt their head back as they take the nipple into the back of their
3. Stimulate the infant’s lip to elicit the rooting reflex. This causes them to open their mouth widely.
4. Their head then tilts back and the nipple points to the roof of the mouth as it enters.
5. The infant’s tongue will protrude over their bottom gum, their chin leading towards the breast, as a large mouthful of
breast tissue is taken into the mouth.
Signs of good attachment
Infant’s chin is close to breast, indenting it, the lower lip is well below the base of the nipple and curls out with full
cheeks demonstrating mouth is full of breast tissue. More of the areola will be seen above their top lip. Their nose is
usually not touching the breast.
Sucking during a feed
The infant will begin with short rapid sucks to stimulate the oxytocin reflex causing milk to flow. This is followed by long
rhythmic sucks during active feeding with swallowing between every few sucks. One or two sucks between swallowing
suggests sufficient milk being taken into infant’s mouth. More sucks suggest less milk and less effective feeding. Towards
end of the feed, the infant flutter sucks as they take in the lower volume fat-rich milk or hind milk.
Signs of effective feeding for the infant include full and rounded cheeks, slow rhythmic jaw movements and hearing
gentle swallows every 1–3 sucks. The mother will feel softening or emptying of her breast and sometimes a tingling of
the let down reflex. She will note an elongated nipple at the end of the feed, but ideally this should not be painful.
Patterns of feeds
Breastfed infants should be allowed to feed responsively and if so, will feed a minimum of 7–8 times per 24 hours for
5–30 min. Feeds may be clustered close to each other, or spread out. Both breasts should be offered. An infant will feed
to appetite and hormone feedback loops trigger the right amount of milk production for their needs.
Signs of effective feeds
Consistent effective feeding is evident by a settled infant that stirs as they approach the next feed. In the first 3 days as
lactation is established and lower volume colostrum is consumed, infants will pass urine approximately three times per
day. Once feeding is established by day 5, they will produce 5 or 6 wet nappies a day. It is not uncommon to see orange
residue consistent with urate crystals in the infant’s nappy in the first days of life. The infant’s stool transitions from meconium over the first few days, to a soft yellow seedy stool by day 4. A well breastfed infant will produce approximately two
stools, the size of a two pound coin per day. It is later on, after approximately 6 weeks that stools can become less frequent, with some well and thriving breastfed babies passing stool once up to every 10 days.
Nipple confusion
This is the idea that a baby will become confused if
they are fed with an artificial nipple and will not go
back to feeding at the breast. It is important to reassure
mothers that even if supplemental feeds have to be
given for a medical indication and have been given by
bottle they will be able to continue breast feeding if
they continue to maintain their lactation by expressing
and have support for positioning and attachment.
Never wake a sleeping baby
It is not unusual to have to wake a newborn baby to
feed. New born babies need to feed 7–8 times in
24hrs, this works out at about once every three hours
although babies will often cluster feed for a few hours
every 24 hours having short, frequent feeds which
often occur at a similar time each day/night followed
by a longer sleep. Parents should be reassured that this
is normal behaviour. Some babies will be more sleepy
than others, and if they are having less than 7 feeds in
24hrs it is important to encourage mothers to be
aware of how often their baby has fed and to gently
wake them for a feed by; holding them, talking to
them, putting them near the breast, undressing them
or changing their nappy to help them to wake.
Mothers should use both breasts at every feed
Often a baby is happy with one breast—it is important
to let a baby feed on one breast until it receives the
hind milk (the milk that a baby gets towards the end
of a feed). Hind milk has a higher fat content and is
important for a baby’s growth and feeling of satiety
post feed.
Babies should not feed from bleeding nipples
If a mother has cracked nipples, it is not uncommon
for her to have a little bit of blood coming from the
Cleugh F, Langseth A. Arch Dis Child Educ Pract Ed 2017;102:8–13. doi:10.1136/archdischild-2016-311456
Best practice
nipple. This is entirely safe for the baby to ingest.
Blood is an irritant to the stomach lining so it may
cause the baby to be more inclined to vomit, but this
is not harmful in itself. If a mother is breast feeding
on a cracked nipple, it is important to warn her that
the baby may have a blood tinged or brownish vomit
so that she does not become panicked when it occurs.
Why breast milk is best3
▸ Breast milk is a dynamic bioactive substance that
varies with each feed, providing key nutrients for
growth and development that research continues to
demonstrate has short-term and long-term benefits
for infants way into adult life.
