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

Dias, Janaína Silva; Vieira, Tatiana de Oliveira; Vieira, Graciete Oliveira

doi:10.1590/1806-93042017000100003

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Saúde Materno Infantil

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

REVIEW • Rev. Bras. Saude Mater. Infant. 17 (1) • Jan-Mar 2017 • https://doi.org/10.1590/1806-93042017000100003 copy

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

Authorship SCIMAGO INSTITUTIONS RANKINGS

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

Score the quality criteria	Duffy et al.,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. 1997	Centouri et al.,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. 1999	Henderson et al.,⁵⁸58 Henderson A, Stamp G, Pincombe J. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth. 2001; 8 (4): 236-42. 2001	Weigert et al.,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. 2005	Shimoda et al.,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. 2005	Abrão et al.,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. 2005	Oliveira et al.,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. 2006	Coca et al.,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. 2009	Coca et al.,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. 2009	Kronborg et al.,³⁶36 Kronborg H, Vaeth M. How Are Effective Breastfeeding Techniqueand Pacifier Use Related to Breastfeeding Problems and BreastfeedingDuration? Birth. 2009; 36: 34-42. 2009	Moraes et al.,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. 2011	Goyal et al.,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. 2011	Prieto-Goméz et al.,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. 2013	Buck et al.,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. 2014	Shimoda et al.,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. 2014	Shimoda et al.,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. 2015	Thompson et al.,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. 2016
Types of study: Intervention= 5; Cohort= 4; Case-control= 3; Cross sectional= 2; Case study= 1	5	5	5	4	2	2	5	3	3	5	2	2	2	4	2	5	4
Structured abstract= 1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1	1	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1
Introduction with background and justification= 1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Population recruitment: National= 3; Local residents= 2; users of units= 1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Selection of the population/sample: Census= 6; simple random= 5; systemati-cally= 4; stratified= 3; by con-glomerates= 2; convenience= 1	1	1	1	5	1	1	5	1	1	1	1	1	1	1	1	1	1
The data collection instru-ment: validated and standar-dized= 3; validated= 2; stan-dardized= 1	3	1	3	3	1	3	3	1	1	3	3	3	3	1	1	1	1
Non-response informed rate = 1	1	1	1	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.
Interviewers’ training= 1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Performed statistical analysis= 1	1	1	1	1	1	1	1	1	1	1	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1
Study limitations and conside-red biases = 1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1	1
Interpreted results according to evidence= 1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	^* * The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.	1
Scale of general results: any-where in the world= 5; conti-nents= 4; the same country= 3; the same geographical region= 2; specific popula-tion= 1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Maximum score= 29	18	13	17	21	11	12	21	13	11	18	13	15	12	15	11	14	14

