Factors associated to nipple trauma in lactation period: a systematic review

Janaína Silva Dias Tatiana de Oliveira Vieira Graciete Oliveira Vieira About the authors

Abstract

Objectives:

To identify the characteristics associated to nipple trauma in nursing mothers and propose a theoretical model explaining in hierarchical levels its determining factors.

Methods:

a systematic review of the literature based on the search of epidemiological studies of factors associated to nipple trauma in the databases of Medical Literature Analysis and Retrieval System Online/Pubmed, Literatura Latino-Americana and Caribe em Ciências da Saúde (Latin American Literature and Caribbean Health Sciences) and ScienceDirect. The conduct on searching articles occurred until June 2016.

Results:

17 articles were selected which investigated 27 variables and found a significant association between 16 of these variables and nipple trauma. The factors associated to nipple trauma reported in two or more studies were: mother of race/color white or yellow, primiparity, inadequate position between mother and child during breastfeeding and handling the infant incorrectly to the mother's breast. Guidance received on handling and positioning the infant during prenatal care was a protective factor against nipple trauma.

Conclusions:

in the theoretical model explaining the factors associated to nipple trauma in hierarchical levels, the variables classified at the proximal level were the most investigated and were identified as risk factors in selected studies, indicating that in the postpartum care period is an important protective factor against nipple trauma.

Key words
Trauma; Injury; Nipple; Breastfeeding

Resumo

Objetivos:

identificar as características associadas ao trauma mamilar em nutrizes e propor um modelo teórico explicativo, em níveis hierarquizados, dos seus fatores determinantes.

Métodos:

revisão sistemática da literatura fundamentada na busca de estudos epidemiológicos sobre os fatores associados ao trauma mamilar nas bases de dados Medical Literature Analysis and Retrieval System Online/Pubmed, Literatura Latino-Americana e do Caribe em Ciências da Saúde e ScienceDirect. A condução da busca dos artigos ocorreu até junho de 2016.

Resultados:

selecionou-se 17 artigos, que investigaram 27 variáveis e encontraram associação significante entre 16 dessas variáveis e o trauma mamilar. Os fatores associados ao trauma mamilar relatados em dois ou mais estudos foram: mãe de raça/cor branca ou amarela, primiparidade, posicionamento inadequado entre mãe e filho durante a mamada e pega incorreta do lactente ao seio materno. A orientação quanto à pega e posicionamento do lactente recebida durante o pré-natal foi fator de proteção contra o trauma mamilar.

Conclusões:

no modelo teórico explicativo dos fatores associados ao trauma mamilar em níveis hierarquizados, as variáveis classificadas no nível proximal foram as mais investigadas e identificadas como fatores de risco nos estudos selecionados, sinalizando que a atenção ao pós-parto é um importante fator de proteção contra os traumas mamilares.

Palavras-chave
Trauma; Lesão; Mamilo; Aleitamento materno

Introduction

It is documented that maternal breastfeeding (MB) confers large benefits to the mother and child's health.11 Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI. Breastfeeding and the use of human milk. Pediatrics. 2005; 115(2):496-506.

2 Toma TS, Rea MF. Benefícios da amamentação para a saúde da mulher e da criança: um ensaio sobre as evidências. Cad Saúde Pública. 2008; 24 (2): 235-46.

3 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde da criança-nutrição infantil: aleitamento materno e alimentação complementar. Brasília, DF; 2009.
-44 WHO (World Health Organization). Infant and young child feeding: Model chapter for text books for medical students and allied health professionals. Geneva; 2009. However, some problems are faced by nursing mothers during breastfeeding, the example is nipple trauma and may contribute to lower prevalence of maternal breastfeeding. Intervention measurements against its determining factors are necessary for the prevention of diseases.55 Riordan J, Bibb D, Miller M, Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact. 2001; 17 (1): 20-3.

6 Ahluwalia IB, Morrow B, Hsia J. Why do women stop breastfeeding? Findings from the pregnancy risk assessment and monitoring system. Pediatrics. 2005; 116 (6): 1408-12.

7 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009; 85 (4): 341-5.

8 Vieira GO, Martins CC, Vieira TO, Oliveira NF, Silva LR. Factors predicting early discontinuation of exclusive breastfeeding in the first month of life. J Pediatr. 2010; 86 (5): 441-4.
-99 Shimoda GT, Soares AV, Aragaki IMM, Mcarthur A. Preventing nipple trauma in lactating women in the University Hospital of the University of Sao Paulo: a best practice implementation project. JBI Database System Rev Implement Rep. 2015; 12 (13): 212-32.

Nipple traumas are characterized by erythema, edema, cracks, fissures, blisters, abrasions and ecchymoses.1010 Ziemer MM, Pigeon JG. Skin changes and pain in the nipple during the 1st week of lactation. J Obstet Gynecol Neonatal Nurs. 1993; 22 (3): 247-56.

11 Giugliani ERJ. Common problems during lactation and their management. J Pediatr. 2004; 80 (5): 147-54.
-1212 Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44. In relation to the types of nipple injuries, there is no consensus as regarding to the degree of impairment of the tissue layer on the nipple-areola region.1313 Coca KP, Abrão ACFV. Avaliação do efeito da lanolina na cicatrização dos traumas mamilares. Acta Paul Enferm. 2008; 21 (1): 11-6.,1414 Cervellini MP, Gamba MA, Coca KP, Abrão ACFV. Injuries resulted from breastfeeding: a new approach to a known problem. Rev Esc Enferm USP. 2014; 48 (2): 346-56.

The lack of clinical definition for nipple trauma results in disagreements, up to a point that its diagnosis and treatment may be compromised.1414 Cervellini MP, Gamba MA, Coca KP, Abrão ACFV. Injuries resulted from breastfeeding: a new approach to a known problem. Rev Esc Enferm USP. 2014; 48 (2): 346-56. It is suggested that in the context of assisting nursing mothers, nipple trauma may be defined as an alteration in the normal anatomy of the nipple skin with the presence of a primary lesion caused by the modification of the color or thickness and not only as a solution of continuity on the skin.1414 Cervellini MP, Gamba MA, Coca KP, Abrão ACFV. Injuries resulted from breastfeeding: a new approach to a known problem. Rev Esc Enferm USP. 2014; 48 (2): 346-56.

