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breastfeeding 'struggles'
care and management for sore and cracked nipples
cracked nippleThis article reviews the care and management offered to women who are experiencing sore or cracked nipples basing it on a case history of one woman’s care. Where breast milk and breast feeding has immediate and long term health outcomes for both the mother and the baby (NICE 2006, UNICEF 2008), the development of sore or cracked nipples threatens the establishment and overall duration of breastfeeding. Breast milk protects babies from gastrointestinal, urinary, respiratory and middle ear infections and some familial skin allergies while maternal benefits of breastfeeding include a reduced risk of premenopausal breast cancer (World Cancer Research Fund 2007) and some forms of ovarian cancer (Gwinn et al 1990). To maximise these health benefits, lactation needs to be established so that breast milk provides all the baby’s nutritional requirements within the first six months of life. Where women develop sore and cracked nipples within the first two to five days of giving birth, there is a need for appropriate advice, support and treatment to ensure that the breast milk continues to be produced and that a way can be found to continue breastfeeding for a longer duration. This article offers some discussion about the occurrence of sore or cracked nipples and the current advice given to women about their management and treatment.
 
 
What breastfeeding problems do mothers experience immediately after giving birth?
 
In my role as a problem solving lactation midwife in the community, I am frequently asked to give advice to pregnant and postnatal women at the Breastfeeding Café where I am based. However, this paper is based on a peer review project I carried out whilst on a postnatal ward of a busy hospital in London, which serves a population of considerable ethnic and social diversity.
 
I was contacted to give assistance to a first time mother with cracked and bleeding nipples.
 
She was still in the hospital postnatal ward and had given birth to a healthy full term 6.5lb baby three days earlier. The baby was in good health and a very lusty feeder.
 
Whilst the mother’s milk had just come in on day three, her nipples had already cracked open by day two. The nipples were bruised black and blue, with the mother wincing in pain every time her baby latched on in her keen effort to demand feed her. Therefore, at the point where I was asked to visit, she was in urgent need of support to enable her to breastfeed her baby successfully.
 
The midwives assisting this mother had already established whether there were any concerns about the way the baby was attaching to the breast as this is the main cause of nipple trauma (Wambach 2003). There did not seem to be any problem with this as the baby was taking in the areola area and not just suckling on the nipple itself but, although it had been ascertained that attachment was correct, instead of the pain from the mother’s nipples subsiding, it increased. By the third day postpartum, the mother was in agony and dreading the experience of feeding her first newborn baby despite midwifery assurances that the soreness would improve with time.
 
Appropriate midwifery care meant the immediate alleviation of the nipple pain this mother was experiencing while still enabling her to give breast milk to her baby. Therefore, the action plan was to use a nipple shield (Powers & Tapia 2004). This suggestion was then discussed with her and her consent obtained to take this course of action as underpinned by the rules and code of practice for midwifery (NMC 2004).
 
Use of the nipple shield resulted in a very positive and immediate outcome as she experienced relief from pain when her baby latched on correctly the next time. Her baby did not appear to be put off by the silicon shield either — which meant that for the first time, this mother was empowered to feel confident about her skills to continue breastfeeding, and to be comfortable. Maternal satisfaction in empathetic midwifery care is what midwives are all about. Hence, I was also elated at being able to provide woman-centred care through effective teamwork (Davies 2000, Schroter et al 2004).
 
 
The role of the breastfeeding supporter 
in taking account of physiology and research
 
My actions were based on a combination of knowledge about the physiology and anatomy of the breast, and on a range of research studies that help inform day to day practice. The causes of cracked nipples despite correct latching, have been identified as being due to the changes that occur in pregnancy, where the areola expands to twice its normal size and continues to expand further during breastfeeding (Huml 2000). However, contrary to popular belief, the areola itself does not have sebaceous glands to keep the tender skin lubricated or the nipple area antiseptic. Instead, Menz (1994), a lactation dermatologist, explains that the areola and nipple tissue are made of a very thin layer of skin much like the delicate tissue on our lips. She also states that there is no evidence to support the belief that the Montgomery glands provide nipple lubrication and antisepsis, although breast milk does contain antibodies, which is why its use on the nipple has been advocated for healing (Akuzzu & Taskin 2000, Huml 2000). Therefore, the argument for using a suitable emollient is based on the understanding that why not apply the same principles of healing chapped lips to cracked nipples to prevent further breakdown of skin tissue, whilst the nipple shield would protect the new tissue from being removed every time the baby’s strong suction loosened the scab formation on top of the delicate healing skin.
 
