- Email: [email protected]
Breast Binding … Is It All That It's Wrapped Up To Be?
PDFlib PLOP: PDF Linearization, Optimization, Protection Page inserted by evaluation version www.pdflib.com – [email protected]
CLINICAL RESEARCH
Breast Binding . . . Is It All That It’s Wrapped Up To Be? Kathy Swift, Jill Janke
Objective: To investigate the difference in breast symptoms between breast binding and support bra wearing in nonbreastfeeding postpartum mothers. Design: A systematic replication of an earlier study by Bristol using a pre-experimental posttest design. Setting: A private, for-profit hospital in a city in the south-central region of the United States. Participants: Sixty nonbreastfeeding postpartum women who gave birth to viable newborns of singleton gestations, had an uncomplicated postpartum, and did not receive hormonal lactation suppressants. Main Outcome Measures: Postpartum breast engorgement, leakage, tenderness, and use of pain relief measures as measured by the Bristol Record of Symptoms. Results: Analysis of the data revealed no significant difference relative to breast engorgement between the two groups during the first 10 postpartum days. However, the breast-binder group reported a greater degree of breast tenderness, breast leakage, and use of other pain relief measures. Conclusion: Breast binding should be discontinued as a method of lactation suppression and use of support bras encouraged. Future studies need to focus on comfort for nonbreastfeeding, postpartum mothers. JOGNN, 32, 332–339; 2003. DOI: 10.1177/ 0884217503253531 Keywords: Breast binding—Engorgement— Leakage—Support bra—Tenderness Accepted: April 2002 In the United States, approximately 40% of childbearing women choose to suppress lactation for various reasons (Lawrence, 1999; Neifert, 1999; Riordan & Auerbach, 1999). Before the advent of pharma332 JOGNN
ceutical products in the early 1930s, women relied on methods such as decreased breast stimulation, limited fluid intake, ice compresses, and mechanical means that included compression binders and support bras. These measures alone usually resulted in cessation of lactation within 7 to 10 days postpartum (Brooten, Brown, Hollingsworth, Tanis, & Donlen, 1983; Spitz, Lee, & Peterson, 1998). Currently, there are no pharmaceutical products on the market for suppression of lactation that are completely risk-free (Stehlin, 1990). Since the use of bromocriptine mesylate (Parlodel, Novartis Pharmaceuticals, East Hanover, NJ) was discontinued in the United States as a lactation suppressant in the early 1990s (Shapiro & Thomas, 1984), mechanical remedies have been revisited. However, little scientific evidence supports these practices.
Purpose The purpose of this study was to compare two mechanical methods of suppressing lactation and to examine the presence and degree of breast symptoms experienced by women in each of two groups during the first 10 days postpartum. The study was designed to answer the following research question: What differences in breast symptoms and use of pain relief measures exist between women who use continuous breast binding and those who use continuous support bra wearing?
Theoretical Framework Two theories guided this study. They included the physiological aspects of mammogenesis and compression theory. Volume 32, Number 3
Mammogenesis Mammogenesis occurs as part of the maturity process of the mammary gland in females during pregnancy. Mammogenesis has been defined simply as “the growth of the mammary gland” (Lawrence, 1999, p. 924) and specifically entails a sequence of changes for the purpose of fully nourishing an infant with breast milk after the birth. The process of mammogenesis begins during the 1st trimester because of the marked increase in the circulating luteal and placental hormones (Guyton, 2000; Lawrence, 1999). During pregnancy, the breast undergoes massive changes involving ductular sprouting, branching, and lobular formation. These physiological changes occur
I
n the United States, approximately 40% of childbearing women choose to suppress lactation for various reasons.
regardless of the woman’s decision whether or not to breastfeed her infant (Lawrence, 1999). Levels of the hormone prolactin, responsible for the production of milk, rise steadily during the course of the pregnancy. Prolactin exerts its effect through receptors on the surface of the alveolar cells and allows the breast to produce milk constituents. The elevated levels of progesterone and estrogen inhibit prolactin, however, during pregnancy (Lawrence, 1999). After the placenta has been delivered, the plasma level of progesterone and estrogen drops significantly. With these inhibitory hormones removed, the anterior pituitary gland secretes large amounts of prolactin for milk production (Lawrence, 1999). Lactation is regulated by stimulation of afferent impulses that are processed at the central nervous system and promote the release of oxytocin from the posterior pituitary. Once released, oxytocin is carried to the mammary gland, where it interacts with the myoepithelial cells, causing milk to be forced through the ductal system to the nipple pores. This reaction, known as the milk ejection reflex, controls the expulsion of milk from the alveoli (Lawrence, 1999). If milk is not removed from the breast, excessive accumulation of breast milk in the ductal system can occur. This glandular distention can lead to increased vascularity and congestion of the venous and lymphatic systems, causing interstitial edema in the breast tissue, which is known as engorgement. Engorgement has been defined as being physiological and pathological in nature. Physiological engorgement is viewed as a normal feature of lactogenesis, which occurs on about the 3rd or 4th postpartum day. Breasts are described as full, firm, and slightly May/June 2003
tender, but with milk flow still present. Physiological engorgement occurs with breastfeeding mothers, and relief is sought through frequent, unrestricted breastfeeding (Peters, 1997). Pathological engorgement occurs when milk is not effectively removed as it forms. Milk production rapidly increases the volume of milk in the breast, with subsequent overdistention of the alveoli. Breasts are described as pathologically engorged when they are painful, swollen, red, and hard, with minimal milk flow. Over a period of 7 to 10 days, this distention gradually causes the production of milk to diminish. Without the recurrent stimulation of breast milk removal, the initiation and continued reaction of the milk ejection reflex will not occur (Peters, 1997).
