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Nipple Pain
L E T T E R S
Nipple Pain Having been a La Leche League leader since 1967 and a hospitalbased lactation consultant for 5 years, I have seen thousands of new nursing mothers. My experience has not led me to the same conclusions as Ziemer and Pigeon (May/June 1993JOGNN).In fact, if I had 20 mothers in my practice present with evidence of so much nipple damage within a short period of time, I would have been frantically trying to find out what was going so wrong to create such an epidemic of nipple pain and damage. My experience has convinced me that nipple damage and pain are not normal. If pain and damage are present, something is wrong. I emphasize positioning “tummy-totummy,” and so do my colleagues. It is unusual to see severe problems. A major flaw in the study published is the lack of control of positioning. I am not saying that poor positioning is the sole cause of sore nipples; however, I feel it can be a major cause. We also do not know if the infants received pacifiers, which can contribute to poor suckling at the breast. The data regarding exclusivity of breastfeeding were not clear. There does appear to be a “normal” amount of tenderness during the first 30 seconds to 1 minute at the breast during the first few days of breastfeeding. This tenderness usually peaks by the 3rd day, disappears by the 5th day, and appears to be related to elasticity of the nipple tissue. This reflects what Newton found in 1952. Newton also quotes Margaret Mead as saying that she does not see nipple
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damage in primitive societies such as we see in the United States. I think the May/June article does a great disservice to understanding and preventing nipple pain by suggesting that normal neonatal sucking causes inflammation and skin damage to the nipple. If we think nipple damage from sucking is “normal,” what are we missing? Patricia Young, RN,BSN, IBCLC
La Leche League Leader Detroit, MI Reference Newton, N. (1952). Nipple pain and nipple damage. Journal of Pediatrics, 41(4), 411-423.
The documentation of nipple changes by Ziemer and Pigeon is interesting, but it does not follow that nipple soreness is a result of “normal” infant suckling. The fact that nipple soreness is common does not make it normal. In the discussion, the authors attempt to argue that Woolridge’s (1986)observations would make one expect nipple changes in areas of the nipple different from those actually occurring. This is a circular argument. What Woolridge demonstrates in his article is normal breastfeeding, which according to him and other authorities should not lead to nipple changes or pain anywhere at all. In the clinical situation, it is often quite easy to decrease nipple
pain and damage considerably, simply by latching the baby on better. This is especially true during the first few days after the baby’s birth. “Simply” may not be exactly the right word, because although the technique should be simple, few health professionals have been trained in how to help mothers do it. However, at least 50% (closer to 75% in recent years) of the women who attend our clinic because of sore nipples get immediate relief with a change in the way the baby is latched on. It is true that the women we see in the clinic have babies who often are older (up to 6 weeks of age) than the ones described in the article, but the dramatic nature of the change cannot fail to impress upon the observer that how the baby is latched onto the breast is a significant factor in nipple pain. And we d o frequently see mothers and babies less than a week after birth. Of course, the attachment of the baby to the breast is not the whole answer to all nipple pain. But to call the sort of pain so many women are having normal is to condemnmany to unnecessary suffering. There is something that can be done to prevent the pain and to treat it if it occurs. I was quite taken aback that the authors would suggest microscopic studies of nipple changes. Are they serious? Jack Newman, MD, FRCPC
Breastfeeding Support Programme Toronto, ONT The JOGNN editor welcomes readers’ comments. Address letters to the editor, JOGNN, 700 14th St., NW, Suite 600, Washington, DC 20005-2019. All letters should be typed double-space and signed by the author. Letters will be published at the editor’s discretion, and JOGNN reserves the right to edit all letters.
Volume 23 Number 1
Reference Woolridge, M. W. (1986). The ‘anatomy’ of infant sucking. Midwifery, 2, 164-71.
There is a significant portion of the Ziemer and Pigeon study that is at odds with what I see in my clinical practice as a lactation specialist. I am baffled by the following statement: “These findings suggest that
Letters
normal breastfeeding induced an inflammatory response that resulted in substantial nipple skin damage for a majority of breastfeeding women in the sample.” “Normal” breastfeeding was never defined. The components of correct positioning, proper latch technique, and appropriate suckling were not documented in any of the sample mothers. There is a difference between skin changes, skin damage, and whether pain is felt with either. An inflammatory process may be present, as I often see in mothers whose nipples are very pink, but many o f these women do not report pain. The uncontrolled nature of the study leaves me with a few questions and comments: 1 . When the nipple is in position for feeding it is elongated, and
the nipple as well as part of the areola are drawn far back into the baby’s mouth. Milk removal, however, is not wholly dependent on suction. Tongue and jaw movements contribute to the second part of suckling. If the nipple is not drawn far enough back into the mouth, it and part of the areola cannot form a teat, leaving the nipple mispositioned and vulnerable to pain and damage. Were any of the babies evaluated to see if they were suckling properly? N o . 2. We have no idea what any of the mothers did in terms of positioning. I see extensive damage when women lean over the baby, push the breast sideways to the baby, when the baby’s mouth is not open wide enough, or when baby chews rather than suckles. Had any of the babies been given pacifiers or bottles? That also is known to affect suckling technique.
