Keywords
nipples/injuries - wound healing/drug effects - lanolin/therapeutic use - breastfeeding/adverse
effects - breastfeeding/nipple pain
Palavras-chave
mamilos/lesões - cicatrização de feridas/efeitos de medicamentos - lanolina/uso terapêutico
- aleitamento materno/efeitos adversos - aleitamento/dor no mamilo
Introduction
Breastfeeding is the most elementary act for meeting the basic human need for nutrition,
but it can be impaired in some situations, especially when women experience nipple
trauma or pain when breastfeeding. It has been shown that breast milk is the best
nutriment for newborns, and that exclusive breastfeeding for at least 6 months has
a direct impact on the social dimension, with improved indicators for maternal and
child morbidity and mortality.
An extensive meta-analysis, published in The Lancet, in 2016, by Victora et al,[1] demonstrated the benefits of breastfeeding for children, including protection against
infections and dental malocclusion, higher intelligence, and lower likelihood of being
overweight or developing diabetes. For nursing mothers, the benefits include lower
incidence of breast cancer, longer intervals between pregnancies, and possible protection
against type 2 diabetes and ovarian cancer.[1]
However, for breastfeeding to be effective, certain measures are necessary, primarily
related to the adherence to breastfeeding, with instructions for position and latching
and treatments in the event of problems. Inadequate breastfeeding can impair the entire
process, with effects ranging from changes in the structure of the skin that covers
the nipples, causing trauma accompanied by pain (or not), to complications that can
make the act of breastfeeding extremely difficult.
In the correct position, the newborn should be close to and facing the mother, with
the buttocks supported and the head and body at the same height as the nipple. The
lips of the newborn should be facing outward with the mouth semi-open, cheeks rounded
and the chin touching the breast. Efficient suction is closely related to a good latch
and tissue integrity of the nipple.[2]
Pain with or without trauma may be closely related to an incorrect positioning of
the baby in relation to the breast of the mother, indicating the need for a careful
assessment by a qualified professional.
A 2013 study by Mariot[3] involving 342 nursing mothers in a children's hospital in southern Brazil found
an 82.5% prevalence of nipple trauma during the breastfeeding process.
In a systematic review by Morland-Schultz et al,[4] it was shown that the incidence of nipple pain during the breastfeeding stage is
of 80% and that, among the various therapies already studied, none has proven to be
effective in treatment. Some reduced the pain scores but did not totally resolve the
symptom. These studies included lanolin, breast milk, warm moist pads, distilled water,
tea bags, hydrogel, gentle massaging only, breastfeeding education only, chlorhexidine
alcohol spray, normal care, polyethylene film, and no treatment.
The same authors have also listed studies in which the outcome analyzed was nipple
trauma, and they concluded that no single procedure is superior to the others. Studies
were reviewed that included no local application, routine care, local heat, vitamin
A, anhydrous lanolin, distilled water, tea bags, lanolin USP, hydrogel mixed with
breast milk, lanolin cream mixed with breast milk, collagenase, dexpanthenol soap,
warm water, nipple protectors, and glycerin gel.[4]
Another important systematic review from the Cochrane Library, by Dennis et al,[5] examined various substances and procedures for treating nipple pain resulting from
trauma and concluded that the evidence was insufficient to determine the best type
of treatment for this problem. They have also mentioned an alternative treatment,
recently recommended by some professionals, which involves using light emitter diode
(LED) phototherapy. Studies of this treatment have suggested that the emission of
hyposignals in the nipple facilitates the trauma healing process and accelerates the
pain reduction process.