The location of the lesion is observed in the upper part of the body and around the base of the nipple, more often found at the tip of the nipple1010 Ziemer MM, Pigeon JG. Skin changes and pain in the nipple during the 1st week of lactation. J Obstet Gynecol Neonatal Nurs. 1993; 22 (3): 247-56.,1212 Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44.,1515 WHO (World Health Organization). La alimentación del lactante y del niño pequeño. Geneva; 2010. involving dermis and epidermis with the presentation in the form of linear ulceration or curved.1313 Coca KP, Abrão ACFV. Avaliação do efeito da lanolina na cicatrização dos traumas mamilares. Acta Paul Enferm. 2008; 21 (1): 11-6. The woman presents symptoms of severe pain on the nipples during breastfeeding.1515 WHO (World Health Organization). La alimentación del lactante y del niño pequeño. Geneva; 2010.

Often nipple traumas are a gateway for pathogenic microorganisms, as mastitis,1111 Giugliani ERJ. Common problems during lactation and their management. J Pediatr. 2004; 80 (5): 147-54.,1616 Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002; 155: 103-14.

17 Giugliani ERJ. Lack of scientific evidence for the treatment of nipple traumas. J Pediatr. 2003; 79 (3): 197-8.
-1818 Cullinane M, Amir LH, Donath SM, Garland SM, Tabrizi SN, Payne MS, Bennett CM. Determinants of mastitis in women in the CASTLE study: a cohort study. BMC Fam Pract. 2015; 16 (1): 181. a Staphylococcus1919 Livingstone VH, Willis CE, Berkowitz J. Staphylococcus aureus and sore nipples. Can Fam Physician. 1996; 42: 654-9. infection and as major complications nipple candidiasis.2020 Amir LH. Candida and the lactating breast: predisposing factors. J Hum Lact. 1991; 7 (4): 177-81.,2121 Tanguay KE, Mcbean MR, Jain E. Nipple candidiasis among breastfeeding mothers. Case-control study of predisposing factors. Can Fam Physician. 1994; 40: 1407-13. A study was carried out during the national vaccination campaign formed by mothers of children under the age of one, and found that lactational mastitis was more prevalent among women who had nipple fissure.2222 Vieira GO, Silva LR, Mendes CMC, Vieira TO. Mastite lactacional e a Iniciativa Hospital Amigo da Criança, Feira de Santana, Bahia, Brasil. Cad Saúde Pública. 2006; 22(6): 1193-200.

Among the various approaches for the prevention of nipple trauma, there is an attention in the relation to the positioning and the adequate handling of the infant to the mother's breast,2222 Vieira GO, Silva LR, Mendes CMC, Vieira TO. Mastite lactacional e a Iniciativa Hospital Amigo da Criança, Feira de Santana, Bahia, Brasil. Cad Saúde Pública. 2006; 22(6): 1193-200.

23 Duffy ER, Percival P, Kershaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates. Midwifery. 1997; 13: 189-96.
-2424 WHO (World Health Organization). Technical consultation on postpartum and postnatal care. Geneva; 2010. as the injury has been related to the strong pressure exerted on the nipple or the friction of the child's mouth during the suction, this may come as a result of inadequate handling.1515 WHO (World Health Organization). La alimentación del lactante y del niño pequeño. Geneva; 2010.

The survey on factors associated to nipple injury is the utmost importance basis on clinical practice for health professionals, as well as for directing intervention measurements and consequently increasing the duration of maternal breastfeeding. This current study aimed to identify the factors associated to nipple trauma, through a systematic review of literatures, additionally to propose a theoretical model explaining its determinants in hierarchical levels.

Methods

This is a systematic review of literatures on the factors associated to nipple trauma in the lactational period, in which a pre-established protocol was used for the search, the selection and data collection, based on Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines for meta-analysis studies and systematic review.2525 Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma Group. Reprint-Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Phys Ther. 2009; 89(9): 873-80.

The review was based on searches of indexed publications in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE)/PubMed, through the National Center for Biotechnology Information (NCBI)2626 NCBI (National Center for Biotechnology Information). [acesso em 2016 jun 16]. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed.
http://www.ncbi.nlm.nih.gov/pubmed...
platform at http://www.ncbi.nlm.nih.gov/pubmed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (Latin American Literature and Caribbean Health Sciences) (LILACS), by the Biblioteca Virtual em Saúde (Virtual Health Library) (BVS)2727 BVS (Biblioteca Virtual em Saúde). [acesso em 2016 jun 18]. Disponível em: http://regional.bvsalud.org.
http://regional.bvsalud.org...
at http://regional.bvsalud.org and ScienceDirect2828 ScienceDirect. [acesso em 2016 jun 18]. Disponível em: http://www.sciencedirect.com/science/search.
http://www.sciencedirect.com/science/sea...
database at http://www.sciencedirect.com/science/search. As a complementary form of bibliographic search, the strategy of comparing the references cited in each reviewed article with the bibliography has been adopted to obtain the aforementioned above.

In order to ensure the searches, Descritor em Ciências da Saúde (Descriptor in Health Sciences) (DeCS) was consulted. The terms used in the search were: "(((trauma [Title/Abstract]) or sore [Title/Abstract]) or breastfeeding [Title/Abstract]) and nipple [Title/Abstract])))". There was no delimitation in the publication period or language restriction. On ScienceDirect database, a filter was used "trauma or sore or breastfeeding and nipple [All Sources (Medicine and Dentistry, Nursing and Health Professions, Psychology, Social Sciences)]" to view the studies of interest. The conduct of searching articles occurred until June 2016.

The inclusion research criteria were considered as: epidemiological studies with quantitative analysis of factors associated to nipple trauma in breastfeeding women. Studies based on literature reviews (systematically or not), research involving specific populations, absence of abstract and study pilot were excluded. Two independent reviewers conducted the searches and assessed the titles and abstracts of the obtained references. All potentially eligible publications for reading in full were selected. The inclusion of the articles and data extraction in the review were also conducted independently, the compared results and the disagreements were solved consensually between both reviewers. In the event of non-agreement between the peers, a third reviewer was consulted.

The appraisal of the quality of the studies were performed based on the type of study, presence of a structured abstract, introduction with background and justification; method on population recruitment; selection of the population/sample; data collection instrument; non-response informed rate; interviewers' training; performance on statistical analysis; study limitation and considered biases; interpreted results according to evidence and general results. The qualification criteria will correspond to a scale2929 Vieira TO, Vieira GO, Martins CC, Santana GS, Silva L. Intenção materna de amamentar: revisão sistemática. Ciênc Saúde Coletiva. 2016; 21 (12): 3845-58. adapted for this study with a maximum score of 29 points for each article. "Score zero" was considered when the information was not specified in the text, or did not meet the minimum criteria for the classification of quality.