Author, Journal, year of publication	Place of study, year performed	Type of study, sample (n)	Objective	Statistical Analysis	Prevalence/ Incidence of nipple trauma	Factors associated to nipple trauma	Factors that were not associated to nipple trauma
Duffy et al.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.; Midwifery, 1997	Perth- Austrália, 1995	Intervention study: convenience sample with 70 primiparous (35 in the control group and 35 in the intervention group)	To evaluate the effect of prenatal orientation in positioning and handling the breast in relation to duration of breastfeeding, pain and nipple trauma	ANOVA, chisquare test	Incidence in the experimental group= 53%; in the control group= 100%	Guidance on the positioning and adequate handling to the mother’s breast	____
Centouri et al.,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. ; J Hum Lact, 1999	Trieste- Itália, 1996- 1997	Intervention study: 219 mothers (96 in the control group and 123 in the intervention group)	Determine the incidence of nipple injury and duration of breastfeeding	ANOVA and Kruskal-Wallis, Fisher test, the Chi-square test, Mantel-Haesnzel	Incidence in the experi-mental group= 73%; in the control group= 76%	The use of baby bottle; The use of pacifier	Prevalence of exclusive maternal breastfeeding at 4 months
Henderson et al.,⁵⁸58 Henderson A, Stamp G, Pincombe J. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth. 2001; 8 (4): 236-42. ; Birth, 2001	Adelaide- Austrália, 1999	Intervention study: 160 mothers	To evaluate the effect of educational program and placement for breastfeeding in primiparous women on the onset of nipple trauma	Fisher test, Chisquare, student t test	Incidence in the Experimental Group= 17%; in the control group= 16%	____	Guidance on the correct positioning between mother-child in the postpartum
Weigert et al.,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.; J Pediatr. 2005	Porto Alegre- Brasil, 2003	Cohort study: 211 mothers and babies	To investigate the influence of breastfeeding technique on nipple injuries on the first month of lactation	Pearson's chisquare test or chi-square test with Yates correction, Student t test	Incidence of 43.6%	Handling the baby: mouth slightly open; Symmetrical handling	Mother/baby positioning: mother with tense shoulders: baby’s head and trunk not aligned; baby’s body away from the mother; baby’s chin does not touch mother’s breast; baby is not supported correctly; Handling of the baby: inferior lip not inverted
Shimoda et al.,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.; Rev Bras Enferm. 2005	São Paulo- Brasil, 2000	A cross-sectional study: 1,020 medical records of puerperal women and newborns	Check the occurrence of the nipple according to the characteritics of the newborn and the puerperal	Chi-square test and two measurement test	Prevalence of 52.75%	7 days incidence of 43.2% in the control group and 48.9% in the intervention group	Type of nipple; Type of childbirth; Baby’s gender; Baby’s weight
Abrão et al.,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.; Acta Paul Enferm. 2005	São Paulo- Brasil, 1996 a 1997	A analytic descriptive study: 124 puerperal women and newborns in maternal breastfeeding	Identify and Validate defining characteristics of diagnosis on ineffective breastfeeding	Chi-square test, Cochran G test	Prevalence of 30.6%	____	Incorrect handling of the nipple-areola region; Parity; Malformed nipples
Oliveira et al.,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.; J Hum Lact. 2006	Porto Alegre- Brasil, 2003	An intervention study: 211 pairs (mother and child) at 7 and 30 days after postpartum (74 in the intervention group and 137 in the control group)	Evaluate the impact of an intervention of breastfeeding technique about nipple problems during the first month after postpartum	Pearson's chisquare test or the chi-square test with Yates correction, Student t -Test	7 days incidence of 43.2% in the control group and 48.9% in the intervention group	____	An intervention on adequate orientation on breastfeeding technique
Coca et al.,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.; Rev Esc Enferm USP. 2009	São Paulo- Brasil, 2004 a 2005	A case-control study: 146 binomials mother and child (73 cases and 73 controls) in the first week of postpartum in maternal breastfeeding	Identify factors related to the position of the child during breastfeeding and apprehension of the nipple	Chi-square, student t -test, univariate analysis and correspondence analysis	____	Mother/baby positioning: Position of the child not alignment. Handling of the baby: Chin away from the breast; Lip facing inward	Mother/baby positioning: Mother with shoulders ten-se and/or perched on the child; Child positioned away from the mother. Handling of the baby: Baby’s mouth slightly open; Tongue not visible; Absence of the asymmetric handling; Quick suction; Non audible swallowing
Coca et al.,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.; J Pediatr. 2009	São Paulo- Brasil, 2004 a 2005	A case-control study: 146 puerperal women (73 cases and 73 controls) with a single pregnancy and exclusive breastfeeding	Identify the factors associated to nipple trauma in women in exclusive maternal breastfeeding	Chi-square test , Student t test and non-conditional logistic regression	____	Does not live with a partner; Breasts turgid and engorged; Semiprotruding and/or malformed nipples; Pre-sence of breastfeeding in the first hour after birth; Primiparity	Maternal age; Maternal schooling; Maternal Race/color; Preparation of the nipples during pregnancy; The baby’s gender; Birth weight
Kronborg et al.,³⁶36 Kronborg H, Vaeth M. How Are Effective Breastfeeding Techniqueand Pacifier Use Related to Breastfeeding Problems and BreastfeedingDuration? Birth. 2009; 36: 34-42.; Birth. 2009	Aarhus- Dinamarca, 2004	An intervention study: 579 pairs mother-child	Investigate the relationship of breastfeeding technique and the use of pacifier with problems in breastfeeding and in the duration of maternal breastfeeding	Chi-square test, logistic regression, using Cox regression method, Kaplan Meier and Log Rank Testing	____	Ineffective Breastfeeding techniqu	Use of a pacifier
Moraes et al.,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.; Arch Pediatr Urug. 2011	Montevideo- Uruguai, 2009 a 2010	A cross-sectional study: 204 mothers and infants	Evaluate the relationship between breastfeeding technique and the presence of nipple trauma before hospital discharge	Chi-square test, logistic regression	Prevalence of 40.1%	Multiparous women; Nipple fissure in previous pregnancies; Technique of feeding with one or two negative parameters; Technique on feeding with three or more negative parameters	____
Goyal et al.,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.; J Fam Comm Med. 2011	Benghazi- Líbia, 2009 a 2010	A cross-sectional study: 192 mothers and children	Assess the positioning, the handle and the suction of Children in breastfeeding admitted to hospitals in Benghazi- Lybia	Chi-square test	____	Positioning; Handling	____
Prieto- Goméz et al.,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.; Rev Colombiana Obstetr Ginecol. 2013	Temuco- Chile, 2010 a 2011	A cross-sectional study: 343 postpartum women for convenience sampling	To determine the prevalence of nipple fissure in mothers in the early puerperium, and practices of health professionals in relation to breastfeeding	Descriptive analysis with prevalence calculation	Prevalence of 46.1%	____	Maternal age; Type of childbirth; Parity; Classification of the newborn according to weight/ gestational age; Previous experience with breastfeeding; Presence of pain
Buck et al.,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.; Breastfeed Med. 2014	Melbourne- Australia, 2009 a 2011	A cohort study: 340 primiparous women	To describe the nipple pain/ injury and its rela-tion to the type of childbirth	Chi-square test	Incidence of 58%	____	Type of childbirth
Shimoda et al.,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.; Rev Min Enferm. 2014	São Paulo- Brasil, 2000	A cross-sectional study: 60 women	Check the association between the persistence of nipples injuries and breastfeeding conditions	Fisher test	Prevalence of 26.7%	Color of the nipple-areola region little pigmentation; Nipple pain; Improper handling of the newborn to the mother's breast	Type of breast feeding; Breast engorgement. Nipple type
Shimoda et al.,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.; JBI Database System Rev Implement Rep. 2015	São Paulo- Brasil, 2013	An intervention study: 196 women and newborns	Evaluate the implementation impact of the Assessment Form on breastfeeding, to observe and guide the mother in the postnatal period, on the rates of nipple trauma	Descriptive analysis with incidence calculation	Incidence of 67.3%	____	Guidance on maternal breastfeeding and breastfeeding technique during the postpartum period
Thompson et al.,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.; Women Birth. 2016	Melbourne- Australia, 2001 a 2007	A cohort study: 653 women	Describe the characteristics of women who participated in the service of breastfeeding and explore the potential risk factors for nipple trauma and breast engorgement	Chi-square test, logistic regression	Incidence of 62.9%	Asymmetric handling infants’ facialmandibular in relation to the breast; Positioning: technique cross-cradle; hand in "scissors" to hold the breast; Lactational mastitis	Breast engorgement