Compression The second theory used in this study was related to the compression of an edematous body area. According to Guyton (2000), edema is the presence of excess fluid in the extracellular space, which is caused by blockage of the venous and lymphatic systems. This blockage prevents the return of interstitial fluid and protein to circulation and allows fluid to accumulate. The basic premise of this theory is that pressure or compression will cause fluid or edema in the interstitial space to be forced back into the venous and lymphatic systems. This concept was applied to the current study with the expectation that a compression binder would minimize engorgement in nonbreastfeeding women.
Literature Review Lactation studies during the last decade have focused on breastfeeding promotion and techniques to assist the breastfeeding dyad (Lawrence, 1999). There has been minimal research on lactation suppression, although current practices are largely anecdotal (Fildes, 1986; Tallant, 1991). Only one study found in the literature specifically evaluated the efficacy of mechanical methods (binder or bra) for suppression of lactation, and it was published more than 30 years ago (Bristol, 1966). In 1966, Bristol tested the theory of active compression for suppressing lactation in a study that compared the effectiveness of using a compression binder (n = 19) versus using a support bra (n = 19) in 38 postpartum women. Both groups wore the binder or bra continuously for the first 14 postpartum days. Bristol (1966) reported no statistically significant difference between the two groups when comparing the presence and degree of breast engorgement and the presence and amount of breast leakage (p > .05). There was a significant difference between the two groups in reported breast tenderness, with the women wearing binders reporting more tenderness than the group that wore the support bras (p < .05). Because
JOGNN 333
the bra was found to be more comfortable than the binder, Bristol (1966) recommended the binder be eliminated as a means of suppressing lactation. However, due to the small sample size and lack of replication, generalizability of the results to other populations is limited.
Methods Research Design A pre-experimental posttest-only design (Polit, Beck, & Hungler, 2001), was used to systematically replicate Bristol’s 1966 study. Two methods of lactation suppression in nonbreastfeeding postpartum mothers were investigated, with participants being randomly assigned to the binder or support bra treatment group.
Hypothesis The following hypothesis was tested: There will be a difference in breast symptoms (engorgement, tenderness, leakage) and in the use of pain relief measures between nonbreastfeeding postpartum women who used a support bra and those who used the breast binder for the first 10 days postpartum.
Participants The criteria for inclusion in the study were that participants must be nonbreastfeeding mothers who gave birth to viable newborns of singleton gestations, had an uncomplicated postpartum, and did not receive hormonal lactation suppressants. A power analysis was conducted using the item mean scores reported in the Bristol study (1966). For an alpha level of .05, a sample size of 26 for each group was needed to obtain a power of 80% for this study. Seventy-nine women were asked to participate. Of those, 17 declined and 2 were lost to follow-up. The remaining 60 participants were randomly assigned to either the breast-binding group or the support bra– wearing group. The sample included similar numbers of White and African American participants (56.7% and 43.3%, respectively). Most of the women were younger than 30 years old (78.3%), married (66.7%), unemployed (73.3%), had not attended college (63.3%), and had a family income of $20,000 or less (61.7%). In addition, most were multiparae (61.7%) and had given birth vaginally (61.7%). To confirm the effectiveness of random assignment, group characteristics were compared. The average age in the binder group (M = 24.8; SD = 4.8) and the bra group (M = 25.0; SD = 4.6) was similar (t = –.19, p > .05). A chisquare test of association was used to compare the other characteristics. There were no significant differences between the breast-binding and support bra groups in 334 JOGNN
parity, ethnic origin, income, education, marital status, employment status, and type of delivery (see Table 1).
Instruments The instruments used in this study consisted of a demographic questionnaire and the Bristol Record of Symptoms (Bristol, 1966). The Bristol instrument contained four Likert-type scale items that measured engorgement, breast tenderness, breast leakage, and use of pain relief measures other than the bra or binder. The instrument was developed by Bristol in consultation with a statistician and the chief of obstetrics in the facility where data were collected for Bristol’s study. Because of insufficient information regarding the psychometric properties of the Bristol instrument, a pilot study was performed prior to the start of data collection to ascertain that the questions were clear and easily understood. The 20 women who participated were asked the questions and also asked to provide feedback on their clarity. No modifications to the instrument were deemed necessary based on the feedback received. Upon completion of the main study, a reliability analysis was conducted and the instrument was found to have a standardized item alpha of .72. Each question regarding engorgement, tenderness, leakage, and other pain relief measures was rated on a scale of 1 to 4 for each of the five data collection periods (postpartum days 1, 3, 4, 9, and 10). The scores for each item were then summed to arrive at a total item score. For the items of breast engorgement, tenderness, and leakage, the minimum daily score was 1 and the maximum was 4. Over the five interviews, the range of possible scores for each item was 5 to 20. The item relating to use of other pain relief measures also was summed over the 5-day period but was scored differently. At each contact women were asked what other pain relief measures they had used. They received a score of 1 if they used only the breast binder or support bra, a score of 2 each time they used an ice bag, a score of 3 for each use of nonnarcotic analgesic, and a score of 4 for each use of a narcotic analgesic. The minimum score was 5, but there was no set maximum score because it depended on the number and type of pain relief events used by a given participant. The rating criteria for each item on the Bristol instrument are presented in Table 2.
