The Effects of Different Breastfeeding Training Techniques for Primiparous Mothers Before Discharge on the Incidence of Cracked Nipples

Abstract

Objective:

This research investigated the effects of different breastfeeding training techniques for primiparous mothers before discharge on the incidence of cracked nipples.

Materials and Methods:

This was a controlled intervention study that was carried out between 2015 and 2016 on 90 mothers living in İzmir. The mothers were divided into three groups: the demonstration-based training group, brochure group, and routine care-receiving group. The mothers in the “brochure group” were provided with breastfeeding training brochures. Mothers in the demonstration-based training group received one-to-one training using designed doll and puppet tools.

Results:

The rate of cracked nipples at age 2 weeks was 63.3% in the routine care-receiving group, 56.7% in the brochure group, and 20% in the demonstration-based training group. At the end of the fourth week, the rate was 30% in the routine care-receiving group and less than 10% in the other two groups (p < 0.005). The LATCH scores were higher in the demonstration-based training group than in the other two groups (p < 0.05). There was no significant difference between the groups in the percentage of exclusive breastfeeding.

Conclusion:

The results documented that breastfeeding training based on one-to-one demonstration utilizing specially designed audiovisual tools was more effective than the other two methods in the prevention of nipple cracks.

Introduction

Breastfeeding provides the ideal food for healthy growth and development of infants.¹ Nevertheless, there are many studies pointing out that breastfeeding problems in the early days of birth pose significant obstacles to successful breastfeeding.^2–7 Among the most common breast problems are breast abscesses, mastitis, sore and cracked nipples, milk-filled breast, flat or inverted nipples.^3,4,8 These problems generally occur within the first or second postpartum week and may continue up to 2 months.^1,9 Mothers have reported that sore or cracked nipples are the second most common cause of discontinuing breastfeeding.¹⁰

Throughout early postpartum period, rate of nipple pain and trauma has been reported to vary between 16% and 86%.^11–13 Of women experiencing cracked nipple problems, 38% carry the risk of giving up breastfeeding.¹⁴ Cracked nipple problems may also lead to early supplementation with formula.^10,15 Studies on nipple cracks have mostly focused on treatment. Studies focusing on the effects of preventive interventions are very few.^16,17 This present study investigated the effects of different training techniques before discharge for primiparous mothers on the subsequent incidence of cracked nipples.

Materials and Methods

Sample

The women who gave birth between October 2015 and March 2016 in the gynecology clinic of a hospital in Tepecik, Izmir, comprised the study population. Mothers, who were literate, 18 years and older, primiparous, and who had full-term births were included in the study. Those who had at-risk newborns or did not want to participate in the study or whose babies were referred from other hospitals were excluded from the study. The sample size was calculated as 90 at the NCSS-PASS 2005 program, by taking the incidence of nipple cracks as 46.0%, with α = 0.05 and 80% power. The sample was divided into three groups, each to include 30 mothers. To prevent contamination bias, first the routine care-receiving group, then the brochure group, and finally the demonstration-based training group were sequentially studied.

Ethics committee approval

The ethics committee approval was given with the decision of number 7 as a result of meeting number 15 dated November 24, 2015, of the İzmir Tepecik Education and Research Hospital Chief Physician Local Ethics Committee. All participants signed an informed consent form.

Data collection tools

Demographic, obstetric, and breastfeeding characteristics questionnaire

The questionnaire included items questioning age, education, employment status, type of delivery, first breastfeeding time after delivery, breastfeeding education status, and nutrition status other than breast milk.

Postdischarge follow-up form

The form was administered to evaluate the mothers' breastfeeding characteristics and nipple cracks at the second and fourth weeks after discharge from the hospital.

LATCH breastfeeding charting scale

The scale was developed by Jensen et al. for health professionals to assess mothers' breastfeeding manners.¹⁸ The reliability and validity study of the Turkish version of the scale was carried out by Yenal and Okumuş in 2003.¹⁹ In this present study, the scale was administered to the mothers before discharge and at the fourth week postdischarge. The scale focuses on the following five specific criteria for the assessment of breastfeeding: the baby's latching onto the breast, the amount of audible swallowing, the mother's nipple type, the mother's level of comfort, and the amount of help the mother needs to hold her infant to the breast. In the LATCH scoring system, each criterion is rated as 0, 1, 2.