Nível distal	Estudos	Associação	Nível intermediário distal	Estudos	Associação	Nível intermediário proximal	Estudos	Associação	Nível proximal	Estudos	Associação
Variables	n	n	Variables	n	n	Variables	n	n	Variables	n	n
Maternal age	2	0	Preparation of the nipples during pregnancy	1	0	Anesthesia at childbirth	1	1	Semi-protruding and/ or malformed nipples	3	1
Race/color white or yellow	3	2	Guidance on the appropriate technique to breastfeed during the prenatal period	1	1	Breastfeeding in the first hour of life	1	1	Guidance on adequate technique to breast-feed in the postpar-tum period	3	0
M a t e r n a l schooling	1	1				Cesarean	3	0	Inadequate positio-ning between mother and child	7	6
Primiparity	4	3				Newborn’s gestational age between 37 and 40 weeks	1	1	Incorrect handling of the infant to the mother’s breast	8	7
Presence of nipple fissure in previous pregnancies	1	1				Classification of the newborn according to weight / gestational age	1	0	Breast engorgement	3	1
Previous experience with breastfeeding	1	0				Baby's Gender	2	0	Nipple Pain	2	1
Previous experience with breastfeeding	1	1				Birth weight	3	0	Type of breastfeeding	1	0
									Breastfeeding durati-on	1	0
									The use of baby bottle	1	1
									The use of a pacifier	2	1
									Lactational mastitis	1	1

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

Acompanhe os números deste periódico no seu leitor de RSS

[TFN1] ^*
The score equal to zero when the information was not specified in the text or when did not meet the defined criteria.

[TFN2] Source: adapted from Vieira et al.²⁹29 Vieira TO, Vieira GO, Martins CC, Santana GS, Silva L. Intenção materna de amamentar: revisão sistemática. Ciênc Saúde Coletiva. 2016; 21 (12): 3845-58.