Procedure The study was conducted at a private, for-profit hospital in a small city in the south-central United States. The hospital had an annual birth rate of approximately 1,600. A university human subjects institutional review board approved the research, as did the hospital from which participants were recruited and the physicians whose clients were asked to participate. Potential volunteers were approached in the hospital on the first postpartum day. A table of random numbers was used to determine Volume 32, Number 3
TABLE 1
Comparison of Demographic Characteristics of Breast Binder and Support Bra Groups
Variables Income $20,000 or less More than $20,000 Marital Status Married Not married Ethnic origin White African American Employment Unemployed Employed Parity Primipara Multipara Birth type Vaginal Cesarean Education No college Some college
Breast-Binder Group (n = 30) %
Support-Bra Group (n = 30) %
Chi Square*
56.7 43.3
66.7 33.3
χ2 = .64 ns
73.3 26.7
60.0 40.0
χ2 = 1.2 ns
36.7 63.3
50.0 50.0
χ2 = 1.1 ns
73.3 26.7
73.3 26.7
χ2 = .00 ns
40.0 60.0
36.7 63.3
χ2 = .07 ns
66.7 33.3
56.7 43.3
χ2 = .64 ns
63.3 36.7
63.3 36.7
χ2 = .00 ns
*df = 1.
group assignment before first contact. Women who agreed to participate were asked to complete the demographic data form, after which the researcher conducted an initial breast examination. Data from the assessment were used to score the Bristol Record of Symptoms. At the
B
reast binders were more painful and resulted in more breast leakage when compared with support bras.
same time, the women were oriented to the instrument and definition of symptoms. Depending on group assignment, they were also instructed in the use of the binder or support bra (see Table 3). Subsequent contact was made via telephone on postpartum days 3, 4, 9, and 10, when participants provided information on their symptoms and use of pain measures. The researcher assigned a score for each item based on the individual’s feedback. May/June 2003
Results The original data analysis plan was to compare the groups using the independent t test. However, an examination of the data suggested that it failed to meet the test assumption of normality. The Shapiro-Wilks test confirmed that the data were significantly skewed (p < .05). After consultation with a statistician, it was decided to use the nonparametric alternative to the independent t test, the Mann-Whitney U test. Descriptive statistics of the dependent variables are presented in Table 4. The analysis showed no significant differences between the groups related to symptoms of engorgement. However, there were significant group differences in symptoms of breast tenderness and breast leakage (p < .05). In both instances, the breast-binding group had higher scores, indicating greater breast tenderness and milk leakage than the group using the support bra (see Table 5). The two groups also differed significantly (p < .05) regarding their use of other pain relief measures. Consistent with the findings regarding breast tenderness, the breast-binder group used more pain relief measures than the support-bra group (see Table 5). The various pain
JOGNN 335
TABLE 2
TABLE 3
Rating Criteria of Bristol Record of Symptoms
Definitions of Support Bra and Breast Binder
Item
Method
Breast engorgement
Breast tenderness
Breast leakage
Pain reliefa
Rating Criteria 1 = Absence of symptoms (before breasts started to fill and after subsidence of symptoms) 2 = Slight degree (breasts begin to fill or after they had been full and started receding) 3 = Moderate degree (full breasts) 4 = Severe degree (skin around breasts became obviously tight or swelling occurred under the arms where neither the binder nor bra could be effective) 1 = No complaint of tenderness voiced or elicited by palpation of, or by accidental pressure on, the breast 2 = Tenderness occurs only on touch or pressure 3 = Awareness of tenderness without touch (with or without a nonnarcotic analgesic) 4 = Tenderness requiring a narcotic for pain relief 1 = Absence of any noticeable discharge 2 = Slight (a drop or two and slight spotting on undergarments) 3 = Moderate (periodic free and easy flow of milk or easy flow during a shower) 4 = Severe or copious (several pads other than an ordinary tissue needed to absorb leakage and if changes are required several times during the day) 1 = No other means needed other than breast binder or support bra 2 = Ice bags used to obtain relief from breast tenderness 3 = Use of nonnarcotic analgesic 4 = Use of narcotic analgesic
aIndividuals
received points for each use of a relief measure. For example, if the woman took acetaminophen on three occasions one day, she would get a score of 9 for that day.
relief methods used by study participants included ice bags, nonnarcotics, and narcotics.
Additional Findings The average daily scores for each of the data collection points were calculated and graphed to determine if onset 336 JOGNN
Support bra
Breast binder
Definition Nylon and/or cotton garment, which completely covers the breast area, has adjustable straps, and at least three rows of hooks in the back to provide support. Cups need to fit smoothly with no overflow at the top, the center seam should lie against the breastbone without gaps between the cups, and the lower edge of the bra should anchor below the shoulder blades. Standard elastic and cotton woven bandage applied around the mother’s breasts. Application should begin by gently pulling the bandage around upper portion of breasts and wrapping around torso with tension. This process should continue until the entire breast area is covered and the end of bandage is reached. To test tightness, a woman should be able to insert one finger easily between the bandage and her body.
TABLE 4
Dependent Variable Scores for Binder and Bra Group Binder Group Variable Engorgement Leaking Tenderness Pain relief measures
Bra Group
M
SD
M
SD
9.4 8.2 9.7 7.8
2.1 1.8 1.8 3.7
9.2 7.2 8.9 6.6
1.9 1.5 1.8 2.6
and duration of engorgement, tenderness, leakage, and use of other pain relief measures differed between the two groups (see Figure 1). Trends in engorgement were similar for both groups, with engorgement peaking on day 4. Leaking and tenderness were worse on days 3 and 4 for both groups, although the breast-binding group had a slower resolution when compared with the support bra group. Both groups saw a rise in the use of pain relief measures on day 3 that peaked on day 4, but the rise was more dramatic for the breast-binder group, although resolution occurred at about the same time for both groups.
