Could persistent nipple pain be caused by the strength of your baby’s suck?

barracudaUp to 90% of women experience nipple pain or soreness in the initial stage of breastfeeding, with the pain peaking in the first week, then gradually subsiding1. But what if, after 6 weeks, breastfeeding still hurts? You have been observed by what seems like hundreds of lactation professionals, and everything looks fine: your baby is latching on properly and you don’t have an infection. It simply feels to you like she is just a very ‘enthusiastic’ feeder, demonstrated by her toe-curlingly strong suck. Surely that couldn’t be the problem… could it?

Very little research has investigated the causes of chronic pain during breastfeeding, but one interesting study in this area has found a link between nipple pain and a baby’s ‘intra-oral vacuum’, or suck2. The study looked at two groups of women: 30 mothers who were experiencing persistent, unexplained nipple pain (without injury), despite help from lactation specialists; and a control group of 30 mothers with no problems breastfeeding. The vacuum produced by each baby whilst on the breast was measured using a small tube taped to the nipple and attached to a pressure sensor. The amount of milk the babies consumed was also measured, by weighing the babies before and after the feed.

The results were startling. The babies of the mothers who experienced pain when feeding exerted a vacuum when they were ‘actively’ sucking (taking in milk) that was more than 50% higher than the babies in the control group. In between these periods, when they were resting, the vacuum produced by the babies in the pain group was more than twice as high. Unfortunately, a stronger suck did not translate into more milk: babies in the pain group consumed on average 42% less milk, despite feeding for a similar length of time.

The cause of the lower milk intake wasn’t clear. There is a possibility that it was due to chance, or the experimental set-up, although the amount consumed in the control group babies matched that recorded in previous research, making this less likely. As pain can interfere with the let-down reflex, it’s possible that the simple fact that it hurt was enough to stop the milk from flowing properly3. This may in turn have affected milk production, as the amount of milk a baby consumes determines the rate at which it is produced4. It is important to point out, however, that all the babies in the study were gaining weight sufficiently, so the lower milk consumption documented in this single feed did not appear to translate into a more general nutrition problem.

The reason for the higher vacuum is also elusive. It may in some way be the effect rather than the cause of the restriction in milk flow, although this is purely speculative, and how and why this would happen isn’t clear. It’s also possible that the babies in the study may have been experiencing some other feeding difficulty that they compensated for with a stronger suck, although this had not been identified by any of the health professionals who had come into contact with them.

The study data indicate quite clearly that the women suffering from persistent, unexplained nipple pain had babies who exerted a significantly higher intra-oral vacuum on the breast when feeding. Although the data can’t prove the stronger suck caused the pain, it’s likely the two are related. Could this be the reason why for some women, breastfeeding never really seems to become comfortable? If you’re on the receiving end of high suction, then it’s easy to see how you could feel ambivalent about these results. On the one hand, it may be a relief to know that breastfeeding can be painful as a result of the way that your baby suckles, and not because of something that you are doing wrong. On the other hand, the prognosis may be a little disheartening, as it isn’t immediately clear how you solve a problem like this.

At present, such a diagnosis is unlikely, as intra-oral vacuum is rarely tested. The results of this study, however, suggest that in situations where chronic nipple pain has no obvious cause, that it probably should be (the authors certainly think so). Discomfort when breastfeeding is a difficult and stressful situation to deal with, and only with more research in this area can a cause (and hopefully a treatment) be identified. In the meantime, it seems that affected mothers need to carry on gritting their teeth, and perhaps reach for the pain killers…

  1. Acta Paediatr. 2008 Sep;97(9):1205-9.
  2. J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37.
  3. J Pediatr. 1948 Dec;33(6):698-704.
  4. J Exp Physiol. 1996 Sep;81(5):861-75.

Peppermint might help prevent early breastfeeding nipple problems

peppermintThere are many substances said to prevent or relieve nipple pain and damage during the early days of breastfeeding, including lanolin, expressed breast milk and water compresses. Unfortunately, none as yet have been found to offer any real improvement over leaving nipples untreated1. Given the prevalence of the problem, however, the search for a preparation that can make early breastfeeding more comfortable continues.

