Nipple Pain Incidence,the Predisposing Factors,the Recovery Period After Care Management,and the Exclusive Breastfeeding Outcome

Abstract

Background:

Nipple pain is the most common complaint of breastfeeding mothers during the immediate postpartum period. Persistent nipple pain is associated with low breastfeeding rate at 6 months postpartum.

Objective:

To further explore the incidence of nipple pain, associated predisposing factors, time for recovery after management, and the impact on exclusive breastfeeding rates.

Materials and Methods:

Included in this study were 1,649 singleton, pregnant women who delivered and had their 1-week follow-up at the breastfeeding clinic during the period of January 2013 to December 2015. The mothers who experienced nipple pain were analyzed for the incidence, the predisposing factors, and the recovery period after care management. The breastfeeding outcome comparison of both, mothers with and without pain, was measured by the exclusive breastfeeding rate at the sixth week postpartum.

Results:

The incidence of nipple pain was at 9.6% by day 7. A predisposing factor of nipple pain was primiparity (relative risk = 1.8, 95% confidence interval 1.3–2.5). The reasons for nipple pain were inappropriate positioning and latching (72.3%), tongue-tie (23.2%), and oversupply (4.4%). The recovery period after care management was 1–2 weeks. There were no statistically significant differences between the 6-week exclusive breastfeeding rates of the mothers with nipple pain with treatment and the mothers without nipple pain.

Conclusion:

Persistent nipple pain was a common problem. The active management, including early detection and treatment, would help the mothers recover within a 2-week period and there was no significant difference of exclusive breastfeeding rates between the mothers who had early care management and the mothers without nipple pain.

Introduction

Nipple pain is the most common complaint of breastfeeding mothers during the immediate postpartum period.¹ The incidence of nipple pain varies based on the definition of nipple pain and how it relates to the time period collecting data.^2–5 Transient nipple pain is often found at the beginning of the breastfeeding episode on the second to third day postpartum and usually improves thereafter.⁵ If persistent nipple pain is ignored, severe complications, including mastitis and breast abscesses, may occur and lead to early breastfeeding cessation.⁶ Nipple pain as a cause of early breastfeeding discontinuation was found in 17% of cases.⁷

The management is dependent on the cause of the nipple pain. Some of the treatments are correcting breastfeeding position and attachment for inappropriate latching, frenotomies for tongue-tie, milk expression before infant feeding for oversupply, and antimicrobial use for infections.^3,4,8 Screening for predisposing factors is likely to help health professionals in follow-up planning. However, there were few studies exploring predisposing factors, management, and breastfeeding outcomes following treatment for nipple pain. We were interested in these concerns in mothers suffering from nipple pain at the end of the first week postpartum.

Materials and Methods

Design

This study is a prospective cohort study. Singleton, postpartum mothers who delivered term infants without postpartum complications and had at least 6 months of breastfeeding intent were recruited for this study. Demographic data and factors reported to have effects on nipple pain and exclusive breastfeeding rates were recorded.^3,9 Nurses gave a nipple pain record form to mothers and advised them to record nipple pain daily in the postpartum ward and at home following discharge. Nipple pain experienced during more than half of the breastfeedings per day was considered significant. Following discharge, breastfeeding clinic follow-ups were set at 1 week. At the breastfeeding clinic, the history, physical examination, and breastfeeding observations were evaluated in the mothers who had persistent, significant nipple pain. Bacterial and fungal cultures were used in the infected cases that were suspected. Causes of nipple pain were diagnosed and a specific treatment for each cause was prescribed. Mothers with significant nipple pain had 1-week follow-ups until the problem was resolved. At the sixth week postpartum, telephone follow-ups were used for collecting the exclusive breastfeeding data and the comparison of outcomes.

Setting

This study was done in the Nakhon Nayok province, which is a rural area in central Thailand. Data were collected from January 2013 to December 2015 at the HRH Princess Maha Chakri Sririndhorn Medical Center, which has a “baby friendly” hospital policy. A routine practice in the postpartum ward is breastfeeding education given on the first day postpartum. The 1-hour course in breastfeeding includes instruction on proper latch. One nurse teaches a group of three to five mothers. Mothers are encouraged to stimulate their infants to feed 8–12 times per day. On the second day postpartum, the mothers and infants are discharged if they have shown no complications. Before discharge, the mother's telephone number is confirmed and the breastfeeding-recording notebook is given to the mother with an explanation of “breastfeeding type” definitions, postpartum symptoms, and complications that may require further clinical counseling.