Nipple pain associated with trauma in the breastfeeding process is more common around
the 2nd day and usually improves by around the 10th day and it has been noted that, in Canada, it is one of the main reasons for stopping
breastfeeding. A study pointed out that 87.3% of the puerperal women started the breastfeeding
process and, of these, only 23.1% breastfed their babies up to 6 months, as recommended
by the World Health Organization (WHO). A direct relationship between stopping breastfeeding
and nipple pain was reported by between 77 and 96% of the women.[5]
[6]
A study conducted in the United States in 2016 reported that 76.5% of the women started
off breastfeeding, but only 49% reached 6 months, and a much smaller proportion (16.4%)
breastfed exclusively.[7]
In a Brazilian study, 72.3% of the women breastfed on the 1st day after the birth,
dropping to 67% in the first 15 days and to only 9.3% at 180 days. Data from the city
of São Paulo was very similar to the national figures: 72% of the women started the
breastfeeding process and only 10% continued up to 180 days.[8]
Based on the concerns about breastfeeding-related problems, Martins et al[9] conducted an experimental study using lanolin to treat surgical wounds in rats.
They observed that lanolin in a concentration of up to 2% was not effective in the
healing process, mainly in the assessment of outcomes in relation to time. However,
in the macroscopic assessment of the group treated with lanolin, the wound had a pinkish
border and no dryness, whereas in the control group (normal care), the border was
reddish and edematous. The absence of edema in the lanolin group may have been associated
with the antiinflammatory action of the eicosapentaenoic and docosahexaenoic acids
present in lanolin.
To date, there is insufficient evidence to demonstrate the superiority of a specific
substance to prevent or improve nipple trauma and pain during the breastfeeding process.
However, La Leche League International, a worldwide organization that provides breastfeeding
support, recommends lanolin as the best substance for pure and safe intervention,
in that it creates a moist healing environment for nipple trauma and provides a semi-occlusive
barrier that promotes retention of internal moisture and prevents dryness. The organization
concludes that lanolin can provide a moist environment to prevent skin sores, promote
epithelial growth, and decrease nipple pain.[6]
Application of the breast milk of mother on the nipple is another widely used procedure
recommended by many professionals and has been adopted as a public policy in various
countries. The Canadian Agency for Drugs and Technologies in Health[10] holds a technical opinion that does not identify any superior substance or procedure
to avoid or improve nipple trauma during breastfeeding. It recommends the use of breast
milk for prevention and treatment of nipple pain and trauma, after analyzing the conclusions
of various randomized and non-randomized studies.
The recommendation of the National Health Service (NHS) in the United Kingdom is based
on the most recent Cochrane review of 2014, which did not identify an effective substance
for healing nipple trauma and pain during breastfeeding and had no single suggestion
for this purpose.[5]
The Australian government published a protocol on nipple trauma during breastfeeding
and based its decision on good latching. It argues that correcting the latch will
naturally reduce the probability of occurrence of nipple pain and trauma. If a trauma
appears, despite having faithfully followed all the steps for breastfeeding, it recommends
that mothers apply their own breast milk, which is a natural bacteriostatic lubricant,
and let it dry. If pain prevents breastfeeding, it is necessary to remove the milk
and administer an oral medication.[11]
Studies come out every year in response to this prevalent problem in the population
of puerperal women who have difficulties breastfeeding their babies and, for this
reason, are liable to wean early. The present study was performed to contribute to
help build knowledge about measures conducive to successful breastfeeding. Its objective
was to compare two treatments—the use of highly purified anhydrous (HPA) lanolin versus
the mother's own breast milk—for women with nipple pain and trauma during the breastfeeding
process.
Methods
This was a randomized clinical trial that compared two interventions for treating
pain associated with nipple trauma during the breastfeeding process. It was conducted
at the Hospital Maternidade Leonor Mendes de Barros (HMLMB), a public hospital certified
by the Baby-Friendly Hospital Initiative (BFHI) in São Paulo, state of São Paulo,
Brazil. Its human milk bank serves, on average, 400 puerperal women per month. Most
are from the health service itself, and ∼ 20% are nursing mothers from outside who
come to the service due to various breastfeeding problems.
