Nipple Pain & Trauma ©2021 Nancy Mohrbacher, IBCLC, FILCA 1

Nipple Pain & Trauma

Overview • Definitions Nipple Pain • Causes of nipple trauma and Trauma: • Comfort tips, Causes & hygiene Treatments • Treatments • Complications of trauma • Other causes of ongoing Nancy Mohrbacher, IBCLC, FILCA nipple pain

What’s Normal • Feel tugging or pulling • No pain or discomfort • Slight discomfort at first Definitions during Weeks 1 or 2 – Hormonal influences? – Covered breasts? – Feeding techniques?

Breastfeeding Pain Reasoning Model

Predisposing Factors Cognitive-Emotive-Social State Incidence • Parity (self-efficacy) • Anxiety, negative • Past history (parents) expectations of nipple pain • Mastalgia • Personal control (partners) • Previous trauma CNS • Social support • Pain education • Fatigue & nutrition – 11% to 96% Modulation • Attention to BF as new skill – Most studies: 70% to 90% Mother Attributes • Nipple shape • Nipple flexibility Chemical Michael Woolridge: Stimulation Baby External Local Nipple pain is a Attributes Influences Stimulation • Inflammatory “biological warning drugs • Tongue tie • Prostaglandins that damage • Small mouth Misc. • Oxytocin is being done.” Mother-Baby • Breast pump • Catecholamines • Cream Interaction • Pad Amir, et al. Aust Fam • Shallow latch • Temperature Phys 2015; 44(3):127-32

Causes of Interactive Causes Nipple Trauma • Shallow latch • Baby pulled off before breaking suction • Poor nipple- baby fit

• 708 consults over 12 mo • 36% involved nipple pain • In 89% pain due to more than one factor (from Not a “position,” most to least common) different, primarily 1. Shallow latch baby-driven 2. Tongue tie approach to newborn nursing 3. Infection 4. Unusual palate Favor NB first 4 to 6 weeks

Watch free video at www.NaturalBreastfeeding.com Kent., et al. Int J Environ Res Public Health 2015; 12:12247-63

With NB, Half Breast/Nipple Problems Early Positioning & Comfort Zone RCT followed 208 women birth-4 mo, ½ used upright holds, ½ NB NB group had half the: • Nipple pain, cracks • Engorgement • Mastitis

Milinco, M., et al. Int Breastfeed J; 2020; 15 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132959/ www.YouTube.com/NancyMohrbacher

Baby Causes Parent Causes

• Engorgement • Flat, inverted nipples

• Oral restrictions • Unusual palate • Torticollis • Sucking issues

Pump and Product Causes Comfort Tips

• Poor quality pump and • Too-high suction Hygiene • Nipple not centered • Poor fit • Wet breast pads

Comfort Tips for Nipple Pain 3 aspects of our role • Remedy cause of pain • Suggest pain- reduction strategies • Prevent infection • Take recommended pain medication • Try positions that allow baby to do the latching • Feed more often to reduce sucking strength • Start baby on least-sore side • Stimulate milk ejection before nursing • Try a nipple shield

Biofilm, Hygiene, and Infection Wash nipple with soap & water

• Coating grown to protect bacteria colony • May be stimulated by saliva • Highly resistant to antibiotics • Daily washing disrupts biofilm

Wilson-Clay & Hoover. • Recommended for Harriott & Noverr. Antimicrob Agents Chemother 2009; 53(9):3914-22 The Breastfeeding Atlas, 2017 other wounds

Treatments 2014 Cochrane Review Conclusion: Insufficient evidence to recommend any treatment for nipple pain

For most parents, pain reduced to mild by 10 days

Dennis, et al. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007366. DOI: 10.1002/14651858.CD007366.pub2

Possible drawbacks of During 1st week creams, ointments after birth, • Unfamiliar taste 91%of • Slippery latch Australian • Remove before nursing nursing parents • Clog nipple pores used topical • Drying (if alcohol) nipple • Some are numbing treatments

Buck, M.L., et al. Clinical Lactation 2015; 6(1):16-23

Ultra-Purified Lanolin All-Purpose Nipple Ointment (APNO) Jackson & Dennis. Mat Child Nutr 2016; 13(3): doi: 10.1111/mcn.12357 Evidence: Clinical & research on nipple trauma Evidence: Clinical & research on nipple trauma • By prescription only RCT (N=186), at Day 4, no – Mupirocin ointment 2%: 15 g statistically significant – Betamethasone ointment 0.1%: 15 g differences found in – Add miconazole powder to • Pain scores make final concentration 2% • % weaned miconazole • BF self-efficacy – Total: 30 g Maternal satisfaction • No more effective than USP lanolin • 53% lanolin Dennis, et al. Breastfeed Med 2012; • 22% control 7(6):473-79