The data extraction was performed by means of the structured form. Once completed the form, the data entry was performed, including: the reference of the article (with the last name of the first author, journal and the year of publication); the study site and the year of data collection; type of study and numbered sample assessed; the objective of the study; statistical analysis applied; prevalence/incidence of the outcome in the study population; factors associated to nipple trauma, as well as the factors that did not obtain the statistical significance level determined.

Aiming to build a theoretical model, the association found between the factors investigated and nipple trauma were analyzed individually, highlighting and quantifying the following aspects: in how many studies were these factors used and how many identified the association to the outcome.

The last step of the study was the construction of a hierarchical model with the organization of the factors listed in the systematic review in levels according to the proximity of the outcome. Four levels of determinants were proposed: 1- distal (individual maternal characteristics and family, related to the characteristics prior to the pregnancy); 2- distal intermediaries (characteristics of prenatal care); 3- proximal intermediaries (characteristics related to childbirth care); 4- proximal characteristics (maternal characteristics of neonates and health care services, related to postpartum and the process of maternal breastfeeding).3030 Boccolini CS, Carvalho ML, Oliveira MIC, Vasconcellos AGG. Fatores associados à amamentação na primeira hora de vida. Rev Saúde Pública. 2011; 45 (1): 69-78.,3131 Boccolini CS. Aleitamento materno: determinantes sociais e repercussões na saúde infantil [tese]. Rio de Janeiro: Ministério da Saúde- Fundação Oswaldo Cruz- Escola Nacional de Saúde Pública Sérgio Arouca; 2012.

Results

In the electronic search 531 articles were found and removed six repeated articles. Evaluated 525 titles and summaries, which 493 references were excluded for not meeting the pre-established criteria and 32 articles were selected for full text reading. Two articles were considered as loss due to the unavailability of the acquisition of the work and five articles were added from the lists of references from the selected articles, resulting in a total of 35 papers that were read thoroughly (Figure 1).

Figure 1
Flowchart of the selection process of studies included in the systematic review on factors associated to nipple trauma in lactational period.

After reading 18 references, three articles used a specific population of premature neonates and seropositive women for the Human Immunodeficiency Virus (HIV), two study pilots, a case study and 12 references for not assessing nipple trauma as an outcome were excluded. At the end of this process, 17 studies met the inclusion criteria (Figure 1).

As for the quality of the studies, no evaluated article obtained the maximum score of 29 points, according to the reference standard applied. The result of the methodology qualification from the selected articles was between 11 to 21 points (Table 1). In relation to the research outline, six studies were cross-sectional, three cohort studies, two casecontrols and six intervention studies. 10 studies were conducted in South America (Brazil, Chile and Uruguay), two in Europe (Italy and Denmark), one in Africa (Libya) and four in Australia. The smaller sample was comprised of 60 women and the largest constituted of 1,020 participants (Table 2).

Table 1
Qualification of selected studies according to the criteria and scores
Table 2
Characteristics of the studies on the factors associated to nipple trauma included in the systematic review.

The prevalence of nipple trauma found in the studies was between 26.7% to 52.75% and the incidence of 16% to 100%. Among the methods of analysis used, four studies used the logistic regression as a multivariate method. In Table 2 shows the variables associated to nipple trauma and the variables with no statistical significance. In Table 3 outlines the number of times each variable was investigated and associated to the outcome of the study.

Table 3
Factors investigated in the evaluated studies and the number of times that were associated to nipple trauma, organized by hierarchical level.

The factors associated to nipple trauma were organized in the respective hierarchical model levels, constructed from the variables studied (Figure 2). At the distal level, which included the individual maternal characteristics and family, it is understood: mother's race/color white or yellow,3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34.,3333 Shimoda GT, Aragaki IMM, Sousa CA, Silva IA. Associação entre persistência de lesão de mamilos e condições de aleitamento materno. Rev Mineira Enferm. 2014; 18 (1): 68-74. primiparity,3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34.,3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52.,3535 Moraes M, Silva L, Faliú B, Sosa C. Técnica de alimentación a pecho y aparición de trauma del pezón previo al alta hospitalaria. Arch Pediatr Urug. 2011; 82 (1): 10-17. presence of nipple fissure in previous pregnancies3535 Moraes M, Silva L, Faliú B, Sosa C. Técnica de alimentación a pecho y aparición de trauma del pezón previo al alta hospitalaria. Arch Pediatr Urug. 2011; 82 (1): 10-17. and mother does not live with a partner.3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52.

Figure 2
The theoretical hierarchy model of risk factors for nipple trauma.

At the distal intermediate level which refers to the characteristics of prenatal care, the guidance received on handling and adequate positioning of the infant to the mother's breast was considered as a protective factor for nipple trauma.2323 Duffy ER, Percival P, Kershaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates. Midwifery. 1997; 13: 189-96. At the proximal intermediate level constituted by the characteristics of childbirth care, an association to nipple injury was observed: the use of anesthesia at childbirth,3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34. gestational age between 37 and 40 weeks3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34. and the presence of breastfeeding in the first hour of life.3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52.

At the proximal level constituted of maternal and newborns characteristics and the health care services related to postpartum and the process of maternal breastfeeding, the variables identified as factors associated to nipple trauma were: semi-protruding and/or malformed nipples,3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34. inadequate positioning between mother and child during breastfeeding,77 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009; 85 (4): 341-5.,1212 Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44.,3535 Moraes M, Silva L, Faliú B, Sosa C. Técnica de alimentación a pecho y aparición de trauma del pezón previo al alta hospitalaria. Arch Pediatr Urug. 2011; 82 (1): 10-17.

36 Kronborg H, Vaeth M. How Are Effective Breastfeeding Techniqueand Pacifier Use Related to Breastfeeding Problems and BreastfeedingDuration? Birth. 2009; 36: 34-42.
-3737 Goyal RC, Banginwar AS, Ziyo F, Toweir AA. Breastfeeding practices: Positioning, attachment (latch-on) and effective suckling - A hospital-based study in Libya. J Fam Comm Med. 2011; 18 (2): 74-9. incorrect handling of the infant to the mother's breast,77 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009; 85 (4): 341-5.,1212 Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44.,3333 Shimoda GT, Aragaki IMM, Sousa CA, Silva IA. Associação entre persistência de lesão de mamilos e condições de aleitamento materno. Rev Mineira Enferm. 2014; 18 (1): 68-74.,3636 Kronborg H, Vaeth M. How Are Effective Breastfeeding Techniqueand Pacifier Use Related to Breastfeeding Problems and BreastfeedingDuration? Birth. 2009; 36: 34-42.