The sample studied was of convenience, due to the number of women attended at the
hospital and the period of data collection, from August 2016 to January 2018. It was
composed of 180 puerperal women, totaling 90 in the HPA lanolin (Lansinoh Laboratories,
Inc., Alexandria, VA, USA) group, called the LA group, and 90 in the breast milk group,
called the BM group. Considering a total loss of 15%, a total of 207 puerperal women
were included in the study by a simple randomization method (coin flipping): 107 in
the BM group and 100 in the LA group with diagnosis of unilateral or bilateral pain
and nipple trauma, whose children were healthy, at term, in exclusive breastfeeding.
There were 17 losses in the BM group and 10 in the LA group. The main reasons were:
no follow-up of the intervention; not allowing the interviewer to enter the house
to collect information; or abandonment of exclusive breastfeeding during the study.
To obtain homogeneity between the groups, all the women received guidance on the positioning
of the baby and adequate handholding of the nipple-areolar region during breastfeeding.
The maternal variables studied were: marital status, self-reported skin color, schooling,
primiparity, number of prenatal consultations, gestational age at delivery, type of
delivery, presence or absence of skin-to-skin contact in the 1st hour postpartum present,
gender of the newborn, nipple type, and type of problem (trauma, pain, or both).
The data collection instrument was specifically designed for the study and previously
tested. The data collection started after the study was approved by the Research Ethics
Committee of the HMLMB under the number 1.575.758; training of the monitors in the
methodological procedures of the study; authorization of the people responsible by
the hospital; and signing of the free and informed consent form by the mothers.
The assessments of breastfeeding were scheduled at three points: at enrollment; 48
hours later, and after 7 days. The first assessment was performed at the time of the
inclusion of the participants in the study, the second 48 hours later, and the third
7 days later. The instrument was a questionnaire with open-ended and closed questions
related to the sociodemographic profile, gestation/puerperium/breastfeeding, and treatment
satisfaction of the participants. In relation to pain associated with nipple trauma,
an instrument was used to assess intensity and quality of nipple pain through a unidimensional
pain assessment scale: a numerical/verbal category scale,[12] with a range from 0 to 10. For trauma, the nipple trauma score (NTS) ([Table 1])[13] was used, which is a validated instrument for assessing and measuring the evolution
of nipple injuries:[13]
[14]
Table 1
Nipple trauma score[13]
|
Score
|
|
0
|
No microscopically visible skin changes
|
|
1
|
Erythema or edema or combination of both
|
|
2
|
Superficial damage with or without scab formation on < 25% of the nipple surface
|
|
3
|
Superficial damage with or without scab formation on > 25% of the nipple surface
|
|
4
|
Partial-thickness wound with or without scab formation on < 25% of the nipple surface
|
|
5
|
Partial-thickness wound with or without scab formation on > 25% of the nipple surface
|
At the time of the first assessment, the diagnosis was performed in relation to pain
associated with nipple trauma, manifested by one or more of the following signs: blisters,
crusting, erythema, bleeding, swelling, or cracks. This assessment was performed by
the team from the human milk bank of the HMLMB and the researchers. After meeting
the inclusion criteria and agreeing to participate in the study, a numerical sequence
was used, by simple randomization, to determine which group each woman would be assigned
to (LA or BM). The instruments were then administered, followed by instructions on
the intervention to be adopted.
The BM group received the following instructions: at the end of each feeding, spread
a fine layer of breast milk on the region where pain was felt and there was an associated
nipple trauma. It was important to wait until it dried naturally before putting on
the bra. The LA group was instructed to spread a fine layer of HPA lanolin on the
region where pain was felt and there was an associated nipple trauma. It was important
to apply a fine layer that covered the whole extension of the trauma and to wait until
it dried naturally before putting on the bra. The two groups were also instructed
to wash their breasts daily, as well as the bra used, with water and neutral soap;
and not to use any type of additional care related to the breast and nipple during
the period of the study.
At the time of the second (after 48 hours) and third (after 7 days) assessments of
the use of HPA lanolin or breast milk, the women were evaluated through the application
of the instruments followed by an orientation.