Inclusion criteria

Singleton, postpartum women who have delivered without complications (i.e., multiple pregnancies, preeclampsia, antepartum hemorrhage, and preterm labor) and who intend to breastfeed for at least 6 months were recruited. Infants had birth weights of more than 2,500 g and were without complications. Mothers had no contraindications to breastfeeding. HIV-positive mothers were included.

Exclusion criteria

Mothers whose infants were diagnosed with galactosemia were excluded from this study.

Sample size

We used 0.05 of α error, 0.95 of power, df = 5, and an effect size equal to 0.4 (odds ratio of early breastfeeding problem was 1.5).¹⁰ The calculated sample size numbered 124 cases. The subjects were totaled with an additional 15% for data loss. The total samples need 143 cases. The time to collect sample was 3 years and 159 mothers with persistent nipple pain were enrolled in this study.

Definitions

Nipple pain was defined as “pain at nipple during infant feedings.” Nipple pain present more than half of the breastfeeding frequencies per day were considered significant nipple pain. Mothers with nipple pain must have significant nipple pain as previously defined and it must persist for a 7-day period.

Tongue-tie is defined as “a short lingual frenulum that limits tongue mobility.”¹¹ The tongue-tied infant has been diagnosed by the Kotlow criteria. Normal length from the tip of the tongue to the frenulum should be greater than 16 mm.¹² As a result, if this length is between 12 and 16 mm, it is categorized as mild tongue-tie. If the length is between 8 and 11 mm, it is categorized as moderate tongue-tie. If the length is between 3 and 7 mm, it is categorized as severe tongue-tie.¹³ If the length is shorter than 3 mm, it is categorized as a complete tongue-tie. For this study, a length shorter than 3 mm has been categorized in the same group as subjects with severe tongue-tie.

Exclusive breastfeeding is defined as no other food or drink (including water) other than breast milk. This includes expressed milk. The infant is able to receive drops and syrups of vitamins, minerals, medicine, and other oral rehydration salts.¹⁴ The exclusive breastfeeding rate data at the sixth week postpartum were collected by telephone follow-up. Mothers were taught to record all breastfeeds and any fluids or foods given to their infant in a breastfeeding notebook that was given to the mother before discharge. Exclusive breastfeeding results were collected from the mother, consistent with the established definitions.

Ethical considerations

This study has been approved by The Ethics committee of the Srinakharinwirot University, Faculty of Medicine.

Statistical analysis

Demographic data are reported in means and percentages. Continuous data were analyzed by t-test. Parity, level of education, and route of delivery were analyzed by the Chi-square test. Predisposing factors and exclusive breastfeeding rates were compared by chi-square test, relative risk, 95% confidence interval (CI) and logistic regression analysis. A p-value of less than 0.05 was considered statistically significant. Statistical analysis was performed using SPSS software (version 23.0, SPSS Incorporated).

Results

The number of postpartum women enrolled in our research project totaled 1,649. There were 463 mothers with nipple pain (28.1%) during the first to sixth day period. Mothers with persistent nipple pain at the end of the first week postpartum numbered 159 cases (9.6%). No infants were diagnosed with galactosemia. The details of the demographic data of the mothers, with and without nipple pain, are shown in Table 1.

Table 1.

Demographic Data of Mothers With and Without Nipple Pain

Mothers' and newborns' data	Nipple pain group (n = 159)	No nipple pain group (n = 1,490)	p
Age (years ± SD)	27.8 ± 6.2	27.6 ± 6.2	0.72
Gestational age (week ± SD)	39.0 ± 1.9	38.9 ± 1.8	0.65
Parity			<0.01^a
Primipara, n (%)	89 (56.0)	622 (41.7)
Multipara, n (%)	70 (44.0)	868 (58.3)
Education			0.585
<Bachelor degree, n (%)	65 (40.9)	576 (38.7)
≥Bachelor degree, n (%)	94 (59.1)	614 (61.3)
Route of delivery			<0.01^a
Vaginal delivery, n (%)	75 (47.2)	953 (64.0)
Cesarean section, n (%)	84 (52.8)	537 (36.0)
Blood loss (mL ± SD)	356.7 ± 140.0	303.3 ± 156.3	<0.01^a
Nipple length (cm ± SD)	1.0 ± 0.3	1.0 ± 0.6	0.410
Birth weight (g ± SD)	3,049.5 ± 422.2	3,004.3 ± 533.4	0.301

Statistically significant (p < 0.05) and the assessment of persistent nipple pain was at day 7 postpartum.

