Pain Management Pain Management

Topics in PAIN MANAGEMENT Vol. 32, No. 3 Current Concepts and Treatment Strategies October 2016 CONTINUING EDUCATION ACTIVITY Clinical Assessment and Management of Breastfeeding Pain

Ruth Lucas, PhD, RN, CLS, and Jacqueline M. McGrath, PhD, RN, FNAP, FAAN Learning Objectives/Outcomes: After participating in this CME/CNE activity, the provider should be better able to: 1. Describe factors that contribute to breast pain and nipple soreness in breastfeeding mothers. 2. Summarize evidence-based strategies and intervention for decreasing pain during breastfeeding. 3. Draw conclusions for guiding individualized breast pain management that is supportive of the unique needs of the mother. Key Words: Nipple pain, Breast pain, Pain, Nipple soreness, Breastfeeding

ore than 90% of new mothers experience pain during have discontinued breastfeeding.5 In addition, within the Mbreastfeeding in the first week after delivery.1 A first 2 weeks after delivery, more than 30% of breastfeeding major reason often cited for breastfeeding cessation in the mothers seek professional lactation support due to pain. Of first 2 weeks after birth is maternal breast and nipple pain.2 these mothers, 45% continue to have chronic pain, even Since 1990, the World Health Organization3 has recom- with intervention.6 mended breastfeeding as optimal nutrition for infants for Many women lack the understanding that breast and nipple the first 6 months of life. In turn, breastfeeding initiation pain is “normal” during breastfeeding initiation. In addition, has increased across the world and has recently reached interventions to manage breast pain are sometimes not an 80% of all infants in the United States.4 Yet, by the time the Dr. Lucas is Assistant Professor, University of Connecticut School of infant is 2 weeks old, 20% of breastfeeding mothers will Nursing, 231 Glenbrook Dr, Unit 4026, Storrs, CT 06269, E-mail: ruth. [email protected], and Nurse Research Scholar, Connecticut Children’s Medical Center, Hartford, Connecticut; and Dr. McGrath is Associate Dean, Research and Scholarship, University of Connecticut School of In This Issue Nursing, Storrs, Connecticut, and Director of Nursing Research, Clinical Assessment and Management of Connecticut Children’s Medical Center, Hartford, Connecticut. Breastfeeding Pain ...... 1 The authors and all staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if CE Quiz ...... 12 any) have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

CME Accreditation Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME activity expires on September 30, 2017. CNE Accreditation Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. LWW, publisher of Topics in Pain Management, will award 2.0 contact hours for this continuing nursing education activity. This activity has been assigned 1.0 pharmacology credits. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This CNE activity expires on October 31, 2018.

