versión impresa ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo abr. 2012
ARTIGO DE REVISÃO
Terapéutica no farmacológica para alivio de la ingurgitación mamaria durante la lactancia: revisión integral de la literatura
Ligia de SousaI; Mariana Lourenço HaddadII; Ana Márcia Spanó NakanoIII; Flávia Azevedo GomesIV
IPhysical therapist. Doctoral Student of the Maternal-Child and Public Health Department, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. email@example.com
IIRN. Doctoral Student of the Maternal-Child and Public Health Department, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. firstname.lastname@example.org
IIIRN, Full Professor of the Maternal-Child and Public Health Department, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. email@example.com
IVRN, Ph.D., Professor of the Maternal-Child and Public Health Department, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. firstname.lastname@example.org
Breast engorgement affects breastfeeding and leads to early weaning. The literature presents techniques for treating engorgement, but there is no agreement as to which is the best treatment. The objective of this study is to identify and analyze the evidence found in the literature regarding non-pharmacological treatments to relieve breast engorgement symptoms during breastfeeding. We performed an integrative literature review of studies published since 1990, on MEDLINE and LILACS, using the keywords: breastfeeding, lactation disorder and therapy. We found ten studies: two systematic literature reviews, seven randomized controlled trials and one quasi-experimental study. The analyzed studies show conflicting results and there is not enough evidence to recommend the implementation of the evaluated treatments. Further randomized controlled trials are necessary to determine effective therapies for treating breast engorgement.
Descriptors: Breast feeding; Lactation disorders; Therapeutics
La ingurgitación mamaria afecta al amamantamiento y causa destete precoz. La literatura presenta técnicas de tratamiento de la ingurgitación, aunque hay divergencias respecto de la mejor terapéutica. Esta investigación objetiva identificar y analizar las evidencias encontradas en literatura acerca de terapéutica no farmacológica para alivio de síntomas de ingurgitación mamaria durante el amamantamiento. Se realizó una revisión integral de la literatura con estudios publicados desde 1990 en las bases MEDLINE y LILACS, utilizando los descriptores: lactancia materna, transtornos de la lactancia y terapia. Fueron encontrados diez estudios, dos de ellos de revisión sistemática de la literatura, siete ensayos clínicos controlados y randomizados, y un estudio cuasi-experimental. Los estudios analizados presentan resultados divergentes y no hay evidencias suficientes para recomendar la implementación de los tratamientos evaluados. Son necesarios más estudios controlados y randomizados para verificar terapias eficaces para el tratamiento de la ingurgitación mamaria.
Descriptores: Lactancia materna; Trastornos de la lactancia; Terapéutica
The first days after childbirth define the beginning and maintenance of lactation, which sometimes includes difficulties that require specific support for women to establish the necessary self-confidence to face them. Some of the possible common disorders is poor milk production, nipple pain and trauma, breast engorgement, and other more serious complications such as mastitis(1).
Considering the broad array of complications common in the lactation period, the present study focuses on breast engorgement. A normal process of lactogenesis, physiological engorgement(2) refers to milk being retained in the alveoli and progressing into an over distension of the alveoli, thus compressing the mammary ducts and obstructing milk flow, which becomes stagnated and evolves into an edema secondary to the vascular and lymphatic stasis(3). Because of the increased intraductal pressure, the accumulated milk undergoes intermolecular changes and becomes more viscous(3), and is popularly known as stoned milk.
Pathological engorgement is characterized by excessive tissue distension and a consequent increase of breast size, with the presence of pain, local hyperemia, breast edema and flattening of the nipples, which make if difficult for the baby to latch on. Women may feel great discomfort, fever, and nausea(3). When no intervention is made to relieve the engorgement, milk production is interrupted and a reabsorption process begins, which is associated with early weaning(4). Breast engorgement may evolve into mastitis, an acute infection of the mammary glands, with clinical outcomes such as inflammation, fever, chills, overall discomfort, weakness, exhaustion, mammary abscesses, and septicemia(5).
