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.

More than 90% of new mothers experience pain during breastfeeding in the first week after delivery.1 A major reason often cited for breastfeeding cessation in the first 2 weeks after birth is maternal breast and nipple pain.2 Since 1990, the World Health Organization3 has recommended breastfeeding as optimal nutrition for infants for the first 6 months of life. In turn, breastfeeding initiation has increased across the world and has recently reached 80% of all infants in the United States.4 Yet, by the time the infant is 2 weeks old, 20% of breastfeeding mothers will have discontinued breastfeeding.5 In addition, within the first 2 weeks after delivery, more than 30% of breastfeeding mothers seek professional lactation support due to pain. Of these mothers, 45% continue to have chronic pain, even with intervention.6

Many women lack the understanding that breast and nipple pain is "normal" during breastfeeding initiation. In addition, interventions to manage breast pain are sometimes not an emphasis in prenatal education, to avoid discouraging mothers from breastfeeding.7 However, this gap in mothers' knowledge endangers continued breastfeeding.2,5 In addition, mothers who are at risk for severe pain during breastfeeding, such as women with preexisting chronic pain conditions, may need additional consultation and support for breastfeeding pain management.

Acknowledging the nipple/breast pain and working closely with the mother to consider strategies that relieve her pain are important (Table 1). Nonjudgmental support of mothers during this time can identify ways to decrease pain while helping them to continue breastfeeding. Wagner et al5 found that if mothers' concerns were not addressed on day 3, mothers had a 9 times greater chance of ceasing breastfeeding. For most mothers, pain peaks by day 3 and subsides by day 7; however, some women continue to have breast pain for up to 6 weeks.5,6 During the first year, it has been documented that the mother-infant dyad makes an average of 36 visits to health care providers.7 These visits, especially during the first weeks after delivery, are an ideal opportunity to support the mother's breastfeeding success while assessing and managing breastfeeding pain.6,8,9

Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating Breast Pain

Mothers experience breastfeeding pain at different points in time and from different factors. Initial pain is related to increased use (8-12 breastfeeding sessions daily). Nipple and breast pain are triggered by infants' poor latch, bacteria and yeast infections, sensitivity because of Reynaud syndrome, allergies causing dermatitis, or from a mother's personal decreased pain thresholds. To best support mothers, clinicians need a general understanding of what causes breast pain and what interventions will help alleviate maternal pain. Generally speaking, breast pain is related to 4 factors: (1) transition to breastfeeding (initiation pain); (2) mechanics of breastfeeding (latch and positioning); (3) organisms that decrease skin integrity (thrush and infections); and (4) tissue sensitivity, such as preexisting dermatologic conditions or Reynaud syndrome.

Pain During Breastfeeding Initiation

Nipple soreness is for the most part normal during breastfeeding initiation. During assessment, the breast and nipple may appear normal or slightly pink. However, many mothers are unprepared for the pain and at a loss about how to manage their pain between feedings.9 The first step in helping mothers to manage pain and soreness is to acknowledge and anticipate the problem and ask mothers for details in a non-judgmental style:

* Where exactly is the pain?

* When does it begin?

* How long does it last?

* Is the pain sharp or dull?

* Are there areas of the breast that hurt more than others?

* Does anything the baby does make the pain worse?

* Does the pain begin or get worse just before breastfeeding, during breastfeeding, or just after breastfeeding the infant?

* What interventions has the mother already tried?