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CO-EDITORS emphasis in prenatal education, to avoid discouraging mothers from breastfeeding.7 However, this gap in mothers’ Elizabeth A.M. Frost, MD knowledge endangers continued breastfeeding.2,5 In addition, Professor of Anesthesiology mothers who are at risk for severe pain during breastfeeding, Icahn School of Medicine at Mount Sinai such as women with preexisting chronic pain conditions, may New York, NY need additional consultation and support for breastfeeding Angela Starkweather, PhD, ACNP-BC, CNRN, FAAN pain management. Professor of Nursing Acknowledging the nipple/breast pain and working closely University of Connecticut School of Nursing with the mother to consider strategies that relieve her pain Storrs, CT are important (Table 1). Nonjudgmental support of mothers during this time can identify ways to decrease pain while ASSOCIATE EDITOR helping them to continue breastfeeding. Wagner et al5 found Anne Haddad that if mothers’ concerns were not addressed on day 3, moth- Baltimore, MD ers had a 9 times greater chance of ceasing breastfeeding. For most mothers, pain peaks by day 3 and subsides by day EDITORIAL BOARD 7; however, some women continue to have breast pain for up Jennifer Bolen, JD to 6 weeks.5,6 During the first year, it has been documented The Legal Side of Pain, Knoxville, TN that the mother-infant dyad makes an average of 36 visits to Michael DeRosayro, MD health care providers.7 These visits, especially during the University of Michigan, Ann Arbor, MI first weeks after delivery, are an ideal opportunity to support James Dexter, MD the mother’s breastfeeding success while assessing and man- University of Missouri, Columbia, MO aging breastfeeding pain.6,8,9 Claudio A. Feler, MD Mothers experience breastfeeding pain at different points in University of Tennessee, Memphis, TN time and from different factors. Initial pain is related to Alvin E. Lake III, PhD increased use (8–12 breastfeeding sessions daily). Nipple and Michigan Head Pain and Neurological Institute, Ann Arbor, MI breast pain are triggered by infants’ poor latch, bacteria and Daniel Laskin, DDS, MS yeast infections, sensitivity because of Reynaud syndrome, Medical College of Virginia, Richmond, VA allergies causing dermatitis, or from a mother’s personal Vildan Mullin, MD University of Michigan, Ann Arbor, MI The continuing education activity in Topics in Pain Management is intended for clinical Alan Rapoport, MD and academic physicians from the specialties of anesthesiology, neurology, psychiatry, physical and rehabilitative medicine, and neurosurgery as well as residents in those fields New England Center for Headache, Stamford, CT and other practitioners interested in pain management. Gary Ruoff, MD Topics in Pain Management (ISSN 0882-5646) is published monthly by West Side Family Medical Center, Kalamazoo, MI Lippincott Williams & Wilkins, 16522 Hunters Green Parkway, Hagerstown, MD Frederick Sheftell, MD 21740-2116. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, or Email New England Center for Headache, Stamford, CT [email protected]. Visit our website at lww.com. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Priority postage paid Stephen Silberstein, MD at Hagerstown, MD, and at additional mailing offices. GST registration number: Jefferson Headache Center, Philadelphia, PA 895524239. POSTMASTER: Send address changes to Topics in Pain Management, Subscription Dept., Lippincott Williams & Wilkins, P.O. Box 1600, 16522 Hunters Green Steven Silverman, MD Parkway, Hagerstown, MD 21740-2116. 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For commercial Marjorie Winters, BS, RN reprints and all quantities of 500 or more, e-mail [email protected]. For Michigan Head Pain and Neurological Institute, Ann Arbor, MI quantities of 500 or under, e-mail [email protected], call 1-866-903-6951, or fax 1-410-528- 4434. Steven Yarows, MD PAID SUBSCRIBERS: Current issue and archives (from 1999) are now available FREE Chelsea Internal Medicine, Chelsea, MI online at www.topicsinpainmanagement.com. Topics in Pain Management is independent and not affiliated with any organization, vendor Lonnie Zeltzer, MD or company. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or UCLA School of Medicine, Los Angeles, CA Editorial Board. A mention of products or services does not constitute endorsement. All com- ments are for general guidance only; professional counsel should be sought for specific situa- tions. 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Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating Breast Pain Cons/Why Not to Intervention Strategy* Pros/Why Recommend Recommend Other Information Prevention of pain Prenatal education9,17,50 Provided at a time when For best outcomes sessions Mothers are unable to mothers may be less need to individualized implement knowledge stressed and more ready and target to unique until the infant breast- to learn needs of individual feeds and every infant mothers breastfeeds differently Postpartum education6,9,19,50 To be effective needs to May be difficult to deliver Regardless of whether the occur soon after birth with enough emphasis mother had prenatal or before breast trauma because mother has many postnatal education occurs other needs at this time continued follow-up is needed; referral to a lactation consultant should be routine Hand hygiene including Improves skin integrity and Avoid routine use of soaps Also includes anything that good drying of hands and decreases risk of on areolae to prevent skin touches the breast or breast after cleaning9,28 infection drying infant mouth (ie, pacifiers, breasts, and clothing) Assessment of pain Targeted assessment of Assessments need to be Mothers may not always Early on, breasts may breast with a history of routine and share important appear normal and thus onset and location of nonjudgmental information; need to ask maternal perceptions are breast pain7-9,22 direct questions. May important take more time to get Look for redness even with good information no current report of pain Targeted assessment of Infant latch and position Needs to be assessed The infant needs to be latch and position during can increase skin during a routine positioned facing the breastfeeding6,13,14 breakdown and breast breastfeeding so that best breast. Entire areola trauma assessment is achieved needs to be inside the infant mouth for good latch. Watch for evidence of sucking over gumming Early pain interventions Expressed breast milk2,26,29 Easily available; has Newer studies have not Level 2 Grade B Oxford antiviral and antibacterial found it to be superior to Centre for Evidence- properties warm water compresses Based Medicine and recommended by UNICEF Lanolin17,21,23,24 Easily available and fairly Contraindicated for Level 2 Grade B Oxford inexpensive mothers allergic to wool Centre for Evidence- Semiocclusive ointment, Based Medicine Newest promotes epithelial research recommends regrowth, and reduces lanolin over breast milk pain and hydrogel dressing (Continues )

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Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating Breast Pain (Continued ) Cons/Why Not to Intervention Strategy* Pros/Why Recommend Recommend Other Information Warm water compresses9,28 Evidence demonstrates During engorgement Can be provided 4–6 times pain relief and has been compresses should be daily after breastfeeding found to be more used to soften breasts to a sessions; can be used to effective than other level of comfort. Too soften plugged milk strategies much heat will prolong sinuses to prevent milk engorgement stagnation Treatment for acute nipple pain and trauma Breast shield15,30 Provides space between Not comfortable for some Ineffective in antenatal and breast and clothing for mothers postnatal treatment for breast to heal. One study flat nipples found when used with lanolin decreased maternal pain Calcium channel-blockers Vasodilator, decrease Systematic cardiac Often Reynaud syndrome (nifedipine)5,14 nipple and breast side effects of not identified until vasospasms lightheadedness, conservative treatment dizziness, low blood for mastitis has failed pressure, headaches Chlorhexidine spray25 Topical antimicrobial spray. Mothers found the spray Not recommended by One small study found a uncomfortable to remove UNICEF or the American decrease in pain and in preparation for next College of Obstetricians increase in healing. Safe feeding. Antiseptic spray and Gynecologists for infant consumption is contraindicated with open wounds Hydrogel dressing9,25 Effective for early nipple Contraindicated in mothers Should be discarded after pain. Moist saline with nipple trauma 24 h dressing, cool and because of their increased soothing, promotes susceptibility to develop epithelial regrowth and infections reduces pain LED phototherapy lights32 Phototherapy enhances No commercial prototype LED lights prototype cellular regeneration, available adapted for the breast local vascularization, and nerve conduction. Decreased pain after first treatment Menthol (peppermint) gel Antimicrobial properties No standardized Traditional therapy for or oil21,29 specifically against preparation for nipple pain in Iran; gram-positive bacteria. breastfeeding mothers approved by the FDA as One study found food peppermint gel more effective than peppermint water or oil for nipple fissures (Continues )