Training materials

Training material for the study included a brochure with practical information, a guideline to breastfeeding and breastfeeding problem, and a model doll, a puppet doll, and a breast model.

Brochure given to the mothers

The brochure provided information both on breastfeeding positions, holding and grasping the breast by using pictures, and on preventive measures and solutions for breast problems.

Illustrated guideline

The guideline included such topics as the importance and benefits of breastfeeding, anatomy of the breast, formation of breast milk, breastfeeding techniques, prevention of breast problems, and breast care. In the guideline, the topics were mostly described using illustrations and messages that encouraged breastfeeding.

Model doll, puppet doll, and breast model

To give demonstration and assist the mothers in developing breastfeeding skills, a breast model made of fabric showing the anatomical characteristics of the breast, a specially sewn puppet, and a model doll were used. The breast model was particularly useful for showing the anatomy of the breast, how milk accumulates, how to correct the inverted nipple, and the area to be grasped by the baby while sucking. Handmade puppets and model dolls were used to demonstrate correct positioning of the baby for breastfeeding.

Intervention

Mothers in the routine care-receiving group were given breastfeeding services by the baby nurse working in the clinic. The mothers in the brochure group were given brochures prepared by the researchers. The mothers in the demonstration-based training group were shown the accurate and inaccurate breast holding positions, how to position the baby, and how to position the breast, and coached how to breastfeed their babies.

At the second week after discharge, the postdischarge follow-up form, and at the fourth week after discharge, both the postdischarge follow-up form and the LATCH breastfeeding charting scale were administered. The assessment of nipple cracks was carried out with breast examination under the supervision of a health professional. The presence of pain, pinkness, redness, edema, crusting, scarring, or bleeding in the nipple was regarded as a crack.

Routine care-receiving group

The participants in this group did not undergo any “special” interventions. To assess their breastfeeding status, they were administered the LATCH breastfeeding charting scale before discharge. The hospital where the study was conducted is a baby-friendly health facility. There are written posters and pictures pointing to the importance of breastfeeding in the institution, and the mother and baby stay in the same room after birth. However, there was no breastfeeding counselor to provide mothers with regular support on breastfeeding. The breastfeeding status of these mothers was assessed by a baby nurse working in the hospital. Support on breastfeeding was provided only to mothers who requested such support, and the mothers were not given any training material on breastfeeding.

Brochure group

The mothers in the brochure group were given a brochure containing practical information on breastfeeding, and their attention was drawn to important points relevant to the issue. In the brochure, illustrations were used to demonstrate the importance and benefits of breastfeeding, breastfeeding positions and techniques, and breast care. After the interview, the mothers' breastfeeding behaviors were assessed with the LATCH breastfeeding charting scale.

Demonstration-based training group

Breast model, puppets, and illustrated guidelines were used, and the breastfeeding training was given through explanations, demonstrations, and practices. The content of the training included such topics as the importance of breastfeeding, benefits of breast milk, breast anatomy, breast problems, breastfeeding techniques and positions, and breast care. The amount of time allocated to the training was 1 hour on average. After the training, the mothers' ability to breastfeed was observed, the LATCH breastfeeding charting scale was administered, and feedback was provided about the misapplications.

Data analysis

The SPSS version 16.0 was used in the statistical analysis of the data. The descriptive characteristics between the groups were presented by number–percentage distributions and compared with the chi-square test. For the intergroup analysis of the difference between the two applications in terms of the LATCH breastfeeding charting scale, the one-way ANOVA was applied for the related measurements. In all the follow-ups, the incidence of nipple cracks in the mothers was analyzed with the chi-square analysis. p Values <0.05 were considered statistically significant.

Results

Ninety mothers completed the study. Characteristics of mothers, standard care (30), brochure group (30), and demonstration group (30) are shown in Table 1. No differences were observed among groups, age, education, family type, previously breastfeeding education, and mode of delivery.

Table 1.

