Abstract
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Nipple pain is not new and was eloquently reported in 1952 by Niles Newton. 3 Nipple pain has been reported increasingly in this decade by mothers as intense and persistent pain lasting weeks, not days. Pain is second only to perceived low milk supply as a reason for discontinuing breastfeeding, according to Buck et al. 1 Pain is also associated with depression, stress disturbances, and even mastitis, according to these authors. As common as pain has been, there has been little scientific study of the issue. Buck et al. 1 reported pain that occurred in the first 8 weeks of breastfeeding in a cohort of 360 primiparous women recruited at 36 weeks of gestation between November 2009 and June 2011 (20 months) who intended to breastfeed at least 8 weeks. They were followed up postpartum by telephone, home visits, and questionnaire. The cohort was well educated with 77% with tertiary degrees or higher, which somewhat limits the study's generalizability. Seventy-nine percent had breast pain in the hospital; others developed pain after discharge, and the pain slowly mitigated over weeks. Twenty percent of the group still had pain at 8 weeks. Fifty-eight percent were diagnosed with cracked or damaged nipples. The mothers had stopped breastfeeding before 8 weeks even though they had prenatal instruction, were committed to breastfeeding, and had delivered in a Baby-Friendly Hospital! Fifty percent did not have enough milk and a myriad of other reasons. Vasospasm was diagnosed only in a small group of women. The problems of breast pain were similar to those described by Niles Newton 3 in 1952, in spite of major changes in hospital care and maternal preparation. The authors concluded that “the most effective means of helping mothers to establish comfortable breastfeeding and to continue breastfeeding as long as they wish has yet to be established.”
An assessment of chronic breast pain was made by Witt et al., 2 who prospectively enrolled 38 women who responded to conservative therapy for their pain and 48 women who were given antibiotics after conservative management failed. Patients were followed up for 12 weeks. More women with Staphylococcus aureus growth failed conservative treatment. For those who failed conventional treatment, the nipple and the milk were cultured, and bacteria-specific antibiotic was ordered. Patients responded dramatically to this specific treatment. The authors pointed out that milk cultures were more effective than nipple cultures.
Taking another approach to the problems of mastitis while breastfeeding, Yoshida et al. 4 measured the taste of the milk from an inflamed breast and compared it with the taste of the milk from an uninflamed breast. Before one can appreciate the significance of milk flavors that were studied, it is helpful to know what umami is. The dictionary 5 defines umami as a taste characteristic of monosodium glutamate associated with meats and other high protein foods. It is sometimes considered to be the fifth basic taste along with sweet, sour, salty, and bitter. Because some infants refuse to suckle from an inflamed breast, the authors explored the taste of the milk as a possible cause of this refusal. They tested milk from 24 healthy mothers and 13 with mastitis. It was concluded that tastes are specifically associated with inflamed breasts with an increase in saltiness and umami. It has been known biochemically that the permeability of the gland changes over time as milk production is established. Sodium has been measured during this period of colostrum production and found to gradually decrease as mature milk is established. Sodium or saltiness and umami may be valuable markers for infection.
A commentary from the W.K. Kellogg Foundation and Christopher and Krell 6 discusses the changing breastfeeding conversation and the present-day culture. They state that a cultural and societal shift is needed. They proclaim that shifting the conversation from a focus on the individual mother to a focus on the breastfeeding system is key to making breastfeeding a public health issue.
The employer and the work environment are key players in this paradigm shift. Christopher and Krell 6 challenge hospitals, employers, and mothers themselves to broaden the scope of the discussion to involve communities, hospitals, workplaces, and public health venues to contribute to this cultural shift.