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Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating Breast Pain (Continued ) Cons/Why Not to Intervention Strategy* Pros/Why Recommend Recommend Other Information Nipple shields6,15,30 Silicone-vented dome Evidence is weak Requires management by provides a layer of trained lactation protection from direct professionals to maintain infants’ sucking. Dome maternal milk volume provides sensory stimulation for infants suck, which elongates nipple Polyethylene film Occlusive dressings, Removing the dressing is Most effective with dressing9,25 promotes epithelial painful for many mothers infrequent dressing regrowth and may increase nipple changes trauma Silver cap31 Silver ancient treatment Contraindicated for Has not be tested against with antimicrobial mothers with metal other therapies properties. Trilaminate allergies silver cup creates a moist environment for epithelial regrowth and reduces pain Tea bag compresses28 Some evidence that pain is Astringent properties, dries Cultural therapy, reduced similarly to warn nipple tissue recommend warm water compresses. Easily compresses as an available and inexpensive alternative Severe breast pain Antidepressants7,14 May be important for Will require increasing breastfeeding support support and management and increasing sense of maternal competence Massage48 Effective for deep breast Muscular spasm after pain releasing pectoralis, breastfeeding may occur inferior aspect, and without nipple pain serratus anterior muscle Propranolol46 Effective for treatment of No published clinical trial Recommended by the chronic jaw pain for in breastfeeding mothers American Breastfeeding women without COMT Medicine Practice Group polymorphisms Treatment of infection Acupuncture39 Provides systematic anti- Some mothers refuse Target pressure points were inflammatory effect. because of fear of heart 3 (circulation), Decreased pain from needles gallbladder 21 (relaxation mastitis 3 d after effect), and spleen 6 treatment compared with (gynecologic effect) the control group using oxytocin nasal spray (Continues )

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Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating Breast Pain (Continued ) Cons/Why Not to Intervention Strategy* Pros/Why Recommend Recommend Other Information Antibiotics36-38 Resolves deep and severe If providing antibiotic Cultures should be pain by decreasing treatment be sure to be obtained after 1 wk of inflammation, S. aureus proactive in preventing persistent pain to rule out most common organism overgrowth with yeast mastitis May need treatment for candidiasis as biofilms may consist of mixed fungal and bacterial colonies Nonsteroidal ointment6,14,43 Effective for dermatitis of Must be removed before nipple and breast feedings to decrease infant exposures Oral fluconazole Resolves deep and severe Difficult to culture. May begin as skin therapy40,41 pain by decreasing Predisposes women to inflammation and invade inflammation mastitis breast sinus causes bacterial colonization Probiotics42 Made from human Patented for commercial Treatment with 200 mg breast milk use in Spain and ∼9 log10 CFU each of Balances the natural Australia Lactobacillus salivarius biofilm, effective against CECT5713 and subclinical S. aureus Lactobacillus gasseri mastitis CECT5714 capsules compared with antibiotics significantly decreased pain and bacterial count by day 21 *Listed in order of preference.

decreased pain thresholds. To best support mothers, clinicians • How long does it last? need a general understanding of what causes breast pain and • Is the pain sharp or dull? what interventions will help alleviate maternal pain. Generally • Are there areas of the breast that hurt more than others? speaking, breast pain is related to 4 factors: (1) transition to • Does anything the baby does make the pain worse? breastfeeding (initiation pain); (2) mechanics of breastfeeding • Does the pain begin or get worse just before breastfeeding, (latch and positioning); (3) organisms that decrease skin integ- during breastfeeding, or just after breastfeeding the infant? rity (thrush and infections); and (4) tissue sensitivity, such as • What interventions has the mother already tried? preexisting dermatologic conditions or Reynaud syndrome. Breastfeeding pain is an interaction between the mother’s Pain During Breastfeeding Initiation ability to modulate her central nervous system signaling of nipple pain while managing her environmental and local stim- Nipple soreness is for the most part normal during breastfeed- ulation.8 More specifically, Amir et al8 propose the Breast- ing initiation. During assessment, the breast and nipple may feeding Pain Reasoning Model to understand the various appear normal or slightly pink. However, many mothers are factors that influence variation in breastfeeding pain. In this unprepared for the pain and at a loss about how to manage their model, central nervous system modulation is an interaction pain between feedings.9 The first step in helping mothers to between prolonged afferent nerve stimulation from the nipple, manage pain and soreness is to acknowledge and anticipate the maternal medical history, including parity or pain tolerance, problem and ask mothers for details in a non-judgmental style: and cognitive, emotional, and social state that supports her • Where exactly is the pain? ability to manage the pain. Mothers need to be assured that • When does it begin? experiencing pain is “normal” initially and not a reflection of