Breastfeeding pain is an interaction between the mother's ability to modulate her central nervous system signaling of nipple pain while managing her environmental and local stimulation.8 More specifically, Amir et al8 propose the Breastfeeding Pain Reasoning Model to understand the various factors that influence variation in breastfeeding pain. In this model, central nervous system modulation is an interaction between prolonged afferent nerve stimulation from the nipple, maternal medical history, including parity or pain tolerance, and cognitive, emotional, and social state that supports her ability to manage the pain. Mothers need to be assured that experiencing pain is "normal" initially and not a reflection of maternal competence. This is especially important because self-rated maternal competence and the presence of maternal postpartum depression can be closely tied to breastfeeding success.10 Providing support and encouragement during this difficult time are important to long-term breastfeeding outcomes.11

These questions also assess external stimuli that predispose mothers to pain, such as a flat nipple, an infant's shallow latch, which traumatizes the nipple, or the use of a breast pump.8,12 Mothers with flat or inverted nipples (10% of all mothers) require interventions to elongate the nipple, including the best practice of pumping before breastfeeding and using a nipple shield during feeding and rubber bands.13-16 Many mothers also use a breast pump to establish maternal milk supply. If mothers are provided with too small a flange for the breast size, the areola and nipple will rub against the flange throughout the pumping session.13,14 Constant rubbing may irritate or in extreme cases cause a friction burn.13,14 The nipple shield, a soft silicone-vented dome placed over the nipple, provides a solid surface for infants to latch, and protects the nipple as the nipple elongates from infants' suction and from infants who create and sustain over 200 mm Hg of negative intraoral pressure during feeding.12-15 Lastly, rubber bands have been used to protrude the flat nipple; however, none of the findings addressed maternal pain from the intervention.16 Even with these strategies, the mother may experience pain as the nipple tissue is stretched or adhesions broken with the infant's sucking.

The evidence is clear that antenatal breastfeeding education prepares mothers to solve issues with infants' position, latch, and sucking effort.6,9 Although postpartum education is timely, it is important to note that nipple pain and trauma may occur with only 1 poor breastfeeding session.6,9,17 Correct positioning of the infant is critical, because if the infant's mouth is misaligned with the nipple, the infant will gum the nipple instead of sucking. In addition, if infants' lips are not flanged out, the tongue can retract, and the infant may gum or strip the nipple against the hard palate instead of the soft palate, both causing nipple damage. Finally, if infants have a short frenulum or tongue-tie, they may not be able to stretch the tongue to the soft palate, thus stripping the nipple against the hard palate causing nipple pain and damage.18 All of these factors contribute to the nipples appearing reddened, cracked, fissured, scabbed, and bleeding.

Mothers should be reminded to make sure the breast is kept dry and clean between breastfeeding sessions to prevent infection. During infants' initial latch, most mothers with nipple trauma experience severe "toe-curling" pain that subsides or dissipates during feeding.6,14 However, if mothers experience severe pain throughout breastfeeding, they may need to pump and provide breast milk until their nipples heal. If mothers notice infants have blood in their mouth or observe blood in their pumped milk, reassure mothers that infants will not be adversely affected by swallowing maternal blood.

Lastly, local stimulation refers to mechanical stimulation. When nipple tissue is traumatized, such as with nipple compression, it releases inflammatory markers such as histamines, bradykinins, and substance P.17 When these markers are liberated, they cause nociceptive responses in small nonmyelinated C fibers.15 Other conditions that predispose mothers to skin breakdown and pain sensation include dermatitis, and vasospasm from Raynaud syndrome.17 Whenever there is skin breakdown on the breast or nipples, mothers are at much greater risk for infections. Health care professionals should encourage mothers to continue to breastfeeding as their nipple heals. Mothers need to be followed up closely during this time to prevent nipple yeast and mastitis. Each of these 3 factors influences the level and intensity of pain experienced during breastfeeding. See Figure 1 for other issues to consider during provision of a supportive breastfeeding pain assessment.

Figure 1. Assessment of breastfeeding pain.

Treatment for Nipple Pain and Trauma

Once a comprehensive assessment with history of onset is completed, clinical interventions to reduce maternal pain must become the focus of breastfeeding management. The challenge is that most topical pain relievers are contraindicated for infant consumption. Even if mothers remove the ointment before feeding, it is unknown how much infants might receive from the skin and the friction to the nipples will be an additional irritant to skin integrity. Thus, management of nipple pain consists of nonpharmacologic topical interventions and preventative education. Pharmacologic intervention is used for inflammatory conditions such as mastitis, candidiasis, or breast dermatitis.