Given the constant wetting of skin from nursing and rapid drying in between feeds, the baby’s strong suction and powerful latch-on effect may predispose the tender moist skin of the nipple and areola to fissuring (Huml 2000). However, there is a need to distinguish between sore nipples where the skin remains intact and cracked nipples where the skin surface is broken, which also has the potential to allow infection to enter into the breast (Buchanan et al 2002, Wambach 2003). Both the advice and suggested treatment may differ depending on whether the nipples are sore or cracked.
 
The pain of sore nipples within the first two to five days postpartum has been rated to be significantly more severe than at any time in cases developing four weeks later. The presence of thrush may also be associated with painful breastfeeding and sore, rather than cracked nipples and should be investigated to exclude this as a possible cause of soreness (www.breastfeedingnetwork.org.uk).
 
Other breastfeeding ‘struggles’ new mothers reported, apart from the early onset of sore and cracked nipples and mastitis, included engorgement with the milk coming in, mental and physical fatigue from the whole experience of labour and giving birth, plus the tension from the soreness of the entire body recovering from childbirth (Glazener et al 1995, Oakley et al 1996, Anderson & Grant 2001, MacArthur et al 2003, Lewis 2004, Parvin et al 2004). The pain of cracked and bleeding nipples was cited as the main reason why many mothers with newborn babies early weaned their babies from breast milk to artificial formula milk within the first two to six weeks of giving birth. In spite of their best intentions to carry on breastfeeding until their babies were six months old, postnatal studies in the UK show that 80–95% of women experience some degree of nipple pain, tenderness and soreness while breastfeeding, though 26–28% go on to suffer extreme pain from chapped, cracked or painfully sore nipples and the areola (Ball 1994, Huml 2000, Anderson & Grant 2001, Buchanan et al 2002, Williams 2003).
 
 
Treatments
 
The accepted treatment of cracked nipples involves advising nursing mothers to continue feeding their babies whilst rubbing breast milk on their nipples after feeds. Then in between feeds, women are advised to keep their nipples clean but exposed to air as a means to aid healing using dry air. A study identified that while applying hind breast milk on the injured area did not offer women immediate therapeutic pain relief, it did aid the eventual healing of cracked nipples. However, a study of 150 mothers with sore nipples in Australia (Reay 1998) recruited 75 women who used lanolin moist healing and a control group of 75 women who used hind milk dry healing, and compared the speed of healing between the two groups. The results showed that by the end of the two week follow-up period, the control group required 40% more home visits than the experimental group using the emollient. The healing process was also observed to be faster in the latter group, whilst the former group experienced more complications and mothers had more adverse comments about their pain (Sharp 1992 cited by Huml 2000).
 
‘Air drying’ causes the surface skin moisture to evaporate quickly, which then shrinks the areola skin irregularly. Tension then results on the outer layer, causing the top layer to crack and break, whilst further rapid drying in between feeds compromises the surrounding breast skin tissue to become brittle and thus more susceptible to fissuring due to the lack of sebaceous glands (Huml 2000).
 
As the outer layer of the nipple (stratum corneum) gets wet every time the baby nurses, the areola collectsmoisture in the skin tissue and swelling occurs. However, advice that mothers air dry their wet nipples with hair dryers or sunshine to rapid dry their cracked nipples as a means of preventing further trauma has now been questioned where this rapid air drying treatment may have the effect of only prolonging their pain (Huml 2000).
 
The breast tissue attempts to heal itself by forming a crusty scab, which consequentially blocks the smooth flow of epithelial cells from repairing the damaged area. There is now clearer evidence that allowing the skin surface to heal within a moist environment is likely to be more effective (Huml 2000, Buchanan et al 2002). One approach to providing such an environment within the challenges of frequent breastfeeds has been to apply some form of barrier lotion, the most common form of this is found in an organic lanolin that is said to aid the healing process by allowing air and moisture to co-exist to promote healing.
 
First and foremost, women need an approach of immediate pain relief from the pain of cracked nipples. Studies like Wilson-Clay (1996, also cited by Powers & Tapia 2004), prove that the judicious use of a nipple shield is the most holistic and therapeutic approach to soothe and decrease the pain from cracked nipple trauma. However, despite the obvious benefits, studies like Brigham (1996) have led to the general consensus that nipple shields may restrict breast milk flow.
 
