Background, prevalence, and key to NDC management of nipple pain and damage in lactation

Introduction

Nipple pain and damage is common in breastfeeding women. But interventions for clinical problems such as breast inflammation and pain remain a research frontier.2, 3

• The Neuroprotective Developmental Care Clinical Guidelines for lactation-related nipple pain and damage propose a new mechanobiological model of nipple pain and damage in breastfeeding.

• NDC clinical guidelines address the common lactation-related problem of pain of the nipple-areolar complex, including of the nipple stroma (that is, structural connective tissue of the mammary papilla in which vasculature, ducts and nerve fibres are embedded).

• Clinicians should maintain a high index of suspicion for viral infection (in particular, herpes simplex and also herpes zoster viruses) in breastfeeding women with nipple pain. You can find more about this here.

• NDC's evolutionary and complex systems approach to lactation-related nipple pain and damage is part of a mechanobiological model of breast inflammation, which is applied more broadly in the NDC breastfeeding domain. The NDC breastfeeding domain is foundational to all other domains of the NDC or Possums programs.21, 22, 23, 24-31

What is the prevalence of lactation-related nipple pain and damage?

Nipple pain is one of the most common reasons for introducing formula or ceasing breastfeeding.32, 33

• In Li et al’s 2008 study of 1323 mothers in the USA, more than a quarter stopped breastfeeding in the first month postpartum; 29.3% cited pain and 36.8% cited sore, cracked, or bleeding nipples as an important reason.34

Nipple pain is a very common experience of breastfeeding women.

• Even at 8 weeks post-birth in Buck et al’s 2014 study, 20% of 340 respondants reported current nipple pain and 8% current nipple damage; 58% reported experiencing nipple pain at some time post-birth.35

• In 2015, an audit of the Western Australia Breastfeeding Centre found that 36% of 1177 consultations by International Board Certified Lactation Consultants (IBCLCs) were for nipple pain.41

Nipple pain, with or without visible damage, occurs most often in the first week post-birth.

• In 2014, Buck et al found that 79% of 317 first-time breastfeeding Australian mothers experienced nipple pain by the time they were discharged home after birth of their baby, despite being motivated to breastfeed, well-educated, and in a ‘Baby Friendly’ accredited institution with extensive postnatal support.35

• A 2021 study of 58 Spanish women found that 97% experienced nipple soreness at 48 hours postpartum, and a higher pain score was associated with skin-to-skin contact lasting more than two uninterrupted hours in the immediate postpartum.36 A 2014 Cochrane review found that nipple pain reduced to mild levels 7-10 days after birth for a majority of breastfeeding women, regardless of treatment used.37

• In a 2020 online survey of 1084 women in the UK who had finished breastfeeding in the past two years, 76% reported having experienced latch-related nipple pain at some time.38

Unfortunately, it is not possible to know which women will go on to develop persistent nipple pain and damage. This is why from the NDC perspective every breastfeeding woman who reports nipple discomfort or pain needs a gestalt intervention as soon as possible.

Over half of women with nipple pain develop visible damage or wounds

Visible signs include blisters, bruises, erythema, oedema, cracks or fissures, ulcers and exudate. These visible signs of damage are associated with increased pain.39

• Using the Numeric Rating Scale of 0-10, women with nipple damage reported a mean score of 6.2 in the first week and 5.8 after that period; women without visible damage reported a mean of 2.7. 40

• Large studies suggest that nipple pain occurs more commonly in Australia, the United States and the United Kingdom than in other parts of the world, such as Brazil, Denmark, South Africa, or Peru, emphasising the importance of environmental factors.41-46

To give an example of possible environmental variables which make nipple pain and damage more prevalent in some locations compared to others, a popularly taught fit-and-hold strategy (shaping the breast with cross-cradle hold) is associated with a fourfold increase in nipple pain.47

Overview of pathophysiology

Lactation-related nipple pain is most commonly a symptom of inflammation due to repetitive application of excessive mechanical stretching and deformational forces to nipple epidermis, dermis and stroma during milk removal.