Lanolin and Expressed Breast Milk

If the maternal nipple and breast is intact, clinical interventions will focus on maintaining skin integrity. Evidence supports the use of nipple massage after application of medical grade lanolin or expressed breast milk17,19-25 after every feeding. Purified lanolin is a yellowish white, fat-based moisturizing ointment derived from sheep fleece. Lanolin should be applied with 3-mm thickness, which provides protection from clothing and is semiocclusive, which keeps the nipple moist between feedings, promotes epithelial regrowth, and reduces pain.17 Expressed breast milk is also applied after each feeding and has antibacterial and antiviral properties.22,23 Both interventions have demonstrated a reduction in maternal pain within 14 days. Several systematic reviews have evaluated both interventions. Vieira et al25 identified both interventions as level 2 evidence based on criteria from the Oxford Center for Evidence-Based Medicine, but they and Lochner et al26 found lanolin to be more effective in reducing pain. In contrast, a Cochrane review23 reported that no method was significantly better at reducing pain.

Nonpharmacologic Interventions

The use of warm compresses before feeding has been found effective in decreasing maternal pain from engorgement and after feeding, and for soothing nipple irritation.9,14 Extra virgin olive oil (EVOO) has immunological and anti-inflammatory properties. In one randomized trial, 2.7% of mothers who treated their nipples with a drop of EVOO, compared with 44% of mothers who treated their nipples with breast milk after breastfeeding, exhibited cracked nipples, which was significant (p < 0.000).27 EVOO has not been compared to lanolin. Other moist dressings are not recommended, including tea bags, due to astringent and drying effect,28 and hydrogels, which, although soothing, are associated with a high incidence of breast and nipple infections.14

Menthol (peppermint) gel or oil is considered safe during pregnancy and lactation by the FDA and is a household remedy in the Middle East to treat nipple fissures.21,29 Menthol demonstrates antimicrobial properties specifically against gram-positive bacteria, and in both small studies performed in Iran, decreased nipple pain and healed nipple fissures in significantly shorter time than lanolin and expressed breast milk.21,29

Breast shields, a vented plastic dome whose base has an opening for the maternal nipple, has been used with or without lanolin to protect the nipple from rubbing against the maternal bra and promote air flow for healing.31 Another form of shield is a nonvented dome composed of trilaminate silver. Silver ions are a natural antibiotic and have emerged as an alternative to antibiotic treatment.31 Mothers place the cap on the breast between feedings. One pilot study found mothers experience a significant decrease in maternal pain within 7 days of a nipple fissure compared with no treatment.28 Lastly, one study used light-emitting diode (LED) phototherapy lights and its ability to promote local vascularization and decrease pain twice a week to treat nipple fissures. For mothers in the treatment group, nipple fissures healed within 4 biweekly visits compared with 8 biweekly visits for controls.29

Engorgement

Breastfeeding pain has been characterized as transient or prolonged.9 The transient pain occurs at 48 to 72 hours after delivery when release of lactogenesis II results in engorgement of breast sinuses. This is a normal physiologic response, even if the mother reports the pain as severe.5,6,14 Engorgement typically lasts 72 hours. As the infant feeds, the neurohormonal pathway gives biofeedback as to the volume of milk the infant requires for growth. Although it is normal, engorgement can be uncomfortable to very painful for mothers. Treatment is a careful balance to support infants' ability to latch on a full breast and decrease maternal pain. Before breastfeeding, mothers may use warm compresses or a breast pump to soften the breast enough for the infant to latch and stimulate milk let down. Although warmth provides comfort, use of warm compresses or warm showers should be cautious as removal of excess milk beyond the infants' need will trigger the neurohormonal pathway to provide additional milk, thus continuing engorgement.14 Maternal massage of the breast to release plugged milk sinus during feeding is imperative, as stagnate milk is a source for bacterial infections.33 Cold compresses, such as a bag of frozen peas or leaves of green cabbage, after feeding can be used to reduce breast swelling and pain.6,14