37 Goyal RC, Banginwar AS, Ziyo F, Toweir AA. Breastfeeding practices: Positioning, attachment (latch-on) and effective suckling - A hospital-based study in Libya. J Fam Comm Med. 2011; 18 (2): 74-9.
-3838 Weigert EML, Giugliani ERJ, França MCT, Oliveira LD, Bonilha ALL, Espiríto Santo LC, Köhler CV. The influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. J Pediatr. 2005; 81 (4): 310-6. presence of breast engorgement,3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52. nipple pain,3333 Shimoda GT, Aragaki IMM, Sousa CA, Silva IA. Associação entre persistência de lesão de mamilos e condições de aleitamento materno. Rev Mineira Enferm. 2014; 18 (1): 68-74. lactational mastitis,1212 Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44. baby bottle feeding3939 Centuori S, Burmaz T, Ronfani L, Fragiacomo M, Quintero S, Pavan C, Davanzo R, Cattaneo A. Nipple care, sore nipples, and breastfeeding: a randomized trial. J Hum Lact. 1999; 15 (2): 125-30. and/or pacifier.3939 Centuori S, Burmaz T, Ronfani L, Fragiacomo M, Quintero S, Pavan C, Davanzo R, Cattaneo A. Nipple care, sore nipples, and breastfeeding: a randomized trial. J Hum Lact. 1999; 15 (2): 125-30.

Discussion

This systematic review investigated epidemiological studies on nipple trauma. The selected studies demonstrated differences in prevalence rates between 26.7% to 52.75%, as well as in the estimated incidences that ranged from 16% to 100%. The variability of the measurements found can be explained, among other reasons, by special features in the definition of the outcome, by the study design, different sample sizes or losses on the follow-ups registered in some studies.

The first week after childbirth, it was the period of the greatest appearance of nipple injuries.3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34.,3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52.,3939 Centuori S, Burmaz T, Ronfani L, Fragiacomo M, Quintero S, Pavan C, Davanzo R, Cattaneo A. Nipple care, sore nipples, and breastfeeding: a randomized trial. J Hum Lact. 1999; 15 (2): 125-30.,4040 Abrão ACFV, Gutierrez MGR, Marin HF. Diagnóstico de Enfermagem Amamentação Ineficaz - Estudo de identificação e validação clínica. Acta Paul Enferm. 2005; 18 (1): 46-55. Corroborating with this finding to other studies,4141 Espiríto Santo LC, Oliveira LD, Giugliani ER. Factors associated with low incidence of exclusive breastfeeding for the first 6 months. Birth. 2007; 34: 212-9.,4242 Abou-Dakn M, Fluhr JW, Gensch M, Wöckel A. Positive Effect of HPA Lanolin versus Expressed Breastmilk on Painful and Damaged Nipples during Lactation. Skin Pharmacol Physiol. 2011; 24: 27-35. that identified a higher incidence of nipple injury between the second and third day of postpartum. However, teaching the technique of breastfeeding within the first few days after childbirth and the observation of breastfeeding are essential for the prevention and reduction of nipple trauma.

The incorrect handling of the infant to the mother's breast and the inadequate positioning between mother and child were associated to nipple trauma in most number of studies, followed by primiparity and mother 's race/color white or yellow. In the adequate handling to the breast, the child must be with the lips facing out, mouth wide open, the appearance of rounded cheeks, the presence of more areola above the child's mouth (asymmetric handling) and the chin touching the mother's breast. In the proper placement during breastfeeding, the child's body is near and facing the mother, the head and body aligned, the mouth is the same height as the nipple and the infant's buttocks supported.4343 UNICEF (United Nations Children's Fund). Breastfeeding management and promotion in a babyfriendly hospital: an 18-hour course for maternity staff. New York; 1993.,4444 UNICEF (United Nations Children's Fund). Breastfeeding management and promotion in a babyfriendly hospital: an 20-hour course for maternity staff. New York; 2009.

Regarding to the infant's handling, studies have identified as unfavorable parameters of the child's chin away from the breast,3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52. the bottom lip facing in,3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52. the mouth a little opened3838 Weigert EML, Giugliani ERJ, França MCT, Oliveira LD, Bonilha ALL, Espiríto Santo LC, Köhler CV. The influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. J Pediatr. 2005; 81 (4): 310-6. and absence of the asymmetrical handling.3838 Weigert EML, Giugliani ERJ, França MCT, Oliveira LD, Bonilha ALL, Espiríto Santo LC, Köhler CV. The influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. J Pediatr. 2005; 81 (4): 310-6. However, in another study, the criterion of asymmetric handling was not a sufficient parameter for defining this, because in the assessment of breastfeeding some mothers had a small areola circumference and for this reason all the nipple-areola region remained covered by the neonate's lips, hindering the view on the observation of breastfeeding.3333 Shimoda GT, Aragaki IMM, Sousa CA, Silva IA. Associação entre persistência de lesão de mamilos e condições de aleitamento materno. Rev Mineira Enferm. 2014; 18 (1): 68-74.

Inadequate technique in breastfeeding, including the handling and the positioning between mother and child was also associated to breast problems in other studies.1212 Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44.,3535 Moraes M, Silva L, Faliú B, Sosa C. Técnica de alimentación a pecho y aparición de trauma del pezón previo al alta hospitalaria. Arch Pediatr Urug. 2011; 82 (1): 10-17.

36 Kronborg H, Vaeth M. How Are Effective Breastfeeding Techniqueand Pacifier Use Related to Breastfeeding Problems and BreastfeedingDuration? Birth. 2009; 36: 34-42.
-3737 Goyal RC, Banginwar AS, Ziyo F, Toweir AA. Breastfeeding practices: Positioning, attachment (latch-on) and effective suckling - A hospital-based study in Libya. J Fam Comm Med. 2011; 18 (2): 74-9. In this aspect, intervention actions are essential to prevent the appearance of nipple injuries.3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52.,3636 Kronborg H, Vaeth M. How Are Effective Breastfeeding Techniqueand Pacifier Use Related to Breastfeeding Problems and BreastfeedingDuration? Birth. 2009; 36: 34-42.,3838 Weigert EML, Giugliani ERJ, França MCT, Oliveira LD, Bonilha ALL, Espiríto Santo LC, Köhler CV. The influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. J Pediatr. 2005; 81 (4): 310-6.

