Event 4: Child Bearing Breast Pain

Child Bearing Related Breast Pain

  • Pain during pregnancy
  • Pain during lactation
  • Sore Nipples
  • Ineffective attachment
  • Short frenulum

Pain During Pregnancy

  • Discomfort and pain can be caused by oversupply of milk and persistent breast engorgement
  • Pregnancy-induced gigantomastia (Rare)
    • Excessive engorgement
    • Breast enlargement is likely hormonal
    • Can result in tissue necrosis and infection
    • Thought to be related to breast tissue hypersensitivity to hormonal influences

Reference

Berens PD, 2015

Pain During Lactation

  • Pressure during breastfeeding is normal
    • Pain during breastfeeding is not
  • According to the CDC, exclusive breastfeeding rates drop 59.8% by 6 months postpartum
    • Main cause of decline is painful nipples and persistent nipple pain
      • Breastfeeding can lead to nipple problems such as the development of microscopic lesions
        • Lesions occur on the nipples and the areola
        • May appear as wounds, fissures, eroded skin, erythema, edema, white or yellow blisters, dark spots, and ecchymosis

Reference

CDC , 2011; Shanazi M, et al., 2015; Kent  JC, et al. , 2015; Dennis CL, Jackson K, & Watson J, 2014

Reasons Women Reported Weaning

Bar chart showing 29% of women reported weaning their babies because breastfeeding is too painful. Another 24% reported weaning because their breasts were overfull or engorged.
Reasons women reported weaning
Sharon Seeks Help from Dr. Spatz

Reasons for Lactation Pain

Mothers reporting:

  • Sore, cracked, or bleeding nipples
  • Baby having trouble latching
  • Breastfeeding as “too painful”

Are less likely to meet breastfeeding goals.

Pain is Not Normal

Sore Nipples

Most commonly due to nipple trauma (Traumatic Nipples):

  • Multiple causes related to improper breastfeeding technique or poor attachment (see Sore Nipple Etiologies)
  • For most women, the greatest nipple pain intensity seems to happen between 3-7 days postpartum 
  • Persistent nipple pain can cause psychological distress. It can interfere with:
    • Sleep
    • Activities 
    • Mood
    • Mother/child bonding 
  • May lead to deprivation of breast milk

Reference

Shanazi M, et al., 2015; Kent  JC, et al. , 2015

Additional Information on Treatments for Sore Nipples

From the Breast Feeding Centre of Western Australia.

Treatments for Sore Nipples
Sore Nipples Treatments Discussion
Correct Positioning and attachment
  • Most common recommendation 
  • When corrected early, breastfeeding duration is prolonged and sore nipple prevalence is reduced
Improving Latch
  • Infants between 4 days- 12 months old, this has been proven to resolve breast pain in 65% of cases
Nipple Shields
  • Short-term remedy for premature infants 
  • Helps with mothers who have flat/inverted nipples
  • Helps decrease intense suction
  • Should not be used too long
Anhydrous Lanolin/Vitamin A Ointments
  • Remedy for nipple pain caused by friction
Frentomy for Ankyloglossia
  • Effective for pain relief and to increase milk transfer 
  • Points to consider: Infant with tongue tie may have already developed and learned usual tongue mechanics which means fixing the tongue tie may not immediately relieve pain in the mother’s nipple
Warm Compress
  • Helps with milk blisters
Antibiotics/Antifungal
  • For breast pain caused by infection or Candida infection
Avoiding Irritants/Topical Corticosteroid Ointment
  • Remedy for Dermatitis and Psoriasis of the nipple
  • Points to consider: Topical steroids can be harmful for present trauma/fissures 
    • Can delay healing
Warmth/ Avoidance of Vasoconstrictors/Prescriptions for Nifedipine
  • Remedy for Raynaud’s Phenomenon.
Reference

Kent JC, et al., 2015; Berens PD, 2015

Topical Treatments for Sore Nipples

Topical Treatments for Sore Nipples
Herbal Treatment Discussion
Lanolin
  • Gives moisture to nipples 
  • Penetrates skin to help facilitate absorption of medicines
  • Can absorb up to 30% of water 
  • Use of Lanolin associated with an increase in the rate of infection 
  • Could be a result of hand hygiene when applying lanolin to the nipples
Dexphanthenol
  • Part of B complex vitamins 
  • Works a moisturizer to help keep skin hydrated by reducing water loss through the epidermis and can help to reduce nipple pain
Peppermint
  • Has been shown to decrease pain and increase healing in nipple trauma 
  • Can help to increase tissue flexibility and prevent fissures 
  • An effective treatment of traumatic nipples for patients interested in using herbal medications
Reference

Shanazi M, et al., 2015; Kent JC, et al., 2015

Treatment of Sore Nipples

Treatment for traumatic nipple pain has shown to be complicated because of the repeated sucking on the nipples by the infant 

  • Constant exposure of the nipple skin to the infant’s oral flora 
  • Microorganisms enter through the nipple fissures 
    • Cause infections
Reference

Shanazi M, et al., 2015

Pain Decrease by Treatment Type
Bar chart showing pain decrease by treatment type for nipple pain, over 3, 7, and 14 days.
Pain decrease for nipple pain based on treatment type
Pain Treatments

Dr. Spatz explains treatments for nipple pain.

