A Comparison of the Effectiveness of Two Methods of Nipple Care

ABSTRACT: This study compared the effectiveness of the application of expressed breastmilk or colostrum with that of hydrous lanolin to women's nipples after breastfeeding for prevention or reduction of nipple pain and trauma during the first 10 post-partum days. Each of the 23 subjects was her own control, applying lanolin to one nipple and expressed breastmilk or colostrum to the other. After every feeding mothers rated nipple pain for each breast on a 4-point scale. On postpartum days 0 to 5, 7, and 10, nipple condition was assessed by investigators who were “blind” to the intervention used on each nipple. Nipple pain and trauma experienced by the women were similar for the two interventions. Of the 95 percent reporting nipple pain during feeding, 26 percent had “extreme pain.” All women experienced nipple trauma. Engorgement, the most common breast problem, correlated positively and significantly with nipple trauma. No significant correlations were found between the following variables: perceived nipple pain and observed nipple trauma, nipple pain and number of feedings perday, nipple pain or trauma and hair or skin color, and nipple pain and prenatal preparation for breastfeeding.     

Comfort Measures in Breastfeeding, Primiparous Women

Objective: To examine various comfort measures and evaluate their effects in alleviating nipple soreness.
Design: Prospectively randomized, experimental study.
Setting: Postpartum unit of a community teaching hospital.
Patients: Seventy-three primiparous, postpartum, breastfeeding women.
Interventions: Subjects were randomly assigned to four groups, with all women receiving instruction about breastfeeding and using one of the following treatments: warm moist tea bag compress, warm water compress, expressed milk massaged into the nipple and areola and air dried, Instruction only (control group). The subjects completed a questionnaire each morning for 7 days regarding nipple soreness.
Main Outcome Measure: Effect of treatments on postpartum nipple pain.
Results: Subjects in the warm water compress group demonstrated significantly less pain on Day 3 than did the tea or breast milk group.
Conclusions: Anticipatory guidance by obstetric nurses may assist breastfeeding women in treating their pain nonpharmacologically.     

A Comparison of Topical Agents to Relieve Nipple Pain and Enhance Breastfeeding

Background: Nipple soreness is one reason why breastfeeding women wean their infants. This study examined the effectiveness of three topical agents—USP-modified lanolin, warm water compresses, and expressed breast milk with air drying—in alleviating nipple pain, and if early predictors of breastfeeding at six weeks could be determined. Methods: One hundred seventy-seven breastfeeding, primiparous women were randomly assigned to one of four groups. All women received education about breastfeeding technique. Numeric rating scales were used to discriminate levels of pain intensity, pain affect, and strength of sucking on day 1. Participants were interviewed by telephone on postpartum days 4, 7, and 14, and during week 6 using the same scales. Results: No significant differences were found among groups for pain intensity, pain affect, or duration of breastfeeding. Results of a logistic regression indicated that older mothers and those who were exclusively breastfeeding (no supplemental feeding) were most likely to be breastfeeding six weeks postpartum. Raw scores supported the use of warm compresses. Conclusion: Further investigation is required into ways of supporting young mothers and how caregivers provide support to breastfeeding mothers in the early weeks after childbirth.     

Prevention of and therapies for nipple pain: a systematic review

OBJECTIVE: To review the literature on nipple pain and to delineate effective strategies for the prevention and treatment of nipple pain in breastfeeding mothers. DATA SOURCES: Computerized searches on MEDLINE, Pre-MEDLINE, CINAHL, and the Cochrane Library. STUDY SELECTION: Articles from indexed journals relevant to the objective were reviewed from January 1983 to April 2004. Preference was given to research-based studies in English. DATA EXTRACTION: Data were extracted and organized under two headings: prevention of nipple pain or trauma and treatment of nipple pain or trauma. The Critical Appraisal Form by J. Briggs was used to extract the data from research-based articles. DATA SYNTHESIS: The health benefits of breastfeeding for mother and infant are well documented; however, nipple pain is a common reason reported by women for the early termination of breastfeeding. Several studies have compared various treatments for either the prevention of or treatment for nipple pain. These treatments include warm water compresses, tea bag compresses, heat, application of expressed mother's milk, lanolin, vitamin A, collagenase, dexpanthenol, hydrogel therapy, glycerin gel therapy, moist occlusive dressing, education regarding proper latch-on and positioning, and no treatment. CONCLUSIONS: No one topical agent showed superior results in the relief of nipple discomfort. The most important factor in decreasing the incidence of nipple pain is the provision of education in relation to proper breastfeeding technique and latch-on as well as anticipatory guidance regarding the high incidence of early postpartum nipple pain.     