In this current study, the set of variables that has been identified as potential predictors were classified in hierarchical levels, according to the proximity of the factor exposure with the outcome. At the proximal level, which refers to the characteristics of the postpartum and breastfeeding process, in addition to the incorrect handling of the infant and the inadequate positioning between mother and child were also considered as predictors of nipple trauma, the nipple type was not favorable, the presence of breast engorgement, nipple pain, the use of baby bottle and pacifier. The occurrence of lactational mastitis was also included in this level.

It was observed that nursing mothers with breasts engorgement presented a greater chance to occur nipple trauma.77 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009; 85 (4): 341-5. In these cases, the complex area of the nipple-areola region is flatten so more distortion of the anatomy of the breast, a fact that makes it difficult to handle the infant correctly, leading to nipples injuries.4545 Cotterman KJ. Reverse pressure softening: a simple tool to prepare areola for easier latching during engorgement. J Hum Lact. 2004; 20 (2): 227-37.,4646 WHO (World Health Organization), UNICEF (United Nations Children's Fund). Baby-Friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva: World Health Organization; 2009. Women with malformed nipples also presented greater chances to occur injuries when compared to breastfeeding women with protruding nipples format.3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34.

The nipple injury was associated to pain,3333 Shimoda GT, Aragaki IMM, Sousa CA, Silva IA. Associação entre persistência de lesão de mamilos e condições de aleitamento materno. Rev Mineira Enferm. 2014; 18 (1): 68-74. a common symptom that may occur in the first few hours of maternal breastfeeding4747 Prieto-Gómez R, Baeza-Weinmann B. Lactancia materna: Prevalencia de grietas y dolor en mujeres que amamantan, región de la araucanía, Temuco, Chile. 2010-2011. Rev Colombiana Obstetr Ginecol. 2013; 64 (3): 229-33. and is indicated as inadequacy of handling the infant to the mother's breast.2424 WHO (World Health Organization). Technical consultation on postpartum and postnatal care. Geneva; 2010. Women who experienced pain during breastfeeding should be assessed by health professionals, with the observation on the feeding technique.2424 WHO (World Health Organization). Technical consultation on postpartum and postnatal care. Geneva; 2010. The diagnosis and early treatment of handling and inadequate positioning can reduce the consequences generated by the women, among all of this, the interruption of maternal breastfeeding.4747 Prieto-Gómez R, Baeza-Weinmann B. Lactancia materna: Prevalencia de grietas y dolor en mujeres que amamantan, región de la araucanía, Temuco, Chile. 2010-2011. Rev Colombiana Obstetr Ginecol. 2013; 64 (3): 229-33.

In relation to the use of baby bottles and/or pacifier, children can present a pattern of inadequate suction of the mother's breast by distorting the movements of the tongue, causing the so-called "nipple confusion". In the usual behavior on the suction of a baby bottle, children use the tongue to control the flow of the milk from the tip of the latex nozzle, while the correct suction on the mother's breast, is the tongue moving in waving motion to remove the milk, protecting the nipple from frictions and injuries.4848 Righard L. Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles? Birth. 1998; 25: 40-4.,4949 Tait P. Nipple pain in breastfeeding women: Causes, treatment, and prevention strategies. J Midwifery Women's Health 2000; 45(3); 2012-5. Studies have reported an association between pacifier use and the technique of inadequate breastfeeding.4848 Righard L. Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles? Birth. 1998; 25: 40-4.,5050 Howard CR, Howard FM, Lanphear B, Blieck EA, Eberly S, Lawrence RA. The effects of early pacifier use on breastfeeding duration. Pediatrics. 1999; 103 (3): E33. However, a review of 14 articles found little evidence of the causal relationship between the use of pacifiers and baby bottles and nipple confusion.5151 Zimmerman E, Thompson K. Clarifying nipple confusion. J Perinatol. 2015; 35 (11): 895-9.

The local or general lactational mastitis is joined to nipple trauma.1212 Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44. The authors emphasized this because it is a retrospective study and they did not allow the determination of cause and effect. Other studies have related nipple fissure to the development of lactational mastitis.1111 Giugliani ERJ. Common problems during lactation and their management. J Pediatr. 2004; 80 (5): 147-54.,1616 Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002; 155: 103-14.,1717 Giugliani ERJ. Lack of scientific evidence for the treatment of nipple traumas. J Pediatr. 2003; 79 (3): 197-8.,1818 Cullinane M, Amir LH, Donath SM, Garland SM, Tabrizi SN, Payne MS, Bennett CM. Determinants of mastitis in women in the CASTLE study: a cohort study. BMC Fam Pract. 2015; 16 (1): 181.,2222 Vieira GO, Silva LR, Mendes CMC, Vieira TO. Mastite lactacional e a Iniciativa Hospital Amigo da Criança, Feira de Santana, Bahia, Brasil. Cad Saúde Pública. 2006; 22(6): 1193-200.,5252 Kvist LJ, Hall-Lord ML, Larsson BW. A descriptive study of Swedish women with symptoms of breast inflammation during lactation and their perceptions of the quality of care given at a breastfeeding clinic. Int Breastfeed J 2007; 2:2

At the proximal intermediate level were identified as factors associated to nipple trauma, the use of anesthesia during childbirth, neonates' gestational age between 37 and 40 weeks and breastfeeding in the first hour of life. There was a significant association between epidural anesthesia received by women for a cesarean section or episiotomy in the vaginal delivery having nipple injury. The presence of discomfort and pain in the surgical incision can compromise the positioning of the puerperal to breastfeed her child, resulting in the appearance of nipple injury.3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34.

Mothers who had cesarean sections were more likely to have problems related to breastfeeding, including nipple fissure, in comparison to women who had vaginal delivery.5353 Boskabadi H, Ramazanzadeh M, Zakerihamidi M, Rezagholizade OF. Risk factors of breast problems in mothers and its effects on newborns. Iran Red Crescent Med J. 2014; 16 (6): 8582.,5454 Suresh S, Sharma KK, Saksena M, Thukral A, Agarwal R, Vatsa M. Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: experience in a tertiary care centre in Northern India. Indian J Public Health. 2014; 58 (4): 270-3. However, there were no relationship observed between nipple injury with the type of childbirth in a cohort study conducted in Australia with 340 primiparous women.5555 Buck ML, Amir LH, Cullinane M, Donath SM. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeed Med. 2014; 9 (2): 56-62.