One study has shown that the temporary use of the nipple shield at the onset of cracked nipples might be of benefit (Powers & Tapia 2004). In their study of 202 breastfeeding women, a cautious use of the nipple shield occurred. This was for a range of reasons, with 62% of women using it to help with problems of flat nipples, 23% to relieve pain from sore (not defined as sore or cracked) nipples and 15% due to engorgement. Where women had started using the nipple shield and then discontinued using it, 67% continued to breastfeed. The median duration of use was two weeks. There is still some lack of consistency in the advice surrounding use of nipple shields and it is probably appropriate to note the time frame of use of nipple shields as a temporary measure, as there is still a need to try to discover what caused the trauma to the nipple in the first place.
 
Studies have also shown that mastitis can result from nipple trauma, due to the impaired milk flow and let down reflex from the woman’s tension at breastfeeding. Where there are clogged milk ducks and painful engorgement, this may further impede breastfeeding and the baby’s difficulty at latching properly leads to difficulties in emptying the breast (Foxman et al 2002, Wambach 2003).
 
 
Reflective conclusion
 
Listening to women’s experiences about breastfeeding, then responding effectively to their individual needs ought to be the approach used by any midwife as part of their problem-solving strategy in woman-centred care. As a background to this scenario, the paper by Powers and Tapia (2004) gives a very good description of how the authors themselves, as experienced lactation consultants, had to reconsider their original views on the use of the nipple shield when faced with the findings from their study. When reviewing the literature on the topic of sore and cracked nipples, it is puzzling to realise how sparse the framework is for evidence on treatments. A Cochrane review on treatments for sore nipples has been withdrawn on the basis that more specificity is required for this topic, and it is to be hoped that an updated review will be more informative, although the research base of evidence for their enquiry does not appear to be overwhelming.
 
Against this background of conflicting evidence, the midwife is expected to organise care based on the best evidence for practice. It is essential that breastfeeding advice, support and recommendations are made for women as individuals within the guidance set by the Baby Friendly standards (NICE 2006, UNICEF 2008). Otherwise, professionals offering advice to breastfeeding women run the risk of dogmatically following outdated or anecdotal advice without considering the basic physiology of the woman’s delicate breast tissue and the original cause of the nipple trauma. There should also be recognition of the mother’s need for immediate psychological comfort from the excruciating pain of nursing on raw and damaged tissue when she is trying to give her baby the ‘best start in life’ (Lewis 2004). Midwives are part of an ever increasing team of breastfeeding support professionals who, when working together should help ensure that breastfeeding is no longer a ‘struggle’ but is a satisfying and health promoting experience for both the mother and her newborn baby (Ladyman 2005).
 
 
Recommendations for practice
 
Despite the prevailing controversy about the application of breastfeeding lanolin creams or the selective usage of silicon nipple shields in severe cases alone, the overall recommendation for practice would include:
 
• Offering midwifery breastfeeding care on an individual basis, rather than dogma on breastfeeding support, in order to build up co-operation between the woman and her midwife, thus promoting the duration of breastfeeding based on the mother’s expressed needs and preferences.
• Encouraging breastfeeding motivation and the Baby Friendly Initiative through client and staff verbal appraisal recognition plus other incentives like sponsored breastfeeding study days.
• Promoting the benefits of breastfeeding antenatally and with real-life examples of volunteer nursing mothers coming in to attend the breastfeeding antenatal class, as case studies from breastfeeding baby cafés have shown an 85% increase in breastfeeding rates among new mothers.
• Encouraging and seeking the advice of an experienced lactation advisor and dermatologist as part of an ongoing learning work experience.
• Encouraging an overall psychosocial breastfeeding environment such as skin to skin contact or co-bed sharing on the postnatal wards for mothers comfortable about doing so, provided information and DH leaflets on the risk factors on cot-death — smoking, drinking, over heating, substance abuse — have been thoroughly discussed with the parents throughout the antenatal period and postnatally.
• Encouraging all postnatal mothers to voice their concerns, queries or even reluctance about breastfeeding without feeling sidelined by the midwifery staff or lactation advisor.
• Continuing to improve practice through effective and collaborative peer review sessions on an ongoing basis and within specific time frames to allow clinical auditing as well.
 