Characterization of Study Participants

	Routinely treated group (n = 30)	Pamphlet group (n = 30)	Demonstration-based group (n = 30)	p
Maternal age (years) [mean (SD)]	27.3 ± 5.98	25.5 ± 5.58	26.5 ± 5.40	0.438
Education (%)
Elementary school	25 (83.3)	22 (73.3)	23 (76.7)	0.136
Higher	5 (16.7)	8 (26.7)	7 (23.3)
Social Security (%)
Yes	25(83.3)	24 (80.0)	21 (70.0)	0.434
No	5 (16.7)	6 (20.0)	9 (30.0)
Family type (%)
Nuclear	22 (73.3)	20 (66.7)	22 (73.3)	0.805
Extended	8 (26.7)	10 (33.3)	8 (26.7)
Previous breastfeeding education (%)
Educated	19 (63.3)	14 (46.7)	13 (43.3)	0.252
Not educated	11 (36.7)	16 (53.3)	17 (56.7)
Mode of delivery (%)
Normal	15 (50.0)	14 (46.7)	14 (46.7)	0.959
C-section	15 (50.0)	16 (53.3)	16 (53.3)

The LATCH breastfeeding charting scale was first administered to the mothers in all the three groups before they were discharged and then at the end of the fourth week follow-up. The mean scores obtained from the LATCH breastfeeding charting scale increased in all the groups in the second administration of the scale. The comparison of the scores obtained by the groups indicated that the increase in the demonstration-based training group was higher than that in the other two groups, and the difference was significant (LATCH score at 4 weeks, standard care: 8.76 ± 1.28, brochure group: 9.06 ± 0.87, demonstration group: 9.63 ± 0.61) (F: 6.304, p < 0.05).

While there was no significant difference between the groups during the interviews before discharge in terms of nipple cracks, a significant difference was noted at the end of the second and fourth week after discharge. Especially at the end of the second week, the incidence of nipple cracks in the demonstration-based training group was very low. Intergroup comparisons of the results obtained in the study are shown in Table 2 (p < 0.05).

Table 2.

Comparison of the Groups in Terms of the Incidence of Nipple Cracks During All the Follow-Ups

Nipple cracks (%)	Routinely treated group (n = 30)	Pamphlet group (n = 30)	Demonstration-based group (n = 30)	χ²	p
At hospital
Yes	9 (30.0)	6 (20.0)	5 (16.7)	1.671	0.434
No	21 (70.0)	24 (80.0)	25 (83.3)
Two weeks after birth
Yes	19 (63.3)	17 (56.7)	6 (20.0)	13.125	0.001
No	11 (36.7)	13 (43.3)	24 (80.0)
Four weeks after birth
Yes	9 (30.0)	3 (10.0)	2 (6.7)	7.274	0.026
No	21 (70.0)	27 (90.0)	28 (93.3)

The percentage of breastfeeding mothers in the demonstration-based group was higher than the other groups, but the differences were not statistically significant (Table 3).

Table 3.

Breastfeeding at Hospital, 2 and 4 Weeks Postpartum

Percentage	Routinely treated group (n = 30)	Pamphlet group (n = 30)	Demonstration-based group (n = 30)	χ²	p
At hospital
EBF	18 (60.0)	19 (63.3)	24 (80.0)
BF and F	12 (40.0)	11 (36.7)	6 (20.0)	3.154	0.207
Two weeks
EBF	12 (40.0)	16 (53.4)	20 (66.7)	6.286	0.179
PB	10 (33.3)	10 (33.3)	8 (26.7)
BF and F	8 (26.7)	4 (13.3)	2 (6.7)
Four weeks
EBF	13 (43.3)	18 (60.0)	22 (73.3)	5.811	0.214
PB	10 (20.0)	8 (26.7)	5 (16.7)
BF and F	7 (23.3)	4 (13.3)	3 (10.0)

BF and F, breastfeeding and formula feeding; EBF, exclusive breastfeeding; PB, predominant breastfeeding.