Recent research reported in the International Breastfeeding Journal and Medical Science Monitor finally seems to offer a ray of hope. It suggests that peppermint, in the form of a gel or ointment, could play a role in preventing nipple soreness and injury from appearing in the first place. A team at the Alzahra Teaching Hospital in Iran conducted two studies examining whether peppermint could prevent nipple problems caused by breastfeeding, after noticing its use by women in the Azarbaijan Province, North West of Iran. As peppermint has antibacterial properties and can increase tissue flexibility2 it does have the potential to prevent this kind of injury occurring, but it has not before been properly evaluated in a clinical setting.

In the first study, 196 women were randomly allocated to either the experimental group, where they were asked to apply peppermint water after each feed, or the control group, where they applied expressed breast milk3. Mothers who applied the peppermint water reported significantly less pain on breastfeeding, and had significantly fewer nipple cracks (9% in the peppermint group and 28% in the milk group) than the other mothers. Cracks that occurred in the peppermint group were also less severe than those in the milk group.

The second study evaluated the effectiveness of a peppermint gel in a double blind study4. 216 women were randomly allocated to one of three groups: the first used peppermint gel after each feed; the second used lanolin; and the third used a placebo gel. The peppermint gel was shown to be more effective than both lanolin and the placebo gel at preventing nipple cracks. Women in this group were also more likely to be exclusively breastfeeding at 6 weeks, possibly because they had suffered less discomfort.

Both these studies were large and well designed, and as such offer reasonable evidence that peppermint may indeed help to prevent the nipple pain and trauma that can occur when women start to breastfeed. These results alone, however, do not constitute conclusive proof that peppermint is a panacea for nipple problems. The main issue is that both experiments were carried out by the same research group, in a part of the world where peppermint is regularly used as a nipple treatment. In the first study women knew they were applying peppermint water, and this may have affected their perceived levels of pain. These mothers were also found to nurse their babies more frequently and for longer periods than those using milk. The authors suggest this may be due to the lower pain levels in this group, but the possibility that the more frequent feeding somehow reduced pain and trauma cannot be ruled out.

In the second study, both the mothers themselves and the researchers classifying the severity of nipple cracks were unaware which type of gel they were applying, reducing the chance that the results were due to a placebo effect. In this experiment, however, there was no true baseline (where nipples were left untreated) against which to compare the peppermint gel. It was better at preventing cracks than the placebo gel (which was the same preparation, just without the peppermint), but we can’t be sure that the gel didn’t make it worse, and the peppermint simply helped to ease the problems caused by the gel.

Despite these shortcomings, this research does provide a strong indication that peppermint may have the potential to protect mothers against nipple soreness and injury. Peppermint has medicinal qualities that suggest it might be helpful in this context, and it is likely to be a reasonably safe and practical treatment, as it is not harmful to babies when consumed in small quantities. Whether future research can replicate these results is yet unknown, but if it can, then an effective preventative measure for nipple problems may finally be on the horizon.

  1. J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37.
  2. Fitoterapia. 2006 Jun;77(4):279-85.
  3. Int Breastfeed J. 2007 Apr 19;2:7
  4. Med Sci Monit. 2007 Sep;13(9):CR406-411

Breast shells: preserving your modesty

shellsWhen I suffered substantial nipple damage in the early weeks of breastfeeding, the ‘moist wound healing’ route didn’t prove effective (see nipple solutions 1: doing nothing), so allowing a bit of air to circulate was the obvious alternative option. Walking around topless wasn’t always practical (although I have to admit it happened quite a bit – apologies to my neighbours) so wearing breast shells provided a workable solution. They seemed to help, psychologically at least, but as I used them on both breasts pretty much all the time, I have no idea whether they really had any effect on the healing process, or the pain I experienced when breastfeeding.

Is there any clinical evidence of their effectiveness? The short answer is not really, although that may be partly because there is very little research looking at the use of breast shells in this context. A couple of studies have reported on the effect of shells used in combination with lanolin, but they obviously don’t tell us anything about the utility of shells in keeping nipples dry12.