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maternal competence. This is especially important because pression, it releases inflammatory markers such as histamines, self-rated maternal competence and the presence of maternal bradykinins, and substance P.17 When these markers are liber- postpartum depression can be closely tied to breastfeeding suc- ated, they cause nociceptive responses in small nonmyelinated cess.10 Providing support and encouragement during this diffi- C fibers.15 Other conditions that predispose mothers to skin cult time are important to long-term breastfeeding outcomes.11 breakdown and pain sensation include dermatitis, and vasos- These questions also assess external stimuli that predispose pasm from Raynaud syndrome.17 Whenever there is skin mothers to pain, such as a flat nipple, an infant’s shallow latch, breakdown on the breast or nipples, mothers are at much which traumatizes the nipple, or the use of a breast pump.8,12 greater risk for infections. Health care professionals should Mothers with flat or inverted nipples (10% of all mothers) encourage mothers to continue to breastfeeding as their nipple require interventions to elongate the nipple, including the best heals. Mothers need to be followed up closely during this time practice of pumping before breastfeeding and using a nipple to prevent nipple yeast and mastitis. Each of these 3 factors shield during feeding and rubber bands.13-16 Many mothers also influences the level and intensity of pain experienced during use a breast pump to establish maternal milk supply. If mothers breastfeeding. See Figure 1 for other issues to consider during are provided with too small a flange for the breast size, the are- provision of a supportive breastfeeding pain assessment. ola and nipple will rub against the flange throughout the pumping session.13,14 Constant rubbing may irritate or in extreme Treatment for Nipple Pain and Trauma cases cause a friction burn.13,14 The nipple shield, a soft sili- Once a comprehensive assessment with history of onset is cone-vented dome placed over the nipple, provides a solid sur- completed, clinical interventions to reduce maternal pain must face for infants to latch, and protects the nipple as the nipple become the focus of breastfeeding management. The challenge elongates from infants’ suction and from infants who create is that most topical pain relievers are contraindicated for infant and sustain over 200 mm Hg of negative intraoral pressure dur- consumption. Even if mothers remove the ointment before feeding feeding.12-15 Lastly, rubber bands have been used to pro- ing, it is unknown how much infants might receive from the trude the flat nipple; however, none of the findings addressed skin and the friction to the nipples will be an additional irritant maternal pain from the intervention.16 Even with these strate- to skin integrity. Thus, management of nipple pain consists of gies, the mother may experience pain as the nipple tissue is nonpharmacologic topical interventions and preventative educa- stretched or adhesions broken with the infant’s sucking. tion. Pharmacologic intervention is used for inflammatory con- The evidence is clear that antenatal breastfeeding education ditions such as mastitis, candidiasis, or breast dermatitis. prepares mothers to solve issues with infants’ position, latch, and sucking effort.6,9 Although postpartum education is timely, it Lanolin and Expressed Breast Milk is important to note that nipple pain and trauma may occur with If the maternal nipple and breast is intact, clinical interventions only 1 poor breastfeeding session.6,9,17 Correct positioning of the will focus on maintaining skin integrity. Evidence supports the infant is critical, because if the infant’s mouth is misaligned with use of nipple massage after application of medical grade lanolin the nipple, the infant will gum the nipple instead of sucking. In or expressed breast milk17,19-25 after every feeding. Purified lano- addition, if infants’ lips are not flanged out, the tongue can lin is a yellowish white, fat-based moisturizing ointment derived retract, and the infant may gum or strip the nipple against the from sheep fleece. Lanolin should be applied with 3-mm thick- hard palate instead of the soft palate, both causing nipple dam- ness, which provides protection from clothing and is semiocclu- age. Finally, if infants have a short frenulum or tongue-tie, they sive, which keeps the nipple moist between feedings, promotes may not be able to stretch the tongue to the soft palate, thus epithelial regrowth, and reduces pain.17 Expressed breast milk is stripping the nipple against the hard palate causing nipple pain also applied after each feeding and has antibacterial and antiviral and damage.18 All of these factors contribute to the nipples properties.22,23 Both interventions have demonstrated a reduction appearing reddened, cracked, fissured, scabbed, and bleeding. in maternal pain within 14 days. Several systematic reviews have Mothers should be reminded to make sure the breast is kept evaluated both interventions. Vieira et al25 identified both inter- dry and clean between breastfeeding sessions to prevent ventions as level 2 evidence based on criteria from the Oxford infection. During infants’ initial latch, most mothers with nip- Center for Evidence-Based Medicine, but they and Lochner ple trauma experience severe “toe-curling” pain that subsides et al26 found lanolin to be more effective in reducing pain. In or dissipates during feeding.6,14 However, if mothers experi- contrast, a Cochrane review23 reported that no method was sig- ence severe pain throughout breastfeeding, they may need to nificantly better at reducing pain. pump and provide breast milk until their nipples heal. If Nonpharmacologic Interventions mothers notice infants have blood in their mouth or observe blood in their pumped milk, reassure mothers that infants will The use of warm compresses before feeding has been found not be adversely affected by swallowing maternal blood. effective in decreasing maternal pain from engorgement and Lastly, local stimulation refers to mechanical stimulation. after feeding, and for soothing nipple irritation.9,14 Extra virgin When nipple tissue is traumatized, such as with nipple com- olive oil (EVOO) has immunological and anti-inflammatory

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Figure 1. Assessment of breastfeeding pain.

properties. In one randomized trial, 2.7% of mothers who are a natural antibiotic and have emerged as an alternative to treated their nipples with a drop of EVOO, compared with 44% antibiotic treatment.31 Mothers place the cap on the breast of mothers who treated their nipples with breast milk after between feedings. One pilot study found mothers experience a breastfeeding, exhibited cracked nipples, which was significant significant decrease in maternal pain within 7 days of a nipple (p < 0.000).27 EVOO has not been compared to lanolin. Other fissure compared with no treatment.28 Lastly, one study used moist dressings are not recommended, including tea bags, due to light-emitting diode (LED) phototherapy lights and its ability astringent and drying effect,28 and hydrogels, which, although to promote local vascularization and decrease pain twice a soothing, are associated with a high incidence of breast and nip- week to treat nipple fissures. For mothers in the treatment ple infections.14 group, nipple fissures healed within 4 biweekly visits com- Menthol (peppermint) gel or oil is considered safe during pared with 8 biweekly visits for controls.29 pregnancy and lactation by the FDA and is a household remedy in the Middle East to treat nipple fissures.21,29 Menthol demon- Engorgement strates antimicrobial properties specifically against gram-posi- Breastfeeding pain has been characterized as transient or pro- tive bacteria, and in both small studies performed in Iran, longed.9 The transient pain occurs at 48 to 72 hours after delivery decreased nipple pain and healed nipple fissures in signifi- when release of lactogenesis II results in engorgement of breast cantly shorter time than lanolin and expressed breast milk.21,29 sinuses. This is a normal physiologic response, even if the mother Breast shields, a vented plastic dome whose base has an reports the pain as severe.5,6,14 Engorgement typically lasts 72 opening for the maternal nipple, has been used with or without hours. As the infant feeds, the neurohormonal pathway gives bio- lanolin to protect the nipple from rubbing against the maternal feedback as to the volume of milk the infant requires for growth. bra and promote air flow for healing.31 Another form of shield Although it is normal, engorgement can be uncomfortable to very is a nonvented dome composed of trilaminate silver. Silver ions painful for mothers. Treatment is a careful balance to support