Different engorgement symptoms are found among 89%(5) and 28.3%(6) of puerperal women, and, regarding its onset, 20% present engorgement in the first week following childbirth(5,7), 46% between the second and fourth week, 23% after the fourth week, and only 11% do not experience breast engorgement(5)
The risk factors for pathological breast engorgement are related to a late start of breastfeeding, infrequent and short feedings, using supplements, newborn's weak sucking(3), sudden increase in milk production(8), nipple lesions, which determining factors include mis-positioning the baby on the breast and a tongue-tie in the infant(9).
Establishing specific hours in the day to breastfeed, controlling the duration of the feed, wearing a tight bra, using bottles, not emptying the breast after nursing in the first days, and a sleepy or premature newborn are factors that permit the onset of breast engorgement(10).
One serious problem related to breast engorgement refers to HIV-positive women, who are advised not to breastfeed their children to avoid transmitting the virus through their milk, and, therefore, most of them experience the pain and discomfort caused by breast engorgement(11).
Literature points to the fact that most nursing women consider breastfeeding problems to be something normal, and, for this reason, suffer unnecessarily, because most of these conditions can be treated. A qualitative study about the meanings that women assign to breast engorgement found that, culturally, signs such as the breasts filled with milk valorize women and characterize them as a nursing woman and do not indicate any abnormality(12).
There is lack of knowledge among the nursing women regarding the care they could take to avoid or treat engorged breasts, considering that approximately 57% do not know what can be done to relieve engorgement symptoms, 23.7% know hot compresses or massages, 11.7% refer to milking, 6.4% breastfeed, 0.8% use medications, and 0.4% suspend breastfeeding when there is breast engorgement(10).
Traditionally, the treatment for breast engorgement should be based on maintaining breastfeeding and systematic manual milking of the breast to balance milk supply and infant demand. Frequent breastfeeding is emphasized, whenever the baby feels hungry, besides advising mothers regarding the correct latching and suction. Other procedures, alone or combined, are common in the everyday routine of health care professionals, following several protocols, which are often controversial, and with no scientific evidence of their efficacy.
Therefore, the objective of this integrative review is to identify and analyze the scientific evidence found in the literature about the non-pharmacological treatment to relieve breast engorgement symptoms in puerperal women who are breastfeeding.
The chosen research method was the integrative review, which presents a synthesis of many published studies and permits to identify, evaluate, and synthesize the knowledge produced about one given theme, and to draw general conclusions about a specific field of study, aiming to find scientific evidence and to deepen the theme for clinical practice(13).
The methodological course followed the following steps: defining the objectives and guiding theme, establishing the inclusion criteria to select the sample, select the data extracted from the selected studies, analysis, discussion and presentation of the results(13). The literature survey was initiated by first identifying the theme and the guiding question. In this review, the guiding theme was the use of non-pharmacological therapies to relieve breast engorgement during breastfeeding. The following guiding question was used: What is the scientific evidence available in the literature about the clinical use of non-pharmacological therapies to relieve breast engorgement during breastfeeding?
The inclusion criteria for the articles were: studies addressing specifically the guiding theme, i.e., the use of non-pharmacological therapies, alone or combined with other treatment techniques, to relieve breast engorgement; in Portuguese, English or Spanish; published between 1990 and 2010; with abstracts available on the selected databases; found on the Data Bases: MEDLINE and LILACS. The search was performed using online access. The controlled descriptors used were breastfeeding, lactation disorder, and therapy.
Articles were included in the integrative review is their methodology could achieve strong evidence (1, 2, and 3), i.e., systematic reviews of multiple randomized controlled clinical trials, controlled randomized clinical trials or studies with a quasi-experimental design(14).
For the analysis, all studies included in the sample were read in full and categorized using a validated data collection instrument(15), to extract data regarding the identification of the articles/authors, type of journal, methodological characteristics, evaluation of the measured interventions and outcomes.
The results were discusses descriptively with the purpose to compare the negative and positive outcomes and provide subsidiary information for evidence-based clinical practice.