• Keratinocytes lock together when mechanical forces exceed desmosome yield points. But if mechanical loads continue to increase, desmosomes may rupture. If these microscopic ruptures track together over many desmosomes and become macroscopically significant, with a visible epithelial fracture, a crack or other epithelial wound results.

• Bending or deformational forces in the nipple stroma cause microhaemorrhages, resulting in an inflammatory response and increased stromal interstital fluid and pressures. This increased inflammatory pressure triggers nociceptive activity and pain perception.

In order to help, clinicians need to understand how the environment of the skin of the nipple-areolar complex is uniquely conducive to wound-healing, and also uniquely exposed to environmental risks. We discuss the protective elements and unique risks of nipple and areola skin here.

References

1. Victora CG, Bahl R, Barros AJD, Franco GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387:475-490.
2. Stuebe AM. We need patient-centred research in breastfeeding medicine. Breastfeeding Medicine. 2021;16(4):349-350.
3. Rey J. Frontier research: bringing the future closer. Lychnos: Notebooks of the Fundacion Generale CSIC. 2011;5(June):https://fgcsic.es/lychnos/en_en/forum/frontier_research_bringing_the_future_closer.
4. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. The Lancet. 2017;390:156–168.
5. Saini V, Brownlee S, Elshaug AG, Glasziou P, Iona Health. Addressing overuse and underuse around the world. Lancet. 2017; doi:10.1016/S0140-6736(16)32753-9.
6. Hoffman T, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening and tests - a systematic review. JAMA Internal Medicine. 2015;175(2):274-286.
7. Hoffman T, Del Mar C. Clinicians' expectations of the benefits and harms of treatments, screening, and tests - a systematic review. JAMA Internal Medicine. 2017;177(3):407-419.
8. Hanoch Y, Rolison J, Freund AM. Reaping the benefits and avoiding the risks: unrealistic optimism in the health domain. Risk Analysis. 2018;39(4):792-804.
9. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.
10. Douglas P. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry alot in the first few months overlooks feeding problems. J Paediatr Child Health. 2013;49(4):e252-e256.
11. Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018:88-89.
12. Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012–2016. Otolaryngol Head Neck Surg. 2020; doi:10.1177/0194599820925415.
13. Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health. 2021;17:17455065211031480.
14. Munblit D, Perkin MR, Palmer D, Allen K, Boyle RJ. Assessment of evidence about common infant symptoms and cow's milk allergy. JAMA Pediatrics. 2020;174:599-608.
15. Wang Y-H, Wintzell V, Ludvigsson JF, Svanstrom H, Pasternake B. Association between proton pump inhibitor use and risk of asthma in children. JAMA Pediatrics. 2021;175(4):394-401.
16. Malchodi L, Wagner K, Susi A, Gorman GH, Hisle-Gorman E. Early antacid exposure increases fracture risk in young children. Pediatics. 2018;142(1):http://pediatrics.aappublications.org/node/140169.full.print.
17. Kvist L. Diagnostic methods for mastitis in cows are not appropriate for use in humans: commentary. International Breastfeeding Journal. 2016;11(2):doi 10.1186/s13006-13016-10061-13001.
18. Ellehauge E, Schmidt Jensen J, Gronhoj C, Hjuler T. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal. 2020;67(5):A01200051.
19. Joseph KS, Kinniburg B, Metcalfe A, Raza N, Sabr Y, Lisonkova S. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open. 2016;4:e33-e40.
20. Dixon B, Gray J, Elliot N, Shand B, Lynn A. A multifaceted programme to reduce the rate of tongue-tie release surgery in newborn infants: Observational study. international Journal of Pediatric Otorhinolaryngology. 2018;113:156-163.
21. Crawford E, Whittingham K, Pallett E, Douglas PS, Creedy DK. An evaluation of Neuroprotective Developmental Care (NDC/Possums Programs) in the first 12 months of life. Maternal and Child Health Journal. 2022;26(1):110-123.
22. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509–518.
23. Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth. 2022;22(94):doi:10.1186/s12884-021-04363-8.
24. Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772.
25. Douglas PS. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Med Hypotheses. 2005;64:887-898.
26. Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013;81:816-822.
27. Douglas P, Miller Y, Bucetti A, Hill PS, Creedy D. Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first three to four months of life ("The Possums Approach"): effects on cry-fuss behaviours and maternal mood. Australian Journal of Primary Health. 2013;21:38-45.
28. Whittingham K, Douglas PS. Optimising parent-infant sleep from birth to 6 months: a new paradigm. Infant Mental Health Journal. 2014;35:614-623.
29. Douglas PS. Pre-emptive intervention for Autism Spectrum Disorder: theoretical foundations and clinical translation. Frontiers in integrative neuroscience. 2019:doi.org/10.3389/fnint.2019.00066.
30. Ball H, Douglas PS, Whittingham K, Kulasinghe K, Hill PS. The Possums Infant Sleep Program: parents' perspectives on a novel parent-infant sleep intervention in Australia. Sleep Health. 2018;4(6):519-526.
31. Ball H, Taylor CE, Thomas V, Douglas PS, Sleep Baby and You Working Group. Development and evaluation of ‘Sleep, Baby & You’ - an approach to supporting parental well-being and responsive infant caregiving. Plos One. 2020;15(8): e0237240.
32. Odom E, Scanlon K, Perrine C, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatics. 2013;131:e726-732.
33. Dias JS, Vieira TDO, Vierira GO. Factors associated to nipple trauma in lactation period: a systematic review. Revista Brasileira de Saude Materno Infantil. 2017;17(1):27-42.
34. Li R, Fein SB, Chen J, Grummer-Strawn LM. Why mothers stop breastfeeding: mothers' self-reported reasons for stopping during the first year. Pediatrics 2008;122:S69-S76.
35. Buck ML, Amir LH, Cullinane M, Donath SM, CASTLE study team. Nipple pain, damage and vasospasm in the first eight weeks postpartum. Breastfeeding Medicine. 2014;9:56-62.
36. Jimenez Gomez MI, Monroy AM, Martin JC. Prevalence of nipple soreness at 48 hours postpartum. Breastfeeding Medicine. 2021;16(4):325-331.
37. Dennis C, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews. 2014(12):doi:101.1002/14651858.CD14007366.pub14651852.
38. Bourdillon K, McCausland T, Jones S. Latch-related nipple pain in breastfeeding women: the impact on breastfeeding outcomes. British Journal of Midwifery. 2020;28(7):406-414.
39. McClellan HL, Hepworth AR, Garbin CP, Rowan MK, Deacon J, Hartmann PE, et al. Nipple pain during breastfeeding with or without visible trauma. Journal of Human Lactation. 2012;28(4):511-521.
40. Coca KP, Amir LH, Da Silva Alves MdR, Barbieri M, Marcacine KO, De Vilhena Abrao ACF. Measurement tools and intensity of nipple pain among women with or without damaged nipples: a quantitative systematic review. Journal of Advanced Nursing. 2018;75:1162-1172.
41. Kent JC, Ashton E, Hardwick C, Rowan MK, Chia ES, Fairclough KA, et al. Nipple pain in breastfeeding mothers: incidence, causes and treatments. International Journal of Environmental Research and Public Health. 2015;12:12247-12263.
42. Puapornpong P, Paritakul P, Suksamarnwong, Srisuwan S, Ketsuwan S. Nipple pain incidence, the predisposing factors, the recovery period after care management, and the exclusive breastfeeding outcome. Breastfeeding Medicine. 2017;12:169-173.
43. Feenstra MM, Kirkeby MJ, Thygesen M, Danbjorg DB, Kronborg H. Early breastfeeding problems: a mixed method study of mothers' experiences. Sexual and Reproductive Health. 2018;16:167-174.
44. Santos KJ, Santana GS, Vierira TdO. Prevalence and factors associated with cracked nipples in the first month postpartum. BMC Pregnancy and Childbirth. 2016;16:209.
45. Doherty T, Sanders D, Jackson D. Early cessation of breastfeeding amongst women in South Africa: an area needing urgent attention to improve child health. BMC Pregnancy and Childbirth. 2012;12:105.
46. Strong GD. Provider management and support for breastfeeding pain. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2011;40:753-764.
47. Thompson RE, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth. 2016;29:336-344.