The incidence of nipple injury in mothers with newborns at term (37 to 40 weeks of gestation) was higher when compared to preterm infants of 32 to 37 weeks.3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34. It may be inferred that the strongest force of suction and a better application of the breast tissue during breastfeeding of children born at term have contributed for nipple injury.

Breastfeeding in the first hour of life was identified as a risk factor for nipple injury,3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52. which according to the authors, the result found is probably related to the handling and the incorrect positioning of the child to be placed for breastfeeding and this is not the strategy of breastfeeding in the first hour of life, as recommended for early establishment in maternal breastfeeding.5656 WHO (World Health Organization). Evidence for ten steps to successful breastfeeding. Geneva: WHO/CHD/98.9; 1998.

At the distal intermediate level, it was noted that guidance received during prenatal care on the technique of breastfeeding was a protective factor against the occurrence of nipple trauma, reflecting on the importance of the completeness care during this period to prevent nipple injuries and its possible consequences, although only one study has evaluated this feature.2323 Duffy ER, Percival P, Kershaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates. Midwifery. 1997; 13: 189-96. Women who have had prenatal guidance presented less pain and nipple trauma during the first four days after childbirth, in addition to a higher prevalence of maternal breastfeeding within the six weeks after childbirth.2323 Duffy ER, Percival P, Kershaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates. Midwifery. 1997; 13: 189-96.

Educational programs in prenatal care can provide necessary knowledge, as well as contribute to increase the mother's confidence in her ability to breastfeed, important characteristics to initiate breastfeeding. The synergism of actions developed during the gestation and after the birth of the child is fundamental to prevent nipple injuries. A study performed with the puerperal women between the second and the fourth day postpartum showed that only 60% of women remembered about the guidance they received on breastfeeding during the prenatal period.4747 Prieto-Gómez R, Baeza-Weinmann B. Lactancia materna: Prevalencia de grietas y dolor en mujeres que amamantan, región de la araucanía, Temuco, Chile. 2010-2011. Rev Colombiana Obstetr Ginecol. 2013; 64 (3): 229-33. Similar to the guidance on breastfeeding technique performed only in the postpartum period which did not determine a positive effect in preventing nipple problems.99 Shimoda GT, Soares AV, Aragaki IMM, Mcarthur A. Preventing nipple trauma in lactating women in the University Hospital of the University of Sao Paulo: a best practice implementation project. JBI Database System Rev Implement Rep. 2015; 12 (13): 212-32.,5757 Oliveira LD, Giugliani ER; Espírito Santo LC, França MC, Weigert EML, Kohler CV, Lourenzi Bonilha AL. Effect of Intervention to Improve Breastfeeding Technique on the Frequency of Exclusive Breastfeeding and Lactation-Related Problems. J Hum Lact. 2006; 22 (3): 315-21.

At the distal level of the hierarchical model of this study, nipple trauma was considered as risk factors for mothers' race/color white or yellow, primiparity, presence of nipple fissure in previous pregnancies and mothers who did not live with a partner.

Nursing mothers' race/white or yellow color were related to nipple injury.3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34.,3333 Shimoda GT, Aragaki IMM, Sousa CA, Silva IA. Associação entre persistência de lesão de mamilos e condições de aleitamento materno. Rev Mineira Enferm. 2014; 18 (1): 68-74. Dark skinned women are less likely to present nipple injuries during breastfeeding due to the greater amount of melanin and consequently the increase of skin resistance to nipple trauma caused by the infants' suction.3232 Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34. However, in a case-control study, breastfeeding women's skin color is not self-referred as a determinant factor for the appearance of nipple trauma.77 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009; 85 (4): 341-5.

The primiparity is a factor that independently can be associated to nipple trauma. A study with puerperal women on exclusive maternal breastfeeding showed that primiparous women have a greater chance to develop nipple injury when comparing those with more than one child.77 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009; 85 (4): 341-5.

The educational program to correct positioning during the postpartum period did not show statistical significance in preventing nipple trauma in an intervention study with primiparous women.5858 Henderson A, Stamp G, Pincombe J. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth. 2001; 8 (4): 236-42. The results of another study3737 Goyal RC, Banginwar AS, Ziyo F, Toweir AA. Breastfeeding practices: Positioning, attachment (latch-on) and effective suckling - A hospital-based study in Libya. J Fam Comm Med. 2011; 18 (2): 74-9. indicated that most multiparous women presented satisfactory parameters in relation to the positioning and handling, which could be a result of the previous experience in the practice of maternal breastfeeding. It should be noted that primiparous women need different approaches to establish breastfeeding.

The presence of nipple fissure in previous gestation was associated to the appearance of nipple injuries in 204 women evaluated before hospital discharge.3535 Moraes M, Silva L, Faliú B, Sosa C. Técnica de alimentación a pecho y aparición de trauma del pezón previo al alta hospitalaria. Arch Pediatr Urug. 2011; 82 (1): 10-17. In this study, it considered only the history of breast complications, no information about the characteristics of the skin and the nipple.

Nipple trauma was associated to the absence of the partner.3434 Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52. The authors discussed that the lack of the partner could leave the woman more insecure, making the practice of breastfeeding difficult. The lack of emotional and social support could interfere in the process of maternal breastfeeding and the occurrence of nipple injuries.4747 Prieto-Gómez R, Baeza-Weinmann B. Lactancia materna: Prevalencia de grietas y dolor en mujeres que amamantan, región de la araucanía, Temuco, Chile. 2010-2011. Rev Colombiana Obstetr Ginecol. 2013; 64 (3): 229-33.

The mother's age, the schooling level, previous experience with breastfeeding, preparing the nipples during the gestation, the type of childbirth, classification of the newborn according to weight and gestational age, the child's gender, birth weight, guidance on positioning the child in the postpartum period, type and duration of maternal breastfeeding, there were no determinate factors for nipple trauma among the selected studies. However, the hierarchical model was kept due to the understanding of the biological plausibility of these characteristics as possible factors associated to nipple trauma.