Discussion The current study supported Bristol’s (1966) findings that breast engorgement developed similarly whether a woman used a breast binder or a support bra. Findings were also similar regarding the complaints of tenderness, Volume 32, Number 3
TABLE 5
Bristol Record of Symptoms Analyzed With the Mann-Whitney U Test on Data Collected During the 1st 10 Days Postpartum Symptom Engorgement Breast binding Support bra Tenderness Breast binding Support bra Leaking Breast binding
n
Mean Rank
30
31.18
30
29.82
30
34.98
30
26.02
30
35.80
Support bra Pain relief techniques used Breast binding
30
25.20
30
34.49
Support bra
30
25.55
z
p
.37
ns
2.02
.043*
2.43
.015*
–2.26
.024*
*p = .05.
with both studies reporting increased tenderness among women using breast binding. Contrary to Bristol’s (1966) nonsignificant results (p > .05), the current study found a difference (p < .05) in milk leakage, with the binder group reporting more leaking. The difference in findings may be due to a lack of power in Bristol’s study because of the smaller sample. There was also support for the theory of mammogenesis. Women in both groups reported the presence and varying degrees of breast engorgement during the 1st 10 postpartum days. This was accompanied by tenderness and leaking. The theory indicated that over a period of approximately 7 to 14 days, the distention in the glandular space would diminish without the continued stimulation of breast milk removal. The recession of breast symptoms in this study occurred within 10 days, which was consistent with the theory. The second theory adopted for this study focused on the properties surrounding the compression of an edematous body part. The premise that applying pressure in the form of compression would alleviate edema in the interstitial space by forcing it into the venous and lymphatic systems was not supported. Support of this theory would have resulted in there being less engorgement in the binder group, yet both groups experienced a similar level of engorgement, which resolved at nearly identical rates May/June 2003
(see Figure 1). The group wearing the binder actually reported more tenderness and leakage, which suggested that the binder acted as a stimulant to milk production when compared with a support bra. It could be that the increased pressure exerted by the binder on the breast triggered the release of prolactin. Another explanation might be the differences in the ease of use for each method. The binder required greater skill to apply, and possibly the pressure applied varied from one application to another. The support bra, by comparison, was easier to apply and provided consistent support that was unlikely to vary.
Limitations A limitation to this study is that there was no way to measure treatment adherence except by self-report. It was possible that some women did not follow the prescribed regimen (bra or binder) and were reluctant to report that to the researcher during the phone interviews. It was also possible that some women did not apply the binder correctly, despite in-hospital education. Although the process of mammogenesis is physiological and should be similar in all women, the sample characteristics might preclude generalizability of the results to different populations.
Recommendations Given the findings of this study, the use of breast binders should be discouraged and the use of a support bra encouraged for postpartum mothers who are bottlefeeding their newborns. Although the breast binder had a similar outcome to the support bra in terms of engorgement, it was apparent that the binder was more painful
B
ased on the findings of this study, the use of breast binders should be discontinued and nonbreastfeeding women should be encouraged to wear a 24-hour support bra.
and stimulated the breast in such a way that there was more leakage. More research is needed on the subject of lactation suppression for nurses to truly provide evidence-based care. Future studies should include other management techniques for engorgement. Although the binder group reported more discomfort, both groups used other pain relief measures. No effort was made to determine which of those were more effective (e.g., ice, nonnarcotic analgesic, narcotic analgesic). More research is also needed on
JOGNN 337
Engorgement Scores
Leaking Scores
3.0
3.0
2.5
2.5
2.0
2.0
1.5
1.5
GROUP
1.0
GROUP
1.0
BINDER BRA
.5 Day 1
Day 3
Day 4
Day 9
Day 10
BINDER BRA
.5 Day 1
Tenderness Scores
Day 3
Day 4
Day 9
Day 10
Pain Relief Measures Used Scores
3.0
3.0
2.5
2.5
2.0
2.0
1.5
1.5
GROUP
1.0
GROUP
1.0
BINDER
BINDER .5 Day 1
BRA Day 3
Day 4
Day 9
Day 10
.5 Day 1
BRA Day 3
Day 4
Day 9
Day 10
FIGURE 1
Onset and duration of engorgement, leakage, tenderness, and use of other pain relief measures.
other treatments currently recommended to women experiencing the discomfort of engorgement, such as extracting small amounts of milk to ease the pressure and using cabbage leaves. REFERENCES Bristol, W. (1966). Comparative effectiveness of compressional and supporting breast binders in suppressing lactation. Nursing Research, 15(3), 203-206. Brooten, D. A., Brown, L. P., Hollingsworth, A. O., Tanis, J. O., & Donlen, J. (1983). A comparison of four treatments to prevent and control breast pain and engorgement in nonnursing mothers. Nursing Research, 32(4), 225-229. Fildes, V. A. (1986). Breasts, bottles & babies: A history of infant feeding. Edinburgh: Edinburgh University Press. Guyton, A. C. (2000). Textbook of medical physiology (10th ed.). Philadelphia: W. B. Saunders. Lawrence, R. A. (1999). Breastfeeding: A guide for the medical profession (5th ed.). St. Louis: C. V. Mosby. Neifert, M. (1999). Clinical aspects of lactation. Promoting breastfeeding success. Clinics in Perinatology, 26(2), 281306.
338 JOGNN
Peters, S. (1997). Resolving breast engorgement. Advance for Nurse Practitioners, 5(2), 62. Polit, D. F., Beck, C. T., & Hungler, B. P. (2001). Essentials of nursing research: Methods, appraisal, and utilization (5th ed.). Philadelphia: Lippincott. Riordan, J., & Auerbach, K. (1999). Breastfeeding and human lactation. Boston: Jones and Bartlett. Shapiro, A. G., & Thomas, L. (1984). Efficacy of bromocriptine versus breast binders as inhibitors of postpartum lactation. Southern Medical Journal, 77(6), 719-721. Spitz, A., Lee, N., & Peterson, H. (1998). Treatment for lactation suppression: Little progress in one hundred years. American Journal of Obstetrics and Gynecology, 179(6), 1-11. Stehlin, D. (1990). Lactation suppression: Safer without drugs. Federal Drug Association Consumer, 24(3), 25-27. Tallant, A. W. (1991). A textbook of obstetrical nursing. 1922. Journal of Human Lactation, 7(4), 199-201.
Kathy Swift, MSN, RNc, IBCLC, is the coordinator of the Breastfeeding Center at Rapides Women’s and Children’s Hospital, Alexandria, LA.
Volume 32, Number 3
Jill Janke, RNc, DNSc, is a professor, School of Nursing, University of Alaska, Anchorage.
May/June 2003
Address for correspondence: Kathy Swift, MSN, RNc, IBCLC, Rapides Women’s and Children’s Hospital, Alexandria, LA 71301. E-mail: [email protected].