There is one small study, conducted some time ago, which evaluated the use of breast shells on their own as a means of alleviating nipple pain3. 20 women who had just started breastfeeding and were experiencing pain were asked to wear a single breast shell whenever they weren’t feeding (the other nipple was kept shell-free, to serve as a control). On the second and fifth days of using the shells the women were asked to rate the level of pain they were experiencing on a 5 point scale, from mild (1) to excruciating (5) during the first two minutes of a feed, and for the period between feeds. Although the mean pain score was higher for the nipple without the shell on day five, this difference was not statistically significant. The study did have an interesting anecdotal result, however. Despite the fact that the shells didn’t lessen pain, 80% of the women said they would consider using them again, so the majority of women felt that they offered some kind of help. The precise nature of the benefit isn’t described in detail, but it appears to be related to improved general comfort and decreased friction with clothing.

Problems mentioned by some women (although it is not reported how many) focused on concerns about the ‘hardness’ of the shell, and the pressure it exerted on breast tissue. The possibility of pressure on milk ducts is also mentioned by shell manufacturers, who advise against using breast shells for extended periods (although they also market the same action as a short term means of relieving engorgement). Whilst the possibility of negative consequences arising from pressure caused by shells can’t be dismissed, there don’t yet appear to have been any reported in the clinical literature, so the extent to which a problem actually exists isn’t clear.

The lack of research in general into either the benefits or drawbacks of breast shells makes it difficult to draw any firm conclusions regarding their use. Whilst problems arising from pressure on breast tissue cannot be dismissed, as yet, these have not been widely reported. There isn’t any data showing they improve nipple pain, although there is anecdotal evidence that they ease discomfort.  You may find they take up too much room in your already overstretched bra, or you might find the way that they stop it rubbing against your nipples provides a little relief. If the latter is the case, breast shells do have one undeniable advantage: they allow you to minimize friction, without having to resort to indecent exposure…

  1. Arch Pediatr Adolesc Med. 1998 Nov;152(11):1077-82.
  2. J Perinat Educ. 2004 Winter;13(1):29-35.
  3. J Nurse Midwifery. 1988 Mar-Apr;33(2):74-7.

Nipple solutions 3: pumping

bottleIn addition to using a nipple shield, both the health visitor and the NCT helpline lady suggested I try expressing milk and feeding it from a bottle, to give my nipples a bit of a rest. C’s response to the shield was not encouraging, so using a breast pump was really the only option I had left if I wanted to carry on. So far I’d just about been able to put up with the pain: if I gritted my teeth through the initial agony, the remainder of the feed was just about bearable. The sight of my nipples, however, was really quite perturbing. The open wound on the outside edge of one was so deep it looked as if the nipple were in danger of detaching. The psychological effects of seeing this type of damage were considerably worse than the pain. I could only assume it was getting worse with each feed, and therefore that I was mutilating myself further.

Despite the obvious arguments for using a pump, and possessing one that was bought before C even arrived, it took me another couple of days to get around to using it. I don’t know quite why I was so reticent, but I think it had something to do with feeling guilty and inadequate not being able to get it right on my own. The turning point was speaking to my friend Zara. It turned out that she’d had exactly the same problem – right down to the fissures in the same place – and had pumped to help with the healing. She’d also had the same feelings of guilt and inadequacy, but had come through the other side and said that it made a massive difference. I wasn’t going to get any extra points for prolonging the pain, so I should just get on with it.

Some women find expressing milk easier than others. The key is prompting the letdown reflex – after that getting milk out is reasonably straight forward. Without your baby actually suckling, however, letdown isn’t always that easy to initiate. Looking at a picture of your baby (or indeed your baby herself) is one way of getting the vital oxytocin flowing. The solution for me was pumping from the really mangled left hand side, while C fed from the slightly less injured right hand side. For about four days, I expressed on the left and fed on the right, feeding C the expressed milk in a bottle if she was still hungry.