The data was analyzed descriptively. For the categorical variables, the absolute and
relative frequencies were presented, and for the numerical variables, summary measurements
(mean, quartile, minimum, maximum and standard deviation [SD]). The existence of associations
between two categorical variables was checked using the chi-squared test or, in cases
of small samples, the Fisher exact test. The Student t-test was used to compare the means of the two treatments, as well as the Kolmogorov-Smirnov
test. To analyze the effect of the treatments over time on behavior and on the NTS,
generalized estimating equations (GEE)[15] were used with identity link functions and normal marginal distributions. The approach
via GEE, which consists of the generalization of generalized linear models, enables
the incorporation of dependency among observations of the same individual resulting
from repeated measurements taken over time.
The GEE models were estimated using the STATA 12 statistical software package (StataCorp
LLC, College Station, TX, USA). For the other analyses, the software IBM SPSS Statistics
for Windows, Version 20.0 (IBM Corp, Armonk, NY, USA) was used.
For all the tests applied, the null hypothesis was that the proportions of the LA
group would be equal to those of the BM group; the alternative hypothesis was that
the proportions of the LA group would be different from those of the BM group.
Results
The information and assessments of 180 nursing mothers were analyzed. The mean age
was 27.5 years (SD = 6.2 years), ranging from 18 to 48 years old. The mean weight
of the newborns was 3,293 g ( ± 512 g). There was no difference between the groups
in relation to the age (p = 0.648) or newborn weight (p = 0.123) variables. The groups were studied by applying statistics tests to assess
homogeneity and subsequent comparison ([Table 2]).
Table 2
Distribution of nursing mothers by characteristics, according to treatment
|
Total
|
Treatment
|
p-value
|
|
Lanolin (LA)
|
Breast milk (BM)
|
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
|
Marital status
|
180
|
(100.0)
|
90
|
(100.0)
|
90
|
(100.0)
|
0.037
|
|
With partner
|
90
|
(50.0)
|
38
|
(42.2)
|
52
|
(57.8)
|
|
|
Without partner
|
90
|
(50.0)
|
52
|
(57.8)
|
38
|
(42.2)
|
|
|
Color (self-reported)
|
180
|
(100.0)
|
90
|
(100.0)
|
90
|
(100.0)
|
0.934[a]
|
|
White
|
93
|
(51.7)
|
46
|
(51.1)
|
47
|
(52.2)
|
|
|
Black/Brown
|
80
|
(44.4)
|
41
|
(45.6)
|
39
|
(43.3)
|
|
|
Yellow and indigenous
|
7
|
(3.9)
|
3
|
(3.3)
|
4
|
(4.4)
|
|
|
Schooling
|
180
|
(100.0)
|
90
|
(100.0)
|
90
|
(100.0)
|
0.900[a]
|
|
Elementary education incomplete
|
8
|
(4.4)
|
4
|
(4.4)
|
4
|
(4.4)
|
|
|
Elementary education complete/secondary education incomplete
|
29
|
(16.1)
|
14
|
(15.6)
|
15
|
(16.7)
|
|
|
Secondary education complete
|
93
|
(51.7)
|
49
|
(54.4)
|
44
|
(48.9)
|
|
|
University
|
50
|
(27.8)
|
23
|
(25.6)
|
27
|
(30.0)
|
|
|
Primiparity
|
180
|
(100.0)
|
90
|
(100.0)
|
90
|
(100.0)
|
0.881
|
