Breastfeeding And Nipple Trauma

Introduction

Definition of nipple trauma

Although there is no standardised definition, nipple trauma is an expression used to describe physical injury or damage to the nipple and surrounding areas. This could involve fissures (cracks), abrasions, oedema (swelling), blisters, bruises, or other forms of trauma affecting up to 76% of breastfeeding mothers within the first week postpartum.1  Nipple wounds or soreness are the main reasons why women reported stopping breastfeeding sooner than they had initially intended. Consequently, early professional intervention, prevention and treatment are essential for successful breastfeeding.²

Importance of breastfeeding

Health benefits of breastfeeding to both mothers and children have long been recognized worldwide. Breast milk is exclusively matched to an infant’s nutritional needs and is a live substance with incomparable immunological and anti-inflammatory properties that protect against a variety of illnesses and diseases for both mother and child.

When compared to mothers who breastfeed, it has been found that those who do not had a higher risk for certain poor health outcomes. A study published by ‘The Lancet’ including several others found that the risk of breast cancer was higher for women who have never breastfed.³

Similarly, ovarian cancer risk was found to be 27% higher for women who had never breastfed compared to those who had breastfed. Leading to the conclusion that exclusive breastfeeding and longer durations of breastfeeding are associated with better maternal health outcomes.

Significance of addressing nipple trauma in breastfeeding

Nipple trauma not only causes physical pain, but can also cause psychological distress interfering with general activity, mood, sleep, and bonding between mother and child. Most women report health advantages and a sense of closeness with their newborn as important factors when deciding to breastfeed.

Although there is no conclusive literature on the subject, breastfeeding might assist in lowering postpartum depression (PPD) risk, an under-diagnosed serious condition experienced by almost 13% of mothers. It can affect the mothers’ ability to fully care for the new​​born with some studies showing that women who breastfed or had longer breastfeeding durations had a much lower risk of PPD.

Causes of nipple trauma

Nipple trauma can be caused by a variety of factors including friction from clothing, excessive breastfeeding, incorrect use of breast pumps, piercings, or accidental injury to the breast. However, incorrect breastfeeding and strong or weak infant sucking are the most common causes of breast fissure. Below are some of the most common causes of nipple trauma;

Poor latch and positioning refers to the way a baby attaches to the breast during breastfeeding and it is an essential component to breastfeeding success. If a baby latches poorly, they may not be able to effectively obtain milk from the breast leading to insufficient milk and nutrition intake, causing poor weight gain. Poor positioning can also result in discomfort for the mother, leading to sore nipples and a decreased desire to breastfeed.

Incorrect breastfeeding techniques (IBT) refers to any method of breastfeeding that may hinder the baby's ability to effectively obtain milk from the breast or cause discomfort for the mother. This can include poor latch, improper positioning, as well as other factors such as not using the correct hold or not allowing the baby to fully empty one breast before switching to the other. Incorrect techniques can lead to issues such as inadequate milk intake, sore nipples and poor baby weight. A sub-Saharan study on IBT concluded that there was a strong correlation between home delivery, lack of education and lack of counselling during pregnancy with IBT.⁴

Infant oral issues with breastfeeding can impact a baby's ability to latch and feed effectively. Some common issues include tongue tie, lip tie, and high palate. A tongue tie occurs when the tissue under the tongue restricts movement, making it difficult for the baby to latch properly. A lip tie occurs when the tissue between the upper lip and gum is too tight and a high palate can make it difficult for the baby to create a proper seal around the nipple as a result the baby may suck harder causing pain and discomfort for the mother.

Nipple cracks and fissures - Nipple pain and fissures are experienced by 80% - 90% of breastfeeding women. A breast fissure is a macroscopic lesion in the areola around the breast, which can present as loss of skin, a wound, erythema (inflammation) or a blister.

Nipple blisters and blebs - Are inflammatory responses to nipple trauma, characterised by blister-like lesions that form on the surface of the nipple. They can appear serous or white in colour, and are often associated with plugged milk ducts and can present with hyperlactation.

Engorgement-related trauma - A painful overfilling of the breasts which can cause them to feel hard, tight and painful and it may lead to premature weaning, cracked nipples, blocked milk duct, mastitis and breast abscess.

Mastitis - breast tissue inflammation resulting in the breast feeling hot and painful, can be a result of a blocked milk duct, if left untreated can lead to breast abscess.

Blocked milk duct - Untreated breast engorgement can lead to a blocked milk duct, obstruction of milk flow in a section of the breast which feels like a tender lump. 

Vasospasm-induced nipple pain - Is a sudden constriction of the blood vessels in the nipple which can cause throbbing pain, stabbing or burning sensation. 

Thrush and nipple damage - Thrush infections can sometimes occur when the nipples become cracked or damaged resulting in the candida fungus that causes thrush to get into the nipple or breast.

Diagnosis

Nipple trauma is often diagnosed during a physical exam by a healthcare provider.

Symptoms

• Swelling 
• Inflamed skin around the areola  
• Breast lump
• Cracks/wounds/blisters
• Breast feeling hot and painful
• Throbbing pain
• Breast abscess
• Breasts feeling hard
• Inability to produce milk following childbirth
• Nipple bleeding

Treatment and management

Treatment for nipple trauma may involve the application of ointments or creams to the affected area, and avoiding further irritation to the nipple. In some cases, healthcare providers might suggest the use of a breast shield or nipple protector as a preventative measure for further trauma. In the case of a nipple infection, antibiotics can be prescribed to clear the infection.

Once the root cause of the nipple trauma has been established improving breastfeeding position can be beneficial. This often involves support from a trained health professional. Expressing a few drops of breast milk onto the affected area has also been shown to help, as breast milk contains elements that aid in healing and counter infection.

Photobiomodulation (low-level laser) therapy has been used for the treatment of nipple pain or nipple trauma in women during the breastfeeding period to reduce pain and heal injury. In severe cases of nipple trauma, surgery may be required to repair any injury caused to the nipple and surrounding areas.

Prevention and support measures of nipple trauma

The best practices in maternal health care comprise predominantly of health education activities regarding breastfeeding. Focusing on correct breastfeeding techniques during prenatal and postpartum care can contribute to the prevention of nipple injury in breastfeeding women.

However, more work is necessary to help women improve breastfeeding techniques. To significantly reduce the incidence of nipple trauma in breastfeeding women, continuous support on appropriate breastfeeding techniques throughout the maternal continuum care is mandatory in empowering breastfeeding mothers to overcome these challenges.

Summary

Nipple trauma affects a large number of breastfeeding mothers causing pain that in some cases results in early termination of breastfeeding sooner than initially intended. Symptoms can include but are not limited to nipple bleeding, breast lumps, cracks or blisters. Management can be through use of topical creams, antibiotics or in severe cases surgical intervention to repair any damage caused. Early intervention health education for expectant mothers is required to reduce the incidence of nipple trauma, empower women and avoid early weaning.