Discussion

Nipple problems that develop during the early postpartum period can interfere with the establishment of successful breastfeeding. The incidence of nipple cracks in the mothers in the routine care-receiving group and brochure group was significantly higher than that in the mothers in the demonstration-based training group, and the rate of use of the correct breastfeeding technique was significantly higher among the mothers in the demonstration-based training group. The findings of other studies assessing the effects of training on breastfeeding and breastfeeding behaviors also noted similar findings.^1,18–22

In a study by Buck et al., 79% of the mothers had nipple pain and 58% had nipple cracks, although they gave birth at a baby-friendly hospital.¹⁰ In a study by McCan et al., it was emphasized that 39% of the mothers had nipple pain during the first month postpartum.¹² In a study by Kartal et al., the incidence of nipple cracks in the postpartum period was 55.8%.⁷ The incidence was 46% in a study by Şahin et al.⁸ In the educational intervention study conducted by Howel et al., attention was drawn to the fact that nipple problems were less common in the training group.²³ All these results suggest that nipple tenderness and pain are widespread in the first weeks of breastfeeding.

The results obtained from the present study show that breastfeeding training was more effective in preventing the nipple cracks than were the other two methods (p < 0.05). Besides the appropriate explanation provided to the mother, demonstration and application of the baby's appropriate latching onto the breast and proper positioning were emphasized. The high incidence of nipple cracks in the brochure group especially at the second week indicated that the provision of a brochure alone was not effective enough. In the routine care group, the incidence of nipple cracks was higher in all follow-ups. In this present study, it was observed that baby nurses had a very limited time to provide individualized breastfeeding counseling due to their intensive work load.

Most of the studies conducted on breastfeeding or elimination of breastfeeding problems recommend that mothers should be provided with practice-based training supported by multiple materials.^15,24,25Ahmed et al. emphasized the importance of providing mothers with training on how to cope with the difficulties that arise during the early postpartum period and of displaying comforting and positive attitudes toward them.¹⁵ In Henderson's study, in which the mothers who received a 30-minute individual training within 24 hours after delivery were compared to the mothers who received routine care, the incidence of nipple tenderness was lower in the former.²⁶

Assessment of breastfeeding ability, breast health, and a newborn's sucking behavior with a primiparous mother is crucial for the prevention of breast problems. The LATCH breastfeeding charting scale scores were higher in the demonstration-based training group at the measurements conducted both in the hospital and at the fourth week follow-up. Previous studies support this result and report that breastfeeding behaviors are better in mothers receiving training and that these mothers experience nipple problems less.^27,28

Of interest was the observation that the number of mothers who exclusively breastfed their babies was higher in the demonstration-based training group than in the other two groups, but that the difference between the groups was not statistically significant. This result can be explained by the fact that the effect of the intervention was not effective enough to persuade mothers to exclusively breastfeed their babies because the focus of the intervention was mainly to prevent nipple cracks. There are other studies also showing that postpartum interventions in the hospital are not effective in encouraging mothers to exclusively breastfeed their babies.^26,29,30 In their study conducted in Australia, Henderson et al. reported that postpartum individual training on breastfeeding positions and holding the baby to the breast was not effective in increasing the duration of breastfeeding.²⁶ In a study conducted in a maternity hospital in France, no significant difference was observed between the mothers who received a 30-minute one-to-one training during the postpartum period and the mothers in the control groups in terms of exclusive breastfeeding.²⁹ In a study by McDonald et al., breast problems were less common in trained mothers, but there was no significant difference between the groups in terms of exclusive breastfeeding.³⁰ In these studies, attention was drawn to the fact that other factors might have prevented statistical significance. This included the likelihood of bias in assigning mothers into intervention and control groups, inadequate sample size, randomization errors, likelihood of the control group being affected by interventions, and inadequate educational content. Visual pictorial materials provided to the brochure group were not sufficient. In contrast, breastfeeding training based on interactive methods and supported by doll model tools was more effective.

Conclusion

The main result of this present study was that training was an effective method to prevent nipple cracks. Interventions involving the use of different doll tools in breastfeeding trainings were the most successful. Further studies with a larger number of infants are needed to evaluate the effect on the rates of breastfeeding exclusivity.

Footnotes

Acknowledgments

We thank the health center staff and mothers for their cooperation. We allow for the use of all information contained in the study.

Disclosure Statement

A.E. contributed to the design, data acquisition, analysis and interpretation, and writing of the manuscript. A.E., Y.Y., D.D.G. managed the research project, completed the data analyses, and wrote the first draft. All authors contributed to interpretation of the results and to the presubmission revisions. All authors read and approved the final manuscript.

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