Studying Low-Level Laser Therapy Studying Silver Nipple Cups

Triple-blind • Pilot study, 40 women randomized clinical with nipple pain and trial (N=59 with trauma similar nipple − 20 silver cups lesions) treated at − 20 expressed milk 0, 24, 48 hr • Day 2, no differences in − Pain After 1st 2 treatments, − Bleeding pain scores during − Fissures breastfeeding • Day 7 & 15 less pain decreased 2.0 Coca, et al. Pain Manag Nurs 2016; Marrazzu, et al. Breastfeed Med 17(4):281-89 2015; 10(5):232-38; N=40

Mastitis

Symptoms: • Painful or tender lump in one or Complications both breasts of • Breast redness Nipple Pain & and/or swelling • Fever Trauma

Photo: UNICEF

Vasospasm Nipple compression can cause vasospasm (23%) • Nipple blanches after feeding • Intense, shooting breast pain between feedings

Photo: Jack Newman, MD

Buck, et al. Breastfeed Med 2014; 9(2):56-62 http://www.breastfeedinginc.ca/content.php?pagename=vid-vasosp

Raynaud’s Prevention Treatment Phenomenon • Nursein a • Warmth, massage Episodic warm area • 30 mg arteriospasm • Use blanket, wear sustained- reducing warm clothes release blood flow to • After nursing, nifedipine extremities massage nipple, 1x/day for 2 wk Affects 20% of apply dry heat, women of avoid air-drying • Vitamin B6— childbearing age nipples 100 mg bid • Avoid cold & for 2 wk More common other triggers with autoimmune disorders Hale & Berens. Clinical Therapy in Breastfeeding Patients, 2010

Superficial Bacterial Infection Candida Infection Possible symptoms in mother: Possible • Plaque symptoms: • Redness • Slowed/no healing • Visible pus • Pain may be (exudate) intense • Yellow scabs • Slowed, Possible symptoms no healing in baby: • Pain • White plaques in mouth may increase, • Diaper rash become intense Walker. The Nipple and Areola in Photo: Jack Newman, MD Breastfeeding and Lactation, 2010 Photo: The Breastfeeding Atlas

Bacterial Dysbiosis and Lactiferous Duct Infection • 79% reported nipple pain “Bacterial overgrowth… • 54% breast pain, possibly…with Candida radiating & not may lead to narrowed • 42% burning laciferous ducts and nipple pain inflamed epithelium.”

Burning nipple pain & Symptoms radiating breast pain • Chronic nipple lesions do not heal can be caused by • Deep breast pain nipple damage • Tender breasts

Amir, et al. BMJ Open 2013; 3(3) •Berens, et al. Breastfeed Med 2016; 11(2):46-53

Bleb or Clogged Milk Pore Treatments • Plugged • Warm saline soaks, olive nipple oil, rub gently pore with towel Nipple Pain • Related • Topical Unrelated to to lecithin Nipple Trauma plugged rubbed into ducts nipple • HCP open • Cause or with sterile effect? needle, express accumulated Photo: The Breastfeeding Atlas material

Dermatologists Diagnose & Treat Herpes Sores Waldman, et al. J Am Acad Dermatol 2018: doi: 10.1016/j.jaad.2018.08.067 Field. J Hum Lact 2016; 32(1):86-88 Heller, et al. Int J Dermatol 2012; 51:1149-61

Can be transmitted from parent to infant & infant to parent

• Impetigo • Psoriasis • Poison Ivy/Oak

Conditions related to allergy or irritation,

Photo: Jack Newman, MD, IBCLC such as dermatitis or eczema Photo: Jack Newman, MD, IBCLC

Other allergy Hormones of symptoms Pregnancy • Wheals • 74% report nipple pain • Scales • May • Hives encourage weaning before birth

Photo: The Breastfeeding Atlas Newton & Theotokatos. Emotion & Reproduction 1979; 20 B:845-49

Allodynia Referred Pain • Feels pain with a Nipple trauma stimulus not may be perceived usually painful as shooting • Hx pain disorder pains in breast Amir, et al. BMJ Open 2013; 3(3)

Injury in another area perceived as nipple pain

Berens, et al. Breastfeed Med 2016; 11(2):46-53

Paget’s Disease • 2-3% breast cancers • Resembles eczema • May include: ̶ Bloody nipple discharge ̶ Nipple redness, scaling, erosion, or Eczema Paget’s Disease ulceration • Usually bilateral • Unilateral ̶ Palpable • Intermittent hx, rapid evolution• Slow steady progression mass/thickening • Moist or dry • Moist • Many wait >30 wk • Irregular but definite edge before seeing MD • Indefinite edge Caliskan, et al. Breast • Nipple always involved Cancer Res Treat 2008; • Nipple may be spared & may disappear 112(3):513-21 • Itching common • Itching common

Overview • Definitions • Causes of nipple trauma Questions? • Comfort tips, [email protected] hygiene • Treatments www.NancyMohrbacher.com~ • Complications www.NaturalBreastfeeding.com of trauma Facebook.com/NancyMohrbacherIBCLC • Other causes Pinterest.com/nancymohrbacher of ongoing @BFReporter nipple pain www.YouTube.com/NancyMohrbacher