Julie Zemaitis DeCesare and Karen Shelton
History of present illness
A 36-year-old gravida 3, para 3 woman presents 2 days postpartum following an uncomplicated vaginal delivery complaining of severe breast soreness and nipple pain with lactation. The pain started with thefirst feeding, became more intense over the past 12 hours, and has gotten worse with each subsequent feeding. She described the pain as a “searing, burning pain” that gets worse as the feeding progresses. She is anxious and crying. She states she is really committed to breast-feeding this child, and is worried she will not be able to continue. She has successfully breast fed her two previous infants, although she had problems with chronic yeast infec- tions in her breasts with her second child. She is taking no medications other than prenatal vitamins and has no other medical problems. Depression screening was negative.
Physical examination
General appearance:Thin, white woman who is slightly anxious
Vital signs:
Temperature: 37.0°C Pulse: 70 beats/min
Blood pressure: 100/70 mmHg Respiratory rate: 14 breaths/min
Abdomen:Soft, nontender uterus palpated 1 cm below the umbilicus
Breast:Bilateral symmetric tenderness, nofluctuance, slight erythema at the nipples, nipples everted (Fig. 59.1)
How would you manage this patient?
The patient has cracked, irritated nipples likely secondary to an improper infant latch. An observational assessment of the feeding session was performed by a lactation consultant. It was observed that the infant’s lips were noted to be curled under forming an incomplete seal, and the nipple was not centered in the infant’s mouth creating an improper areolar grasp. Instruction on proper latch techniques were provided and recommendations for breast-feeding pillows and other comfort measures were reviewed including pure lanolin solution, rubbing expressed milk into the nipple, and hydrogel pads.
She was advised to feed on the side with the least amount of discomfortfirst and wasfitted with a 24 mm nipple shield.
The patient noted gradual improvement with the next feeding sessions, and went on to breast-feed successfully for 12 months.
Cracked nipples
The Department of Health and Human Services “Healthy People 2020” goal for breast-feeding are 81.9%, 60.6%, and 34.1% in the early postpartum period, 6 months, and 12 months, respectively. In 2010, these breast-feeding rates are 76.5%, 49.0%, and 27.0%, respectively [1] As reviewed in the American College of Obstetricians and Gynecologists
“Breast feeding: maternal and infant aspects”[2], breast pain is the second most common reason for early discontinuation of breast-feeding. As a clinician, an understanding of the
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 59.1 Breast.
causes and treatments of common breast problems resulting in cracked nipples is important to improve current breast- feeding rates.
When a patient presents with cracked nipples, she will often report pain on lactation that is described as burning or searing. The pain gets worse as the feeding session con- tinues, and often starts with one of the first few feeding sessions. Common physical examinationfindings for nipple pain include bilateral and symmetrical tenderness, slight redness, and dry andflakey skin on the nipple. Smallfissures or cracks can be noted upon close inspection of the nipples and areola.
Breast causes of cracked nipples include engorgement, mastitis, plugged milk ducts, yeast, and skin disorders. Almost all women experience some form of breast engorgement in the postpartum period, and most commonly present within the first two weeks. Engorged breasts can promote nipple cracking, as well as act as an entry point for bacteria. Infant causes of nipple cracking include poor latch, improper position, and infant teething, while maternal causes of sore and cracked nipples are improper pumping techniques with mechanical pumps and harsh cleansing agents on the breast. Skin condi- tions of the breast such as psoriasis, thrush, and contact dermatitis can cause also cause nipple soreness and cracking while breast-feeding [3].
If a woman develops cracked nipples, the treatment is multifactorial. Supportive care isfirst line, and it is important to encourage the mom to continue to breast-feed despite the discomfort. Feeding from the less painful sidefirst is import- ant, as the infant suck is less vigorous after they are somewhat satiated. Additionally, frequent small feedings can help facili- tate a less vigorous suck. Expressing some milk and gently rubbing into the nipples can sooth the tender area. Pure lanolin rubbed into the nipples before and after feeding can prevent chafing and cracking. It is important to change wet nursing bras/undergarments to keep the breast clean, dry and to prevent chaffing. Use of a commercial available nursing nipple pad can facilitate this. Hydrogel pads are used to sooth chaffed and cracked nipples. These dressings are designed to keep the breast moist to facilitate healing, provide immediate pain relief and adsorb drainage. Finally, it is key to promote proper hand washing, as cracked breasts are very prone to infectious complications.
If supportive care does not quickly improve, a nipple shield is recommended. This is a nipple-shaped sheath worn over the areola and nipple during breast-feeding. Shields vary in size and are made of soft, thin silicone with holes at the end of the nipple section to allow breast milk to pass through (Fig. 59.2).
Nipple shields are used to allow mothers to continue breast- feeding until her cracked or sore nipples heal. Nipple shields should be of temporary use and aim is always to return to regular breast-feeding.
Thrush or yeast will need to be treated in both the mother and infant, and should be suspected as a cause of cracked nipples if the mother complains of persistent redness, itchy
or burning nipple pain, shooting pains in the breast after feeding, or intense pain that is not improved with better latch and positioning. The nipples and areola may appear pink or red, shiny, orflaky. This condition should be suspected when the infant has thrush, or the mother has persistent erythema.
Treatment of the mother with oralfluconazole (Diflucan®) for 10–14 days, as well as treating the infant with nystatin is appropriate. Mastitis should also be considered as a cause of nipple soreness and erythema; however, it can be differentiated from other causes by fever andfluctuance.
Prevention of cracked nipples in the breast-feeding experience is crucial for long-term success. Keys to prevention include the correct latch and position early on. Education and observation of the feeding experience can correct the latch before any breast problem occurs. Prevention of engorgement will also preclude cracked nipples. Feeding on demand, as much as every two hours in the newborn period, helps to prevent this condition. Additionally, manually expressing milk prior to feeding can help the infant more effectively latch.
Taking the baby offthe breast, by gently breaking suction with the tip of a clean maternal finger will prevent trauma from occurring at the nipple. Proper hygiene to the breast decreases contamination with skinflora; however, harsh/heavily scented cleansers can themselves be a source of breast trauma.
Fig. 59.2 Nipple shield.
Case 59: A 36-year-old woman with nipple pain postpartum
In summary, it is important to address and acknowledge that nipple pain is a common occurrence in lactation, and present solutions and interventions to prevent cracking and further complications. Antepartum education regarding expectations, proper latch, and infant position can be provided by clinicians well before thefirst feeding session. Techniques on supportive care and how to manage/prevent nipple cracking is important to facilitate and improve breast-feeding rates.
Key teaching points
Most breast-feeding women experience nipple pain at some point, and it is one of the most common reasons for early discontinuation of breast-feeding.
Improper latch is one of the most common causes of nipple pain and cracked nipples.
Prevention of cracked nipples by education regarding proper latch and proper infant position for feeding can be provided in the antepartum period.
Use of lanolin, hydrogel dressings, and nipple shields are interventions that can be employed once the cracking has occurred.
References
1. Centers for Disease Control and Prevention. Breastfeeding. Available at http://www.cdc.gov/breastfeeding/data/
nis_data/
2. American College of Obstetricians and Gynecologists. Breast feeding:
maternal and infant aspects. Committee Opinion No. 361.Obstet Gynecol2007;
109(2 Pt 1):479–80. Reaffirmed 2013.
3. Lawrence R, Lawrence R.
Breastfeeding: A Guide for the Medical Professional, 7th edn. Maryland Heights, MO, Elsevier Health Sciences, 2010.