▸ Immunological agents confer protection against
common pathogens, reducing infant morbidity from
gastrointestinal and respiratory infections.
▸ Long-term benefits include reduced obesity, diabetes
and higher IQ.
▸ Maternal benefits of breast feeding include reduced
risk of breast and ovarian cancer.
Mothers should not breast feed if they are on medication
There are very few medications that a mother will
take that precludes her from breast feeding. If a
mother is using or dependent on illicit drugs breast
feeding is not advised. Also, if a mother is being prescribed chemotherapy, especially antimetabolites that
interfere with DNA replication and cell division,
breast feeding should be avoided. Other psychotropic
drugs may need to be avoided. Importantly, if medication is needed in breast feeding the safest drug should
always be chosen. Mothers dependant on medication
should be identified prior to delivery and a multidisciplinary approach including a feeding plan for the
baby should be agreed.
Mothers should not breast feed if they are unwell
If a mother is unwell she can continue breast feeding
and the breast milk will be protective. This includes if
the mother has a respiratory infection or a gastroenteritis. A mother can also feed a baby on a breast that
has mastitis, and it is often the process of the baby
sucking on the breast which relieves engorgement and
blocked ducts and allow the mastitis to resolve.
(In certain circumstances such as maternal infection
with HIV, active untreated tuberculosis and human
T-cell lymphotropic virus type I or II you will be
advised to avoid breast feeding. If these mothers are
diagnosed at the time of birth there should be a birth
plan for the baby that includes feeding advice).
Maternal factors can have a significant impact on
breast feeding, and a meticulous maternal history is
essential. If a mother breast fed previously, what was
this experience like and how long did she feed for?
Mothers who have previously breast fed may be more
adept at identifying the current problem, while this
may be more difficult for a woman with no experience of breast feeding, requiring a more thorough
exploration of the issues.
Maternal stress and fatigue can have a significant
impact on breast milk production by stimulating
Table 1 Maternal complications affecting breast feeding and how to manage them
Painful, swollen, oedematous breast secondary to milk stasis.
Emptying of milk from breast, preferably through feeding, or
expressing if feeding is not possible, applying cold compresses in
between feeds may provide comfort, and warming and massaging
breasts prior to feeding/expressing in a warm shower or bath will
enable milk flow if engorgement is severe.
Blocked duct
Localised tenderness, swelling and inflammation secondary to
milk stasis due to blockage of a duct.
Emptying of milk from breast preferably through feeding. Useful to
massage area of tenderness, which indicates location of blocked duct
—this will facilitate drainage. Often thickened milk will pass followed
by a stream of milk—this will cause prompt relief of symptoms.
Flu-like illness accompanied by temperature and aches and pains.
This will follow engorgement of the breast—unilateral or
bilateral. It is secondary to milk stasis and is initially
non-infective but can be complicated by secondary infection if
milk is not passed.
Emptying of the breasts is the most effective treatment—through
feeding and expressing. It is safe for baby to continue feeding on the
engorged breast. If secondary infection is suspected, ie the symptoms
do not settle 24 hours after emptying the breast—consider
penicillinase-resistant antibiotics, ie flucloxacillin. Warm compresses
and NSAIDs can aid in symptom relief.
Occurs when a blocked duct is not relieved and secondary
infection forms an abscess.
An abscess needs to be surgically drained and treated with a
penicillinase-resistant antibiotic.
Painful during feeds. May bleed.
If the infant is feeding on the breast they may swallow some
blood. This is a common cause of bloody vomits in infants, but
is not harmful to the infant.
NSAID, non-steroidal anti-inflammatory drug.
Needs time to heal—feed on the breast as tolerated. Expressing may
give some relief, but emptying of milk from breast must be
maintained to avoid engorgement and possible mastitis. Check the
breastfeeding basics, as poor attachment may exacerbate symptoms.
Cleugh F, Langseth A. Arch Dis Child Educ Pract Ed 2017;102:8–13. doi:10.1136/archdischild-2016-311456
Best practice
Table 2 Conditions of the infant’s mouth that can affect breast feeding
Localised infection of candida which may affect maternal
nipple and infant’s mouth. May present with pain in the
nipple on feeding and white curd like coating on infant’s
tongue. The tongue of the infant, like the maternal nipple,
may be painful. This will exacerbate difficulty feeding.
