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

May 14, 2009 — Elizabeth Jay

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.
Posted in Nipple problems, Research, Strong suck. Tags: , , , , , , . 7 Comments »

Peppermint might help prevent early breastfeeding nipple problems

May 2, 2009 — Elizabeth Jay

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
Posted in Nipple problems, Peppermint, Research. Tags: , , , , , , , , . 2 Comments »

Let down by my let-down

April 21, 2009 — Elizabeth Jay

pramIn theory, I am a strong supporter of nursing in public: it is the perfect way to demystify and promote breastfeeding, and the only realistic way to feed your baby when you’re on the move. In practice, I have always struggled with it. In the first few weeks, when it was excruciatingly painful, and the latching on ‘dance’ (as it is optimistically termed) C and I performed actually resembled a boxing match, my reticence was understandable. Three months later, with a finely-honed technique, I had run out of excuses.

One weekend, I decided to get some much needed public nursing practice in on a trip to a family-friendly department store. Previously, I had fed C in the car, or in the specially provided breastfeeding area. One trip to this part of the store was enough, however (it was an open-plan extension to the nappy changing facility) and I decided to feed C in the cafe, where I’d previously seen lots of other women breastfeeding.

To set the scene: this particular store is packed with the kind of educated, middle class parents who understand the importance of breastfeeding, and wouldn’t dream of raising any objection. My husband J went off to get some drinks, and I settled down to feed C. She was peckish, but not overly so, and was happy enough to spend some time performing the short suckling movements that help initiate let-down. Ten minutes later, she was starting to get frustrated. What was going on? Nothing was coming out! I hadn’t nursed for several hours, so had plenty of milk on board, but for some reason my let-down reflex was failing to function.

After another five minutes of suckling, and a bit of time reassuring a very confused C, my milk finally kicked in. I’m not quite sure why my let-down deserted me on this particular day, but I can only put it down to the noise and stress of feeding in a public place. In situations which other mothers find problematic, such as expressing milk when their baby is absent, I have no problem at all. When I think someone might be watching, however, I often end up in a vicious cycle of stress->no let-down->more stress.

As time has gone on, I find it easier to relax, and haven’t yet had a repeat of this particularly serious let-down failure. Although I can still suffer from performance anxiety from time to time, I try not to let it put me off completely, and as ever, things are improving with time.

Posted in Feeding in public, Journal, Let-down difficulties. Tags: , , , , , . 3 Comments »

Can stress affect the let-down reflex?

April 20, 2009 — Elizabeth Jay

cartoon of person with numbers flying round their headOne piece of advice you might have heard from midwives (and well-meaning friends and family), is to make sure you breastfeed in quiet and relaxing surroundings. Given the choice, this is probably what you’d opt for (who wants to feed in noisy and distracting surroundings?), but could it actually cause a problem if you’re not able to do this?

Well, there’s a possibility it could. For some time, medical evidence has existed that indicates temporary stress or distraction can interfere with the let-down, or milk ejection reflex, meaning your baby has to wait longer for milk to start flowing freely.

Normally, cues that indicate your milk will soon be required (such as your baby crying before a feed, or suckling at the start of one1) trigger the release of the hormone oxytocin, which enters the bloodstream in ‘pulses’ a few minutes apart, forcing milk to flow from the ducts and out of the nipple (see ‘Breastfeeding and Human Lactation’ by Jan Riordan for a full description of this somewhat complicated process.)

In 1948, an experiment conducted with a single breastfeeding woman indicated that distractions can inhibit the release of oxytocin, delaying the start of milk ejection2. This effect was confirmed in a more recent study, which monitored the oxytocin levels in the blood of three groups of breastfeeding mothers who had given birth five days previously3. The first group was asked to perform difficult verbal arithmetic problems whilst nursing their babies (the stress condition), the second was subjected to the noise of a building site through earphones (the noise condition) and the third breastfed without these distractions (the control group).

Oxytocin release occurred significantly later and less frequently in the noise and arithmetic groups than it did in the control group, indicating that these temporary stressors impaired the mothers’ let-down reflexes. The amount of milk the babies consumed (measured by weighing them before and after the feed) did not differ between the groups, however, so although stress affected the frequency of let-down, it did not appear to prevent babies from consuming an adequate amount of milk.

These results demonstrate that mild temporary stress, such as trying to perform difficult arithmetic problems (five days after giving birth!) or being exposed to the noise of construction work can delay the let-down reflex, both at the start of a feed, and throughout its duration. This may explain why in situations where you feel under pressure or distracted (for me, this certainly applies to feeding in public), it feels like your milk takes forever to appear – not great when you’re trying to deal with an angry baby. Fortunately, this problem doesn’t appear to affect the amount of milk your baby consumes overall, so it isn’t necessarily anything to worry about (this would probably only make it worse, after all…) Nevertheless, it is an irritation that both you and your baby would probably prefer to avoid, and therefore the perfect excuse to insist that your surroundings whilst breastfeeding are as chilled out as possible.