|
No
|
85
|
(47.2)
|
42
|
(46.7)
|
43
|
(47.8)
|
|
|
Yes
|
95
|
(52.8)
|
48
|
(53.3)
|
47
|
(52.2)
|
|
|
Number of prenatal visits
|
179
|
(100.0)
|
90
|
(100.0)
|
89
|
(100.0)
|
0.498
|
|
≤ 6 visits
|
25
|
(14.0)
|
11
|
(12.2)
|
14
|
(15.7)
|
|
|
≥ 7 visits
|
154
|
(86.0)
|
79
|
(87.8)
|
75
|
(84.3)
|
|
|
Gestational age at delivery
|
171
|
(100.0)
|
84
|
(100.0)
|
87
|
(100.0)
|
0.437
|
|
37–38 weeks
|
22
|
(12.9)
|
8
|
(9.5)
|
14
|
(16.1)
|
|
|
39–40 weeks
|
123
|
(71.9)
|
63
|
(75.0)
|
60
|
(69.0)
|
|
|
41–42 weeks
|
26
|
(15.2)
|
13
|
(15.5)
|
13
|
(14.9)
|
|
|
Type of delivery
|
180
|
(100.0)
|
90
|
(100.0)
|
90
|
(100.0)
|
1.000
|
|
Vaginal
|
92
|
(51.1)
|
46
|
(51.1)
|
46
|
(51.1)
|
|
|
Cesarean section
|
88
|
(48.9)
|
44
|
(48.9)
|
44
|
(48.9)
|
|
|
Skin-to-skin contact in the delivery room
|
178
|
(100.0)
|
88
|
(100.0)
|
90
|
(100.0)
|
0.463
|
|
Yes
|
148
|
(83.1)
|
75
|
(85.2)
|
73
|
(81.1)
|
|
|
No
|
30
|
(16.9)
|
13
|
(14.8)
|
17
|
(18.9)
|
|
|
Gender of the newborn
|
179
|
(100.0)
|
89
|
(100.0)
|
90
|
(100.0)
|
0.042
|
|
Male
|
80
|
(44.7)
|
33
|
(37.1)
|
47
|
(52.2)
|
|
|
Female
|
99
|
(55.3)
|
56
|
(62.9)
|
43
|
(47.8)
|
|
|
Type of nipple[b]
|
|
|
|
|
|
|
|
|
Protruding
|
97
|
(96.0)
|
50
|
(96.2)
|
47
|
(95.9)
|
1.000[a]
|
|
Semi-protruding
|
76
|
(98.7)
|
36
|
(97.3)
|
40
|
(100.0)
|
0.481[a]
|
|
Semi-inverted
|
6
|
(66.7)
|
4
|
(66.7)
|
2
|
(66.7)
|
1.000[a]
|
|
Flat
|
3
|
(37.5)
|
1
|
(33.3)
|
2
|
(40.0)
|
1.000[a]
|
|
Type of problem
|
180
|
(100.0)
|
90
|
(100.0)
|
90
|
(100.0)
|
1.000[a]
|
|
Trauma only
|
6
|
(3.3)
|
3
|
(3.3)
|
3
|
(3.3)
|
|
|
Pain only
|
11
|
(6.1)
|
5
|
(5.6)
|
6
|
(6.7)
|
|
|
Trauma and pain
|
163
|
(90.6)
|
82
|
(91.1)
|
81
|
(90.0)
|
|
a
p-value – Descriptive level of the chi-squared test or of the Fisher exact test.
b Multiple response - the total of the percentages does not equal 100%.
[Table 2] shows the equivalence among the groups of puerperal women who participated in the
study. The prevalences did not differ statistically regarding self-reported skin color,
parity, number of prenatal visits, education, type of delivery, gestational age at
delivery, and type of nipple. On the other hand, different distributions were identified
for marital status and gender of the babies, with a higher percentage of women with
partners and of male babies in the BM group. For these two cases, after the evaluation
of the adjusted effects, it was noted that there was no interference in the final
results. As for skin-to-skin contact and breastfeeding within the first hour after
birth, the data showed that there was no significant difference, with a prevalence
of breastfeeding with babies placed next to their mothers immediately after birth
in both groups.
In both groups, there was a prevalence of protruding nipples and pain associated with
trauma in both nipples. The data related to the means and to the confidence interval
(CI) of 95% for the pain and trauma (NTS) scores are presented in [Table 3].