Postpartum Positioning and Attachment Education for Increasing Breastfeeding: A Randomized Trial

Background: Although lactation experts suggest that a correct positioning and attachment technique reduces breastfeeding problems and enhances long‐term breastfeeding, evidence from randomized trials is lacking. The objective of this study was to evaluate the effect of postpartum positioning and attachment education on breastfeeding outcomes in first‐time mothers. Method: A randomized trial was performed in a public hospital in Adelaide, South Australia, where 160 first‐time mothers were randomly allocated to receive either structured one‐to‐one education (experimental group) or usual postpartum care (control group) within 24 hours of birth. The primary outcome was breastfeeding at 6 weeks and 3 and 6 months postpartum; other outcomes were nipple pain and trauma in hospital and at 6 weeks and 3 and 6 months, and satisfaction with breastfeeding. Results: No significant differences occurred in breastfeeding rates between the groups at each endpoint, although a trend in the direction of lower rates was seen at each endpoint in the experimental group. This group reported less nipple pain on days 2 (p= 0.004) and 3 (p= 0.04), but this was not sustained on follow‐up. No differences were observed in nipple trauma in hospital or in self‐reported nipple pain and/or trauma at the three endpoints. Experimental group women were less satisfied with breastfeeding at 3 and 6 months postpartum when using a one‐item measure; however, a multiple‐item measure showed no significant differences at the three endpoints. Conclusions: The intervention did not increase breastfeeding duration at any assessment time or demonstrate any differences between the groups on secondary outcomes. The trend toward lower breastfeeding rates in the experimental group suggests a need for a larger trial to evaluate whether or nor postpartum positioning and attachment education may negatively affect breastfeeding.     

Diagnostic value of signs and symptoms of mammary candidosis among lactating women.

Mammary candidosis in lactating women is not well defined and is most often presumptively diagnosed by signs and symptoms. This study evaluates the sensitivity, specificity, positive predictive value, and likelihood ratios of signs and symptoms of mammary candidosis based on the presence of Candida species on the nipple/areola or in the milk. In this prospective cohort study, the nipple/areola skin and milk of 100 healthy breastfeeding mothers were cultured from each breast at 2 weeks postpartum, and mothers were interviewed regarding signs and symptoms associated with mammary candidosis between 2 and 9 weeks postpartum. Positive predictive value for Candida colonization was highest when there were 3 or more signs or symptoms simultaneously or when flaky or shiny skin of the nipple/areola was reported together or in combination with breast pain.     

The use of nipple shields by breastfeeding women

The use of nipple shields when breastfeeding has given rise to concerns about possible harmful effects. A study was carried out to examine this issue. A lactation consultant's (LC) patients using nipple shields were compared with her other patients who were not using nipple shields, and an incidental sample of all postnatal breastfeeding women. The three groups were compared on discharge from hospital and at 3 months. Breastfeeding rates and problems (nipple trauma and mastitis) were studied: on discharge from hospital the LC patients who were not using nipple shields were significantly less likely to be breastfeeding than either of the other two groups. At 3 months, both LC groups were less likely to be breastfeeding than the postnatal group; there was no significant differences between the women using nipple shields and those who were not. There were no significant difference in reported problems in the 3 groups. It is concluded that women with breastfeeding problems are more likely to give up breastfeeding than those women who do not have major problems, and that the use of nipple shields is not a contributing factor and does not appear to compromise lactation.     