Lanolin Treatment

Dr. Spatz explains more about lanolin treatment for sore nipples.

Reference

Shanazi M, et al., 2015

Treatment of Lactation Pain

  • Effective early lactation management is vital to avoid early weaning or breastfeeding cessation 
  • Early detection in intervention helps to prevent ongoing pain and psychological distress 
    • Herbal medicines have been used to help with pain
Medication Treatment

Dr. Spatz discusses medication treatment for lactation pain with Sharon.

Reference

Shanazi M, et al., 2015; Kent JC, et al., 2015

Ineffective Attachment

First, watch what effective attachment looks like.

Now, listen to Dr. Spatz describe the effects of ineffective attachment.

Dr. Spatz describes how a nipple shield can help address ineffective attachment.

Short Frenulum

Illustration shows short frenulum on an infant, with a series of dots indicating a surgical cut midway up the frenulum to release the tongue for greater movement.
Short frenulum. Compliments of The Mayo Clinic
 http://www.mayoclinic.org/ 

Dr. Spatz checks Sharon's baby for a short frenulum.

Mastitis

Mastitis is an inflammatory condition in the breast, often associated with lactation, occurring in women of all ages.

  • Sometimes milk stasis is the cause of mastitis 
  • Sometimes associated with infection 
  • Onsite of mastitis is often sudden 
  • Mastitis commonly occurs during early postpartum period

Definition of Mastitis

Dr. Spatz tells Shanita about the definition of mastitis.

Mastitis Prevention

Dr. Spatz tells Shanita different ways to prevent mastitis.

Reference

Maldonado-Lobon JA, et al., 2015; Berens PD, 2015; Afshariani R, et al., 2014

Incidence of Mastitis

  • 3%-33% of breastfeeding women will develop lactational mastitis.
  • Can be associated with infection.
A breast inflamed and red from mastitis
Compliments of The Mayo Clinic
http://www.mayoclinic.org/diseases-conditions/mastitis/basics/definition/con-20026633​​​​​

Most breast infections occur in breastfeeding women when bacteria enters the breast through cracks in the nipple. In severe infections, abscesses may occur.

Reference

Maldonado-Lobon JA, et al., 2015; Berens PD, 2015; Afshariani R, et al., 2014

Mastitis and Medical Reason for Early Weaning

  • Mastitis and painful breastfeeding may be linked to mammary bacterial dysbiosis. 
    • Potential pathogens increase at the expense of the normal mammary microbiota
      • Most organisms causing infections come from the infant’s oropharynx or nasal passage 
  • Mastitis is the main medical reason for early weaning

Reference

Maldonado-Lobon, J. A., et al., 2015; Berens, P. D. , 2015

Mastitis Risk Factors

  • Factors that inhibit adequate drainage of the gland/plugged ducts
  • Poor infant attachment
  • Sore nipples
  • Nipple trauma that allows for organisms to enter
  • Mastitis with prior breastfeeding experiences
  • Using breast pumps/manual pumps
  • Nipple cracks
  • Recent use of antifungal creams

Follow-up Visit for Mastitis

Shanita returns to Dr. Spatz with pain.

Reference

Maldonado-Lobon JA, et al., 2015; Berens PD, 2015

Complications of Mastitis

  • Cessation of breastfeeding
  • Breast tissue injury
  • Breast abscess
  • Recurrence
  • Pain
  • Illness

Reference

Afshariani R, et al., 2014

Treatment Considerations for Mastitis

  • Pain and inflammation control is a vital component to treating mastitis 
  • Treatment should be started immediately
  • Inflammation control is vital because painful breasts could prevent mother from removing milk effectively or feeding their baby 
    • This could lead to further complications of mastitis

Treatment of Mastitis

Dr. Spatz tells Shanita about treatment options for mastitis.

Antibiotics for Mastitis

Dr. Spatz goes over the use of antibiotics to treat mastitis with Shanita.

Reference

Afshariani R, et al., 2014

Question and Answer with Dr. Spatz on Child Bearing Related Breast Pain

Advice for New Moms

Mastitis

Medication

What Can We Tell New Mothers?

Who to Call?

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