For some mothers, pain from oversupply persists beyond the first week. Milk oversupply also has nutritional implications for the infant. Infants may become full on the foremilk composed of low milk fat and water and obtain less of the high-fat hind milk needed for growth and development. Interventions to decrease milk supply include tea made from sage, a member of the mint herbal family, careful use of pseudoephedrine, and oral contraceptive pills containing estrogen.14

Pain or engorgement, past the first week, is considered abnormal and should be evaluated by a lactation health care professional.

Organisms That Decrease Skin Integrity Leading to Pain

Diagnosing nipple pain related to infections requires a thorough inspection of the breast, and a good discussion with the mother about the history of onset. Depending on the causative agent, topical or oral antibiotics (Staphylococcus aureus) may be considered. If the causative agent is Candida, antifungals might be prescribed.9,25,34,36 When there is evidence of an infection, expressed breast milk should not be used as a topical agent nor should nipple ointments, gels, creams, or dressings be used.9,25,34,36 The latest research does not support their continued use. Increasing the opportunity for a warm moist environment increases the susceptibility of the mother-infant dyad to poorer skin integrity and potential for increased infections or recurring infections.9,35

Mastitis or breast infection is typically triggered by a break in skin integrity or stagnation of milk within the milk sinuses, allowing bacteria such as S.aureus to proliferate.14,36 It is usually occurs after the second or third week of breastfeeding and is characterized by soreness and reddened areas of the breast. The occurrence is most often unilateral, although bilateral and repeat infections can occur. Signs and symptoms of mastitis include chills, increased temperature, and maternal fatigue.36-38 Treatment may include the use of antibiotics and analgesics and rest and hydration.14,36,37 Mothers are encouraged to breastfeed frequently and apply warm compresses after feeding. An alternative approach, using acupuncture compared with standard treatment for mastitis, found a significant decrease in breast pain at 3 and 4 days of treatment.39 Regardless of any treatment, the breast should be cleaned and kept dry until the next feeding. Breastfeeding through the mastitis episode can be difficult for the mother, yet providing extra support and encouragement is important to long-term breastfeeding outcomes.14,34,36,37

Candidiasis occurs as an overgrowth of naturally occurring yeast that lives normally on the skin and mucous membranes.40,41 The warm and moist environment found in the infant's mouth and on the mother's breast increases the risk for yeast to overgrow. Candidiasis infections can occur at any time during breastfeeding; however, it is important to note that if the mother or infant has been treated with antibiotics, the risk is increased and more intense assessments need to occur.38,40,41 Diagnosis is by clinical symptoms, although a DNA and polymerase chain reaction (PCR) assay for candidiasis are becoming readily available.14,36,41 When there is a delay in treatment, because of the need to work up other differentials, it is important to keep good communication with the mother.36,40,41

With candidiasis there is persistent soreness and redness in the nipples; burning and itching may also be present. In addition, mothers often report that pain is increased during breastfeeding 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 mother and the infant and other family members who may have symptoms. Many strategies may be used concurrently, such as: (1) initially, nipple ointments and topical antifungal agents and/or Gentian violet (<0.5% aqueous solution) may be used daily for no more than 7 days; (2) nystatin suspension or miconazole oral gel for the infant's mouth; and (3) human milk probiotics to treat subclinical mastitis. Vigilant hand hygiene is critical, along with hygienic care of the breasts between feedings. This includes cleaning and care of anything that goes into the infant's mouth. If resistant, oral fluconazole (200 mg once, then 100 mg daily for 7-10 days) may be prescribed.14,36,41,42 Lastly, acidophilus can be added to the mother's daily intake to help balance the normal flora growth. Reinfection is common, so it is important to work with the mother to appreciate the course of infections and best understand what makes the mother-infant dyad more susceptible to infections so the cycle can be broken. Helping mothers not only to understand the need for acute immediate care strategies but to also consider the bigger picture of what is occurring long term will help with working through this process.36,40,41