Table 3
Pain and nipple trauma score estimates (mean ± 95% CI) by treatment group. Generalized
estimating equations (GEE) model is indicated at the bottom of the table
|
Assessment time
|
p-value
|
|
Baseline
|
48 hours
|
7 days
|
|
Pain
|
|
|
|
< 0.001
|
|
LA
|
3.8 (3.3–4.2)A
|
5.9 (5.5–6.4)
|
3.6 (3.2–4.1)B
|
|
|
BM
|
2.0 (1.6–2.5)B
|
5.4 (5.0–5.9)
|
5.4 (4.9–5.8)A
|
|
|
NTS
|
|
|
|
0.460
|
|
LA
|
2.3 (2.1–2.5)
|
1.9 (1.6–2.1)
|
0.9 (0.6–1.1)
|
|
|
BM
|
2.0 (1.8–2.2)
|
1.7 (1.5–2.0)
|
0.8 (0.6–1.1)
|
|
Abbreviations: BM, breast milk group; CI: confidence interval; LA, lanolin group;
NTS, nipple trauma score.
p-value - Descriptive level for interaction in the GEE model.
(A) and (B) have different means according to contrasts (comparison of groups at each
time period).
Effect of time on pain in the breast milk group (p < 0.001): baseline < 48 hours = 7 days, and in the lanolin group (p < 0.001): baseline = 7 days < 48 hours.
Effect of time on the NTS for the breast milk and lanolin groups (p < 0.001): baseline > 48 hour > 7 days.
N = 533 observations in relation to 179 nursing mothers for pain score.
N = 536 observations in relation to 180 nursing mothers for NTS.
[Table 3] shows that, over time, different behaviors were noted for the pain score means but
not for the NTS between the two groups. In relation to the pain scale, specifically,
the mean of the LA group was higher than that of the BM group; both were similar at
48 hours, but at 7 days, the mean of the LA group was lower than that of the BM group.
Therefore, in terms of the evolution of pain over time, there was, on average, an
increase from the first to the second assessment in both groups. This was not the
case at the third assessment, when the BM group maintained the same pain levels, whereas
there was a drop in the LA group, with a lower mean pain score than at the first assessment.
[Table 3] also shows that, in relation to the NTS, both groups had similar means at the three
assessments. Regarding the evolution over time, the mean at the first assessment was
higher in both groups than at the second assessment, which, in turn, was higher than
at the third assessment. [Table 4] shows the behavior of the nursing mothers according to the NTS, according to each
assessment.
Table 4
Distribution of the nursing mothers by nipple trauma score, according to the assessment
periods and treatment group
|
Lanolin group (LA)
|
Breast milk group (BM)
|
|
Baseline
|
48 hours
|
7 days
|
Baseline
|
48 hours
|
7 days
|
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
|
Score/Total
|
88
|
(100.0)
|
88
|
(100.0)
|
88
|
(100.0)
|
89
|
(100.0)
|
89
|
(100.0)
|
89
|
(100.0)
|
|
0 - No microscopically visible skin changes
|
3
|
(3.4)
|
13
|
(14.8)
|
45
|
(51.1)
|
5
|
(5.6)
|
14
|
(15.7)
|
49
|
(55.1)
|
|
1 - Erythema or edema or combination of both
|
16
|
(18.2)
|
25
|
(28.4)
|
17
|
(19.3)
|
19
|
(21.3)
|
24
|
(27.0)
|
12
|
(13.5)
|
|
2 - Superficial damage with or without scab formation on < 25% of the nipple surface
|
43
|
(48.9)
|
28
|
(31.8)
|
22
|
(25.0)
|
47
|
(52.8)
|
37
|
(41.6)