The article search in the present integrative review, performed according to the previously established inclusion criteria, yielded ten studies hat addressed the studied theme. All ten articles were found on the MEDLINE database and none on the LILACS database. An overview of the analyzed articles is presented in this section.
Among the articles found, two were published on a general nursing journal, one on a obstetrical nursing specialized journal, one on a physical therapy journal, four were published on health area journals addressing breastfeeding and childbirth, and two were systematic review articles published on the Cochrane Library.
Regarding the type of study design, there were two were systematic literature review studies, seven randomized controlled clinical trials and one quasi-experimental study. Therefore, regarding the articles' evidence strength, two articles were of evidence level 1, seven of level 2, and one level 3.
Regarding the study objective, i.e., the use of non-pharmacological therapies to relieve the pain from breast engorgement, and according to the pre-established criteria, we identified the following therapeutic resources: acupuncture, hot compresses combined with massage, hot and cold compresses applied alternately, cold compresses, cabbage leaves, and therapeutic ultrasound.
The systematic literature reviews on the studied theme addresses, besides the non-pharmacological resources, some pharmacological agents used to relieve breast engorgement symptoms, which are part of the present study objectives. Although the drugs presented in the systematic literature review(16-17) show positive outcomes, there is a need for more discussions about the collateral effects of the drugs used for the engorged breast, which should also specify the newborn's consumption of drugs through breast milk.
Most of the analyzed articles compared the therapeutic resources to other resources or conventional treatment (massages, milking the breast, instructions, and others). This may have harmed the interpretation of the results in terms of identifying whether or not the studied technique was effective, comparing it to a control group or placebo. Only one study that used engorged breasts used a placebo group and did not show any improvement of the signs and symptoms. This study obtained only pain relief, which, for the authors themselves was due to the deep heat caused by the ultrasound waves, which does not justify its use for treating breast engorgement(24).
According to literature, the application of cabbage leaves at different temperatures is a technique used to treat engorged breasts. However, the studies present conflicting results and none of them used a placebo or control group without treatment(7,21-23). Furthermore, we could discuss if the effects in the relief of symptoms or pain secondary to the engorgement relief are due to the cabbage leaf or to its temperature, considering that one study has found similar results for chilled cabbage leaves and a cold gel bag(22).
Another aspect that raises questions regarding the use of the cabbage leave in clinical practice is the need to perform an effective sterilization of the leave to avoid any bacterial proliferation, which would produce an infectious process, through the nipple pores or trauma.
The application of local heat directly on the engorge breasts promotes vasodilation, and thus increases circulation and, consequently, the volume of milk in the breasts, which, physiologically, would lead to an increase in the engorgement(4). However, no studies aimed at studying the hot compress specifically. It was used in association with massages (Gua-Sha Therapy)(18). The hot compress was also used alternately with the cold compress, proving more effective for pain relief when compared to the use of cabbage leaves, although this was a quasi-experimental study(7).
The cold compress is responsible for reducing the milk production when applied over the engorged breast. The cold temperature causes temporary vasoconstriction that reduced the blood flow, edema and lymphatic drainage thus reducing the production of milk(4). In the studied articles, cold compresses were reported to produce effective pain relief, but data was presented regarding the milk production after its application.
Acupuncture showed an effective reduction of breast engorgement symptoms, and is often used in clinical practice because it does not produce any side effects, particularly if compared to the use of nasal spray containing oxytocin(19). However, the women's request for using conventional resources was similar for groups that used acupuncture or those using only the conventional treatment(20).
The Gua-Sha Therapy refers to shaving the skin using pressure until small petechiae emerge. The movement is performed seven time each cycle for two two-minute cycles. This technique was proven effective to relive breast engorgement signs and symptoms compared to massages combined with hot compresses. According to the study authors, this resource is of easy application and low cost, and thus consists of an appropriate non-pharmacologic technique for breast engorgement, in which health care professionals can help the women both physically and psychologically(18).
In the systematic literature review, some techniques were considered to offer a promising treatment for breast engorgement, but there were insufficient evidence to justify a diffuse implementation of any of the described techniques. The authors concluded that the review studies have poor evidence. Most of the studies do not have sufficient statistical power to detect differences between the groups and, therefore, the results are inconclusive. For this reason, evidence is insufficient to recommend the broad implementation of the evaluated treatments(16).