JOGNN 339
CLINICAL RESEARCH
Breast Binding . . . Is It All That It’s Wrapped Up To Be? Kathy Swift, Jill Janke
Objective: To investigate the difference in breast symptoms between breast binding and support bra wearing in nonbreastfeeding postpartum mothers. Design: A systematic replication of an earlier study by Bristol using a pre-experimental posttest design. Setting: A private, for-profit hospital in a city in the south-central region of the United States. Participants: Sixty nonbreastfeeding postpartum women who gave birth to viable newborns of singleton gestations, had an uncomplicated postpartum, and did not receive hormonal lactation suppressants. Main Outcome Measures: Postpartum breast engorgement, leakage, tenderness, and use of pain relief measures as measured by the Bristol Record of Symptoms. Results: Analysis of the data revealed no significant difference relative to breast engorgement between the two groups during the first 10 postpartum days. However, the breast-binder group reported a greater degree of breast tenderness, breast leakage, and use of other pain relief measures. Conclusion: Breast binding should be discontinued as a method of lactation suppression and use of support bras encouraged. Future studies need to focus on comfort for nonbreastfeeding, postpartum mothers. JOGNN, 32, 332–339; 2003. DOI: 10.1177/ 0884217503253531 Keywords: Breast binding—Engorgement— Leakage—Support bra—Tenderness Accepted: April 2002 In the United States, approximately 40% of childbearing women choose to suppress lactation for various reasons (Lawrence, 1999; Neifert, 1999; Riordan & Auerbach, 1999). Before the advent of pharma332 JOGNN
ceutical products in the early 1930s, women relied on methods such as decreased breast stimulation, limited fluid intake, ice compresses, and mechanical means that included compression binders and support bras. These measures alone usually resulted in cessation of lactation within 7 to 10 days postpartum (Brooten, Brown, Hollingsworth, Tanis, & Donlen, 1983; Spitz, Lee, & Peterson, 1998). Currently, there are no pharmaceutical products on the market for suppression of lactation that are completely risk-free (Stehlin, 1990). Since the use of bromocriptine mesylate (Parlodel, Novartis Pharmaceuticals, East Hanover, NJ) was discontinued in the United States as a lactation suppressant in the early 1990s (Shapiro & Thomas, 1984), mechanical remedies have been revisited. However, little scientific evidence supports these practices.
Purpose The purpose of this study was to compare two mechanical methods of suppressing lactation and to examine the presence and degree of breast symptoms experienced by women in each of two groups during the first 10 days postpartum. The study was designed to answer the following research question: What differences in breast symptoms and use of pain relief measures exist between women who use continuous breast binding and those who use continuous support bra wearing?
Theoretical Framework Two theories guided this study. They included the physiological aspects of mammogenesis and compression theory. Volume 32, Number 3
Mammogenesis Mammogenesis occurs as part of the maturity process of the mammary gland in females during pregnancy. Mammogenesis has been defined simply as “the growth of the mammary gland” (Lawrence, 1999, p. 924) and specifically entails a sequence of changes for the purpose of fully nourishing an infant with breast milk after the birth. The process of mammogenesis begins during the 1st trimester because of the marked increase in the circulating luteal and placental hormones (Guyton, 2000; Lawrence, 1999). During pregnancy, the breast undergoes massive changes involving ductular sprouting, branching, and lobular formation. These physiological changes occur
I
n the United States, approximately 40% of childbearing women choose to suppress lactation for various reasons.
regardless of the woman’s decision whether or not to breastfeed her infant (Lawrence, 1999). Levels of the hormone prolactin, responsible for the production of milk, rise steadily during the course of the pregnancy. Prolactin exerts its effect through receptors on the surface of the alveolar cells and allows the breast to produce milk constituents. The elevated levels of progesterone and estrogen inhibit prolactin, however, during pregnancy (Lawrence, 1999). After the placenta has been delivered, the plasma level of progesterone and estrogen drops significantly. With these inhibitory hormones removed, the anterior pituitary gland secretes large amounts of prolactin for milk production (Lawrence, 1999). Lactation is regulated by stimulation of afferent impulses that are processed at the central nervous system and promote the release of oxytocin from the posterior pituitary. Once released, oxytocin is carried to the mammary gland, where it interacts with the myoepithelial cells, causing milk to be forced through the ductal system to the nipple pores. This reaction, known as the milk ejection reflex, controls the expulsion of milk from the alveoli (Lawrence, 1999). If milk is not removed from the breast, excessive accumulation of breast milk in the ductal system can occur. This glandular distention can lead to increased vascularity and congestion of the venous and lymphatic systems, causing interstitial edema in the breast tissue, which is known as engorgement. Engorgement has been defined as being physiological and pathological in nature. Physiological engorgement is viewed as a normal feature of lactogenesis, which occurs on about the 3rd or 4th postpartum day. Breasts are described as full, firm, and slightly May/June 2003
tender, but with milk flow still present. Physiological engorgement occurs with breastfeeding mothers, and relief is sought through frequent, unrestricted breastfeeding (Peters, 1997). Pathological engorgement occurs when milk is not effectively removed as it forms. Milk production rapidly increases the volume of milk in the breast, with subsequent overdistention of the alveoli. Breasts are described as pathologically engorged when they are painful, swollen, red, and hard, with minimal milk flow. Over a period of 7 to 10 days, this distention gradually causes the production of milk to diminish. Without the recurrent stimulation of breast milk removal, the initiation and continued reaction of the milk ejection reflex will not occur (Peters, 1997).
Compression The second theory used in this study was related to the compression of an edematous body area. According to Guyton (2000), edema is the presence of excess fluid in the extracellular space, which is caused by blockage of the venous and lymphatic systems. This blockage prevents the return of interstitial fluid and protein to circulation and allows fluid to accumulate. The basic premise of this theory is that pressure or compression will cause fluid or edema in the interstitial space to be forced back into the venous and lymphatic systems. This concept was applied to the current study with the expectation that a compression binder would minimize engorgement in nonbreastfeeding women.
