Nipple nuances - California WIC Association

Nipple nuances: From
pain to peppermint
and what the
textbooks don’t cover
Marsha Walker, RN, IBCLC
Marshalact@gmail.com
I have no conflicts of
interest to declare
Anatomy of the nipple
• Cooper (1840) found 7-12
patent ducts that drained
lobes
• Found up to 22 straight
tubes within the nipple
• Not all ductal systems
opened into the nipple tip
• Number of ducts in nipple
greater than number of
openings in nipple tip
From: Cooper AP. Anatomy of the breast. London: Longman, Orme, Green,
Browne and Longmans,1840.
Nipple anatomy
Rusby et al. (2007) Breast Cancer Res Treat;106:171-179
• Mean of 24 ducts
(range of 5-50)
• 10% of indentations
on nipple tip
associated with
sebaceous or sweat
ducts
• One main collecting
duct can drain up to
23% of the total
breast volume
Nipple anatomy
• Only 7 of 34 ducts
entering the nipple had
an opening on the nipple
surface
• Group of central orifices
with peripheral openings
• Most ducts in a central
bundle that narrows to a
waist 2mm beneath the
skin
• Central bundle occupies
21%-67% of the cross
section of the nipple
Nipple anatomy
Gooding et al. (2010) J Ultrasound Med;29:95-103
• Duct diameter increases
at multiple branching
points
• Enlarged milk-laden
regions can be seen
within the ductal system
– Milk sinuses not seen
• Ducts are tiny and close
to the surface
– Ultrasound cannot identify
ducts <.5mm
– Compression can occlude
these ducts
Nipple anatomy
Thanaboonyawat et al. (2013) J Hum Lact 29;480-483
• Measured nipples
during pregnancy of
Thai women
• Mean length 9.3mm
 to 11.2mm
• Mean width 13.6mm
 to 15.9mm
• Areola width  by
12.3mm
Nipple classification
• Pseudo inverted
– Nipple appears inverted but
when areola is compressed
it everts
• Connective tissue thought
to be deficient, but length
of underlying ductwork is
normal
• Infant should be able to
elongate nipple sufficient
for proper latch
Nipple classification
• Inverted
– Failure of mammary pit
to elevate
– Short lactiferous ducts
– Fibrous alteration of
connective tissue
prevents it from
projecting
– Lactiferous ducts
imbedded in resistant
collagen fibers
Nipple classification
Han & Hong (1999) Plast Reconstruc Surg; 104:389-395
• Plastic surgeons’ definition relative to degree of
fibrosis
• Grade I: nipple is easily pulled out manually,
maintains its projection, minimal fibrosis
• Grade II: can be manually pulled out but does
not maintain protrusion, retreats back into
areola, moderate fibrosis
• Grade III: can barely be manually pulled out,
severe fibrotic bands, less soft tissue underlying
the nipple
Classification of nipples
Sanuki et al (2008). Aesth Plast Surg; 33:563-565
• Type I: when nipple
height is > diameter
• Type II: when nipple
height is < diameter
• Type III: when nipple is
inverted
• Type IV: other shapes
such as multiple or
bifurcated
• Type II without
constricture was most
common type of nipple
Flat nipples
• Suboptimal
breastfeeding
behavior and delayed
onset of lactation are
related to flat nipples
• Extra vigilance for
mothers with flat or
inverted nipples
– Risk for inadequate
milk intake and
damaged nipples
Nipple length as a screening tool
Puapornpong, et al. (2013). Nipple length and its relation to success in
breastfeeding. J Med Assoc Thai, 96, (Suppl 1), S1-S4
• Measured nipple
length relationship
to LATCH scores
of >8
• Mothers with nipple
length of 7mm and
higher had better
scores and more
successful
breastfeeding
Other causes of flat nipples
• Overweight or obesity
– Excess periareolar
adipose tissue may
expand areola to the
point where traction is
placed on the nipple
itself
• Areolar edema
– Nipples flattened by
fluid distension
Double and bifurcated nipples
• Each nipple may have its own
ductal system
• Areola may be enlarged on
affected side
• Multiple nipples may be
completely separate from each
other or joined by a ridge of
areolar tissue
• Some arrangements may present
as a cluster of nipples resembling
a mulberry
• Infant with a small mouth may
have trouble taking in the entire
structure
• If using a pump, the arrangement
of nipples must fit properly into a
pump flange to avoid tissue
damage
Interventions for nipple alterations
•
•
•
•
Hoffman’s exercises
Nipple rolling
Breast shells
Surgery
– Can sever too many
ducts, especially the
central ones
– Can compromise
sensitivity of
nipple/areolar complex
Maybe breast shells actually work?