|
23
|
(25.8)
|
|
3 - Superficial damage with or without scab formation on > 25% of the nipple surface
|
13
|
(14.8)
|
13
|
(14.8)
|
1
|
(1.1)
|
9
|
(10.1)
|
7
|
(7.9)
|
4
|
(4.5)
|
|
4 - Partial-thickness wound with or without scab formation on < 25% of the nipple
surface
|
5
|
(5.7)
|
3
|
(3.4)
|
3
|
(3.4)
|
6
|
(6.7)
|
1
|
(1.1)
|
1
|
(1.1)
|
|
5 - Partial-thickness wound with or without scab formation on > 25% of the nipple
surface
|
8
|
(9.1)
|
6
|
(6.8)
|
0
|
(0.0)
|
3
|
(3.4)
|
6
|
(6.7)
|
0
|
(0.0)
|
To better evaluate the evolution of the severity of trauma through the NTS, in cases
of severe trauma with greater extension (score 3—superficial lesion > 25% of the nipple
surface, with or without crusting) and depth (scores 4 and 5—partial thickness lesion,
with or without crusting), improvement was considered to have occurred if the next
scores received were 0 (no visible trauma), 1 (erythema or edema without lesion),
or 2 (superficial lesion < 25% of the nipple surface, with or without crusting). [Table 5] and [Fig. 1] present this distribution by treatment group and assessment periods.
Fig. 1 Distribution of improvement by treatment and assessment periods.
Table 5
Distribution of improvement by treatment and assessment periods
|
Total
|
Treatment
|
p-value
|
|
Lanolin group (LA)
|
Breast milk group (BM)
|
|
n
|
(%)
|
n
|
(%)
|
n
|
(%)
|
|
Baseline × 48 hours
|
178
|
(100.0)
|
89
|
(100.0)
|
89
|
(100.0)
|
0.667
|
|
Improvement
|
25
|
(14.0)
|
14
|
(15.7)
|
11
|
(12.4)
|
|
|
No improvement
|
153
|
(86.0)
|
75
|
(84.3)
|
78
|
(87.6)
|
|
|
48 hours × 7 days
|
177
|
(100.0)
|
88
|
(100.0)
|
89
|
(100.0)
|
0.110
|
|
Improvement
|
32
|
(18.1)
|
20
|
(22.7)
|
12
|
(13.5)
|
|
|
No improvement
|
145
|
(81.9)
|
68
|
(77.3)
|
77
|
(86.5)
|
|
|
Baseline × 7 days
|
178
|
(100.0)
|
88
|
(100.0)
|
90
|
(100.0)
|
0.025
|
|
Improvement
|
40
|
(22.5)
|
26
|
(29.5)
|
14
|
(15.6)
|
|
|
No improvement
|
138
|
(77.5)
|
62
|
(70.5)
|
76
|
(84.4)
|
|
p-value – descriptive level of the chi-square test.
[Table 5] and [Fig. 1] illustrate that the improvement percentages from the first assessment period (baseline)
to the second (48 hours), and from the second to the third (7 days) were not different
in both groups. However, it was noted that the improvement percentage from the first
to the third assessment period was almost two times higher in the LA group when compared
with the BM group, representing a statistically significant difference.
Discussion
Studies have shown that there is a higher incidence of nipple pain and injuries in
primiparas, fair-skinned women and mothers with male newborns, and that these discomforts
appear mainly in the first week after birth.[13]
[16]
[17]
[18]
[19] The data in the present study corroborates previous studies in relation to the number
of children and skin color, but differs in relation to the gender of the newborn and
to the time at which the pain or trauma first occurred, since it was higher for females,
and a higher number of nursing mothers reported pain and trauma in both nipples 24
hours after birth.
