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Why Does It Hurt?

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Why Does It Hurt? Why does it hurt? • Understand the diverse etiology of breastfeeding associated pain Why does it hurt? • Be able to complete a detailed history and physical exam for a mother-baby dyad with breastfeeding associated pain A differential diagnosis • Understand how to counsel a mother regarding likely for breastfeeding-associated pain diagnosis and treatment of pain Alison Stuebe, MD, MSc [email protected] Caring for women for life Take-home points Most pain begins with traumatic injury to Cultures can be helpful to diagnose the the nipple – a problem at the secondary problem, but: “oroboobular interface” • not all problems with nipples are yeast For mothers who are pumping, pain may • not all oral thrush in infants is a result from pump overuse or misuse problem • not all bacteria in milk or on nipples Fixing pain requires fixing this problem – is a problem generally with the expertise of a lactation The prevalence of postpartum consultant depression and anxiety symptoms among mothers with breastfeeding- Trauma can cause a secondary associated pain is high problems: • Mastitis Among women with a predisposition to • Dermatitis chronic pain and/or anxiety, symptoms • Infection may persist after the trauma and/or the • Vasospasm secondary problem resolve • Functional pain How common is breastfeeding-associated pain? Who are your patients? 12.3 10.9 11.5 9 6.4 6.5 6.3 4.6 2.4 2.6 Day 1 72.5% 1 2 3 4 5 6 7 8 9 10 14.5 12.5 12.8 11.8 10.9 9.4 9.2 4.3 4.4 5.4 95.1% Week 1 1 2 3 4 5 6 7 8 9 10 11.7 11.9 12.6 9.4 10.4 6.3 6.7 4.4 3.4 79.5% 2.7 Week 2 1 2 3 4 5 6 7 8 9 10 http://www.cdc.gov/ifps/results/ch2/table2-37.htm Is it yeast? Is it yeast? Nipple Milk P<0.0001 P<0.0001 40% 34% 15% 9% 5% 3% 3% 2% C. albicans S. aureus C. albicans S. aureus Pain No Pain Pain No Pain Amir LH, Garland SM, Dennerstein L, Farish SJ: Candida albicans: is it associated with nipple pain in lactating women? Gynecol Obstet Invest 41:30-34, 1996 Is it yeast? • All women with pain were treated with miconazole oral gel for the nipple and the baby’s mouth, as well as oral antifungal medication (nystatin capsules). • One week later, mean pain level had decreased significantly, supporting the author’s hypothesis that yeast was the causative agent • Interestingly, miconazole and clotrimazole are active against S. aureus as well as C. albicans Alsterholm M, Karami N, Faergemann J: Antimicrobial activity of topical skin pharmaceuticals - an in vitro study. Acta Derm Venereol 90:239-245, 2010 Is it yeast? How often is yeast there anyway? Single mother 25% with positive yeast culture diagnosed with 43.6% MRSA abscess 34.6% 34.6% 13% 3% 0% Glucan Yeast Baby's mouth Mother's breast Mother's mouth Controls Cases Hale TW, Bateman TL, Finkelman MA, Berens PD. The absence of Candida albicans in milk samples of women with clinical symptoms of ductal candidiasis. Breastfeed Med 2009;4:57-61. Zöllner MS et al. Pesqui Odontol Bras. 2003 Apr-Jun;17(2): 151-5. Is it yeast? Burning nipple pain plus Not burning pain plus breast pain breast pain 34% 52% 48% 66% 1-8 1-8 weeks • Prospective study of 360 nulliparous women recruited during pregnancy 34% »Case: burning nipple pain & non-mastitis breast pain 48% 52% 66% »19% of women reported these two symptoms in weeks 1-8 2-8 weeks 2-8 »Authors attributed pain at 1 week to adjustment to breastfeeding Candida present No Candida present Is it yeast? What causes breastfeeding-associated pain? • Comparing women with and without nipple pain: »Amir 1996: Staph aureus was more strongly associated with Infant suck pain than yeast, and mothers improved with medication that mechanics / Tissue trauma Maternal mood, treats both yeast and staph pump use catastrophization »Hale: In milk samples, there was more evidence of fungal Predisposition to Central Maternal Irritation / species in control women than women with pain eczema, vasospasm, nociception perception Inflammation »Zolner: In an asymptomatic population, 1/3 of mothers and inflammation pathways of pain baby had yeast in their mouths and on the breast Infant / maternal Superinfection / Disordered pain perception: exposure to antibiotics, »Amir 2013: half of women with burning nipple and breast dysbiosis migraines, vestibulitis, pain had molecular evidence of candida – but so did 1/3 of dietary probiotics chronic pain women without pain • Bottom line: It it sounds like yeast, it’s probably not What causes breastfeeding-associated pain? Fix the OBI: Case history • 37 yo G3P3 at 7 weeks postpartum, referred for persistent Infant suck breastfeeding-associated pain mechanics / Tissue trauma Maternal mood, »Breastfed each of older two infants for 1 year and recalls pump use catastrophization significant pain for first 2-3 months with each baby »Pain greatest during latch and let down, then gradually Predisposition to Central Maternal Irritation / eczema, vasospasm, nociception perception abates. Infant slips off breast with let down and pulls off or Inflammation inflammation pathways of