Re-thinking lactation-related nipple pain and damage

Abstract

Nipple pain is a common reason for premature cessation of breastfeeding. Despite the benefits of breastfeeding for both infant and mother, clinical support for problems such as maternal nipple pain remains a research frontier. Maternal pharmaceutical treatments, and infant surgery and bodywork interventions are commonly recommended for lactation-related nipple pain without evidence of benefit. The pain is frequently attributed to mammary dysbiosis, candidiasis, or infant anatomic anomaly (including to diagnoses of posterior or upper lip-tie, high palate, retrognathia, or subtle cranial nerve abnormalities). Although clinical protocols universally state that improved fit and hold is the mainstay of treatment of nipple pain and wounds, the biomechanical parameters of pain-free fit and hold remain an omitted variable bias in almost all clinical breastfeeding research. This article reviews the research literature concerning aetiology, classification, prevention, and management of lactation-related nipple–areolar complex (NAC) pain and damage. Evolutionary and complex systems perspectives are applied to develop a narrative synthesis of the heterogeneous and interdisciplinary evidence elucidating nipple pain in breastfeeding women. 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, resulting in inflammation and epithelial fracture. Mechanical stretching and deformation forces may cause stromal micro-haemorrhage and inflammation. Although the environment of the skin of the nipple–areolar complex is uniquely conducive to wound healing, it is also uniquely exposed to environmental risks. The two key factors that both prevent and treat nipple pain and inflammation are, first, elimination of conflicting vectors of force during suckling or mechanical milk removal, and second, elimination of overhydration of the epithelium which risks moisture-associated skin damage. There is urgent need for evaluation of evidence-based interventions for the elimination of conflicting intra-oral vectors of force during suckling.

Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management

“…Disrupts human milk microbiome, decreases Lactobacillus and Bifidobacteria populations, may increase risk of breast inflammation 5,37,70 Education about breastfeeding techniques Ineffective. Although laid back breastfeeding has been shown to modestly decrease risk of nipple pain if applied from birth, there are no breastfeeding approaches which have been demonstrated to be effective as prevention [58][59][60][61] Prophylactic topical treatments, for example, mupirocin or fusidic acid Disrupt nipple-areolar complex microbiome, overhydrate the epithelium, and increases risk of epithelium pain and damage 19,37 Combination of breast massage and low-frequency pulse treatment Low certainty of evidence suggesting efficacy 37 BLBI: benign lactation-related breast inflammation.…”

“…Elimination of mechanical forces that cause high intraluminal pressures: a. Avoidance of conflicting vectors of force upon the nipple and breast tissue during milk removal, which compress lactiferous ducts (and also cause nipple pain, inflammation, and damage); 5,12,19,27,28 b. Avoidance of micro-vascular trauma in breast stroma, for example, by lump massage, which increases stromal tension, worsening compression of lactiferous ducts; 5 c.…”

“…The third article addresses aetiology, classification, prevention, and management of lactation-related inflammation of the nipple–areolar complex. 19…”

Application of Traditional Chinese Medical Science Characteristic Nursing Mode Based on Evidence-Based Medicine to Puerperal Breast Tenderness and Pain

“…In the early stage of breastfeeding, hormones such as prolactin and adrenocorticotropic hormone of the maternal organism are important for lactation regulation and the incidence of postpartum breast swelling and pain is higher. Postpartum breast distension is a common phenomenon among new mothers, and breast distension, nipple pain, and milk stagnation not only affect the postpartum recovery of the mother but also have a negative impact on the newborn's breastfeeding [ 18 , 19 ].…”

Cultural beliefs, attitudes and perceptions of lactating mothers on exclusive breastfeeding in The Gambia: an ethnographic study

“…Breastfeeding causes backache for some mothers. Despite the backache, mothers choose this as an alternative and they have historically associated breastfeeding with pain and weariness [42].…”