Literature Review Lactation studies during the last decade have focused on breastfeeding promotion and techniques to assist the breastfeeding dyad (Lawrence, 1999). There has been minimal research on lactation suppression, although current practices are largely anecdotal (Fildes, 1986; Tallant, 1991). Only one study found in the literature specifically evaluated the efficacy of mechanical methods (binder or bra) for suppression of lactation, and it was published more than 30 years ago (Bristol, 1966). In 1966, Bristol tested the theory of active compression for suppressing lactation in a study that compared the effectiveness of using a compression binder (n = 19) versus using a support bra (n = 19) in 38 postpartum women. Both groups wore the binder or bra continuously for the first 14 postpartum days. Bristol (1966) reported no statistically significant difference between the two groups when comparing the presence and degree of breast engorgement and the presence and amount of breast leakage (p > .05). There was a significant difference between the two groups in reported breast tenderness, with the women wearing binders reporting more tenderness than the group that wore the support bras (p < .05). Because
JOGNN 333
the bra was found to be more comfortable than the binder, Bristol (1966) recommended the binder be eliminated as a means of suppressing lactation. However, due to the small sample size and lack of replication, generalizability of the results to other populations is limited.
Methods Research Design A pre-experimental posttest-only design (Polit, Beck, & Hungler, 2001), was used to systematically replicate Bristol’s 1966 study. Two methods of lactation suppression in nonbreastfeeding postpartum mothers were investigated, with participants being randomly assigned to the binder or support bra treatment group.
Hypothesis The following hypothesis was tested: There will be a difference in breast symptoms (engorgement, tenderness, leakage) and in the use of pain relief measures between nonbreastfeeding postpartum women who used a support bra and those who used the breast binder for the first 10 days postpartum.
Participants The criteria for inclusion in the study were that participants must be nonbreastfeeding mothers who gave birth to viable newborns of singleton gestations, had an uncomplicated postpartum, and did not receive hormonal lactation suppressants. A power analysis was conducted using the item mean scores reported in the Bristol study (1966). For an alpha level of .05, a sample size of 26 for each group was needed to obtain a power of 80% for this study. Seventy-nine women were asked to participate. Of those, 17 declined and 2 were lost to follow-up. The remaining 60 participants were randomly assigned to either the breast-binding group or the support bra– wearing group. The sample included similar numbers of White and African American participants (56.7% and 43.3%, respectively). Most of the women were younger than 30 years old (78.3%), married (66.7%), unemployed (73.3%), had not attended college (63.3%), and had a family income of $20,000 or less (61.7%). In addition, most were multiparae (61.7%) and had given birth vaginally (61.7%). To confirm the effectiveness of random assignment, group characteristics were compared. The average age in the binder group (M = 24.8; SD = 4.8) and the bra group (M = 25.0; SD = 4.6) was similar (t = –.19, p > .05). A chisquare test of association was used to compare the other characteristics. There were no significant differences between the breast-binding and support bra groups in 334 JOGNN
parity, ethnic origin, income, education, marital status, employment status, and type of delivery (see Table 1).
Instruments The instruments used in this study consisted of a demographic questionnaire and the Bristol Record of Symptoms (Bristol, 1966). The Bristol instrument contained four Likert-type scale items that measured engorgement, breast tenderness, breast leakage, and use of pain relief measures other than the bra or binder. The instrument was developed by Bristol in consultation with a statistician and the chief of obstetrics in the facility where data were collected for Bristol’s study. Because of insufficient information regarding the psychometric properties of the Bristol instrument, a pilot study was performed prior to the start of data collection to ascertain that the questions were clear and easily understood. The 20 women who participated were asked the questions and also asked to provide feedback on their clarity. No modifications to the instrument were deemed necessary based on the feedback received. Upon completion of the main study, a reliability analysis was conducted and the instrument was found to have a standardized item alpha of .72. Each question regarding engorgement, tenderness, leakage, and other pain relief measures was rated on a scale of 1 to 4 for each of the five data collection periods (postpartum days 1, 3, 4, 9, and 10). The scores for each item were then summed to arrive at a total item score. For the items of breast engorgement, tenderness, and leakage, the minimum daily score was 1 and the maximum was 4. Over the five interviews, the range of possible scores for each item was 5 to 20. The item relating to use of other pain relief measures also was summed over the 5-day period but was scored differently. At each contact women were asked what other pain relief measures they had used. They received a score of 1 if they used only the breast binder or support bra, a score of 2 each time they used an ice bag, a score of 3 for each use of nonnarcotic analgesic, and a score of 4 for each use of a narcotic analgesic. The minimum score was 5, but there was no set maximum score because it depended on the number and type of pain relief events used by a given participant. The rating criteria for each item on the Bristol instrument are presented in Table 2.
Procedure The study was conducted at a private, for-profit hospital in a small city in the south-central United States. The hospital had an annual birth rate of approximately 1,600. A university human subjects institutional review board approved the research, as did the hospital from which participants were recruited and the physicians whose clients were asked to participate. Potential volunteers were approached in the hospital on the first postpartum day. A table of random numbers was used to determine Volume 32, Number 3
TABLE 1
Comparison of Demographic Characteristics of Breast Binder and Support Bra Groups
Variables Income $20,000 or less More than $20,000 Marital Status Married Not married Ethnic origin White African American Employment Unemployed Employed Parity Primipara Multipara Birth type Vaginal Cesarean Education No college Some college
Breast-Binder Group (n = 30) %
Support-Bra Group (n = 30) %
Chi Square*
56.7 43.3
66.7 33.3
χ2 = .64 ns
73.3 26.7
60.0 40.0
χ2 = 1.2 ns
36.7 63.3
50.0 50.0
χ2 = 1.1 ns
73.3 26.7
73.3 26.7
χ2 = .00 ns
40.0 60.0
36.7 63.3
χ2 = .07 ns
66.7 33.3
56.7 43.3
χ2 = .64 ns
63.3 36.7
63.3 36.7
χ2 = .00 ns
*df = 1.
