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      <h1 id="top">8.2 Nipple Pain</h1>
      <div>
    <p> Nipple pain is a common early postpartum concern. </p>
    <p class="listTitle"> It causes mothers </p>
    <ul>
      <li> to wean early <sup><a href="#note1">1</a></sup> <sup><a href="#note2">2</a></sup> <sup><a href="#note3">3</a></sup> <sup><a href="#note4">4</a></sup> <span class="aside"> (is a reason given by one third of mothers who wean prior to 6 weeks postpartum) </span> </li>
      <li> emotional distress <sup><a href="#note1">1</a></sup> <span class="aside"> (women with nipple pain experience high levels of emotional distress, which resolves once the pain resolves) </span> </li>
    </ul>
    <p class="listTitle"> Nipple pain can be caused by several factors: </p>
    <ul>
      <div class="columns"><div class="column" style="width: 50%">
          <li> Technical issues: <ul><li> poorly latched baby </li><li> baby with incorrect sucking technique </li><li> incorrect use of lactation aids, eg. a breast pump, nipple shields, breast shells, etc. </li></ul> </li>
          <li> Maternal anatomy issues <ul><li> non-protractile nipples - not always resulting in nipple pain/damage </li><li> firm, dense breast tissue </li></ul> </li>
          <li> Dermatological conditions of the nipple <ul><li> dermatitis (atopic and contact) </li><li> psoriasis, and other skin conditions </li></ul> </li>
        </div><div class="column" style="width: 50%">
          <li> Infections <ul><li> fungal overgrowth, eg. candidiasis </li><li> bacterial infections, eg. staph aureus </li><li> viral infections, eg. herpes simplex </li></ul> </li>
          <li> Neurovascular conditions <ul><li> vasospasm of the nipple </li><li> Raynaud's phenomenon </li><li> nerve response to damaged nipples </li></ul> </li>
          <li> Infant anatomy issues <ul><li> high arched palate or a bubble palate </li><li> short lingual frenulum<br /></li><li> receding/small mandible </li><li> teething <br /> </li></ul> </li>
        </div></div><br style="clear: both" />
    </ul>
    <p> Transient nipple pain is common during the first week postpartum, peaking at day 3 and decreasing by day 7. <sup><a href="#note5">5</a></sup> There is no damage evident and the pain disappears within a short time of commencing the feed (ie, about 30 seconds). </p>
  </div>
      <div class="section" id="Technique_factors"><h2>Technique factors</h2>
    <div>
      <p> Historically, an intervention to try to prevent nipple damage was to limit the number of feeds and length of time on the breast. A Cochrane Review <sup><a href="#note6">6</a></sup> concluded that this practice was associated with an <strong>increased</strong> incidence of sore nipples, engorgement and the need to give additional (formula) feeds, and is therefore not recommended. <br /> </p>
      <p> One study noted that 94% of women with breastfeeding problems had babies who had a "superficial, nipple-sucking" technique. <sup><a href="#note7">7</a></sup> <br /> </p>
      <p> Many authors implicate a poorly latched baby as being the major culprit of nipple damage. <sup><a href="#note8">8</a></sup> <sup><a href="#note9">9</a></sup> <sup><a href="#note10">10</a></sup> </p>
      <p> It has also been noted that there is a correlation between the early use of bottles and/or pacifiers and a disorganized suck and nipple damage. <sup><a href="#note7">7</a></sup> <sup><a href="#note11">11</a></sup> </p>
      <p class="listTitle"> From this body of work it is clear that <strong>the most common cause</strong> of nipple pain and nipple damage is preventable by: </p>
      <ul>
        <li><strong>teaching correct positioning and latching techniques,</strong> and </li>
        <li>
          <strong>avoiding artificial nipples (teats/pacifiers/dummies) during the learning period.</strong>
        </li>
      </ul>
      <p> </p>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Back to basics</h3>
      <div>Poor latch (whether from maternal technique or infant ability) may exist in the presence of other factors mentioned above.<br />In assisting the mother, go back to basic principles of position and latch FIRST to obtain a clearer picture of the other factors.<br /></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Quality assurance activity</h3>