There were no studies identifying the contextual level approach in respect to the factors related to the support actions and protection on maternal breastfeeding within the location (city/town), so this level will not be included in the hierarchical model proposed.

Regarding to the limitations of this present study, there is the possibility of not identifying and selecting some studies about the topic addressed and, for not entering in the search criteria that was established. Another limitation was observed regarding the methodological quality of the studies found, however, only four used the logistic regression as a multivariate analysis, limiting the possibility to identify confounders and effect modifiers. Furthermore, in virtue of the heterogeneity of the studies listed, it was not possible to employ the use of quantitative synthesis of the results by means of meta-analysis.

Final Considerations

Nipple trauma is a common problem among women in the lactational period, which can start immediately after the delivery. The main risk factors identified were: the incorrect handling of the infant to the mother's breast, the inadequate positioning between mother and child, primiparity and maternal race/color defined as white or yellow, characteristics observed, respectively in seven, six, three and two reviewed studies.

Other factors were identified as determinants for nipple trauma in at least one study: the presence of nipple fissure in previous gestations, mothers who did not live with a partner, the use of anesthesia during delivery, newborn's gestational age between 37 and 40 weeks, semi-protruding and/or malformed nipples, presence of breast engorgement, nipple pain, lactational mastitis, the use of baby bottle and/or pacifier. The guidance received on handling and appropriate positioning during the prenatal care was shown as a protective factor for nipple trauma.

The characteristics related to postpartum and maternal breastfeeding, classified in the proximal hierarchical level were the most investigated and identified as risk factors, indicating that the preventive actions aiming to reduce nipple trauma should be developed mainly in the postpartum period, with teaching techniques of breastfeeding. Although the results analyzed by different levels contribute to the understanding of the processes involved in the occurrence of nipple injuries, the current study does not have a definitive conclusion, since the practice of MB is the result of the interaction of multiple individual and contextual determinants.