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infants’ ability to latch on a full breast and decrease maternal Regardless of any treatment, the breast should be cleaned and pain. Before breastfeeding, mothers may use warm compresses kept dry until the next feeding. Breast feeding through the or a breast pump to soften the breast enough for the infant to latch mastitis episode can be difficult for the mother, yet providing and stimulate milk let down. Although warmth provides comfort, extra support and encouragement is important to long-term use of warm compresses or warm showers should be cautious as breastfeeding outcomes.14,34,36,37 removal of excess milk beyond the infants’ need will trigger the Candidiasis occurs as an overgrowth of naturally occurring neurohormonal pathway to provide additional milk, thus continu- yeast that lives normally on the skin and mucous mem- ing engorgement.14 Maternal massage of the breast to release branes.40,41 The warm and moist environment found in the plugged milk sinus during feeding is imperative, as stagnate milk infant’s mouth and on the mother’s breast increases the risk is a source for bacterial infections.33 Cold compresses, such as a for yeast to overgrow. Candidiasis infections can occur at any bag of frozen peas or leaves of green cabbage, after feeding can time during breastfeeding; however, it is important to note be used to reduce breast swelling and pain.6,14 that if the mother or infant has been treated with antibiotics, For some mothers, pain from oversupply persists beyond the the risk is increased and more intense assessments need to first week. Milk oversupply also has nutritional implications for occur.38,40,41 Diagnosis is by clinical symptoms, although a the infant. Infants may become full on the foremilk composed of DNA and polymerase chain reaction (PCR) assay for candidi- low milk fat and water and obtain less of the high-fat hind milk asis are becoming readily available.14,36,41 When there is a needed for growth and development. Interventions to decrease delay in treatment, because of the need to work up other dif- milk supply include tea made from sage, a member of the mint ferentials, it is important to keep good communication with herbal family, careful use of pseudoephedrine, and oral contra- the mother.36,40,41 ceptive pills containing estrogen.14 With candidiasis there is persistent soreness and redness in the Pain or engorgement, past the first week, is considered nipples; burning and itching may also be present. In addition, abnormal and should be evaluated by a lactation health care mothers often report that pain is increased during breastfeeding professional. and may seem to radiate into the breast. It is important to begin treatment as soon as a diagnosis is made and to treat both the Organisms That Decrease Skin Integrity mother and the infant and other family members who may have Leading to Pain symptoms. Many strategies may be used concurrently, such as: Diagnosing nipple pain related to infections requires a thor- (1) initially, nipple ointments and topical antifungal agents and/ ough inspection of the breast, and a good discussion with the or Gentian violet (<0.5% aqueous solution) may be used daily mother about the history of onset. Depending on the causative for no more than 7 days; (2) nystatin suspension or miconazole agent, topical or oral antibiotics (Staphylococcus aureus) may oral gel for the infant’s mouth; and (3) human milk probiotics be considered. If the causative agent is Candida, antifungals to treat subclinical mastitis. Vigilant hand hygiene is critical, might be prescribed.9,25,34,36 When there is evidence of an along with hygienic care of the breasts between feedings. This infection, expressed breast milk should not be used as a topical includes cleaning and care of anything that goes into the agent nor should nipple ointments, gels, creams, or dressings infant’s mouth. If resistant, oral fluconazole (200 mg once, then 14,36,41,42 be used.9,25,34,36 The latest research does not support their con- 100 mg daily for 7–10 days) may be prescribed. Lastly, tinued use. Increasing the opportunity for a warm moist envi- acidophilus can be added to the mother’s daily intake to help ronment increases the susceptibility of the mother-infant dyad balance the normal flora growth. Reinfection is common, so it to poorer skin integrity and potential for increased infections or is important to work with the mother to appreciate the course of recurring infections.9,35 infections and best understand what makes the mother-infant Mastitis or breast infection is typically triggered by a break dyad more susceptible to infections so the cycle can be broken. in skin integrity or stagnation of milk within the milk sinuses, Helping mothers not only to understand the need for acute allowing bacteria such as S. aureus to proliferate.14,36 It is usu- immediate care strategies but to also consider the bigger picture of what is occurring long term will help with working through ally occurs after the second or third week of breastfeeding and 36,40,41 is characterized by soreness and reddened areas of the breast. this process. The occurrence is most often unilateral, although bilateral and repeat infections can occur. Signs and symptoms of mastitis Preexisting Dermatologic Conditions and Pain Sensitivity include chills, increased temperature, and maternal fatigue.36-38 Treatment may include the use of antibiotics and Mothers with preexisting skin allergies such as eczema, pso- analgesics and rest and hydration.14,36,37 Mothers are encour- riasis, or other dermatologic conditions are at increased risk aged to breastfeed frequently and apply warm compresses for breast pain because of the potential for decreased skin after feeding. An alternative approach, using acupuncture integrity.43 They need even greater support, including good compared with standard treatment for mastitis, found a signif- hygiene and drying the breast between feedings, and the rou- icant decrease in breast pain at 3 and 4 days of treatment.39 tine use of a topical corticosteroid to relieve symptoms.