Topical treatments include nystatin and miconazole with
systemic fluconazole reserved for infection resistant to
topical treatment.
To avoid reinfection ensure any teats, dummies, nipple
shields are sterilised, change breast pads frequently and
wash bras in hot wash.
Anatomical restrictions to
feeding (ie cleft palate or
Submucous cleft palate may be missed on neonatal check
and may cause difficulty feeding.
A small chin may also make it difficult to latch
appropriately and may cause difficulty feeding.
A cleft palate will need referral to cleft team—for help
with feeding and eventual closure.
For some infants this will resolve as they grow, but support
from the lactation team will be needed. Those infants with
more significant anomalies will need referral to a paediatric
specialist and will often require multidisciplinary
Tongue tie (ankyloglossia)
Associated with a short and or tight lingual frenulum. May
inhibit tongue movement and cause difficulty feeding in
some infants (although approximately 50% of babies with
ankyloglossia will feed without difficulty).9
If there is significantly impaired feeding, frenotomy may be
performed. Frenotomy is a low-risk, minor procedure which
can be performed without anaesthetic in infants. Mothers
have described better feeding post procedure but placebo
effect is difficult to quantify.8 9 Be aware of your local
unit’s policy with regard to performing frenotomy.
dopamine and norepinephrine release, which can have
an inhibitory effect on prolactin synthesis, thus hindering lactation. Significant peripartum blood loss,
anaemia and dehydration can also reduce milk production.3 Genuine, insufficient breast milk supply is
rare, and with good input from a lactation consultant,
midwife or specialist health visitor, most women will
be able to produce adequate breast milk for growth,
so refer early when these issues arise.
It is important to remember that an adequate milk
supply may eventually diminish if the appropriate
technique is not established. Prolactin and oxytocin
are released in response to stimulation at the nipple
by the baby sucking. Further control of lactation is
influenced by the ‘feedback inhibitor of lactation’ or
FIL. This polypeptide exercises local control over the
breast, inhibiting synthesis when existing milk is not
removed. This helps to avoid the complications of the
breast becoming too full and allows the supply to
reflect the demand once breast feeding is established.3
Difficulty with latch and attachment reduces FIL
action, making the mother more prone to a host of
complications including engorgement, blocked ducts,
mastitis, breast abscess and cracked nipples. These
conditions, outlined in table 1, can be painful and
exacerbate any difficulties already present, making
early treatment important for the continuation of successful breast feeding.
Poor feeding can be a presenting symptom in an unwell
baby, so a doctor’s initial objective should be to assess
alertness, state (irritability), hydration and skin colour.
This initial assessment should include heart rate, respiratory rate, temperature and capillary refill time. Poor
feeding and irritability associated with abnormal signs
should prompt you to rule out serious pathology such as
sepsis, severe hyperbilirubinaemia, respiratory compromise, cardiac conditions and metabolic disorders. If
there are symptoms and signs that cause concern, immediate resuscitation and appropriate management should
commence by a specialist team.
Once reassured that the infant is not in need of any
immediate intervention, a more leisurely examination
can commence. Particular attention should be paid to
the mouth to rule out conditions that can impede
feeding including thrush, cleft palate, micrognathia
and tongue tie, as outlined in table 2.8–10 A thorough
examination of the baby’s neurology including the
ability to suck should also be performed, as children
with neurological or genetic anomalies may often
present with poor feeding.
Most infants lose weight in the first week, but regain
it by 2 weeks. Those born at less than 37 weeks gestation may take 3 weeks to regain their birth weight. On
average, there is a 7% weight loss.11 For infants who
have lost less than <10%, assessing breast feeding and
supporting the family are usually all that is needed.
Refer the family to the community midwife or health
visiting team to continue the support at home.