References

  • 1
    Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI. Breastfeeding and the use of human milk. Pediatrics. 2005; 115(2):496-506.
  • 2
    Toma TS, Rea MF. Benefícios da amamentação para a saúde da mulher e da criança: um ensaio sobre as evidências. Cad Saúde Pública. 2008; 24 (2): 235-46.
  • 3
    Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde da criança-nutrição infantil: aleitamento materno e alimentação complementar. Brasília, DF; 2009.
  • 4
    WHO (World Health Organization). Infant and young child feeding: Model chapter for text books for medical students and allied health professionals. Geneva; 2009.
  • 5
    Riordan J, Bibb D, Miller M, Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact. 2001; 17 (1): 20-3.
  • 6
    Ahluwalia IB, Morrow B, Hsia J. Why do women stop breastfeeding? Findings from the pregnancy risk assessment and monitoring system. Pediatrics. 2005; 116 (6): 1408-12.
  • 7
    Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009; 85 (4): 341-5.
  • 8
    Vieira GO, Martins CC, Vieira TO, Oliveira NF, Silva LR. Factors predicting early discontinuation of exclusive breastfeeding in the first month of life. J Pediatr. 2010; 86 (5): 441-4.
  • 9
    Shimoda GT, Soares AV, Aragaki IMM, Mcarthur A. Preventing nipple trauma in lactating women in the University Hospital of the University of Sao Paulo: a best practice implementation project. JBI Database System Rev Implement Rep. 2015; 12 (13): 212-32.
  • 10
    Ziemer MM, Pigeon JG. Skin changes and pain in the nipple during the 1st week of lactation. J Obstet Gynecol Neonatal Nurs. 1993; 22 (3): 247-56.
  • 11
    Giugliani ERJ. Common problems during lactation and their management. J Pediatr. 2004; 80 (5): 147-54.
  • 12
    Thompson R, Kruske S, Barclay L, Linden K, Gao Y, Kildea S. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women Birth. 2016; 29 (4): 336-44.
  • 13
    Coca KP, Abrão ACFV. Avaliação do efeito da lanolina na cicatrização dos traumas mamilares. Acta Paul Enferm. 2008; 21 (1): 11-6.
  • 14
    Cervellini MP, Gamba MA, Coca KP, Abrão ACFV. Injuries resulted from breastfeeding: a new approach to a known problem. Rev Esc Enferm USP. 2014; 48 (2): 346-56.
  • 15
    WHO (World Health Organization). La alimentación del lactante y del niño pequeño. Geneva; 2010.
  • 16
    Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002; 155: 103-14.
  • 17
    Giugliani ERJ. Lack of scientific evidence for the treatment of nipple traumas. J Pediatr. 2003; 79 (3): 197-8.
  • 18
    Cullinane M, Amir LH, Donath SM, Garland SM, Tabrizi SN, Payne MS, Bennett CM. Determinants of mastitis in women in the CASTLE study: a cohort study. BMC Fam Pract. 2015; 16 (1): 181.
  • 19
    Livingstone VH, Willis CE, Berkowitz J. Staphylococcus aureus and sore nipples. Can Fam Physician. 1996; 42: 654-9.
  • 20
    Amir LH. Candida and the lactating breast: predisposing factors. J Hum Lact. 1991; 7 (4): 177-81.
  • 21
    Tanguay KE, Mcbean MR, Jain E. Nipple candidiasis among breastfeeding mothers. Case-control study of predisposing factors. Can Fam Physician. 1994; 40: 1407-13.
  • 22
    Vieira GO, Silva LR, Mendes CMC, Vieira TO. Mastite lactacional e a Iniciativa Hospital Amigo da Criança, Feira de Santana, Bahia, Brasil. Cad Saúde Pública. 2006; 22(6): 1193-200.
  • 23
    Duffy ER, Percival P, Kershaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates. Midwifery. 1997; 13: 189-96.
  • 24
    WHO (World Health Organization). Technical consultation on postpartum and postnatal care. Geneva; 2010.
  • 25
    Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma Group. Reprint-Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Phys Ther. 2009; 89(9): 873-80.
  • 26
    NCBI (National Center for Biotechnology Information). [acesso em 2016 jun 16]. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed
    » http://www.ncbi.nlm.nih.gov/pubmed
  • 27
    BVS (Biblioteca Virtual em Saúde). [acesso em 2016 jun 18]. Disponível em: http://regional.bvsalud.org
    » http://regional.bvsalud.org
  • 28
    ScienceDirect. [acesso em 2016 jun 18]. Disponível em: http://www.sciencedirect.com/science/search
    » http://www.sciencedirect.com/science/search
  • 29
    Vieira TO, Vieira GO, Martins CC, Santana GS, Silva L. Intenção materna de amamentar: revisão sistemática. Ciênc Saúde Coletiva. 2016; 21 (12): 3845-58.
  • 30
    Boccolini CS, Carvalho ML, Oliveira MIC, Vasconcellos AGG. Fatores associados à amamentação na primeira hora de vida. Rev Saúde Pública. 2011; 45 (1): 69-78.
  • 31
    Boccolini CS. Aleitamento materno: determinantes sociais e repercussões na saúde infantil [tese]. Rio de Janeiro: Ministério da Saúde- Fundação Oswaldo Cruz- Escola Nacional de Saúde Pública Sérgio Arouca; 2012.
  • 32
    Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurence in lactating women. Rev Bras Enferm. 2005; 58 (5): 529-34.
  • 33
    Shimoda GT, Aragaki IMM, Sousa CA, Silva IA. Associação entre persistência de lesão de mamilos e condições de aleitamento materno. Rev Mineira Enferm. 2014; 18 (1): 68-74.
  • 34
    Coca KP, Gamba MA, Silva RSE, Abrão ACFV. Does breast feeding position influence the onset of nipple trauma? Rev Escola Enferm USP. 2009; 43 (2): 446-52.
  • 35
    Moraes M, Silva L, Faliú B, Sosa C. Técnica de alimentación a pecho y aparición de trauma del pezón previo al alta hospitalaria. Arch Pediatr Urug. 2011; 82 (1): 10-17.
  • 36
    Kronborg H, Vaeth M. How Are Effective Breastfeeding Techniqueand Pacifier Use Related to Breastfeeding Problems and BreastfeedingDuration? Birth. 2009; 36: 34-42.
  • 37
    Goyal RC, Banginwar AS, Ziyo F, Toweir AA. Breastfeeding practices: Positioning, attachment (latch-on) and effective suckling - A hospital-based study in Libya. J Fam Comm Med. 2011; 18 (2): 74-9.
  • 38
    Weigert EML, Giugliani ERJ, França MCT, Oliveira LD, Bonilha ALL, Espiríto Santo LC, Köhler CV. The influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. J Pediatr. 2005; 81 (4): 310-6.
  • 39
    Centuori S, Burmaz T, Ronfani L, Fragiacomo M, Quintero S, Pavan C, Davanzo R, Cattaneo A. Nipple care, sore nipples, and breastfeeding: a randomized trial. J Hum Lact. 1999; 15 (2): 125-30.
  • 40
    Abrão ACFV, Gutierrez MGR, Marin HF. Diagnóstico de Enfermagem Amamentação Ineficaz - Estudo de identificação e validação clínica. Acta Paul Enferm. 2005; 18 (1): 46-55.
  • 41
    Espiríto Santo LC, Oliveira LD, Giugliani ER. Factors associated with low incidence of exclusive breastfeeding for the first 6 months. Birth. 2007; 34: 212-9.
  • 42
    Abou-Dakn M, Fluhr JW, Gensch M, Wöckel A. Positive Effect of HPA Lanolin versus Expressed Breastmilk on Painful and Damaged Nipples during Lactation. Skin Pharmacol Physiol. 2011; 24: 27-35.
  • 43
    UNICEF (United Nations Children's Fund). Breastfeeding management and promotion in a babyfriendly hospital: an 18-hour course for maternity staff. New York; 1993.
  • 44
    UNICEF (United Nations Children's Fund). Breastfeeding management and promotion in a babyfriendly hospital: an 20-hour course for maternity staff. New York; 2009.
  • 45
    Cotterman KJ. Reverse pressure softening: a simple tool to prepare areola for easier latching during engorgement. J Hum Lact. 2004; 20 (2): 227-37.
  • 46
    WHO (World Health Organization), UNICEF (United Nations Children's Fund). Baby-Friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva: World Health Organization; 2009.
  • 47
    Prieto-Gómez R, Baeza-Weinmann B. Lactancia materna: Prevalencia de grietas y dolor en mujeres que amamantan, región de la araucanía, Temuco, Chile. 2010-2011. Rev Colombiana Obstetr Ginecol. 2013; 64 (3): 229-33.
  • 48
    Righard L. Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles? Birth. 1998; 25: 40-4.
  • 49
    Tait P. Nipple pain in breastfeeding women: Causes, treatment, and prevention strategies. J Midwifery Women's Health 2000; 45(3); 2012-5.
  • 50
    Howard CR, Howard FM, Lanphear B, Blieck EA, Eberly S, Lawrence RA. The effects of early pacifier use on breastfeeding duration. Pediatrics. 1999; 103 (3): E33.
  • 51
    Zimmerman E, Thompson K. Clarifying nipple confusion. J Perinatol. 2015; 35 (11): 895-9.
  • 52
    Kvist LJ, Hall-Lord ML, Larsson BW. A descriptive study of Swedish women with symptoms of breast inflammation during lactation and their perceptions of the quality of care given at a breastfeeding clinic. Int Breastfeed J 2007; 2:2
  • 53
    Boskabadi H, Ramazanzadeh M, Zakerihamidi M, Rezagholizade OF. Risk factors of breast problems in mothers and its effects on newborns. Iran Red Crescent Med J. 2014; 16 (6): 8582.
  • 54
    Suresh S, Sharma KK, Saksena M, Thukral A, Agarwal R, Vatsa M. Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: experience in a tertiary care centre in Northern India. Indian J Public Health. 2014; 58 (4): 270-3.
  • 55
    Buck ML, Amir LH, Cullinane M, Donath SM. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeed Med. 2014; 9 (2): 56-62.
  • 56
    WHO (World Health Organization). Evidence for ten steps to successful breastfeeding. Geneva: WHO/CHD/98.9; 1998.
  • 57
    Oliveira LD, Giugliani ER; Espírito Santo LC, França MC, Weigert EML, Kohler CV, Lourenzi Bonilha AL. Effect of Intervention to Improve Breastfeeding Technique on the Frequency of Exclusive Breastfeeding and Lactation-Related Problems. J Hum Lact. 2006; 22 (3): 315-21.
  • 58
    Henderson A, Stamp G, Pincombe J. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth. 2001; 8 (4): 236-42.

Publication Dates

  • Publication in this collection
    Jan-Mar 2017

History

  • Received
    31 Aug 2016
  • Accepted
    16 Feb 2017
Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br