  1. Br Med J (Clin Res Ed). 1983 Jan 22;286(6361):257-9.
  2. J Pediatr. 1948 Dec;33(6):698-704.
  3. Obstet Gynecol. 1994 Aug;84(2):259-62
Posted in Let-down reflex, Research, Stress. Tags: , , , , , , , , . 2 Comments »

When should mastitis be treated with antibiotics?

April 13, 2009 — Elizabeth Jay

pillsMastitis – inflammation of the breast tissue – is a common problem for breastfeeding women. Although it can be associated with bacterial infection, this is rarely its primary cause (see milk stasis – not infection – is the main cause of mastitis). Many doctors nevertheless choose to treat it with antibiotics, ‘just in case’ infection is present. Given the uncertain relationship between bacteria and mastitis, what are the benefits – and drawbacks – of taking antibiotic medication?

There are disappointingly few properly controlled studies looking at the antibiotic treatment of mastitis. A recent Cochrane Review analyzing all the research in this area found only two studies that were sufficiently well designed or reported to provide unbiased evidence1. One study looked at the effects of two different types of antibiotic (Amoxicillin and Cephradine), and found that they were equally good at relieving symptoms. Unfortunately, as the study didn’t have a control group of women who did not take any medication, it is not clear whether the antibiotics actually helped them recover, or whether the mothers would simply have recovered over time anyway.

In the second study, mothers who had ‘infectious mastitis’ (diagnosed when both bacteria and white blood cell counts were higher than normal) were assigned to three groups. In the first group, the women were advised to treat the mastitis by emptying the affected breast every six hours (feeding their baby as normal and then expressing any remaining milk); in the second, mothers were asked to follow the same breast emptying routine, and were also prescribed a course of antibiotics (Penicillin, Ampicillin or Erythromycin); in a third control group no treatment was recommended. The results showed that antibiotics did indeed have a beneficial effect: whilst women in the breast-emptying group recovered more quickly than those who weren’t treated, those taking the medication recovered fastest of all.

This single study does appear to show that antibiotics can help treat mastitis associated with bacterial infection. Does this provide adequate evidence for treating all cases of mastitis in this way? Well, not really, for a number of reasons.

Firstly, the antibiotics were shown to be effective when infection was present. In many cases of mastitis, infection is not present, so antibiotics wouldn’t be any use. A risk of prescribing antibiotics without diagnosing infection is that it may not treat the root of the problem. As mastitis is more commonly caused by milk stasis than infection, it is vital to tackle this issue to ensure proper recovery and avoid reoccurrence.

Inappropriate antibiotic treatment is also problematic as it increases the chance that the bacteria may become resistant to the drug. Staphylococcus aureus is the bacteria most commonly associated with mastitis, and a well-known strain of this – MRSA – is already resistant to antibiotics, so this is potentially a serious problem2.

There is also the possibility that antibiotics taken by breastfeeding mothers may have adverse effects on their babies. Exposure to antibiotics through breast milk has been linked with problems such as minor infant breathing difficulties3 and diarrhoea4. Although such complications are not regarded as serious enough stop women from taking medication when they need it (particularly if it enables them to continue breastfeeding), it seems sensible to avoid putting babies at any unnecessary risk, particularly given that this area is currently under-researched1.

So, what does all this mean for mothers who have mastitis, and health professionals who are trying to treat it? There is some evidence that antibiotics help treat mastitis when infection, diagnosed using both bacteria and white blood cell counts, is known to exist. Ideally, antibiotics would be prescribed only in this situation, as using them unnecessarily increases the chance bacteria will develop resistance to them – leading to strains such as MRSA – and may expose babies to unnecessary health problems. Diagnosing infection is notoriously difficult, however, as the bacteria which potentially cause infection can be present even when infection itself isn’t5, and measuring both white blood cell and bacteria counts is rarely going to be practical in a normal health care setting, such as a GP surgery. In a paper published last year discussing this difficult issue, Linda Kvist and colleagues recommend a daily follow-up of mothers with mastitis, and the prescription of antibiotics when symptoms are persistent. In the meantime (and indeed, in the first instance) treating milk stasis, the primary cause of mastitis, remains the top priority.

  1. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005458
  2. Int Breastfeed J. 2008 Apr 7;3:6.
  3. Pediatrics. 2007 Jan;119(1):e225-31
  4. Am J Obstet Gynecol. 1993 May;168(5):1393-9.
  5. Mastitis: causes and management. World Health Organization; 2000.
Posted in Antibiotics, Mastitis, Research. Tags: , , , , , , . 4 Comments »
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