Chanprapaph et al. (2013). Breastfeed Med; 8:408-412.
• Sample of 90 mothers
with at least 1 short
nipple length <7mm
• Experimental group
wore shells 8h/day
• 49% showed
conversion to normal
size nipples
Interventions for nipple alterations
• Mechanical stretching by
suction
– Tissue expansion through
continuous long-term
suction
– Derived from plastic and
aesthetic surgery
• Niplette
– Falls off easily (need
lubricant around the base
for better adhesion)
– Potential for too much
suction (pain/bleeding)
– Can be used prior to each
feeding but presence of
milk in the mold impairs
suction
Supple Cups
Bouchet-Horwitz J. Clinical Lactation 2011; 2:30-33.
• Worn prenatally to
evert nipples
• Requires gel to help
hold in place and
breast shells if worn
under a bra
• Comes in 4 sizes
• Can be used post
delivery to evert
nipples prior to each
feeding
Interventions after baby is born
•
•
•
•
•
•
•
Nipple rolling
Breast pump
Cold compress
Breast shells
Teacup hold
Modified syringe
Nipple shield
Rubber bands
Chakrabarti & Basu. (2011) Breastfeeding Medicine; online first
• Rubber band cut from
condom placed
around base of nipple
for each feeding
• Wrapped 3 times or
so around modified
syringe for application
• Plunger is gently
pulled to raise the
nipple and band is
slipped over base of
nipple
Rubber bands
(don’t try this at home!)
• Used only during
feedings
• Mothers did not
experience pain
• Rubber bands did not
slip off into baby’s
mouth
• Prevented the nipple
from reverting back to
a flat position
Nipple surface
• Melanin in nipple skin is
>2x that in breast skin
– Protection from ultraviolet
light
– Helps skin resist abrasion
• Nipple tip has papillarlike elevations with
unique crevices and
nipple pore openings
• Mothers with nipple
anomalies have higher
incidence of nipple
trauma
Assessing nipple wounds
• Don’t have a
standardized scale
or mechanism to
assess nipple
wounds
Sore nipples
Zeimer & Pigeon (1993). JOGNN 22;247-256
• Common reason for
weaning
• Not all pain may be from
faulty positioning or
sucking
• Magnified photos
showed visible skin
changes
– Erythema, edema of papillar
bumps
– Fissures which widened over
time
– Fluid filled papillae
Nipple positioning
Jacobs et al. (2007) J Hum Lact;23:52-59
• Only 25% of infants drew
nipple tip to junction of
hard & soft palate
• Distance was 5mm with
range of 4.0+1.3mm
• Positioning outside these
ranges may be
associated with nipple
pain
Nipple distortion
• Inadequate breast
tissue drawn into mouth
• Compression and
suction concentrated on
distorted area
• Nipple not compressed
and extended to twice
its resting length
• Pinched into a
compression stripe
• 65% rate of fissures in
studies describing
causes of nipple pain
Ankyloglossia
Geddes et al. (2008) Pediatr; 122:e188-e194
• 2 types of sucking
dynamics with tongue tie
– Pinched nipple tip; long
distance from junction of
hard & soft palate
– Nipple pinched at base and
tip close to hard & soft
palate junction
• Release of frenulum
reduced nipple distortion,
altered tongue
movement, relieved pain
Feeding Plan Considerations Prior to
Frenotomy (or if Frenotomy Will Not be Done)
• Use positions that encourage
forward and downward
movement of the infant’s
tongue such as placing the
infant ventrally (semi-prone),
completely vertical, or in an
upright clutch hold.
• Modifications surrounding
latch-on can include: stroking
the infant’s tongue down and
forward with an index finger
prior to latch, providing chin or
jaw support to help maintain
the latch, using techniques to
evert nipples if they are flat,
and shaping the breast for a
deep latch.
Feeding Plan Considerations Prior to
Frenotomy (or if Frenotomy Will Not be Done)
• Nipple shield if nipples are too
sore or damaged
• May need to pump following
each feeding to assure an
adequate milk supply and to
provide a supplement if infant
can’t transfer sufficient
amounts of milk at breast
• Infant weight should be
checked every 3 days until an
adequate pattern of weight gain
is established.