group assignment before first contact. Women who agreed to participate were asked to complete the demographic data form, after which the researcher conducted an initial breast examination. Data from the assessment were used to score the Bristol Record of Symptoms. At the
B
reast binders were more painful and resulted in more breast leakage when compared with support bras.
same time, the women were oriented to the instrument and definition of symptoms. Depending on group assignment, they were also instructed in the use of the binder or support bra (see Table 3). Subsequent contact was made via telephone on postpartum days 3, 4, 9, and 10, when participants provided information on their symptoms and use of pain measures. The researcher assigned a score for each item based on the individual’s feedback. May/June 2003
Results The original data analysis plan was to compare the groups using the independent t test. However, an examination of the data suggested that it failed to meet the test assumption of normality. The Shapiro-Wilks test confirmed that the data were significantly skewed (p < .05). After consultation with a statistician, it was decided to use the nonparametric alternative to the independent t test, the Mann-Whitney U test. Descriptive statistics of the dependent variables are presented in Table 4. The analysis showed no significant differences between the groups related to symptoms of engorgement. However, there were significant group differences in symptoms of breast tenderness and breast leakage (p < .05). In both instances, the breast-binding group had higher scores, indicating greater breast tenderness and milk leakage than the group using the support bra (see Table 5). The two groups also differed significantly (p < .05) regarding their use of other pain relief measures. Consistent with the findings regarding breast tenderness, the breast-binder group used more pain relief measures than the support-bra group (see Table 5). The various pain
JOGNN 335
TABLE 2
TABLE 3
Rating Criteria of Bristol Record of Symptoms
Definitions of Support Bra and Breast Binder
Item
Method
Breast engorgement
Breast tenderness
Breast leakage
Pain reliefa
Rating Criteria 1 = Absence of symptoms (before breasts started to fill and after subsidence of symptoms) 2 = Slight degree (breasts begin to fill or after they had been full and started receding) 3 = Moderate degree (full breasts) 4 = Severe degree (skin around breasts became obviously tight or swelling occurred under the arms where neither the binder nor bra could be effective) 1 = No complaint of tenderness voiced or elicited by palpation of, or by accidental pressure on, the breast 2 = Tenderness occurs only on touch or pressure 3 = Awareness of tenderness without touch (with or without a nonnarcotic analgesic) 4 = Tenderness requiring a narcotic for pain relief 1 = Absence of any noticeable discharge 2 = Slight (a drop or two and slight spotting on undergarments) 3 = Moderate (periodic free and easy flow of milk or easy flow during a shower) 4 = Severe or copious (several pads other than an ordinary tissue needed to absorb leakage and if changes are required several times during the day) 1 = No other means needed other than breast binder or support bra 2 = Ice bags used to obtain relief from breast tenderness 3 = Use of nonnarcotic analgesic 4 = Use of narcotic analgesic
aIndividuals
received points for each use of a relief measure. For example, if the woman took acetaminophen on three occasions one day, she would get a score of 9 for that day.
relief methods used by study participants included ice bags, nonnarcotics, and narcotics.
Additional Findings The average daily scores for each of the data collection points were calculated and graphed to determine if onset 336 JOGNN
Support bra
Breast binder
Definition Nylon and/or cotton garment, which completely covers the breast area, has adjustable straps, and at least three rows of hooks in the back to provide support. Cups need to fit smoothly with no overflow at the top, the center seam should lie against the breastbone without gaps between the cups, and the lower edge of the bra should anchor below the shoulder blades. Standard elastic and cotton woven bandage applied around the mother’s breasts. Application should begin by gently pulling the bandage around upper portion of breasts and wrapping around torso with tension. This process should continue until the entire breast area is covered and the end of bandage is reached. To test tightness, a woman should be able to insert one finger easily between the bandage and her body.
TABLE 4
Dependent Variable Scores for Binder and Bra Group Binder Group Variable Engorgement Leaking Tenderness Pain relief measures
Bra Group
M
SD
M
SD
9.4 8.2 9.7 7.8
2.1 1.8 1.8 3.7
9.2 7.2 8.9 6.6
1.9 1.5 1.8 2.6
and duration of engorgement, tenderness, leakage, and use of other pain relief measures differed between the two groups (see Figure 1). Trends in engorgement were similar for both groups, with engorgement peaking on day 4. Leaking and tenderness were worse on days 3 and 4 for both groups, although the breast-binding group had a slower resolution when compared with the support bra group. Both groups saw a rise in the use of pain relief measures on day 3 that peaked on day 4, but the rise was more dramatic for the breast-binder group, although resolution occurred at about the same time for both groups.
Discussion The current study supported Bristol’s (1966) findings that breast engorgement developed similarly whether a woman used a breast binder or a support bra. Findings were also similar regarding the complaints of tenderness, Volume 32, Number 3
TABLE 5
Bristol Record of Symptoms Analyzed With the Mann-Whitney U Test on Data Collected During the 1st 10 Days Postpartum Symptom Engorgement Breast binding Support bra Tenderness Breast binding Support bra Leaking Breast binding
n
Mean Rank
30
31.18
30
29.82
30
34.98
30
26.02
30
35.80
Support bra Pain relief techniques used Breast binding
30
25.20
30
34.49
Support bra
30
25.55
z
p
.37
ns
2.02
.043*
2.43
.015*
–2.26
.024*
*p = .05.