History, physical and laboratory findings, and clinical outcomes of lactating women treated with antibiotics for chronic breast and/or nipple pain.

This chart review study describes the history, physical and laboratory findings, and clinical outcomes in patients who presented to a lactation specialist between 1997 and 2002 and were treated with antibiotics for their chronic breast and/or nipple pain. A total of 69 charts were reviewed. Five were excluded because of loss of follow-up. Eighty-two percent of patients described postpartum breast tenderness, 74% had nipple sores postpartum, and 79% were tender on physical examination. Nipple lesions were present among 73% of the women. Breast milk or nipple cultures were performed for 60 of 64 patients and were positive for pathogenic bacteria among 50% of the patients cultured. The average duration of antibiotic treatment was 5.7 weeks, and 94% of the women had pain resolution. Symptoms of deep breast aching, breast tenderness on palpation, and nipple lesions may be suggestive of a bacterial lactiferous duct infection. Treatment with antibiotics for 4 to 6 weeks may be appropriate.     

Pain or Pleasure: The Dilemma of Early Breastfeeding

ABSTRACT: For many women breastfeeding in the early days after childbirth is a painful rather than a pleasureable experience. Sixteen factors which have been reported to have an association with nipple discomfort were studied in 102 women in the first 96 hours after delivery. Only three of these 16 factors were found to be significantly associated with nipple pain. Both flat and inverted nipples and frequency of breastfeeding had significant negative associations with nipple discomfort. Engorgement of the breasts was found to have a significant positive correlation with nipple pain during breastfeeding. Breast preparation in the prenatal period was among the 13 factors which was not related to soreness in the early nursing period.     

Candida and the lactating breast: predisposing factors.

Candida albicans infection of the nipples and breast ducts is a cause of sore nipples and "shooting" breast pain during lactation. A questionnaire which sought to identify predisposing factors was given to 51 women with candidiasis of the lactating breast, 18 women with other breastfeeding difficulties, and 29 women breastfeeding without any difficulties. Nipple damage in early lactation, mastitis, recent use of antibiotics postpartum, long-term use prior to pregnancy, and history of vaginal thrush were positively associated with candidiasis of the lactating breast. Thrush, especially oral thrush, was more common in babies of mothers in the candida group. However, some mothers with symptomatic candida infection reported none of these predisposing factors.     

Impacts of breast-care techniques on prevention of possible postpartum nipple problems

An experimental study was designed to compare the effectiveness of three techniques on the prevention or reduction of nipple pain and cracked nipples during the first ten days postpartum. The methods were to apply warm compresses, to apply expressed breast milk or to give no treatment other than keeping the nipples dry and clean. Applying warm compresses or expressed breast milk was found to be less effective in preventing cracked nipples than simply keeping the nipples dry and clean. The number of cases with nipple pain was less in the group that applied expressed breast milk.     

Breast size increment during pregnancy and breastfeeding in mothers with polycystic ovary syndrome: a follow-up study of a randomised controlled trial on metformin versus placebo

Please cite this paper as: Vanky E, Nordskar J, Leithe H, Hjorth-Hansen A, Martinussen M, Carlsen S. Breast size increment during pregnancy and breastfeeding in mothers with polycystic ovary syndrome: a follow-up study of a randomised controlled trial on metformin versus placebo. BJOG 2012;119:1403-1409. Objective To study the significance of breast size increment in pregnancy, and the impact of metformin during pregnancy on breastfeeding in women with polycystic ovary syndrome (PCOS). Design A follow-up study of a randomised controlled trial (the PregMet study). Setting Eleven secondary care centres. Population Women with PCOS during pregnancy and postpartum. Methods Women with PCOS were randomised to treatment with metformin or placebo from the first trimester to delivery. Questionnaires were sent to 240 participants 1?year postpartum: 186 responded. Main outcome measures Pre-pregnancy and late-pregnancy brassiere size and breastfeeding patterns were registered, and androgen levels were measured in the mothers. Results No difference in breast size increment and breastfeeding were found between the placebo and metformin groups. Breast size increment correlated positively with the duration of both exclusive and partial breastfeeding, whereas body mass index (BMI) correlated negatively with the duration of partial breastfeeding. Dehydroepiandrostenedione-sulphate (DHEAS), testosterone and free testosterone index (FTI) in pregnancy did not correlate with breast size increment or duration of breastfeeding. Women with no change in breast size were more obese, had higher blood pressure, serum triglycerides and fasting insulin levels, and had a shorter duration of breastfeeding compared with those with breast size increment. Conclusions Metformin and androgens had no impact on breastfeeding. Women with PCOS who had no breast size increment in pregnancy seem to be more metabolically disturbed and less able to breastfeed.     