• Even if a tongue-tied infant can
feed at the breast, he may not
feed at optimum efficiency and
may require pumped milk
supplements
Persistent nipple pain and strong vacuum
McClellan et al. (2008) Acta Paediatrica;97:1205-1209
• Studied mothers with persistent nipple pain
where positioning and latch were correct
• Infants causing pain
– exerted stronger vacuum
– transferred less milk
• All components of suck cycle were stronger
– Baseline seal at breast 61% stronger
– Vacuum during active sucking 50% stronger
– Peak vacuum 31% stronger
Potential interventions
• More frequent feeding
to reduce strong
sucking due to hunger
• Changes in
positioning (ventral)
• Sucking on mother’s
finger prior to feeding
• Use of nipple shield
Treatments for sore nipples
Warm
Lanolin
compresses Vit E
Commercial
creams
Lotrimin AF
Wet teabags Herbs
Saline soak
Triple
Hydrogel
antibiotic
Olive oil
All purpose Peppermint
nipple
water and
ointment
gel
Expressed
breastmilk
Homeopathic
remedies
Coconut oil
A&D
ointment
Bacitracin
Monistat
Micatin
Bactroban
Medihoney
Systemic
antibiotics
LED
phototherapy
No single agent is clearly superior to others
• Warm water compresses enhance blood flow to
wound; helps remove waste products
• Saline soaks (1/4-1/2 t/quart of water)
• Breastmilk is bactericidal
• Commercial nipple creams can have undesirable
ingredients
• Environmental Safety Group cosmetic safety
database
– Rates products for toxicity, carcinogens, allergies, etc
– 0-2 low hazard, 3-6 moderate hazard, 7-10 high hazard
– http://www.cosmeticsdatabase.org/browse.php?categor
y=nipple%20cream%20(for%20moms)
Lanolin vs breastmilk
Abou-Dakn et al. (2011) Skin Pharmacol Physiol;24:27-35
• N=84 (45 lanolin group, 39
EBM group)
• Lanolin group showed faster
decrease in pain
• Healing rate faster in lanolin
group + more new trauma in
EBM group at day 3
• 15% weaning rate at 14
days in EBM group; 7%
weaned in lanolin group
• Moist wound healing
eliminates crust formation
with re-epithelization 50%
faster
Lanolin and infection
Sasaki et al. Clin Lact 2014; 5:28-31
• Sample size 124
• 38 with nipple pain did not use lanolin
(18% developed signs of infection)
• 27 with nipple pain used lanolin (62%
developed signs of nipple or breast
infection)
• Fungal infection was the most frequent
pathogen
LED Phototherapy
Chaves et al. Photomed Laser Surg. 2012; 30;172-178.
• Experimental group received 8 LED
phototherapy treatment sessions (twice
each week)
• Improved nipple lesion healing
• Pain intensity reduction seen in
experimental group
• LED phototherapy seen as an effective
tool to accelerate healing of nipple trauma
A, B, C, experimental group at 1, 4, and 8th sessions
D, E, F, control group at 1, 4, and 8th sessions
Experimental participant had nipple trauma completely
healed by 4th session compared with control which was not
completely healed until 8th session
Plant extracts for topical application
Hsu (2005) J Am Acad Derm; 52:1049-1059
Hsu et al. (2003) J Pharm Exp Therapeutics; 306:29-34
• Produce flavonoid
compounds with
phenolic components
– Highly reactive
– Neutralize free radicals
• Green tea contains
catechins that facilitate
natural wound healing
– Polyphenols stimulate
aged keratinocytes,
energize cell division &
DNA synthesis, reduce
healing time
Peppermint (Mentha piperita)
• Calming, numbing effect on skin irritations
Increases tissue flexibility, improves resistance to cracking,
antibacterial, anti-inflammatory, fungicidal
Randomized double blind study of 3 groups (n=163)
Lanolin, peppermint gel, or placebo gel rubbed on nipples
after each feed to prevent sore nipples
Nipple cracks: 22.6% placebo, 6.9% lanolin, 3.8%
peppermint gel
At 6 weeks, 27% placebo group supplementing with
formula, 13% lanolin group, 5.6% peppermint group
Manizeh et al. (2007) Med Sci Monitor 13 CR406-CR411
Peppermint water
Manizheh et al. (2007) Intl Breastfeed J;2,7
• Peppermint water used on nipples
following each feeding was 3x more
effective in preventing nipple cracks than
expressed breastmilk (27% breastmilk vs
9% peppermint water)
• Both studies used prophylactically, not on
existing nipple wounds
• Peppermint gel effective in reducing pain
Peppermint (menthol essence)
as treatment for cracked nipples
• 110 women with nipple fissures
• 55 in peppermint group; 55 in control
group using expressed breastmilk
• Pain intensity score lower in peppermint
group
• Damage severity less in peppermint group
Akbari et al. J Res Med Sci 2014; 19(7): 629-633
Olive oil
• Biologically active components-fatty acids,
tocopherols, carotenoids
• Used for eczema, dermatoses, rosacea,
wound healing; antioxidant, antiinflammatory