with both studies reporting increased tenderness among women using breast binding. Contrary to Bristol’s (1966) nonsignificant results (p > .05), the current study found a difference (p < .05) in milk leakage, with the binder group reporting more leaking. The difference in findings may be due to a lack of power in Bristol’s study because of the smaller sample. There was also support for the theory of mammogenesis. Women in both groups reported the presence and varying degrees of breast engorgement during the 1st 10 postpartum days. This was accompanied by tenderness and leaking. The theory indicated that over a period of approximately 7 to 14 days, the distention in the glandular space would diminish without the continued stimulation of breast milk removal. The recession of breast symptoms in this study occurred within 10 days, which was consistent with the theory. The second theory adopted for this study focused on the properties surrounding the compression of an edematous body part. The premise that applying pressure in the form of compression would alleviate edema in the interstitial space by forcing it into the venous and lymphatic systems was not supported. Support of this theory would have resulted in there being less engorgement in the binder group, yet both groups experienced a similar level of engorgement, which resolved at nearly identical rates May/June 2003
(see Figure 1). The group wearing the binder actually reported more tenderness and leakage, which suggested that the binder acted as a stimulant to milk production when compared with a support bra. It could be that the increased pressure exerted by the binder on the breast triggered the release of prolactin. Another explanation might be the differences in the ease of use for each method. The binder required greater skill to apply, and possibly the pressure applied varied from one application to another. The support bra, by comparison, was easier to apply and provided consistent support that was unlikely to vary.
Limitations A limitation to this study is that there was no way to measure treatment adherence except by self-report. It was possible that some women did not follow the prescribed regimen (bra or binder) and were reluctant to report that to the researcher during the phone interviews. It was also possible that some women did not apply the binder correctly, despite in-hospital education. Although the process of mammogenesis is physiological and should be similar in all women, the sample characteristics might preclude generalizability of the results to different populations.
Recommendations Given the findings of this study, the use of breast binders should be discouraged and the use of a support bra encouraged for postpartum mothers who are bottlefeeding their newborns. Although the breast binder had a similar outcome to the support bra in terms of engorgement, it was apparent that the binder was more painful
B
ased on the findings of this study, the use of breast binders should be discontinued and nonbreastfeeding women should be encouraged to wear a 24-hour support bra.
and stimulated the breast in such a way that there was more leakage. More research is needed on the subject of lactation suppression for nurses to truly provide evidence-based care. Future studies should include other management techniques for engorgement. Although the binder group reported more discomfort, both groups used other pain relief measures. No effort was made to determine which of those were more effective (e.g., ice, nonnarcotic analgesic, narcotic analgesic). More research is also needed on
JOGNN 337
Engorgement Scores
Leaking Scores
3.0
3.0
2.5
2.5
2.0
2.0
1.5
1.5
GROUP
1.0
GROUP
1.0
BINDER BRA
.5 Day 1
Day 3
Day 4
Day 9
Day 10
BINDER BRA
.5 Day 1
Tenderness Scores
Day 3
Day 4
Day 9
Day 10
Pain Relief Measures Used Scores
3.0
3.0
2.5
2.5
2.0
2.0
1.5
1.5
GROUP
1.0
GROUP
1.0
BINDER
BINDER .5 Day 1
BRA Day 3
Day 4
Day 9
Day 10
.5 Day 1
BRA Day 3
Day 4
Day 9
Day 10
FIGURE 1
Onset and duration of engorgement, leakage, tenderness, and use of other pain relief measures.
other treatments currently recommended to women experiencing the discomfort of engorgement, such as extracting small amounts of milk to ease the pressure and using cabbage leaves. REFERENCES Bristol, W. (1966). Comparative effectiveness of compressional and supporting breast binders in suppressing lactation. Nursing Research, 15(3), 203-206. Brooten, D. A., Brown, L. P., Hollingsworth, A. O., Tanis, J. O., & Donlen, J. (1983). A comparison of four treatments to prevent and control breast pain and engorgement in nonnursing mothers. Nursing Research, 32(4), 225-229. Fildes, V. A. (1986). Breasts, bottles & babies: A history of infant feeding. Edinburgh: Edinburgh University Press. Guyton, A. C. (2000). Textbook of medical physiology (10th ed.). Philadelphia: W. B. Saunders. Lawrence, R. A. (1999). Breastfeeding: A guide for the medical profession (5th ed.). St. Louis: C. V. Mosby. Neifert, M. (1999). Clinical aspects of lactation. Promoting breastfeeding success. Clinics in Perinatology, 26(2), 281306.
338 JOGNN
Peters, S. (1997). Resolving breast engorgement. Advance for Nurse Practitioners, 5(2), 62. Polit, D. F., Beck, C. T., & Hungler, B. P. (2001). Essentials of nursing research: Methods, appraisal, and utilization (5th ed.). Philadelphia: Lippincott. Riordan, J., & Auerbach, K. (1999). Breastfeeding and human lactation. Boston: Jones and Bartlett. Shapiro, A. G., & Thomas, L. (1984). Efficacy of bromocriptine versus breast binders as inhibitors of postpartum lactation. Southern Medical Journal, 77(6), 719-721. Spitz, A., Lee, N., & Peterson, H. (1998). Treatment for lactation suppression: Little progress in one hundred years. American Journal of Obstetrics and Gynecology, 179(6), 1-11. Stehlin, D. (1990). Lactation suppression: Safer without drugs. Federal Drug Association Consumer, 24(3), 25-27. Tallant, A. W. (1991). A textbook of obstetrical nursing. 1922. Journal of Human Lactation, 7(4), 199-201.
Kathy Swift, MSN, RNc, IBCLC, is the coordinator of the Breastfeeding Center at Rapides Women’s and Children’s Hospital, Alexandria, LA.
Volume 32, Number 3
Jill Janke, RNc, DNSc, is a professor, School of Nursing, University of Alaska, Anchorage.
May/June 2003
Address for correspondence: Kathy Swift, MSN, RNc, IBCLC, Rapides Women’s and Children’s Hospital, Alexandria, LA 71301. E-mail: [email protected].
JOGNN 339