January 1994
3. Positioning and how the baby is suckling are certainly related to pain because changes in either can and do modify the amount of pain felt by a mother. I have worked for 17 years with more than 10,000 mother-baby pairs and can reduce or eliminate the pain in many (not all) situations by correcting positioning, latch, and eliciting milk flow. This is seen and known in clinical practice by most lactation consultants/specialists who work on a daily basis with mothers and babies. 4 . What kinds of wound healing treatments are being talked about in this article? More creams, dressings, and medications? What about correcting what really causes the problem? How about proper prevention and management? Although skin changes can and do occur, damage and pain are reduced or avoided when mothers are taught correctly from the start. Wound healing treatments such as tea bags, hair dryers, creams, and oils seldom fix the problem; they usually just have a feel-good effect. If the wound heals without addressing the cause, will damage and pain simply recur once treatment stops? 5 . If practitioners are not to assume that most nipple pain is caused by incorrect positioning or suckling, then the article implies that pain and damage for all correctly suckling and positioned pairs are normal. This is unfortunate; I have already been shown this article by staff nurses who have started using the data as proof that positioning makes no difference. This thinking will
backfire as even less help is offered to mothers, thus increasing the incidence and severity of the problem we are trying to avoid. 6 . What the slides show is an uncontrolled situation. What would slides show and mothers say if breastfeeding technique were controlled for? The uncontrolled nature of this study can be interpreted as calling for even more vigilance in how mothers are taught to breastfeed, so that this type of pain and damage do not occur. Marsha Walker, RN,IBCL C President, Lactation Associates Weston, M A
Drs. Ziemer and Pigeon are to be applauded for their study on the natural history of nipple soreness among breastfeeding mothers during the 1st week postpartum. Too much of what we tell breastfeeding mothers is based on anecdote or insufficiently supported dicta rather than on careful observation and quantification. The study Shows that by applying the scientific method to breastfeeding, valuable clinical information can be obtained. Elizabeth L. Williams, MD, MPH Clinical Instructor in Medicine and Research Associate Palo Alto, CA
The authors reply.
..
That nipple pain occurs in up to 96% of women (Hewat & Ellis, 1987; Ziemer, Paone, Carroll, & Cole, 1990) suggests it is typical and, therefore, expected and not abnormal. Although breastfeeding is a natural phenomenon, it does not automatically follow that it also is painless. Childbirth is another natural, recurring, “normal” event that is associated with discomfort. For our study, breastfeeding was
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Nipple Pain Having been a La Leche League leader since 1967 and a hospitalbased lactation consultant for 5 years, I have seen thousands of new nursing mothers. My experience has not led me to the same conclusions as Ziemer and Pigeon (May/June 1993JOGNN).In fact, if I had 20 mothers in my practice present with evidence of so much nipple damage within a short period of time, I would have been frantically trying to find out what was going so wrong to create such an epidemic of nipple pain and damage. My experience has convinced me that nipple damage and pain are not normal. If pain and damage are present, something is wrong. I emphasize positioning “tummy-totummy,” and so do my colleagues. It is unusual to see severe problems. A major flaw in the study published is the lack of control of positioning. I am not saying that poor positioning is the sole cause of sore nipples; however, I feel it can be a major cause. We also do not know if the infants received pacifiers, which can contribute to poor suckling at the breast. The data regarding exclusivity of breastfeeding were not clear. There does appear to be a “normal” amount of tenderness during the first 30 seconds to 1 minute at the breast during the first few days of breastfeeding. This tenderness usually peaks by the 3rd day, disappears by the 5th day, and appears to be related to elasticity of the nipple tissue. This reflects what Newton found in 1952. Newton also quotes Margaret Mead as saying that she does not see nipple
12
JOGNN
damage in primitive societies such as we see in the United States. I think the May/June article does a great disservice to understanding and preventing nipple pain by suggesting that normal neonatal sucking causes inflammation and skin damage to the nipple. If we think nipple damage from sucking is “normal,” what are we missing? Patricia Young, RN,BSN, IBCLC
La Leche League Leader Detroit, MI Reference Newton, N. (1952). Nipple pain and nipple damage. Journal of Pediatrics, 41(4), 411-423.