      <div>Would you and a small group of colleagues be able to organize an audit of all cases of nipple damage on discharge from your maternity unit over a one-month period? <br /> It may be as simple as just an incident report, though trying to determine a cause for each would be useful. You may like to discuss with your colleagues the significance of this data once collected. Together you could work on ways to reduce the incidence before surveying again.</div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="Maternal_anatomy_issues"><h2>Maternal anatomy issues</h2>
    <div>
      <p class="listTitle">General tips:</p>
      <ul>
        <li>Always start any 'difficulty latching' attempt to breastfeed with a well positioned baby in skin-to-skin contact with mother.</li>
        <li>Gentle touch or massage, or a cold cloth over the nipple will stimulate the erectile tissue.</li>
        <li>Compress the breast to hold the shape, ensuring the compression points on the breast coincide with where the baby's bottom and top jaws will be. Some mothers find it helpful to maintain this hold for a minute or two until sucking well established.</li>
        <li>While the breast is still soft prior to lactogenesis II is the best time for the baby to learn to breastfeed from his mother's breasts. If an artificial teat, whether it be a bottle nipple or a nipple shield, is introduced before giving the baby this opportunity the baby is more likely to require the 'super' stimulation of a formed shape at the posterior hard palate to stimulate sucking for all future feeds.</li>
      </ul>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 8.3</h3><p>Complete Activity 8.3 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div class="section" id="Inverted_or_non-protractile_nipples"><h3>Inverted or non-protractile nipples</h3>
      <div>Non-protractile or inverted nipples are difficult to draw out. Attempt to shape the breast well and hold that shape until infant is well established on the breast.<br /><br />Some devices may assist:<br /></div>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="200" height="300" src="images/modified_syringe.gif" alt="Syringe on right modified for mother to gently draw out non-protractile or inverted nipple." /><p>Syringe on right modified for mother to gently draw out non-protractile or inverted nipple. <br />Photograph &copy;  Health e-Learning</p></div>
        </div><div class="column" style="width: 50%">
          <div>
            <p> Devices such as the modified syringe, or commercially available devices have assisted mothers to draw their nipples out to enhance baby's ability to latch. Using a hand pump for a minute or so can also draw out the nipple. Some mothers may find it more comfortable if her partner is able to suck the breast/nipple into a teat shape immediately before feeding the baby. <br /></p>
            <p>These techniques are not always necessary though as many babies latch well to the breast regardless of nipple protractility. <br /></p>
            <p>
              <span style="font-style: italic;">Remember it is breastfeeding, not nipple feeding.</span>
            </p>
          </div>
        </div></div><br style="clear: both" />
    </div>
    <div class="columns"><div class="column" style="width: 50%">
        <div class="captionBox"><img width="225" height="338" src="images/feed_with_shield.jpg" alt="Infant well-latched to nipple shield." /><p>Infant well-latched to nipple shield. <br />&copy; B. Wilson-Clay IBCLC</p></div>
      </div><div class="column" style="width: 50%">
        <div>
          <p> Sometimes a nipple shield may be successful. A risk:benefit assessment needs to be thoroughly explored first. Short-term benefits may lead to long-term complications for the breastfeeding dyad. In the past, nipple shields have been associated with decreased milk transfer, infant weight loss and decreased milk supply.<sup><a href="#note12">12</a></sup> <sup><a href="#note13">13</a></sup> <sup><a href="#note14">14</a></sup> Even with modern, thin nipple shields their use has been associated with premature weaning<sup><a href="#note15">15</a></sup> yet one study of preterm infants showed increased milk transfer over two consecutive feeds.<sup><a href="#note16">16</a></sup><br /></p>
          <p>Milk transfer via a shield, before lactogenesis II, will be negligible and therefore shields are <strong>not started</strong> until mother has established a good milk supply. <br /></p>
          <p>
            <span style="font-style: italic;">Note: Once a nipple shield has been introduced, observe for a good deep latch and nutritive sucking pattern. Follow-up assessment of infant condition and maternal milk supply is very important with the aim to weaning off the shield when the initial problem has resolved.</span>