For those infants who have lost more than 10%,
assessment should be made by a paediatric specialist
to rule out underlying causative pathology. It is
important to check sodium levels, as these babies are
at risk of hypernatraemic dehydration and bilirubin if
they look jaundiced. Most children will get a degree
of physiological jaundice in the first days of life as
haemolysis occurs and the immaturity of the liver
enzymes impedes excretion of the bilirubin through
Cleugh F, Langseth A. Arch Dis Child Educ Pract Ed 2017;102:8–13. doi:10.1136/archdischild-2016-311456
Best practice
the liver. As levels of unconjugated bilirubin rise, lethargy and poor feeding become exacerbated. Part of a
doctor’s assessment of a poorly feeding baby includes
plotting their bilirubin on standardised charts appropriate for their gestational age and day of life, and
treating with phototherapy if levels reach treatment
threshold.12 If the infant has very high bilirubin levels
—other causes such as sepsis and blood group incompatibility should be considered. If the infant is otherwise well, and bilirubin and sodium are within
acceptable parameters, trouble shooting the basics of
breast feeding with careful consideration of any maternal issues can identify problems that may be rectified
with sufficient support. Early involvement of the
breast feeding team is key, admitting the infant to the
postnatal ward if necessary, or following them up in
an ambulatory environment.
Box 2
Tools for soothing the unsettled infant
The 5 S’s:14
▸ Swaddling—with infant’s hands up to face for
▸ Side lying—infant held by parent lying on their side
▸ Shushing—make calm shushing noises
▸ Swinging—gentle rocking in parent’s arm
▸ Sucking—on breast or hands, but avoiding dummy
Other tools:
▸ Skin-to-skin contact with parent
▸ Massage infant’s tummy in gentle clockwise motion
with organic sunflower oil, following anatomy of large
▸ Bicycle action with infant’s legs
▸ Warm bath
▸ Put down in safe place and leave room for few
minutes to clear head and seek support from family
Summary points
▸ Despite extensive evidence about the benefits of
breast feeding for both infants and mothers, breastfeeding rates in UK remain low.
▸ Most infants presenting with feeding issues are
otherwise well but are often over diagnosed with
clinical conditions such as maternal milk insufficiency, cow’s milk intolerance or reflux.
▸ With simple advice and troubleshooting common problems, all child health professionals can support
mothers to establish and continue breast feeding
exclusively for longer.
Test your knowledge
1. In UK, the rates of exclusive breast feeding at
6 months are:
A. 10%
B. 7%
C. 25%
D. 1%
E. 3%
2. Signs of good attachment and effective feeding
include: (select all that apply)
A. Infant’s lower lip is well below the base of the
mother’s nipple with more of areola seen above
their top lip
B. Infant’s cheeks are sucked in
C. One or two long rhythmic sucks between
D. Softening of breasts
E. Pain in mother’s nipple
3. With regard to hormonal control of lactation, which of
the following is correct?
A. Prolactin stimulates myoepithelial cell contraction
causing milk ejection along lactiferous ducts to the
B. Skin-to-skin contact stimulates oxytocin release
facilitating lactation
C. Maternal prolactin levels are higher at night
D. Issues with the infant’s attachment reduce FIL
action, increasing complications such as mastitis
E. Maternal stress triggers dopamine and norepinephrine release which has an inhibitory effect on prolactin synthesis
4. The average weight loss in a breastfeeding term infant
in the first week of life is
A. 10%
B. 7%
C. 25%
D. 1%
E. 3%
5. Which of the following are true?
A. Breastfed infants should be allowed to feed
responsively to cues such as fist sucking, tongue
protrusion and moving their head form side to side
B. The otherwise well unsettled baby is likely to have
an underlying condition such as reflux or cow’s
milk protein intolerance requiring treatment
C. Breast milk jaundice is an indication to stop breast
D. The most effective treatment for mastitis is emptying of the breast via feeding
E. Bloody vomit in breastfed infants is not uncommon, usually caused by cracked nipples
The answers are after the references.
Cleugh F, Langseth A. Arch Dis Child Educ Pract Ed 2017;102:8–13. doi:10.1136/archdischild-2016-311456
Best practice
After the baby has regained their birth weight, they
should continue to gain weight at the rate of 200–215 g
a week until 3 months of age, or ‘an ounce a day, except
on Sunday’.
The assessment of a poorly feeding baby is challenging, normally requiring a multidisciplinary approach.
The entire assessment is one that can be filled with
emotion, a tired mother who may be fragile, sometimes an equally tired partner and occasionally a few
grandparents with strong opinions thrown into the
mix. Listening carefully and performing a thorough
examination of the child will help to build trust and
guide further treatment. All babies with poor weight
gain will require follow-up. The reason for the poor
weight gain may not always be evident during that
first consultation. Often the consultation is not about
diagnosis and treatment but about offering support
and thoughtful follow-up. If the patient is assessed in
the busy environment of A&E and admission is not
indicated, it is appropriate for the baby to be followed
in the community. As the mother gains confidence
and better technique, the baby will usually start to
gain weight. If this does not happen, the baby should
be linked to the appropriate services and can be
referred for further treatment or investigations.