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Before feeding the infant, corticosteroid creams need to be Conclusions removed to decrease infant exposure. Mothers who are more A majority of women who breastfeed will experience nipple susceptible to allergic reactions could be more likely to expe- and breast pain, particularly during breastfeeding initiation. rience breast pain if they use ointments or creams as a sup- Preparing women to develop strategies for managing pain dur- portive measure while breastfeeding. Once allergic reactions ing breastfeeding is ideally a focus of antenatal breastfeeding occur, the irritant (ointment or cream) needs to be discontin- education. However, not all women are able to attend or com- ued and the area kept clean and dry.9,14 plete educational sessions before birth. With greater recogni- Sometimes mothers experience nipple vasospasms with tion, acknowledgment, and support for dealing with nipple and breastfeeding that can be acutely painful. These spasms are breast pain during breastfeeding, there is a better chance that due to a reduction in circulation and can cause blanching of mothers will continue breastfeeding up to or beyond the recom- the nipple or nipple discoloration. Sometimes the pain radi- mended duration. Clinicians’ assessment of the pain and poten- ates into the breast, as with Candida. As such the cause of the tial contributing factors can provide direction for interventions pain can be easily misdiagnosed. Occurrence is greater in the focused on supporting the mother to continue breastfeeding. winter months and in thin women with poorer circulation and 41 More intensive follow-up should take place for women who a family history of Reynaud syndrome. Because the syn- have mastitis or candidiasis to ensure that symptoms resolve drome is often affected by temperature, the most effective and to increase the likelihood of good breastfeeding outcomes. intervention is making sure the environment is not cold dur- Mothers at risk for severe pain during breastfeeding, such as ing breastfeeding and applying warm water compresses after women with preexisting dermatologic or chronic pain condi- breastfeeding. If these interventions are not effective, nifedi- tions, may need additional consultation and support. Ultimately, pine 30 to 60 mg sustained release daily, or immediate release 14,45 the time and effort provided in helping mothers to achieve bet- 10 to 20 mg thrice a day, for 2 weeks, may be prescribed. ter breastfeeding outcomes will contribute to infant health and Mothers with a history of pain disorder may experience long-term population health outcomes. ■ excruciating pain with breastfeeding, light touch, or drying with a tool. These mothers may require pharmacologic management References of round-the-clock nonsteroidal anti-inflammatory ointments.26 1. Division of Nutrition Physical Activity and Obesity. Infant Feeding If mothers do not respond well, additional therapy of proprano- Practices Survey II: Results. In: National Center for Chronic lol beginning at 20 mg 3 times a day and antidepressants may Disease Prevention and Health Promotion, ed. Atlanta, GA: Centers for Disease Control and Prevention; 2009. be needed.43,44 Lastly, one study found that massage therapy tar- 45 2. Odom EC, Li R, Scanlon KS, et al. Reasons for earlier than desired geting problematic areas is effective. cessation of breastfeeding. Pediatrics. 2013;131(3):e726-e732. Clinicians may not understand the severity of pain mothers 3. WHO/UNICEF. The Innocenti Declaration. Paper presented at: experience during breastfeeding. In part because there is no Breastfeeding in the 1990s: A Global Initiative; July 30, 1990; standardized assessment for maternal pain, systematic assess- Spedale degli Innocenti, Florence, Italy. ment of breastfeeding pain has been scarce. In addition, many 4. Centers for Disease Control and Prevention. Breastfeeding Report studies had small samples in varying populations, making it Card—United States, 2014. Atlanta, GA: Centers for Disease difficult to compare or combine results. Conducting research Control and Prevention; 2014. in this area is difficult, yet it is very important to the continua- 5. Wagner EA, Chantry CJ, Dewey KG, et al. Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. tion of breastfeeding for the first year of life. Pediatrics. 2013;132(4):e866-e875. In general, if health care clinicians expect mothers to con- 6. Kent JC, Ashton E, Hardwick CM, et al. Nipple pain in breastfeed- tinue breastfeeding their infant, management strategies need ing mothers: Incidence, causes and treatments. Int J Environ Res to be quick and effective. Breastfeeding pain needs to be Publ Health. 2015;12(10):12247-12263. acknowledged and accompanied by individualized counseling 7. McCallum S, Rowe H, Gurrin L, et al. Unsettled infant behavior that addresses the unique needs of the mother given her cur- and health services use: a cross sectional community survey in Melbourne, Australia. J Paediatr Child Health. 2011;47: rent condition and history with breastfeeding strategies. Pain 818-823. management needs to include both nonpharmacologic and 8. Amir LH, Jones LE, Buck ML. Nipple pain associated with breast- pharmacologic strategies. In a retrospective chart review, feeding: incorporating current neurophysiology into clinical rea- Strong49 found that prescription of medications was used soning. Aust Fam Physician. 2015;44(3):127-132. most frequently for management of breast pain. Counseling 9. Morland-Schultz K, Hill PD. Prevention of and therapies for nipple and nonpharmacologic measures were rarely documented. pain: a systematic review. J Obstet Gynecol Neonatal Nurs. There were also few referrals to lactation support services. 2005;34(4):428-437. Health professionals must use the best evidence to guide 10. Watkins S, Meltzer-Brody S, Zolnoun D, et al. Early breastfeeding experiences and postpartum depression. Obstet Gynocol. assessment and management of breastfeeding pain, particu- 2011;118:214-221. larly because conflicting advice is known to be a contributing 11. Linton S, Shaw W. Impact of psychological factors in the experi- factor in breastfeeding cessation.50 ence of pain. Phys Ther. 2011;91:700-711.