SD, standard deviation.

The variables that had shown statistically significant differences were parity, the route of delivery, and blood loss. When logistic regression analysis was used, parity was the only significant variable. The relative risk of nipple pain in primiparous compared with multiparous women was 1.8 (95% CI 1.3–2.5).

The reasons for nipple pain, inappropriate position, improper latching, tongue-tie, and oversupply, were diagnosed at the end of the first week. The details of causes of nipple pain are shown in Table 2.

Table 2.

The Percentages of Causes of Nipple Pain at the End of the First Week

The reasons for nipple pain	No. of cases	%	Recovery period (week)
Inappropriate position and latching	115	72.3	1–2
Tongue-tie	37	23.2	1
Oversupply	7	4.4	1

Inappropriate positioning and latching were diagnosed after observing the mothers' and infants' breastfeeding techniques, while at the breastfeeding clinic. Health professionals including lactation consultants and nurses would assist the mothers in practicing the correct positioning and proper latching. There were 86 cases (74.8%) in which the nipple pain resolved in 1 week and there were 29 cases (25.2%) in which the nipple pain resolved within 2 weeks.

The incidence of tongue-tied infants in this study was 14.9% (246 cases). There were 124 infants with mild tongue-tie (7.5%), 95 infants with moderate tongue-tie (5.7%), and 27 infants with severe tongue-tie (1.6%). There was no nipple pain in the mothers who had infants with mild tongue-tie. Our hospital guideline treatment for moderate to severe tongue-tie infants was frenotomy. After tongue-tie treatment counseling, the moderate-to-severe tongue-tie infants with nipple pain and difficulties in latching were 85 cases and were treated with frenotomies before discharge. The other 37 infants were followed up as the mothers and families required more time to come to a decision. At the breastfeeding clinic, the mothers with moderate to severe tongue-tied infants (37 cases) had experienced persistent, significant nipple pain. The frenotomies were arranged and done within 1 week. All mothers' nipple pain complaints were resolved when the mothers had follow-up evaluations after 2 weeks.

There were seven cases (4.4%) in which oversupply was the diagnosis causing nipple pain. Manual expression before infant feeding was advised. The nipple pain had resolved by the 1-week follow-up in all cases.

When exclusive breastfeeding rates were compared between the mothers with nipple pain after care management and the mothers without nipple pain at the sixth week postpartum, there were no statistically significant differences. The details are shown in Table 3. All of the cases in the nipple pain group could be contacted for data collection. We were only able to contact 1,198 of the 1,490 cases in the group without nipple pain for follow-ups.

Table 3.

The Comparison of the Exclusive Breastfeeding Rates Between Mothers with Nipple Pain with Early Treatment and the Mothers Without Nipple Pain at the Sixth Week Postpartum

Exclusive breastfeeding rate	Nipple pain group (n = 159)	No nipple pain group (n = 1,198)	p	Relative risk	95% CI
At the sixth week postpartum, n (%)	94 (59.1)	741 (61.9)	0.51	1.05	0.91–1.20

CI, confidence interval.

Discussion

Nipple pain was commonly found in postpartum mothers. The incidence of persistent nipple pain at the end of the first week postpartum was 9.6%. The incidence of nipple pain in this study had some differences recorded from a previous study (study of Kent et al.⁴ and Buck et al.⁵) as there were different parameters for the definition of the pain, time in the collection of data for the population suffering from nipple pain, and the participants' ethnicity. From the demographic data of the mothers and infants, the associated factors of nipple pain were parity, route of delivery, and blood loss. The route of delivery has shown an effect on blood loss.¹⁵ However, parity was the only factor that continued to show an effect on nipple pain after the data were analyzed by logistic regression. We offer an explanation that primiparous mothers may have experienced more adverse effects from inappropriate positioning and improper latching, which have shown to be the most common causes of nipple pain.^4,16,17 Mothers with cesarean deliveries required assistance in breastfeeding positioning to a greater extent than the mothers with vaginal deliveries.¹⁸ However, close advise and care by health professionals may have decreased potential effects related to cesarean delivery in this study.