The documentation of nipple changes by Ziemer and Pigeon is interesting, but it does not follow that nipple soreness is a result of “normal” infant suckling. The fact that nipple soreness is common does not make it normal. In the discussion, the authors attempt to argue that Woolridge’s (1986)observations would make one expect nipple changes in areas of the nipple different from those actually occurring. This is a circular argument. What Woolridge demonstrates in his article is normal breastfeeding, which according to him and other authorities should not lead to nipple changes or pain anywhere at all. In the clinical situation, it is often quite easy to decrease nipple
pain and damage considerably, simply by latching the baby on better. This is especially true during the first few days after the baby’s birth. “Simply” may not be exactly the right word, because although the technique should be simple, few health professionals have been trained in how to help mothers do it. However, at least 50% (closer to 75% in recent years) of the women who attend our clinic because of sore nipples get immediate relief with a change in the way the baby is latched on. It is true that the women we see in the clinic have babies who often are older (up to 6 weeks of age) than the ones described in the article, but the dramatic nature of the change cannot fail to impress upon the observer that how the baby is latched onto the breast is a significant factor in nipple pain. And we d o frequently see mothers and babies less than a week after birth. Of course, the attachment of the baby to the breast is not the whole answer to all nipple pain. But to call the sort of pain so many women are having normal is to condemnmany to unnecessary suffering. There is something that can be done to prevent the pain and to treat it if it occurs. I was quite taken aback that the authors would suggest microscopic studies of nipple changes. Are they serious? Jack Newman, MD, FRCPC
Breastfeeding Support Programme Toronto, ONT The JOGNN editor welcomes readers’ comments. Address letters to the editor, JOGNN, 700 14th St., NW, Suite 600, Washington, DC 20005-2019. All letters should be typed double-space and signed by the author. Letters will be published at the editor’s discretion, and JOGNN reserves the right to edit all letters.
Volume 23 Number 1
Reference Woolridge, M. W. (1986). The ‘anatomy’ of infant sucking. Midwifery, 2, 164-71.
There is a significant portion of the Ziemer and Pigeon study that is at odds with what I see in my clinical practice as a lactation specialist. I am baffled by the following statement: “These findings suggest that
Letters
normal breastfeeding induced an inflammatory response that resulted in substantial nipple skin damage for a majority of breastfeeding women in the sample.” “Normal” breastfeeding was never defined. The components of correct positioning, proper latch technique, and appropriate suckling were not documented in any of the sample mothers. There is a difference between skin changes, skin damage, and whether pain is felt with either. An inflammatory process may be present, as I often see in mothers whose nipples are very pink, but many o f these women do not report pain. The uncontrolled nature of the study leaves me with a few questions and comments: 1 . When the nipple is in position for feeding it is elongated, and
the nipple as well as part of the areola are drawn far back into the baby’s mouth. Milk removal, however, is not wholly dependent on suction. Tongue and jaw movements contribute to the second part of suckling. If the nipple is not drawn far enough back into the mouth, it and part of the areola cannot form a teat, leaving the nipple mispositioned and vulnerable to pain and damage. Were any of the babies evaluated to see if they were suckling properly? N o . 2. We have no idea what any of the mothers did in terms of positioning. I see extensive damage when women lean over the baby, push the breast sideways to the baby, when the baby’s mouth is not open wide enough, or when baby chews rather than suckles. Had any of the babies been given pacifiers or bottles? That also is known to affect suckling technique.
January 1994
3. Positioning and how the baby is suckling are certainly related to pain because changes in either can and do modify the amount of pain felt by a mother. I have worked for 17 years with more than 10,000 mother-baby pairs and can reduce or eliminate the pain in many (not all) situations by correcting positioning, latch, and eliciting milk flow. This is seen and known in clinical practice by most lactation consultants/specialists who work on a daily basis with mothers and babies. 4 . What kinds of wound healing treatments are being talked about in this article? More creams, dressings, and medications? What about correcting what really causes the problem? How about proper prevention and management? Although skin changes can and do occur, damage and pain are reduced or avoided when mothers are taught correctly from the start. Wound healing treatments such as tea bags, hair dryers, creams, and oils seldom fix the problem; they usually just have a feel-good effect. If the wound heals without addressing the cause, will damage and pain simply recur once treatment stops? 5 . If practitioners are not to assume that most nipple pain is caused by incorrect positioning or suckling, then the article implies that pain and damage for all correctly suckling and positioned pairs are normal. This is unfortunate; I have already been shown this article by staff nurses who have started using the data as proof that positioning makes no difference. This thinking will
backfire as even less help is offered to mothers, thus increasing the incidence and severity of the problem we are trying to avoid. 6 . What the slides show is an uncontrolled situation. What would slides show and mothers say if breastfeeding technique were controlled for? The uncontrolled nature of this study can be interpreted as calling for even more vigilance in how mothers are taught to breastfeed, so that this type of pain and damage do not occur. Marsha Walker, RN,IBCL C President, Lactation Associates Weston, M A
Drs. Ziemer and Pigeon are to be applauded for their study on the natural history of nipple soreness among breastfeeding mothers during the 1st week postpartum. Too much of what we tell breastfeeding mothers is based on anecdote or insufficiently supported dicta rather than on careful observation and quantification. The study Shows that by applying the scientific method to breastfeeding, valuable clinical information can be obtained. Elizabeth L. Williams, MD, MPH Clinical Instructor in Medicine and Research Associate Palo Alto, CA
The authors reply.
..
That nipple pain occurs in up to 96% of women (Hewat & Ellis, 1987; Ziemer, Paone, Carroll, & Cole, 1990) suggests it is typical and, therefore, expected and not abnormal. Although breastfeeding is a natural phenomenon, it does not automatically follow that it also is painless. Childbirth is another natural, recurring, “normal” event that is associated with discomfort. For our study, breastfeeding was
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