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12. McClellan HL, Geddes DT, Kent JC, Garbin CP, Mitoulas LR, 32. Chaves ME, Araujo AR, Santos SF, et al. LED phototherapy Hartmann PE. Infants of mothers with persistent nipple pain exert improves healing of nipple trauma: a pilot study. Photomed Laser strong sucking vacuums. Acta Pædiatr. 2008;97(9):1205-1209. Surg. 2012;30(3):172-178. 13. Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. Risk factors 33. Witt AM, Bolman M, Kredit S, Vanic A. Therapeutic breast mas- for suboptimal infant breastfeeding behavior, delayed onset of lac- sage in lactation for the management of engorgement, plugged tation, and excess neonatal weight loss. Pediatrics. ducts, and mastitis. J Hum Lact. 2016;32(1):123-131. 2003;112(3):607-619. 34. Betzold CM. Results of microbial testing exploring the etiology of 14. Berens P, Eglash A, Malloy M, et al. Academy of Breastfeeding deep breast pain during lactation: A systematic review and meta- Medicine. ABM clinical protocol #26: Persistent pain with breast- analysis of nonrandomized trials. J Midwifery Womens Health. feeding. Breastfeed Med. 2016;11(2):46-53. 2012;57(4):353-364. 15. Ekström A, Abrahammson H, Eriksson RM. Women’s use of nipple 35. Heller MM, Fullerton-Stone H, Murase JE. Caring for new moth- shields:Their influence on breastfeeding uration after a process- ers: diagnosis, management and treatment of nipple dermatitis in oriented education for health professionals. Breastfeed Med. breastfeeding mothers. Int J Dermatol. 2012;51(10):1149-1161. 2014;9(9): 459-466. 36. Amir LH, Cullinane M, Garland SM, et al. The role of micro- 16. Chakrabarti K, Basu S. Management of flat or inverted nipples organisms (Staphylococcus aureus and Candida albicans) in the with simple rubber bands. Breastfeed Med. 2011;6(4):215-219. pathogenesis of breast pain and infection in lactating women: 17. Allen KT. A randomized controlled trial evaluating lanolin for the study protocol. BMC Pregnancy Childbirth. 2011;11:54. treatment of nipple pain among breastfeeding women [Dissertation]: 37. Witt A, Mason MJ, Burgess K, et al. A case control study of bacte- Nursing, University of Toronto (Canada); 2014. rial species and colony count in milk of breastfeeding women with 18. Geddes DT, Kent JC, McClellan HL, et al. Sucking characteristics chronic pain. Breastfeed Med. 2014;9(1):29-34. of successfully breastfeeding infants with ankyloglossia: A case 38. Witt AM, Burgess K, Hawn TR, et al. Role of oral antibiotics in study. Acta Pædiatr. 2010;99:301-303. treatment of breastfeeding women with chronic breast pain who 19. Pugh LC, Buchko BL, Bishop BA, et al. A comparison of topical fail conservative therapy. Breastfeed Med. 2014;9(2):63-72. agents to relieve nipple pain and enhance breastfeeding. Birth. 1996; 39. Kvist LJ, Hall-Lord ML, Rydhstroem H, et al. A randomised- 23(2):88-93.20. controlled trial in Sweden of acupuncture and care interventions 20. Mohammadzadeh A, Farhat A, Esmaeily H. The effect of breast for the relief of inflammatory symptoms of the breast during lacta- milk and lanolin on sore nipples. Saudi Med J. 2005;26(8): tion. Midwifery. 2007;23(2):184-195. 1231-1234. 40. Duncan D. Candida and breastfeeding. Br J Midwifery. 21. Melli MS, Rashidi MR, Nokhoodchi A, et al. A randomized trial 2015;23(2):98-100. of peppermint gel, lanolin ointment, and placebo gel to prevent nipple crack in primiparous breastfeeding women. Med Sci Monit. 41. Amir L, Donath S, Garland S, et al. Does Candida and/or 2007;13(9):Cr406-411. Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia. BMJ Open. 22. Abou-Dakn M, Fluhr JW, Gensch M, Wockel A. Positive effect 2013;3:e002351. of HPA lanolin versus expressed breastmilk on painful and dam- aged nipples during lactation. Skin Pharmacol Physiol. 2011; 42. Arroyo R, Martín V, Maldonado A, Jiménez E, et al. Treatment of 24(1):27-35. infectious mastitis during lactation: Antibiotics versus oral admin- istration of lactobacilli isolated from breast milk. Clin Infect Dis. 23. Dennis CL, Jackson K, Watson J. Interventions for treating painful 2010;50(12):1551-1558. nipples among breastfeeding women. Cochrane Database Syst Rev. 2014;12:1-69. 43. Barrett ME, Heller MM, Fullerton Stone H, Murase JE. 24. Rennie AM, Cowie J, Hindin PK, Jewell S. The management of Dermatoses of the breast in lactation. Dermatol Ther. nipple pain and/or trauma associated with breastfeeding. Best 2013;26(4):331-336. Practice. 2009;13(4):17-20. 44. Barrett ME, Heller MM, Stone HF, Murase JE. Raynaud 25. Vieira F, Bachion MM, Mota DDCF, Munari DB. A systematic phenomenon of the nipple in breastfeeding mothers: an underdiag- review of the interventions for nipple trauma in breastfeeding nosed cause of nipple pain. JAMA Dermatol. 2013;149(3): mothers. Image J Nurs Sch. 2013;45(2):116-125.14. 300-306. 26. Lochner JE, Livingston CJ, Judkins DZ. Clinical inquiries: Which 45. Thompson A, Pope J. Calcium channel blockers for primary interventions are best for alleviating nipple pain in nursing moth- Raynaud’s phenomenon: A meta-analysis. Rheumatology. ers? J Fam Pract. 2009;58(11):612a-612c. 2005;44:145-150. 27. Cordero MJA, Villar NM, Barrilao RG, et al. Application of extra 46. Tchivileva I, Lim P, Smith S, et al. Effect of catechol-Omethyl- virgin olive oil to prevent nipple cracking in lactating women. transferase polymorphism on response to propranolol therapy in Worldviews on Evid Based Nurs. 2015;12(6):364-369. chronic musculoskeletal pain: A randomized, double-blind, pla- 28. Lavergne NA. Does application of tea bags to sore nipples while cebo-controlled, crossover pilot study. Pharmacogenet breastfeeding provide effective relief? JOGNN. 1997;26(1):53-58. Genomics. 2010;20:239-248. 29. Akbari SAA, Alamolhoda SH, Baghban AA, Mirabi P. Effects of 47. Sriraman NK, Melvin K, Meltzer-Brody S. ABM clinical protocol menthol essence and breast milk on the improvement of nipple fis- #18: Use of antidepressants in breastfeeding mothers. Breastfeed sures in breastfeeding women. J Res Med Sci. 2014;19(7):629-633. Med. 2015/07/01 2015;10(6):290-299. 30. Brent N, Rudy SJ, Redd B, et al. Sore nipples in breast-feeding 48. Kernerman E, Park E. Severe breast pain resolved with pectoral women: a clinical trial of wound dressings vs conventional care. muscle massage. J Hum Lact. 2014;30:287-291. Arch Pediatr Adolesc Med. Nov 1998;152(11):1077-1082. 49. Strong G. Provider management and support for breastfeeding 31. Marrazzu A, Sanna MG, Dessole F, Capobianco G, Piga MD, pain. JOGNN. 2011;40(6):753-764. Dessole S. Evaluation of the effectiveness of a silver-impregnated 50. Hauck Y, Graham-Smith C, MCInerney J, Kay S. Western medical cap for topical treatment of nipple fissure of breastfeeding Australian women’s perceptions of conflicting advice around mothers. Breastfeed Med. 2015;10(5):232-238. breast feeding. Midwifery. 2011;27: e156-e162.