            <br />
          </p>
          <p>
            <br />
          </p>
          <p>
            <br />
          </p>
        </div>
      </div></div><br style="clear: both" />
  </div>
      <div class="section" id="Infant_anatomy_issues"><h2>Infant anatomy issues</h2>
    <div class="section" id="Ankyloglossia_tongue_tie_"><h3>Ankyloglossia (tongue tie)</h3>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="300" height="206" src="images/tongue-tie1.JPG" alt="Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue." /><p>Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue. <br />&copy; Dr E. Jain</p></div>
        </div><div class="column" style="width: 50%">
          <div>
            <p> Ankyloglossia is a membranous attachment between the inferior aspect of the tongue and the anterior floor of the mouth, just beneath or directly onto the posterior alveolar ridge. This short or tight lingual frenulum may prevent the baby from extending the tongue over the bottom gum line or elevating the tongue (a very essential action for breastfeeding). </p>
          </div>
        </div></div><br style="clear: both" />
      <div class="section" id="Presentation"><h4>Presentation</h4>
        <div>
          <p> 80% of cases of poor latch as a result of ankyloglossia presented at 2 days postpartum; whereas 60% of women with nipple pain from ankyloglossia presented after day 2.<sup><a href="#note17">17</a></sup> </p>
          <p class="listTitle"> If not treated the most common outcomes include: </p>
          <ul>
            <li> poor latch </li>
            <li> nipple pain </li>
            <li> severe nipple damage </li>
            <li> constantly feeding </li>
            <li> infant failure to thrive (inadequate milk transfer) <br /> </li>
          </ul>
        </div>
      </div>
      <div class="section" id="Treatment"><h4>Treatment</h4>
        <div>Several factors need to be considered. Adequate tongue movement and function is essential for breastfeeding. Mild anomalies may have minimal effect on tongue function. However, when tongue-tie is noted, it must always be considered as causative of any breastfeeding problems until proven otherwise. <br /> <br style="font-weight: bold;" /> <span style="font-weight: bold;"> Frenotomy </span> <br /> This is a simple surgical procedure to release the restriction and provide greater movement. <br /> <br /> The following outcomes of frenotomy have been achieved: <br /><ul><li> Where poor latch was their major complaint, 100% of women found latch was improved.<sup><a href="#note17">17</a></sup> <br /></li><li>Of those presenting with nipple pain, mean pain score reduced from 6.9 to 1.2 immediately after the procedure.<sup><a href="#note17">17</a></sup></li><li> A significant decrease in nipple pain score reported after frenotomy compared to after sham procedure.<sup><a href="#note18">18</a></sup></li><li>Ultrasound post-frenotomy demonstrated less nipple compression by the tongue and was associated with "better attachment, increased milk transfer and less maternal pain".<sup><a href="#note19">19</a></sup></li></ul></div>
      </div>
    </div>
  </div>
      <div class="section" id="Nipple_infections"><h2>Nipple infections</h2>
    <div class="section" id="Fungal_overgrowth_candidiasis_thrush_yeast_"><h3>Fungal overgrowth (candidiasis, thrush, yeast)</h3>
      <div><p><dfn> Candida albicans </dfn> is a fungus (a form of yeast), which exists normally on the mucous membranes of the gut and vagina and usually presents no problems to a healthy individual. Factors that cause an imbalance of the normal flora of the body often result in candidiasis - the condition caused by an overgrowth and change in form of the fungus as it infects the host tissue. </p><p class="listTitle"> Factors often associated with nipple candidiasis are: </p><ul><li> presence of vaginal candidiasis - up to 25% of women are affected by end of pregnancy <sup><a href="#note20">20</a></sup> </li><li> use of antibiotics <sup><a href="#note1">1</a></sup> </li><li> break in skin integrity of nipple </li><li> infant who has oral candidiasis (acquired during birthing or being introduced on fingers, etc) </li><li> infant use of pacifiers/dummies <sup><a href="#note21">21</a></sup> <sup><a href="#note22">22</a></sup> - may also contribute to persistence of infant oral infection </li><li> use of bottles - 23% of lactating women who used bottles tested positive for <dfn> Candida </dfn> and 20% had nipple candidiasis. A risk factor for colonization of the mother was bottle use in the first 2 weeks postpartum. Of these women 57% had weaned by 9 weeks postpartum, compared to 31% who were negative for <dfn> Candida </dfn> . <sup><a href="#note23">23</a></sup> </li></ul> Amongst women who reported breastfeeding associated pain, C.albicans is the most commonly cultured organism. <sup><a href="#note24">24</a></sup> <br /></div>
