BREASTFEEDING MEDICINE Volume 11, Number 2, 2016 ABM Protocol ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2016.29002.pjb ABM Clinical Protocol #26: Persistent Pain with Breastfeeding Pamela Berens,1 Anne Eglash,2 Michele Malloy,2 Alison M. Steube,3,4 and the Academy of Breastfeeding Medicine A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for man- aging common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. Purpose cracked, or bleeding nipples as an important reason.6 Several authors have found a relationship between breastfeeding- o provide evidence-based guidance in the diagnosis, associated pain and postpartum depression.7,8 (II-2, III) evaluation, and management of breastfeeding women T These studies suggest that breastfeeding-associated pain is with persistent nipple and breast pain. linked with significant psychological stress; thus, mothers presenting with pain should be evaluated for mood symptoms Definitions and followed closely for resolution or treatment as needed. Among breastfeeding women, it can be challenging to Timely identification and appropriate management of per- distinguish pathologic pain from discomfort commonly re- sistent breastfeeding-associated pain are crucial to enable ported in the first few weeks of breastfeeding. In this proto- women to achieve their infant feeding goals. col, we define persistent pain as breastfeeding-associated Although the literature on persistent nipple and/or breast pain lasting longer than 2 weeks. We are not addressing acute pain is limited and the differential diagnosis is extensive, a or recurrent mastitis as it is covered in ABM Protocol #4 number of etiologies and management strategies are emerg- Mastitis, Revised March 2014.1 ing, most of which are based on expert opinion. The highly individual nature of the breastfeeding relationship combined with the complexity of the lactating breast, including its Background anatomy, physiology, and dynamic microbiome, adds chal- Pain and discomfort associated with breastfeeding are lenges to the clinicians’ efforts. common in the first few weeks postpartum.2 (II-2) (Quality of evidence [levels of evidence I, II-1, II-2, II-3, and III] is based History and Examination on the U.S. Preventive Services Task Force Appendix A Task Assessment of persistent pain begins with a careful history Force Ratings3 and is noted in parentheses.) Since this is and physical examination of both mother and infant, with a common cause for early breastfeeding cessation,4 the particular attention to the following: mother–baby dyad should be evaluated by a lactation spe- cialist. Beyond this early period, reports of pain generally Breastfeeding history decline, but as many as one in five women report persistent B Previous breastfeeding experiences/problems/pain 5 pain at 2 months postpartum. While initial discomfort with B Nipple/breast sensitivity before pregnancy early latch may be considered physiological, pain severe en- B Milk supply (ongoing engorgement, high supply ough to cause premature weaning should not. In one study of versus low supply) 1323 mothers who stopped breastfeeding during the first B Pattern of breastfeeding (frequency, duration, one, or month postpartum, 29.3% cited pain and 36.8% identified sore, both breasts) 1Department of Obstetrics and Gynecology, University of Texas Health Sciences Center at Houston, Houston, Texas. 2Department of Family and Community Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. 3Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina. 4Carolina Global Breastfeeding Institute, Department of Maternal and Child Health, Gillings School of Global Public Health, Chapel Hill, North Carolina. 1 2 ABM PROTOCOL B Expression of milk, frequency, hand expression, and/ B Assessment of maternal mood using a validated in- or type of pump strument, such as the Edinburgh Postnatal Depression B Mother’s attitudes toward breastfeeding and her Scale breastfeeding goals Infant Pain history B Symmetry of head and facial features (including jaw B Onset postpartum angle, eye/ear position) B Early nipple trauma (abrasions, cracks, bleeding) B Oral anatomy (presence/absence of lingual frenulum, B Context (with latch, during breastfeeding, between evidence of thrush, palate abnormality, submucosal breastfeeds, with milk expression) cleft) B Location (nipple and/or breast; superficial versus deep) B Airway (looking for nasal congestion) B Duration (timing, intermittent, or constant) B Head and neck range of motion B Character (burning, itching, sharp, shooting, dull, B Infant muscle tone