• Contains squalene, the main component
of skin surface polyunsaturated lipids
which is quickly and deeply absorbed
restoring suppleness and flexibility
Olive oil
Al-Waili (2005) Arch Med Res;36:10-13
• Examined a mixture of honey, beeswax, and
olive oil relative to growth of Staph aureaus and
Candida albicans on growth media
• This mixture is used in treatment of diaper rash,
psoriasis, and eczema
• No growth seen when only honey was used on
media
• Milk to moderate growth with only beeswax or
only olive oil
• Media with mixture had clear zone of growth
inhibition
Olive oil for prevention
of sore nipples
• 56 mothers applied extra virgin olive oil to
one nipple and lanolin to the other after
nursing
• 89% more satisfied with olive oil
• Sore nipples observed in 33.9% lanolin and
7.1% olive oil
• No nipple pain in 66.1% olive oil group and
46.4% lanolin group
Oguz et al. J Family Med Community Health 2014; 1(4): 1021
Ozonated olive oil
Kim et al (2009) J Korean Med Sci;24:368-374
Sakazaki et al (2007) Ozone: Sci & Engineering;29:503-507
• Shown to be effective in animal models for
accelerating wound repair and promoting
granulation tissue formation
• Oilve oil treated with gaseous ozone
• Have a wide range of activities during entire
healing process
• Microbes have a poor defense against strong
antioxidants
– Which is why there is no bacterial resistance to ozone
• No studies could be found on its use in nipple
wound healing
Coconut oil
Verallo-Rowell et al. (2008) Dermatitis;19:308-315
Nevin KG& Rajamohan. (2010) Skin Pharmacol Physiol;23:290-297
• Virgin coconut oil (VCO) was more effective
against Staph aureus than olive oil in adult
dermatitis study
• VCO-treated wounds healed much faster, as
indicated by a decreased time of complete
epithelization and higher levels of various skin
components
• Lacking studies of coconut oil use on sore
nipples
• Reported anecdotally by lactation consultants
Medihoney
• Exerts antimicrobial action against a broad
spectrum of fungi and bacteria, including
antibiotic-resistant bacteria such as
methicillin-resistant S. aureus, multidrugresistant gram-negative organisms, and
vancomycin-resistant enterococci
• Honey has been used successfully as a
dressing for wounds, including burns,
ulcers, infected surgical wounds,
necrotizing soft tissue infections,
meningococcal wounds, and abdominal
wound dehiscence
Medihoney
• A meta-analysis of seven randomized
controlled trials involving the use of
honey as a wound dressing showed it to
be superior to antiseptics and/or systemic
antibiotics for wound healing, maintenance
of sterility, and eradication of infection
– Moore et al. BMC Complement Altern Med 2001;1 : 2
• Bactericidal against multiple strains of bacteria.
• Biofilm was penetrated by biocidal substances in
honey
– Merckoll et al. (2009) Scand J Infect Dis;41:341-347
Medihoney
• Breast pads
containing honey are
• Honey in product is
available online
irradiated to destroy
• The gel may contain
botulism spores
80% honey plus wax.
• Honey has been used
The wax ingredient
since 2000 BC for wound
may not be good if
healing
there is a very deep
• http://manukahealth.co.nz/
crack/wound on the
• http://www.dermasciences.com/
nipple. Moms may be
better off with the
paste if there is a
deep wound.
Medihoney
• Make sure that the
mother is not allergic
to honey before using
Medihoney.
• Some mothers may
feel a slight stinging
because the honey
preparations (gel,
paste, hydrogel
dressing) has a low
pH.
• If this persists then
Medihoney may need
to be discontinued.
Biofilms
• Bacteria can grow in
colonies and protect
the colony with a
coating called a
biofilm
• Biofilms may be
stimulated by saliva
• Highly resistant to
antibiotics
Biofilms
• Wash nipple/areola
with soap and water
• Can follow with
coating of mupirocin
(Bactroban)
• If persistent and/or
resistant, coat with
Medihoney
• Medihoney reported
effective against
MRSA
• Biofilms grow on
pacifiers too
Small colony variants
• Small colony variants (SCVs) of Staphylococcus
aureus are slow-growing morphological variants
that have been implicated in
persistent, relapsing, and antibiotic-resistant
infections
• Can takes weeks of antibiotics to clear
• Mothers may present with chronic nipple lesions
that do not heal, deep breast pain, and tender
breasts
– Eglash et al (2006)
More remedies
• Hydrogel dressings
– Pain relief
– Moist wound healing
– Should not be sticky, leave
residues or small pieces
that adhere to nipples
• All purpose nipple
ointment
– Mupirocin 2% ointment (15
grams)
– Betamethasone 0.1%
ointment (15 grams)
– To which is added
miconazole powder so that
the final concentration is
2% miconazole.