The reasons leading to nipple pain were inappropriate breastfeeding position, improper latching, tongue-tie, and oversupply. The inappropriate positioning and latching were reported for their relationships with nipple pain.¹⁷ The correction of breastfeeding positioning and latching could help decrease the incidence of nipple pain.^4,19 The methods for nipple pain resolution have helped us in clarifying the final diagnoses of reasons for nipple pain as revealed in this study. The nipple pain resolved after care management within 2 weeks, but in most of cases, it had resolved in 1 week. The period of nipple pain resolution after treatment was shorter than had been seen in the study of Kent et al. (100% versus 57% in 2 weeks). We believe that early effective treatment at the end of the first week helped the mothers show a faster improvement.

Tongue-tie was found in 23.2% of the nipple pain cases in this study. The incidence of tongue-tie was similar to the results of a previous study.²⁰ However, the percentage of tongue-tie that resulted in nipple pain was likely greater than the incidence reported as the most tongue-tie cases (87 cases) had already been treated by frenotomies during the postpartum mothers' hospital stay. Following the frenotomies, the moderate and severe tongue-tied babies with difficulties in latching were able to breastfeed and the symptoms of nipple pain improved immediately.^8,21–23 The mothers with tongue-tie infants treated by frenotomies before discharge had no persistent nipple pain at the breastfeeding clinic follow-up. Most of the mothers with tongue-tied infants, whose infants were treated by frenotomy after discharge, had immediate improvement in their nipple pain. There were 5 of the 37 cases that required a 1-week period for pain resolution. We believed that the delayed treatment might be associated with delayed resolution because the nipple pain would progress to nipple trauma, which needs more time for resolution.

Oversupply has been found to be a reason for nipple pain in this study. We offer the explanation that, when the flow of milk is fast, the baby must force more pressure at the nipple to control the speed of flow of milk. This results in the mothers' suffering from nipple pain. The manual expression of breast milk before infant feedings decreases intraductal pressure and the flow of milk and helps to relieve the nipple pain. Nipple pain resulting from oversupply was improved after appropriate management and care. All of the mothers who experienced oversupply had periods of nipple pain that resolved within 1 week.

The other causes of nipple pain, including infections and vasospasm, were not seen in this study. It is possibly due to the early approach and management care provided at the end of the first week. We have not found mastitis in the mothers presenting with nipple pain during the 6-week follow-up period. It is possible that the short follow-up time period and early correction of inappropriate latch and positioning contributed to the absence of mastitis noted in our study. No women in this study had nipple pain due to vasospasm. This is possibly due to the fact that the mothers in this study lacked risk factors such as a prior diagnosis of any underlying autoimmune diseases or history of prior breast surgery.^24,25

When comparing the exclusive breastfeeding rates between the mothers experiencing nipple pain with early treatment and the mothers without nipple pain at the sixth week postpartum, no statistically significant differences were found. We believe that the early management care and the short period of nipple pain resolution were likely to have a key role. Therefore, the health professional should prioritize a strict follow-up for mothers with nipple pain and provide early management care, especially in the first week postpartum.

Strengths of this study include the daily recorded frequency of nipple pain and the low loss of mothers to follow-up. A limitation of our study was a small sample size of mothers with nipple pain. Due to this, we were unable to ascertain all potential reasons for nipple pain. Further studies with larger sample sizes and longer periods of follow-up should be done.

Conclusion

Persistent nipple pain was a common problem. The active management, including early detection and treatment, would help mothers recover within 2 weeks. There were no significant differences in exclusive breastfeeding rates in our population between those mothers with pain who had early care management and those mothers without nipple pain.

Footnotes

Acknowledgments

The authors extend their gratitude to the HRH Princess Maha Chakri Sririndhorn Medical Center and the Faculty of Medicine, Srinakharinwirot University, for supporting our research.

Disclosure Statement

No competing financial interests exist.

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