aching) B Other infant behavior that may give clues to under- B Pain severity using rating scale, such as 0–10 lying neurologic problems, for example, nystagmus B Associated signs and symptoms (skin changes, nipple A breastfeeding session should be directly observed to color change, nipple shape/appearance after feeding, assess the following: fever) B Exacerbating/ameliorating factors (cold, heat, light Maternal positioning touch, deep pressure) Infant positioning and behavior at the breast B Treatment thus far (analgesia, including nonsteroidal Latch (wide-open mouth with lips everted) anti-inflammatory drugs and/or narcotic prepara- Suck dynamics—pattern of feeding, nutritive and non- tions), antibiotics, antifungals, steroids, herbs, lubri- nutritive sucking, sleeping cants, other supplements Shape and color of nipple after feeding Maternal history If the mother is expressing milk, the clinician should di- B Complications during pregnancy, labor, and birth rectly observe an expressing session to assess the following: (medical conditions, interventions) Hand expressing technique B Medical conditions (especially Raynaud’s phenome- Breast shield/flange fit non, cold sensitivity, migraines, dermatitis, eczema, Breast pump dynamics, including suction and cycle chronic pain syndromes, candida infection, family frequency with the pump the mother is using history of ankyloglossia) B Evidence of trauma from the breast pump History of breast surgery and reason B Medications Laboratory studies, such as milk and nipple cultures B Allergies (Table 2), may be considered based on the history and B Depression, anxiety physical exam findings such as the following: B History of herpes simplex or zoster in the nipple/ Acute mastitis or mastitis that is not resolving with breast region antibiotics B History of recent breast infections Persistent nipple cracks, fissures, or drainage Infant history Erythema or rashes suggesting viral or fungal B Birth trauma or abnormalities on examination infection B Current age and gestational age at birth Breast pain out of proportion to examination (appear B Birth weight, weight gain, and general health normal, but very tender, breasts or nipples) B Behavior at the breast (pulling, squirming, biting, coughing, shortness of breath, excessive sleepiness) B Fussiness Differential Diagnosis B Gastrointestinal problems (reflux symptoms, bloody The potential causes of persistent breast and nipple pain stools, mucous stools) are numerous, may occur concurrently or sequentially, and B Medical conditions/syndromes include the following: B Previous diagnosis of ankyloglossia; frenotomy B Medications Nipple damage Dermatosis Examination should include the following: Infection Mother Vasospasm/Raynaud’s phenomenon B General appearance (pale [anemia], exhaustion) Allodynia/functional pain B Assessment of nipples (skin integrity, sensitivity, Table 1 lists symptoms and management of the different purulent drainage, presence/absence of rashes, col- diagnoses described below. oration, lesions) B Breast examination (masses, tenderness to light/deep Nipple damage pressure) B Sensitivity to light or sharp touch on body of breast, Epidermal compromise increases the risk of developing in- areola, and nipple fection and pain. Breastfeeding or using a breast pump to ex- B Manual expression of milk (assess for pain with press milk can induce an inflammatory response in nipple skin, maneuver) which may result in erythema, edema, fissures, and/or blisters. ABM PROTOCOL 3 1. Abnormal latch/suck dynamic 1. Eczematous conditions B Suboptimal positioning. Often cited as the most These conditions can affect any skin, but are com- common cause of sore nipples, suboptimal positioning monly seen on and around the areola in breastfeeding of the infant during a breastfeed can lead to a shallow women. Attention to the distribution of skin irritation latch and abnormal compression of the nipple between and lesions may help identify the underlying cause/ the tongue and palate.9–11 (II-2, III, III) trigger. Eczematous rashes vary considerably. B Disorganized or dysfunctional latch/suck: The abil- B Atopic dermatitis (eczema): This condition occurs in ity of an infant to properly latch and breastfeed is women with an atopic tendency and may be triggered dependent, among other factors, on prematurity, oral by skin irritants and other factors such as weather and and mandibular anatomy, muscle tone, neurological temperature change.19 maturity, and reflux or congenital abnormities, as B Irritant contact dermatitis: Common offending