 
About the author
 
Jacqui S Nancey, RM Bsc(Hons), is a specialist problem solving midwife and runs Mamas & Papas Problem Solving Breastfeeding Café at Mamas & Papas Cibo Café in Regent St, Central London every second and fourth Monday & Tuesday mornings of the month 10.30am till noon. See her website: newbornparentingcourse.com
 
 
References
 
Akkuzu G, Taskin L (2000). Impacts of breast-care techniques on prevention
of possible postpartum nipple problems. Professional Care of Mother and Child
10(2):38-9, 41.
Anderson T, Grant M (2001). The art of community-based breastfeeding support. The
Blandford Breastfeeding support group, incorporating the ‘Blandford Bosom Buddies’.
MIDIRS Midwifery Digest 11(suppl 1):S20-3.
Ball JA (1994). Reactions to motherhood: the role of postnatal care. 2nd ed. Hale: Books
for Midwives Press.
Brigham M (1996). Mothers’ reports on the outcome of nipple shield use. Journal of
Human Lactation 12(4):291-7.
Buchanan P, Hands A, Jones W (2002). Assessing the evidence: cracked nipples and
moist wound healing. Available from: www.breastfeedingnetwork.org.uk/
Davies C (2000). Getting health professionals to work together. BMJ 320(7241):1021-2.
Foxman B, D’Arcy H, Gillespie B et al (2002). Lactation mastitis: occurrence and
medical management among 946 breastfeeding women in the United States.
American Journal of Epidemiology 155(2):103-14.
Glazener CMA, Abdalla M, Stroud P et al (1995). Postnatal maternal morbidity: extent,
causes, prevention and treatment. British Journal of Obstetrics and Gynaecology
102(4):282-7.
Gwinn ML, Lee NC, Rhodes PH et al (1990). Pregnancy, breast feeding, and oral
contraceptives and the risk of epithelial ovarian cancer. Journal of Clinical
Epidemiology 43(6):559-68.
Huml S (2000). Sore nipples – taking a new look at an old problem using a
dermatological perspective. New Digest 8:24-6.
Ladyman S (2005). Improving postnatal care for every woman. British Journal of
Midwifery 13(2):68-70.
Lewis G ed (2004). Why mothers die 2000 – 2002: the sixth report of the Confidential
Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press.
MacArthur C, Winter HR, Bick DE et al (2003). Redesigning postnatal care: a
randomised controlled trial of protocol-based midwifery-led care focused on individual
women’s physical and psychological health needs. Health Technology Assessment
7(37): 98 pages.
Menz J (1994). Dermatology of the nipple/breast. ALCA Conference: Adelaide, Australia.
National Institute for Health and Clinical Excellence (2006). Routine postnatal care of
women and their babies. London: NICE:207-52.
Nursing and Midwifery Council (2004). Midwives rules and standards. London: NMC.
Oakley A, Hickey D, Rajan L et al (1996). Social support in pregnancy: does it have
long-term effects? Journal of Reproductive and Infant Psychology 14(1):7-22.
Parvin A, Jones CE, Hull SA (2004). Experiences and understandings of social and
emotional distress in the postnatal period among Bangladeshi women living in Tower
Hamlets. Family Practice 21(3):254-60.
Powers D, Tapia VB (2004). Women’s experiences using a nipple shield. Journal of
Human Lactation 20(3):327-34.
Reay J (1998). Healing effect of a moist wound agent (Lansinoh) on breastfeeding
women’s damaged nipples. [Short report on unpublished theses] University of
Western Sydney.
Schroter S, Black N, Evans S et al (2004). Effects of training on quality of peer review:
randomised controlled trial. BMJ 328(7441):673-5.
UNICEF UK Baby Friendly Initiative (2008). The seven point plan for sustaining
breastfeeding in the community. Available from: www.babyfriendly.org.uk/pdfs/
The_Seven_Point_Plan_September_2008.pdf
Wambach KA (2003). Lactation mastitis: a descriptive study of the experience. Journal
of Human Lactation 19(1):24-34.
Williams J (2003). The Baby Café: a fresh idea for supporting breastfeeding mothers.
Community Practitioner 76(5):161-2.
Wilson-Clay B (1996).Clinical use of silicone nipple shields. Journal of Human
Lactation 12(4):279-85.
World Cancer Research Fund (2007). Food, nutrition, physical activity, and the
prevention of cancer: a global perspective. Second report. Available from:
http://www.wcrf-uk.org/research
Nancey JS. MIDIRS Midwifery Digest, vol 18, no 4, December 2008,
pp 561–564.
Original article. © MIDIRS 2008.