Using the pump and feeding simultaneously gave me an interesting way to monitor the extent to which the expressing helped. I had the same injury on both sides (albeit not as badly on the right), but only used the pump on one. It definitely provided me with some relief – expressing was much less painful than feeding – and the nipple did heal eventually, but the right side also healed completely, without any intervention. The healing actually occurred slightly faster on the right hand side, although this might be expected, as the injury wasn’t quite so serious. It seemed that the midwife who told me that things would eventually improve of their own accord was right after all. I think the problem for me was caused by the fact that my nipples weren’t quite the right shape initially (for C’s mouth at any rate – I don’t know if it would be different with another baby) and the skin broke so they could be stretched into a better one. Certainly, they now look quite different to how they did originally – pointy where they were once quite flat. When they healed, extra skin grew over the fissures where they’d stretched, rather than the skin knitting together at the point where it was originally joined, providing further evidence that my nipples were simply going through a (very painful!) transitional process.

Although it seems that both nipples would probably have recovered of their own accord if I’d continued feeding C as normal, I would strongly recommend using a pump if your nipples are suffering. It really helps to relieve the pain, and if you plan to bottle feed later on (whether with expressed milk or formula), introducing it early (and continuing regularly) means you should meet less resistance later on. Even if you take into account the constant pump dismantling, sterilizing and constructing, it’s a win-win situation!

Nipple solutions 2: shells and shields

shell

Although I’ve criticized the health service for their, ‘breastfeeding is easy as long as you do it right’ line (a criticism that I stand by), the health visitors and midwives I have spoken to have generally been sympathetic. They have also been willing to deviate from the official advice when it’s obvious that it isn’t working.

Faced with my mutilated nipples, two midwives suggested nipple shields.  A shield is a silicon or rubber teat that you hold over the nipple to protect it during a feed. It is shaped like a large nipple, with holes in the end for the milk to come through. Apparently, they can affect milk supply, so do not have NHS approval, although I have since discovered that this recommendation may be rather out of date (see the nipple shields research post). I didn’t have any luck with shields (C looked at me as if I were mad – she was going to put one of those in her mouth?!) but I have spoken to many women who found them useful.

Breast shells, on the other hand, did prove to be a hit. In contrast to shields, you use shells in between feeds, to protect sore nipples or draw flat ones out (they apply a small amount of suction). They consist of a silicon disk with a hole in the middle for your nipple, topped off with a half a clear plastic tennis ball that acts as a protective bubble around your nipple and stops the fabric of your clothes coming into contact with it. The plastic bit also has holes in, to allow air to circulate. The instructions said to always make sure these were facing upwards, an instruction that I initially failed to heed. What difference would the direction of the holes make? I discovered the answer to this when I noticed a substantial wet patch on my t-shirt. A significant amount of milk can collect in them if you have them on for any period of time, and this milk will naturally leak out of any holes it finds. If you can motivate yourself to sterilize the shells regularly, you can store this milk for later use, but it wasn’t really a priority for me at that point. In the end, I put a breast pad in each shell to soak up any rogue milk (making sure the holes pointed upwards, of course.) Although this will have hindered the air flow a little, the shells still proved very effective in preventing discomfort, and seemed to allow my nipples to heal more easily. I say ‘seemed’ because the effect may have been psychological – when using the shell, my nipple looked less mangled, and I thus assumed it was improving.

I should probably mention, however, that I didn’t exactly use the shells as specified on the box. The instructions state that you shouldn’t use them for more than a couple of hours at a time, as they can cause blocked ducts. I weighed up the potential for blocked ducts against the possibility of my nipples healing a bit faster, and decided the chance of the latter made it reasonable to risk the former. This meant, in practice, that I ended up using them all the time, including at night. Fortunately I didn’t suffer any blocked ducts, although I did end up stretching a rather expensive Elle McPherson nursing bra (and looking like Madonna during her pointy cone bra period unless I dressed very carefully).  To date, there has been very little clinical research investigating the effectiveness (or not) of breast shells (see breast shells: preserving your modesty), but they seemed to help me get through a difficult time. If you want to take the pressure off your nipples – and are willing to risk increasing it on your milk ducts – they may be worth a try.