pain coughs Infant / maternal »Prior to consultation, treated with expressed milk on nipples, Superinfection / Disordered pain perception: exposure to antibiotics, heat, Nystatin, Diflucan, Nifedipine and Atenolol dysbiosis migraines, vestibulitis, dietary probiotics chronic pain • Physical Exam »During feeding, mother notes onset of pain concurrent with let down and audible tongue clicking »Once initial let-down complete, infant latches without pain Fix the OBI: Tongue tie and What causes breastfeeding-associated pain? breastfeeding-associated pain Denise Both & Kerri Frischknecht, Breastfeeding: An Infant suck Illustrated Guide to mechanics / Tissue trauma Maternal mood, Diagnosis and Treatment © Elsevier pump use catastrophization 2008 Predisposition to Central Maternal Irritation / eczema, vasospasm, nociception perception Inflammation inflammation pathways of pain Infant / maternal Superinfection / Disordered pain perception: exposure to antibiotics, dysbiosis migraines, vestibulitis, dietary probiotics chronic pain Buryk et al. (2011). Pediatrics, 128(2), 280-288. What causes breastfeeding-associated pain? What causes breastfeeding-associated pain? What causes breastfeeding-associated pain? Arroyo. Clin Infect Dis 2010; 50: 1551-1558. What causes breastfeeding-associated pain? Pain is not a unidimensional construct Gracely pain scale Infant suck mechanics / Tissue trauma Maternal mood, pump use catastrophization Predisposition to Central Maternal Irritation / eczema, vasospasm, nociception perception Inflammation inflammation pathways of pain Infant / maternal Superinfection / Disordered pain exposure to antibiotics, dysbiosis perception: migraines, dietary probiotics vestibulitis, chronic pain Catastrophization Maternal mood and breastfeeding-associated pain Associated with activation of sensory processing Early breastfeeding pain is associated with postpartum structures in functional MRI studies. depression OR postpartum depression at 2 Never Sometimes Always months, severe pain vs. no pain When I feel pain think or think or feel think or Prospective data 10 feel that that feel that from 2586 women 1. It is terrible and I feel it’s 0 1 2 3 4 5 6 never going to get any better. who initiated breastfeeding in the 2. It is awful and I feel that it 0 1 2 3 4 5 6 Infant Feeding overwhelms me. 1.96 2.13 2.24 3. I feel my life isn’t worth Practices Survey II. 0 1 2 3 4 5 6 living. 1 4. I worry all the time about 0 1 2 3 4 5 6 whether it will end. 5. I feel I can’t stand it 0 1 2 3 4 5 6 anymore. 6. I feel like I can’t go on. 0 1 2 3 4 5 6 0.1 First Day First Week Second Week Gracely RH et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain 127:835-843, 2004 Watkins, Zolnoun, Meltzer-Brody and Stuebe. Obstet Gynecol August 2011 Allodynia / Functional pain Breast sensitivity exam • Definition: pain resulting from a stimulus (such as light touch of the skin) which would not normally provoke pain. • Presenting symptoms and signs »History of nipple trauma »Exquisite pain with light touch / brushing of nipple »Shooting, burning pain »Areolar color change during / after feeding (may be blanching or purple) »Persistent shooting pain after local anesthetic applied to areola Asbill Sign Functional Pain •Descending pathways modulate pain signals, acting as a filter for sensory input •When this filter is broken, allodynia and chronic pain can develop •Fixing the pain requires repairing the filter Ossipov MH, Dussor GO, Porreca F. Central modulation of pain. The Journal of clinical investigation 2010;120:3779-87. What causes breastfeeding-associated pain? Infant suck mechanics / Tissue trauma Maternal mood, pump use catastrophization Predisposition to Central Maternal Irritation / eczema, vasospasm, nociception perception Inflammation inflammation pathways of pain Infant / maternal Superinfection / Disordered pain perception: exposure to antibiotics, dysbiosis migraines, vestibulitis, dietary probiotics chronic pain http://www.mombaby.org/breastfeeding Phone triage, EPDS and LC evaluation The EPDS LC evaluation Evaluation and management by clinician and LC Infant Anatomy Latch and Milk Transfer Oral thrush Inappropriate latch Tight frenulum Poor milk transfer Arched palate Poor pre-post test weights Disorganized suck Use of supplements Tortocollis Poor growth trajectory Overactive letdown / oversupply Maternal Anatomy Pumping Regimen Nipples difficult to grasp Flange fit observed to be Nipple fissures inappropriate during pumping Crusting Use of long durations, repeated Pustules stim cycles, high suction Plaques Large milk volume Nipples change color postfeeding Maternal/infant oversupply Throbbing pain symptoms Breast erythema, induration, tenderness Differential Diagnosis E&M provider assessment: Pain ± trauma Vasospasm Vasospasm Denise Both & Kerri Frischknecht, Breastfeeding: An Illustrated Guide to Diagnosis and Treatment © Elsevier 2008 E&M provider assessment: Pain ± trauma Oversupply Oversupply E&M provider assessment: Pain ± trauma Functional pain Pain is a part of daily living, and suffering is optional.
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