Preexisting Dermatologic Conditions and Pain Sensitivity

Mothers with preexisting skin allergies such as eczema, psoriasis, or other dermatologic conditions are at increased risk for breast pain because of the potential for decreased skin integrity.43 They need even greater support, including good hygiene and drying the breast between feedings, and the routine use of a topical corticosteroid to relieve symptoms. Before feeding the infant, corticosteroid creams need to be removed to decrease infant exposure. Mothers who are more susceptible to allergic reactions could be more likely to experience breast pain if they use ointments or creams as a supportive measure while breastfeeding. Once allergic reactions occur, the irritant (ointment or cream) needs to be discontinued and the area kept clean and dry.9,14

Sometimes mothers experience nipple vasospasms with breastfeeding that can be acutely painful. These spasms are due to a reduction in circulation and can cause blanching of the nipple or nipple discoloration. Sometimes the pain radiates into the breast, as with Candida. As such the cause of the pain can be easily misdiagnosed. Occurrence is greater in the winter months and in thin women with poorer circulation and a family history of Reynaud syndrome.41 Because the syndrome is often affected by temperature, the most effective intervention is making sure the environment is not cold during breastfeeding and applying warm water compresses after breastfeeding. If these interventions are not effective, nifedipine 30 to 60 mg sustained release daily, or immediate release 10 to 20 mg thrice a day, for 2 weeks, may be prescribed.14,45

Mothers with a history of pain disorder may experience excruciating pain with breastfeeding, light touch, or drying with a tool. These mothers may require pharmacologic management of round-the-clock nonsteroidal anti-inflammatory ointments.26 If mothers do not respond well, additional therapy of propranolol beginning at 20 mg 3 times a day and antidepressants may be needed.43,44 Lastly, one study found that massage therapy targeting problematic areas is effective.45

Clinicians may not understand the severity of pain mothers experience during breastfeeding. In part because there is no standardized assessment for maternal pain, systematic assessment of breastfeeding pain has been scarce. In addition, many studies had small samples in varying populations, making it difficult to compare or combine results. Conducting research in this area is difficult, yet it is very important to the continuation of breastfeeding for the first year of life.

In general, if health care clinicians expect mothers to continue breastfeeding their infant, management strategies need to be quick and effective. Breastfeeding pain needs to be acknowledged and accompanied by individualized counseling that addresses the unique needs of the mother given her current condition and history with breastfeeding strategies. Pain management needs to include both nonpharmacologic and pharmacologic strategies. In a retrospective chart review, Strong49 found that prescription of medications was used most frequently for management of breast pain. Counseling and nonpharmacologic measures were rarely documented. There were also few referrals to lactation support services. Health professionals must use the best evidence to guide assessment and management of breastfeeding pain, particularly because conflicting advice is known to be a contributing factor in breastfeeding cessation.50

Conclusions

A majority of women who breastfeed will experience nipple and breast pain, particularly during breastfeeding initiation. Preparing women to develop strategies for managing pain during breastfeeding is ideally a focus of antenatal breastfeeding education. However, not all women are able to attend or complete educational sessions before birth. With greater recognition, acknowledgment, and support for dealing with nipple and breast pain during breastfeeding, there is a better chance that mothers will continue breastfeeding up to or beyond the recommended duration. Clinicians' assessment of the pain and potential contributing factors can provide direction for interventions focused on supporting the mother to continue breastfeeding. More intensive follow-up should take place for women who have mastitis or candidiasis to ensure that symptoms resolve and to increase the likelihood of good breastfeeding outcomes. Mothers at risk for severe pain during breastfeeding, such as women with preexisting dermatologic or chronic pain conditions, may need additional consultation and support. Ultimately, the time and effort provided in helping mothers to achieve better breastfeeding outcomes will contribute to infant health and long-term population health outcomes.

References