Management of nipple pain and/or trauma associated with breast‐feeding
Authors: Page Tamara , Lockwood Craig , Guest Kylie 
Published: August 2003

Executive summaryObjective The objective of this systematic review was to present the best available evidence related to the management of nipple pain, post childbirth in breast‐feeding women. The specific objective of the review was to determine the effectiveness of interventions used by and for breast‐feeding women to prevent and/or reduce nipple pain and trauma.Selection criteria The review considered all studies that included women who breast‐fed with or without painful or traumatised nipples of any aetiology post childbirth.Interventions of interest were: (i) interventions aimed to prevent or reduce pain and/or trauma to nipples post commencement of breast‐feeding; and (ii) treatments for painful or traumatised nipples post commencement of breast‐feeding.The primary outcomes of interest were those related to the prevention and treatment of nipple pain and/or trauma in women post childbirth, in terms of:

•Incidence and prevalence of nipple pain
•Pain intensity
•Incidence and prevalence of nipple trauma
•Healing rates of traumatised nipples
•Breast‐feeding duration.

This review considered randomised‐controlled trials (RCT) that evaluated the effectiveness of interventions and treatments associated with breast‐feeding practices. In the absence of RCTs other research designs such as non‐randomised controlled trials and before and after studies were considered for inclusion in a narrative summary to enable the identification of current practices and possible future strategies.Search strategy The search sought to find both published and unpublished studies in the English language. Databases were searched up to and including August 2002 and included MEDLINE, CINAHL, Current Contents, Cochrane Library, Expanded Academic Index, Electronic Collections Online, Turning Research Into Practice (TRIP), The Australian Breast‐feeding Association Lactation Resource Centre, Dissertation Abstracts and Proceedings First. The reference lists of all identified studies were searched for additional studies.Assessment of methodological quality All studies were checked for methodological quality using two reviewers, and data were extracted using a data extraction tool.Results There is a plethora of research that evaluates the effectiveness of the many interventions used to prevent or treat nipple pain and or trauma for breast‐feeding women. Most of the studies were heterogeneous with regard to sample demographics, interventions evaluated and outcomes assessed. For this reason the majority of the review is in narrative form, with graphical presentation via meta‐view graphs of the more statistically significant outcomes. Consistent information given in education sessions to breast‐feeding women would assist in identifying which type of instruction is the most effective; however, different education information was given in the studies or no details were supplied as to what education was actually given.Many of the RCTs in this review were based on small sample sizes and specific sociocultural settings. Small sample sizes limit the ability to reliably generalise findings, as there is a risk of false positive results. Furthermore, in some cases, studies did not attain statistical significance although they may have if larger sample sizes had been used. These are common limitations associated with RCTs. The authors of this review recommend full consideration be given to the sample size and study setting prior to implementation of the review recommendations in order to determine applicability to varied clinical settings. The results section highlights sample size issues for each included study.With this limited evidence, no single intervention was identified that offers a dramatic effect in terms of treating pain and or trauma in breast‐feeding women. However, there is potential for some benefits for reducing pain and increasing comfort and thereby maximising breast‐feeding duration.Conclusions  In terms of prevention, warm water compresses are recommended for the prevention of nipple pain, and simply keeping the nipples clean and dry is recommended for the prevention of cracked nipples. In terms of treatment, warm water compresses are recommended for the reduction of nipple pain, and expressed breast‐milk reduces the duration of cracked nipples. Hydrogel dressings were associated with a high incidence of infections and their use cannot be recommended. Systemic antibiotics are recommended if a positive culture for Staphylococcus aureus is obtained.Education for positioning and attachment of the baby to the breast for breast‐feeding women needs further studies to assess whether it is more effective as a preventative measure for nipple pain and/or trauma. Warm water compresses warrant further investigation into their effectiveness in nipple pain. Studies assessing the impact of engorgement, pacifiers and feeding bottles on nipple pain and/or trauma are suggested.Further investigation of the interventions used in many of these studies could be conducted using one intervention at a time in comparison to no treatment. Specific research priorities should include RCTs to assess: (i) lanolin in comparison to no treatment; (ii) lanolin and shells in comparison to no treatment; and (iii) expressed breast‐milk in comparison to no treatment.