It is estimated that between 80 and 96% of women experience some degree of pain in
the first week after birth. In most cases, the reason is related to a trauma that
contributes to giving up breastfeeding.[13]
[20]
[21]
[22]
[23]
In this sense, studies related to measures to alleviate breastfeeding discomfort have
been conducted so that mothers can nurse their babies without having this period marked
by suffering due to pain. A review of breastfeeding discomfort showed that there is
controversy regarding the prevention of nipple pain and trauma, related to technique
and interventions. It has been suggested that a single intervention is not sufficient
to improve technique or reduce nipple trauma, but it has also been suggested that
further studies be conducted.[24] Some studies have compared the use of breast milk with the use of HPA lanolin cream
for treating nipple trauma and pain in nursing mothers.
In a comparative study, Abou-Dakn et al (2011)[13] found that there was a significant reduction in breastfeeding-related pain in the
group that used HPA lanolin. It was also noted that the trauma healing rates were
significantly higher after 14 days of topical treatment, and that benefits appeared
after the first 3 days.[13]
In the present study, the results were similar regarding the improvement in pain and
trauma, but the results were noted after 7 days of using HPA lanolin. The data regarding
pain and trauma were analyzed separately.
In relation to nipple pain in nursing mothers, specifically, the present study identified
beneficial effects in the group that used HPA lanolin, with a significant decrease
in complaints (p < 0.001). The women assigned to the LA group had, on average, more pain than the
breast milk group, but after 48 hours the mean pain scores of both groups were similar.
Improvement was noted on the 7th day of treatment; there was a considerable reduction in the LA group, with a lower
mean pain score than at the baseline of the study, which was not the case with the
BM group.
In 2014, another randomized and controlled trial conducted at the University of Toronto,
in Canada, assessed the effectiveness of lanolin for treating nipple pain among nursing
mothers. Of the 186 participants, 93 were randomized to the treatment group and 93
to normal care. Seven days after the randomization, there was a clinically relevant
decrease in nipple pain in both groups. However, there were no statistically significant
differences between the groups for other outcomes. Despite these findings, the women
in the treatment group were significantly more satisfied with the use of lanolin than
those who received normal care.[6]
Pain while breastfeeding has been an object of study for years, and there is a consensus
among researchers that its presence discourages women from continuing to breastfeed
and can inhibit lactation and significantly undermine the naturalness in the act of
breastfeeding.[25] Apart from the pain, nipple injury, whether associated or not, can aggravate the
health condition of the woman and greatly increase the likelihood of early weaning.
A study conducted in 2008 in Brazil among 50 puerperal women with nipple trauma produced
similar findings. The use of HPA lanolin yielded statistically significant positive
results (p < 0.001) in treating women with injuries on both nipples. The size of the injuries
decreased at the assessment after 24 hours in the experimental group, compared with
the group that used breast milk.[18]
In a controlled randomized trial with 35 nursing mothers in each group, Shanazi et
al (2015)[25] compared the effects of the use of lanolin, peppermint, and dexpanthenol cream for
treating nipple trauma in breastfeeding mothers. The results were similar using the
three substances, leading to the conclusion that peppermint can be considered an effective
option for treating traumatized nipples in patients who want to use plant-based medications.[25]
The present study used the NTS to assess the evolution of the severity of traumas
during the period of treatment with breast milk and HPA lanolin. In cases of severe
traumas in extension (score = 3) and depth (scores = 4 and 5), improvement was considered
to have occurred when the scores dropped to 0, 1, or 2. The results showed that between
the first and second assessments, and between the second and third, no difference
in improvement between the two groups was noted. However, when the results of the
two groups were examined in relation to the improvement between the first and third
assessments, after 7 days, the superior results in the group that used HPA lanolin
(29.5%), compared with the breast milk group (15.6%) were clear and statistically
significant (p = 0.025). Therefore, the present study demonstrated that the use of HPA lanolin cream
for 7 days improved nipple trauma and promoted the continuation of breastfeeding.
Conclusion
The present study on the effects of using HPA lanolin compared with breast milk for
treating nipple pain and trauma in nursing mothers found a statistically significant
improvement in terms of both pain and trauma through the use of HPA lanolin, evidenced
more clearly after 7 days of treatment.