      <div class="section" id="Presentation"><h4>Presentation</h4>
        <div>
          <p class="listTitle">Nipple candidiasis commonly presents with the following signs and symptoms</p>
          <ul>
            <li>acute breast/nipple pain after a period of pain-free feeding</li>
            <li>deep shooting, burning, or stabbing pain in the breast</li>
            <li>burning nipple pain, during and for some time after a breastfeed</li>
            <li>nipple and/or areola may be red, shiny or flakey; though may show no changes</li>
            <li><dfn>Candida</dfn> may be obvious in the baby's mouth</li>
          </ul>
        </div>
      </div>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="250" height="245" src="images/flakey_thrush_400_BI.jpg" alt="Note the dry, flakey area at base of nipple." /><p>Note the dry, flakey area at base of nipple. <br />&copy; B.Ingle IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div class="captionBox"><img width="296" height="293" src="images/thrush2_BI.jpg" alt="Note the shiny, red areola." /><p>Note the shiny, red areola. <br />&copy; B. Ingle, IBCLC</p></div>
        </div></div><br style="clear: both" />
      <div class="section" id="Management"><h4>Management</h4>
        <div><p> Observe a breastfeed to ensure latch is optimal, preventing further nipple damage. <br /> </p><p><span style="font-style: italic;"> Candida </span> branches and multiples rapidly and exists in many different stages at the same time. Management is aimed at eradicating the pathogen and preventing re-infection. The mother's doctor will confirm the diagnosis and may prescribe a pharmaceutical antifungal agent. <br /> </p><p><span style="font-weight: bold;"> Antifungal agents </span> that have been found to be effective in treating nipple candidiasis include: </p><ul><li> Gentian violet - painted on the nipples. This purple dye kills <dfn> Candida </dfn> on contact. <span class="aside"> (not readily available in some countries) </span> </li><li> Pure coconut oil - rubbed into nipples and ingested for candida in other sites. 100% effective against candida albicans <sup><a href="#note25">25</a></sup> </li><li> Miconazole - cream applied sparingly to nipples, oral gel, and powder. Effective in 99% of cases. <sup><a href="#note26">26</a></sup> </li><li> Fluconazole - systemic agent, usually administered orally. </li><li> Nystatin cream, tablets and pessaries. Not usually the drug of first choice. Resistance has developed to this drug, only being effective in 54% of cases. <sup><a href="#note26">26</a></sup> </li></ul><p class="listTitle"> Educate the mother about the following <span style="font-weight: bold;"> supportive strategies </span> that will enhance the antifungal treatment and prevent re-infection. </p><ul><li> Meticulous attention to hygiene. <br /> <ul><li> wash hands in warm, running soapy water before and after breastfeeding and any time when potentially infected areas have been touched, drying hands on a paper towel. </li><li> discard reusable gel breast pads if they were being used and don't recommence until infection is cured, and preferably not at all. </li><li> wash bras and cloth nursing pads daily and dry in direct sunlight if possible. </li><li> boil pacifiers or artificial teats/nipples daily and replaced frequently. <br /> </li><li> wash and thoroughly dry all toys, etc the baby puts in his mouth. </li></ul> </li><li> Rinse the nipples in a bicarbonate of soda solution to create an alkaline skin environment. Nipples may respond differently to traditional vaginal thrush soothing treatments.</li><li> Consider and treat all possible sources of recurring infection <br /> <ul><li> trim the baby's finger nails to prevent <span style="font-style: italic;"> Candida </span> being harbored under the nail and transferred to the mouth. </li><li>the moist fold under the breasts of large breasted women<br /></li><li> other children, maternal vaginal infection, sexual partner, a pet </li></ul> </li><li> Some women have reported faster resolution of symptoms when they eliminate simple sugars and yeasts from their diet and consume pure coconut oil, acidophillus and/or bacillo bifidus either in yoghurt form or in a commercially prepared capsule. </li></ul><span style="font-weight: bold;"> Treatment of the infant </span><br /> The infant may be a source of a re-infection cycle. Check the infant's mouth mucosa carefully. It may be necessary to treat the mouth with an appropriate infant preparation such as miconazole gel. <br /> <br /></div>