Diagnosis and management of Candida of the nipple and breast

Diagnosis and treatment of ductal and/or nipple candidiasis in breastfeeding women is complicated by the variety of symptoms women experience. The differential diagnosis includes candidiasis of the nipple, candidiasis of the breast, bacterial infection of either nipple or breast, and other less common problems such as Raynaud's syndrome. Diagnosis and treatment are based on history, physical examination, and presenting symptomatology because cultures of breast milk are often inconclusive. Differential diagnoses and treatment options are reviewed.     

Breast Abscess in Lactation

A.B. is a 29‐year‐old gravida 1 para 1001 who experienced recurrent lactational breast abscess requiring surgical treatment. Her obstetric, medical, surgical, family, and social histories are unremarkable. She takes no medications and does not use alcohol, tobacco, or drugs. She gave birth at 41 weeks'gestation to a female infant, weighing 8 pounds 5 ounces. Her intrapartum course and immediate postpartum course were within normal limits. Breastfeeding was initiated within 40 minutes of birth and was successful. Her infant nursed on demand approximately every 2 to 4 hours while in the hospital. A.B. was discharged home with her baby at 28 hours postpartum. On day 3 postpartum, A.B.'s left nipple became cracked and bleeding. This was self‐treated with lanolin ointment and correction of latch‐on technique. Ten days postpartum, A.B. was diagnosed with mastitis and treated with dicloxacillin for 10 days. After 8 days of antibiotic treatment, she reported continued breast pain with a firm area of exquisite pain and redness in the upper outer quadrant of her left breast. The midwife ordered a breast ultrasound which revealed a 4‐cm abscess in the left breast. A.B. was referred to a therapeutic radiologist who performed an ultrasound‐guided needle aspiration of the abscess and obtained 15 mL of fluid. The fluid culture was positive for Staphylococcus aureus. She was treated postprocedure with doxycycline, and the breast pain, firmness and redness resolved within 36 hours. The rationale for treatment with doxycycline is unknown and subject to inquiry because S aureus is not sensitive to doxycycline. 1 Two weeks after the procedure, the abscess returned, and she was again treated with ultrasound‐guided needle aspiration and a regimen of amoxicillin with clavulanate. The abscess partially resolved, but worsened 6 days later. At that time, A.B. was referred to a breast surgeon who surgically incised and drained this 6‐cm abscess under general anesthesia. She was discharged home the same day with an indwelling Penrose drain. Two days later, the drain was removed and the wound was healing normally. A.B. continued breastfeeding exclusively throughout all of these events and was completely healed by 3 weeks after the incision and drainage. At 5 months postpartum, she had not experienced further breast infections and was continuing to breastfeed her baby.     

Treating postpartum breast edema with areolar compression.

This case study describes an occurrence of gross edema in the breast and areolar tissue of a mother in the first 2 days postpartum that interfered with the early initiation of breastfeeding. The mother developed severe generalized fluid retention during labor and early postpartum. Her breasts were naturally large. The edema in her breasts made the areola and nipple tissue firm and nonpliable. The mother successfully latched her newborn onto her breast after being shown areolar compression (AC), a technique developed and named by the authors. AC reduces nipple and areola edema by using gentle positive pressure on the areola. The baby continued to successfully latch onto the breast after AC was used and taught to the mother.