Regarding the breast engorgement assessment instruments, the analyzed studies used visual description, the identification of breast tension, breast temperature, and the assessment of the symptoms and pain caused by the engorgement. To do this, the studies used the visual analog pain scale and the numeric pain scale. The lack of standards regarding the aspects of study assessment can make it difficult to analyze the benefits of the used resources.
Regarding the care provided by professionals in the postpartum period, it is important to emphasize that the most effective way of reducing the incidence of breast engorgement in the immediate postpartum is prevention, which can be done by effectively milking the exceeding milk after the feedings(3). The guidance and aide practices of the nursing team can have a direct effect on the production of milk, and, therefore, on breast-feeding. The skin-to-skin contact combined with early suction increases milk production and demand within four days after childbirth and has a positive effect on the duration of breast-feeding(25).
Giving a single instruction along with the breast-feeding techniques before hospital discharge does not have a positive effect on the prevention of breast engorgement, as it affects 35.1% of women seven days after a single guiding session, and 37.8% 30 days after they receive the guidance. Women who have not received any breast-feeding guidance at all at the maternity present 34.3% and 36.5% of breast engorgement seven and thirty days after discharge, respectively(26). These data evidence the need for effective guidance about breast-feeding techniques and practices, which should begin in the prenatal period and be followed throughout the first postpartum weeks.
Programs related to breast-feeding encouragement and guidance, the creation of strategies that increase the nursing women's knowledge, and offering consistent support to women during the breast-feeding process are effective ways to maintain exclusive breast-feeding. Authors observe there is a need to approximate the nursing women's familiar cultural context, considering that the difficulties to breast-feed often occur do to the lack of appropriate support from the health service, i.e., the services center the practice on the biological dimension of care, underestimating approached that take psychological, social, and cultural conditioning factors into consideration(27).
In this perspective, problems detected during breast-feeding would be reduced or eliminated through humanized attitudes and postures, such as active and guided participation of the women's companions in the prenatal and postpartum, which would avoid the use of abusive resources, such as the women using excessive medications(28).
Nevertheless, after the breast engorgement situation is set in, appropriate resources are essential to treat it and maintain exclusive breast-feeding until the infant is six months old, according to the Ministry of Health.
This evokes the importance of studies that aim at analyzing non-pharmacological resources to relieve breast engorgement. The articles analyzed in the present integrative review present strong evidence, but there is still a lack of consistency as to which therapy is the best. An important aspect observed among the analyzed studies is the lack of statements regarding the opinions of the participants and their preferences regarding treatment options.
The present review suggests that health care professionals should use resources based on scientific evidence. The data permit to recommend acupuncture and the Gua-Sha therapy as non-pharmacological resources that could safely replace drug treatment in nursing women. Regarding the other resources, we understand that some, which are, in fact, used in clinical practice, could worsen breast engorgement symptoms, e.g. the application of heat due to the physiology of its action, as previously stated, or using cabbage leaves, to which there are no studies reporting the possibilities of infection from its use. We can affirm that non-pharmacological resources are welcome to evaluate breast engorgement, but we observe there is a need for more studies in this area so that these resources can contribute to the health care for puerperal women, and, this way, promote a more humanized practice from pregnancy to postpartum.
Most difficulties that occur during lactation, when early treated, are easy to solve and result in satisfactory experiences for the woman and newborn, considering that breast-feeding is an important process after childbirth, with a positive relationship with the newborn's feeding and benefits for the woman's health. Furthermore, the body proximity established a bond relationship between mother and child.
Following this line of thought, we observe there is a need for prevention and treatment assistance and techniques for problems that affect breast-feeding, such as breast engorgement. We emphasize, mainly, on the development of national controlled and randomized clinical trials to relieve breast engorgement, because, until this moment, no other study on this theme and with this design and methodological rigor was found, only studies that are mostly descriptive and focused on guidance and prevention of lactation disorders.
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