        <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 8.5</h3><p>Complete Activity 8.5 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
      </div>
    </div>
    <div class="section" id="Bacterial_infection"><h3>Bacterial infection</h3>
      <div class="columns"><div class="column" style="width: 50%">
          <div class="captionBox"><img width="288" height="295" src="images/staph_sm_BI.jpg" alt="Look closely at the nipple, noting the exudate." /><p>Look closely at the nipple, noting the exudate. <br />&copy; B.Ingle IBCLC</p></div>
        </div><div class="column" style="width: 50%">
          <div><dfn></dfn> Whenever nipple skin integrity is broken the risk of colonization with bacterial <strong>and</strong> fungal pathogens is significantly increased. <br /><dfn>Staphylococcus aureus</dfn> is the most common causative organism of bacterial infections on the nipple, though streptococcus may also be implicated.<br /><br /><p class="listTitle"><span style="font-weight: bold;">Diagnosis</span> is usually made following careful history taking:</p> <ul><li>pain described as stinging,</li><li>observation of nipple damage,</li><li>presence of an exudate that could be yellow to red and crusting,</li><li>a delay in wound healing</li></ul><br /></div>
        </div></div><br style="clear: both" />
      <div>
        <span style="font-weight: bold;"> Management: </span>
        <ul>
          <li> Treat the original cause of the break in nipple skin integrity. </li>
          <li> Clean the nipple wound in a saline solution. </li>
          <li> Apply antibiotic ointment as ordered by the doctor. A compound many find useful is a combination of betamethasone ointment, mupirocin ointment and miconazole powder making an anti-inflammatory, antibiotic and antifungal ointment. <sup><a href="#note27">27</a></sup> A doctor may prescribe this and a compounding pharmacy supply it. </li>
          <li> It has been suggested that prophylactic oral antibiotics when nipple bacterial infection is diagnosed will prevent subsequent mastitis. <sup><a href="#note28">28</a></sup> However, in an unsuccessful attempt to replicate that study, the authors reported a significant number of women reluctant to take antibiotics prophylactically.<sup><a href="#note29">29</a></sup> </li>
        </ul>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/warning.png" class="icon" alt="" /><h3>Be vigilant</h3>
        <div>A bacterial nipple infection is a strong risk factor for the development of infective mastitis.<br /></div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
  </div>
      <div class="section" id="Treatment_of_nipple_damage"><h2>Treatment of nipple damage</h2>
    <blockquote>
      <div>There is nothing to be achieved by treating sore or damaged nipples if you don't simultaneously treat the cause.</div>
    </blockquote>
    <div><p> After identifying the cause and initiating an appropriate action plan, the mother may also benefit from some other supportive measures to give added relief.</p>Breastmilk contains anti-infective agents and epidermal growth factor to prevent infections and heal any damage, as well as the hindmilk being high in fat to soothe the nipple. When you remove the cause of the damage, the nipple will heal quickly even while the mother continues to breastfeed on the affected breast. <p class="listTitle">After performing a meta-analysis<sup><a href="#note30">30</a></sup> on the available research on treatment methods for nipple damage best practice is to</p><ol><li>apply warm water compresses <span style="font-style: italic;">to relieve pain</span>, and</li><li>apply breastmilk <span style="font-style: italic;">to hasten healing</span> of cracked nipples.</li></ol><p> None of the following are recommended: lanolin, ointments, aerosol sprays, film dressing and hydrogel dressings.</p><p>You can read the whole Best Practice information sheet on <img alt="External" src="design/external.gif" /><a href="http://www.jbiconnectplus.org/ViewSourceFile.aspx?0=500" title="External link" target="_blank"><span style="font-style: italic;">Management of nipple pain and/or trauma associated with breastfeeding.</span></a><br /></p></div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/warning.png" class="icon" alt="" /><h3>What about resting the nipple?</h3>