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Topics in Pain Management CE Quiz

To earn CME credit using the enclosed form, you must read the certificate immediately. Please note: Lippincott CME Institute, Inc., will CME article and complete the quiz and evaluation assessment survey on not mail certificates to online participants. Online quizzes expire on the the enclosed form, answering at least 70% of the quiz questions correctly. due date. Select the best answer and use a blue or black pen to completely fill To earn nursing CNE credit, you must take the quiz online. Go to in the corresponding box on the enclosed answer form. Please indi- www.nursingcenter.com, click on CE Connection on the toolbar at the cate any name and address changes directly on the answer form. If your top, and select Browse by Journal. On the next page, select Topics in name and address do not appear on the answer form, please print that Pain Management. information in the blank space at the top left of the page. Make a photo- Log-in (upper right hand corner) to enter your username and copy of the completed answer form for your own files and mail the orig- password. First-time users must register. After log-in, locate and click inal answer form in the enclosed postage-paid business reply envelope. on the CE activity you are interested in. There is only one correct Your answer form must be received by Lippincott CME Institute by answer for each question. A passing score for this test is 7 correct September 30, 2017. Only two entries will be considered for credit. answers. If you pass, you can print your certificate of earned contact Online CME quiz instructions: Go to http://cme.lww.com and click hours and access the answer key. If you fail, you have the option of tak- on “Newsletters,” then select Topics in Pain Management. Enter your ing the test again at no additional cost. For questions, contact Lippincott username and password. First-time users must register. After log-in, Williams & Wilkins: 1-800-787-8985. The registration deadline for follow the instructions on the quiz site. You may print your official CNE credit is October 31, 2018.

1. Assessing breastfeeding pain is important because 6. Which of the following topical interventions for treatment A. breastfeeding pain is always associated with infection of nipple pain are supported by Oxford Center for B. pain is a common reason for cessation of breastfeeding Evidence-Based Medicine level 2 evidence? C. breastfeeding pain is a key indicator of engorgement A. Peppermint and purified lanolin D. neurohormones released into breast milk are harmful B. Trilaminate silver and warm compresses 2. Breastfeeding pain C. Purified lanolin and expressed breast milk A. usually peaks during the first 3 days after birth D. Petroleum jelly and shea butter B. is normal after the first week 7. The Breastfeeding Pain Reasoning Model proposes that C. is not important information during a breastfeeding assessment maternal pain during breastfeeding is affected by D. is abnormal only if the pain has neuropathic features A. maternal social, emotional, and cognitive state 3. Individualized counseling for managing breastfeeding pain B. maternal nipple shape needs to include C. positioning during breastfeeding A. assessment of skin integrity, history of onset and symp- D. maternal age, race, and ethnicity toms, characterization of the pain, treatment of pain 8. Although all mothers are at risk for nipple pain and trauma with antibiotics, analgesics, and/or antifungals during the first week of the infant’s life, which one of the B. assessment of skin integrity, history of onset, pain following indicates increased risk? intensity, other symptoms that accompany the pain, dis- A. First-time mothers cussion of “normal” versus “abnormal” pain B. History of preexisting dermatologic conditions C. assessment, history of onset and symptoms, apprecia- C. History of antibiotic use tion of the mother’s perception of her pain, understand- D. History of diabetes ing of strategies already tried by the mother, and acknowledgment of maternal competence 9. Engorgement occurs within 72 hours after delivery and is D. history of onset and symptoms, characterization of the characterized as pain, discussion about seeing the lactation specialist A. severe pain B. neurohormonal pathway regulation of milk supply 4. Interventions for infection should include C. filling of milk sinuses A. analgesics prescribed along with antibiotics D. an abnormal physiologic process B. after 24 hours of antibiotic therapy, resume breastfeeding C. use of breastmilk on the nipples after feedings to 10. Mothers who persist with severe pain during breastfeeding increase immune function after treatment with antifungals and antibiotics should be D. resume breastfeeding only after infection clears evaluated for A. Reynaud syndrome 5. Antenatal breastfeeding education significantly decreases B. eczema breastfeeding pain by providing C. mastitis A. strategies to maintain nipple integrity D. fibromyalgia B. instruction on proper infant positioning and latch C. management of lactogenesis II D. medications to increase or decrease the milk supply

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