The unsettled, but well infant
Remember an unsettled infant is very stressful for
parents. Be empathic and acknowledge this, taking
time to allay concerns about underlying causes.
Troubleshooting the basics of breast feeding may
provide a simple solution, as an unsettled baby may
just be hungry with a poor latch. Use the tools in box
1 and UNICEF UK’s assessment and ‘off to the best
start’ resources.5 7
The tendency for health professionals is to over
medicalise these infants and diagnose an underlying
condition. Most commonly these include cow’s milk
protein intolerance and gastro-oesophageal reflux.
Careful history and examination should be undertaken
to determine if these are a possible cause, seeking
advice from a senior paediatric specialist if unsure.
If no clinical or feeding issues are identified on
troubleshooting, infantile colic is often attributed as a
diagnosis. However, cause for excessive crying in an
otherwise well infant is poorly understood. The key is
working with parents to support them through this
trying period.13
You can suggest some tools such as in box 2 and
refer to the health visiting team for ongoing support
in the community as well as breastfeeding support
groups local to the family.
Correction notice This paper has been amended since it was
published Online First. In the section of the article titled
‘Common myths and misconceptions’ the paragraphs under
‘Nipple confusion’ have been amended.
Twitter Follow Francesca Cleugh at @FranCleugh
Acknowledgements We thank the breastfeeding team at
Imperial College Healthcare NHS Trust—Ellie Matthews
(lactation consultant), Anna Conrad (specialist dietician), Kristy
O’Connor (speech and language therapist) and Annie Aloysius
(speech and language therapist).
Competing interests None declared.
Provenance and peer review Commissioned; internally peer
1 McAndrew F, Thompson J, Fellows L, et al. Infant feeding survey
2010. Leeds: Health and Social Care Information Centre, 2012.
2 Moore ER, Anderson GC, Bergman N, et al. Early skin-to-skin
contact for mothers and their healthy newborn infants.
Cochrane Database Syst Rev 2012.
3 WHO. Infant andYoung Child Feeding. Model Chapter for
Textbooks for Medical Students and Allied Health Professionals.
2009. http://www.who.int/maternal_child_adolescent/
documents/9789241597494/en/ (accessed online June 2015).
4 UNICEF UK. The Baby Friendly Initiative. http://www.unicef.
org.uk/babyfriendly/ (accessed Jun 2015).
5 UNICEF UK. http://www.unicef.org.uk/BabyFriendly/Resources/
Breastfeeding-assessment-form/ (accessed online Jul 2015).
6 Eisenberg SR, Bair-Merritt MH, Colson ER, et al. Maternal
report of advice received for infant care. Pediatrics 2015;136:
7 Department of Health. Off to the Best Start Leaflet. 2011. http://
PublicationsPolicyAndGuidance/DH_125826 (accessed Jul 2015).
8 Hall DMB, Renfrew MJ. Tongue tie. Arch Dis Child
9 Power RF, Murphy JF. Tongue-tie and frenotomy in infants
with breastfeeding difficulties: achieving a balance. Arch Dis
Child 2015;100:489–94.
10 Bowley DM, Arul GS. Fifteen-minute consultation: the infant
with a tongue tie. Arch Dis Child Educ Pract Ed
11 Noel-Weiss J, Courant G, Woodend AK. Physiological weight
loss in the breastfed neonate: a systematic review. Open Med
12 NICE. Neonatal jaundice. Treatment threshold graphs. 2010.
cg98-neonatal-jaundice-treatment-threshold-graphs (accessed
Aug 2015).
13 McKenzie SA. Fifteen-minute consultation: troublesome crying
in infancy. Arch Dis Child Educ Pract Ed 2013;98:209–11.
14 Karp H. 2002. http://www.happiestbaby.com/
the-five-s-way-to-calm-a-fussy-baby/ (accessed Aug 2015).
Answers to the multiple choice questions
A, C, D
B, C, D, E
A, D, E
Cleugh F, Langseth A. Arch Dis Child Educ Pract Ed 2017;102:8–13. doi:10.1136/archdischild-2016-311456