      <div>Severely damaged nipples may need to be rested for 24 hours or longer for initial healing to occur. During this time regular expressing of breastmilk will be required. <br /><br />We live in a time of technology and gadgets. A breast pump (electric or manual) is often the only option considered for milk removal. Just as infants who exert a stronger baseline peak and pause vacuum will cause more pain for their mothers compared to infants with vacuum within normal range<sup><a href="#note31">31</a></sup> so too the vacuum of breast pumps has been associated with increased nipple pain and damage.<sup><a href="#note32">32</a></sup> If a pump is to be used careful instruction to mothers about the correct use will prevent a bad situation becoming worse.<br /><br />Hand expressing breastmilk may be a better option for many mothers.<br /></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Group Activity</h3>
      <div>
        <p>
			Review your unit's Breastfeeding Policy for the management of nipple damage. Is it up-to-date and evidence-based? Is this the procedure all your colleagues follow?
		</p>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <ul>
          <li> Nipple pain threatens breastfeeding continuance. </li>
          <li> The many causes of nipple pain. </li>
          <li> The most important basic principle to address nipple pain. </li>
          <li> How to assist mothers with non-protractile nipples. </li>
          <li> Identification of ankyloglossia and impact on breastfeeding dyad. </li>
          <li> How to recognise nipple infections such as candidiasis and Staph aureus. </li>
          <li> Treatment choices for nipple candidiasis and Staph aureus. </li>
          <li> Supportive management for damaged nipples. </li>
        </ul>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="Self-test_quiz"><h2>Self-test quiz</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div></div><div class="activity" id="activity_rg">
<script type="text/javascript">
/* <![CDATA[ */
var rgqs = {settings : {type : 'matching', shuffle : 'both'}, questions : [
	new Matching('This is the organism most commonly cultured in mothers reporting nipple pain.', 'Candida albicans'),
	new Matching('Nipple infections by this organism significantly increase the risk of mastitis.', 'Staph. aureus'),
	new Matching('Candida albicans is often harbored in these implements, causing infection and re-infection.', 'pacifiers and teats'),
	new Matching('Staph aureus infection of the nipple has a characteristic feature.', 'yellow exudate'),
	new Matching('This is the pharmacological treatment required for Candida albicans.', 'antifungal'),
	new Matching('Treatment with this increases the risk of candidiasis.', 'antibiotics'),
	new Matching('If untreated this could result in the infant failing to thrive.', 'ankyloglossia')
]};

/* ]]> */</script>
<p class="instructions">Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column</p></div><script type="text/javascript">renderActivity('rg');</script>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#amir96" title="See full details">#</a> Amir LH et al. (1996) Candida albicans: is it associated with nipple pain in lactating women?</li>
          <li id="note2"><a href="references.html#schw02" title="See full details">#</a> Schwartz K et al. (2002) Factors associated with weaning in the first 3 months postpartum.</li>
          <li id="note3"><a href="references.html#lewa06" title="See full details">#</a> Lewallen LP et al. (2006) Breastfeeding support and early cessation.</li>
          <li id="note4"><a href="references.html#amir05a" title="See full details">#</a> Amir LH et al. (2005) Why do women stop breastfeeding? A closer look at not enough milk among Israeli women in the Negev Region.</li>
          <li id="note5"><a href="references.html#morl05" title="See full details">#</a> Morland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review.</li>
          <li id="note6"><a href="references.html#renf00" title="See full details">#</a> Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.</li>
          <li id="note7"><a href="references.html#righ98" title="See full details">#</a> Righard L (1998) Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles?</li>
          <li id="note8"><a href="references.html#gunt45" title="See full details">#</a> Gunther M (1945) Sore Nipples: Causes and Prevention</li>
