Image analysis revealed five signs of nipple trauma. Erythema and swelling were the most frequently observed signs during postpartum week 1. However, the agreement rate was lower than that for other signs, suggesting the possibility of conflicting interpretations in clinical evaluation.
The aim of this study was to clarify the change process of nipple tissue after initiating breastfeeding. MethodsFifty Japanese breastfeeding women were enrolled at an obstetrics and gynecology clinic in Sapporo, Japan, from October 2016 to January 2017. Collected photographs were processed for color correction using CASMATCH ® (KENIS Ltd., Osaka, Japan) and size correction using image-editing software (Photoshop 6, Adobe System Inc., Tokyo, Japan) and were displayed in chronological order. Visual analysis was conducted by three researchers based on the following seven nipple skin changes defined in a previous study: "erythema", "swelling", "blistering", "scabbing", "fissure", "purpura", and "peeling". In addition, these data were analyzed together with nipple pain and characteristics of participants. Observed results are organized based on three factors: the order of signs, chronological changes in one sign, and the relationship among the sings. A model was developed to describe the change process of nipple tissue. ResultsA total of 776 images were collected, and the following 15 patterns pertaining to the change process of nipple tissue were revealed. There were seven patterns pertaining to the order of signs: 1) development of "erythema" and /or "swelling" → improvement or healing; 2) "erythema" and/ or "swelling" → "fissure" → epithelialization → healing; 3) "fissure" → healing; 4) "erythema" and /or "swelling" → "blistering" → rupture → "scabbing"; 5) "blistering" → rupture → "scabbing"; 6) "erythema" → "scabbing"; and 7) "erythema" and /or "swelling" → "scabbing" → "erythema" of the peeled area. There were four patterns of chronological changes in one sign: 1) course of "fissure", 2) course of "blistering", 3) developing patterns of bloody "scabbing", and 4) signs that predicted peeling of "scabbing". There were four patterns of relationships among the sings: 1) relationship between "erythema" and/ or "swelling" and development of "blistering" or "scabbing", 2) relationship between "swelling" and "blistering", 3) relationship between "swelling" and "peeling" or worsening of "scabbing", and 4) relationship between "purpura" and /or "peeling" and the others. ConclusionThe change process of nipple tissue after initiating breastfeeding was presented based on daily nipple images. The findings of this study suggest that observations focusing on minor changes in the nipple tissue, such as "erythema" and /or "swelling" prevents more severe nipple trauma that can lead to the discontinuation of breastfeeding.
Background: No consensus on the definitions of nipple trauma has been reported. Thus, different individuals assess identical events inconsistently. Research Aims: To establish clear definitions for the seven signs of nipple trauma related to breastfeeding—erythema, swelling, scabbing, blistering, fissure, purpura, and peeling—and to reach consensus among multiple specialists. Methods: We implemented a longitudinal, prospective survey design using a 3-step Delphi method. In the first survey we targeted specialists in breastfeeding, dermatology, and cosmetics, and we presented images as representative cases during a set of semi-structured interviews. In the second and third surveys, we questioned midwives who were certified as “advanced midwives” through mail, using a questionnaire prepared based on the results of the first survey. The agreement criteria of this study were as follows: (1) a median of 2.0 or below; (2) an interquartile range of 1.0 or below; and (3) at least 51% showing responses of either “strongly agree” or “agree.” Results: Based on the responses of the 42 experts, we reached a consensus on 48 items: eight related to erythema, 10 to swelling, nine to scabbing, seven to blistering, seven to fissure, four to purpura, and three to peeling. We then classified these items based on the condition or possible mechanism of the wound. Finally, we developed an observation tool: “seven signs of nipple trauma associated with breastfeeding,” along with images. Conclusions: Application of this tool for breastfeeding support could improve objectivity in observing and evaluating nipple trauma.
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