More causes of sore nipples
• Eczema
– Erythema, blisters, oozing,
crusts, fissures
– Itching or burning is typical
– High colony counts of S aureus,
especially with cracks on the
nipple
– Treated with topical
corticosteroids and antibiotics
• If appearing on only 1 nipple,
rule out Paget’s disease
– Red, scaly plaque starting on
nipple, spreading to areola
– Oozing, crusting, itching,
burning, skin thickening,
erythema, nipple retraction
– May start out as vesicular
eruption, persistent soreness,
pain/itching of nipple
– Biopsy establishes diagnosis
Psoriasis on nipple and areola
Herpes
• Transmission from
mother to infant and from
infant to mothers has
occurred but is rare
• Herpetic nipple lesions
may be very similar to the
more common nipple
erosions caused by
trauma from poor latch
• Because prompt
diagnosis and treatment
of HSV infection is so
important in newborns,
clinicians should maintain
a high index of suspicion
when examining vesicular
lesions on a mother’s
nipples during the
neonatal period
Raynaud’s phenomenon
• Vasospasm of the arterioles
causing intermittent ischemia,
seen as pallor, followed by
cyanosis as the venous blood is
deoxygenated, and then
erythema when reflex
vasodilatation occurs
• Heat
• Nifedipine 30 mg sustained
release tablet
• Massage blood back into nipple
(Diana West)
• calcium and magnesium, evening
primrose oil (gamma linoleic
acid), and fish oil
(eicosapentanoic acid and
docosahexanoic acid)
eicosapentanoic acid and
docosahexanoic acid).
Raynaud’s (con’t)
• Cause may be related to a defect in nitric
oxide synthesis or metabolism
• Nitric oxide is a vasodilator
• Nitric oxide is synthesized from the amino
acid L-arginine
• Oral L-arginine 500mg x3/day may provide
relief
Nipple bleb
• Blocked nipple pore
• Milk seeping under epidermis
• Tendency for epithelial
overgrowth, possibly
encouraged by epithelial
growth factor in breastmilk
• Warm saline soaks, olive oil,
gentle rubbing with towel,
scraping with tweezers
• Open with sterile needle and
express out accumulated
material (may be thick and
stringy)
• Topical lecithin rubbed into
nipple
– Lawrence & Lawrence- may
be buildup of cells like
seborrheic dermatitis or cradle
cap
Nipple bleb
O’Hara. (2012). Breastfeed Med 7; (Suppl.1), S-2
• Histology of blebs
• Short daily course of
showed no bacteria or
thin layer of midfungi but presence of
potency steroid under
immune cells
occlusive dressing to
enhance penetration
• Removal by punch
into inflamed tissue
biopsy resolved pain
• Inflammatory
and symptoms
response to nipple
• Tissue reaction to
trauma
leaked milk infiltrating
into surrounding
tissue
Mammary candidosis
• Diagnosed presumptively
• 3 or more signs occurring
simultaneuosly, especially
in combination with
shiny/flakey skin
• Shiny/flakey skin, sore,
burning, pain, stabbing,
skin changes
• Skin scraping on 10%
KOH wet mount
• Laboratory testing
(addition of iron to
counteract lactoferrin)
Treatments
•
•
•
•
•
•
Treat both mother and baby
APNO
Gentian violet
Grapefruit seed extract
Probiotics
Fluconazole
– If no relief after 14-21 days of
fluconazole, pain may have a
different cause (bacterial)
• Medihoney
– May help with resistant
situations
• Coconut oil
– C albicans has a high
susceptibility to coconut oil
Incorrect pump flange size
• Nipples swell during
pumping by as much as
3-4mm (Wilson-Clay &
Hoover 2008)
• May need a different size
flange for each breast
• Nipple cream or olive oil
applied to nipple may
make better seal and
prevent abrasion
• If nipple is 20mm in
diameter at base or
larger, may need one size
larger flange
May need larger flange if:
• Nipple rubs or sticks
• Nipple does not move freely
after 5 minutes
• All of nipple does not fit into
nipple tunnel
• Mother experiences pain
• Nipple tip becomes sore or
blistered
• Areas of the breast are not
well drained
• Ring of sloughed skin seen
on inside of flange
• Base of nipple blanches while
pumping
• Pumpin’ Pal Super Shield
option if no flanges are
suitable
Treatment options for damaged nipples