          <li id="note9"><a href="references.html#prac02" title="See full details">#</a> Prachniak GK (2002) Common breastfeeding problems</li>
          <li id="note10"><a href="references.html#wigh01" title="See full details">#</a> Wight NE (2001) Management of common breastfeeding issues</li>
          <li id="note11"><a href="references.html#cent99" title="See full details">#</a> Centuori S et al. (1999) Nipple care, sore nipples, and breastfeeding: a randomized trial</li>
          <li id="note12"><a href="references.html#wool80" title="See full details">#</a> Woolridge MW et al. (1980) Effect of a traditional and of a new nipple shield on sucking patterns and milk flow.</li>
          <li id="note13"><a href="references.html#jack87" title="See full details">#</a> Jackson DA et al. (1987) The automatic sampling shield: a device for sampling suckled breast milk.</li>
          <li id="note14"><a href="references.html#auer90" title="See full details">#</a> Auerbach KG (1990) The effect of nipple shields on maternal milk volume.</li>
          <li id="note15"><a href="references.html#pinc08" title="See full details">#</a> Pincombe J et al. (2008) Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.</li>
          <li id="note16"><a href="references.html#meie00" title="See full details">#</a> Meier PP et al. (2000) Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding.</li>
          <li id="note17"><a href="references.html#ball02" title="See full details">#</a> Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad</li>
          <li id="note18"><a href="references.html#grif04" title="See full details">#</a> Griffiths DM (2004) Do Tongue Ties Affect Breastfeeding?</li>
          <li id="note19"><a href="references.html#gedd08a" title="See full details">#</a> Geddes DT et al. (2008) Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound.</li>
          <li id="note20"><a href="references.html#cotc98" title="See full details">#</a> Cotch MF et al. (1998) Epidemiology and outcomes associated with moderate to heavy Candida colonization during pregnancy</li>
          <li id="note21"><a href="references.html#comi06" title="See full details">#</a> Comina E et al. (2006) Pacifiers: a microbial reservoir</li>
          <li id="note22"><a href="references.html#dasi09" title="See full details">#</a> da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.</li>
          <li id="note23"><a href="references.html#morr05" title="See full details">#</a> Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women</li>
          <li id="note24"><a href="references.html#andr07" title="See full details">#</a> Andrews JI et al. (2007) The yeast connection: is Candida linked to breastfeeding associated pain?</li>
          <li id="note25"><a href="references.html#ogbo07" title="See full details">#</a> Ogbolu DO et al. (2007) In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.</li>
          <li id="note26"><a href="references.html#hopp96" title="See full details">#</a> Hoppe JE et al. (1996) Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group</li>
          <li id="note27"><a href="references.html#newm05" title="See full details">#</a> Newman J et al. (2005) Dr Jack Newman's Guide to Breastfeeding (The Ultimate Breastfeeding Book of Answers)</li>
          <li id="note28"><a href="references.html#livi99" title="See full details">#</a> Livingstone V et al. (1999) The treatment of staphylococcus aureus infected sore nipples: a randomized comparative study</li>
          <li id="note29"><a href="references.html#amir04" title="See full details">#</a> Amir LH et al. (2004) A failed RCT to determine if antibiotics prevent mastitis: Cracked nipples colonized with Staphylococcus aureus: A randomized treatment trial</li>
          <li id="note30"><a href="references.html#jbi09" title="See full details">#</a> Johanna Briggs Institute et al. (2009) The management of nipple pain and/or trauma associated with breastfeeding.</li>
          <li id="note31"><a href="references.html#mccl08" title="See full details">#</a> McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums</li>
          <li id="note32"><a href="references.html#clem10" title="See full details">#</a> Clemons SN et al. (2010) Breastfeeding womens experience of expressing: a descriptive study.</li>
        </ol>
      </div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li class="current">8.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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