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Healthcare quality in breastfeeding: implementation of the nipple trauma index

ABSTRACT

Objective

assess the efficacy of the Nipple Trauma Indicator Instrument implemented in the rooming-in facility t of a university teaching hospital as a healthcare quality indicator.

Method

exploratory, descriptive, retrospective study, with analysis of the Nipple Trauma Indicator tool of 1,691 mothers admitted in rooming-In from June to November 2012. Data were presented as absolute frequencies and percentages and statistical tests were administered.

Results

the mean rate of nipple trauma was 55.5%. The most frequent trauma was excoriation (62,2%) and the main cause was incorrect attachment of the newborn (44%). Maternal and neonatal factors associated with nipple trauma are also presented.

Conclusion

the Nipple Trauma Indicator provides a picture of breastfeeding healthcare, contributing to the construction of this quality indicator.

Breast feeding; Nipples; Wounds and injuries; Quality indicators, health care

RESUMO

Objetivo

Avaliar a adequação do instrumento Indicador de Trauma Mamilar, implantado no Alojamento Conjunto de um Hospital Universitário, como indicador de qualidade assistencial.

Método

Estudo exploratório-descritivo, retrospectivo, com análise do instrumento Indicador de Trauma Mamilar de 1.691 puérperas, admitidas na unidade de Alojamento Conjunto no período de junho a novembro de 2012. Os dados foram apresentados em forma de frequências absolutas e percentuais, sendo aplicados testes de associação.

Resultados

A média de índice de trauma mamilar foi de 55,5%, o trauma mais frequente, a escoriação (62,2%), sendo a principal causa a pega inadequada do recém-nascido (44%). Apresentam-se também os fatores maternos e neonatais que se associaram ao trauma mamilar.

Conclusão

O Indicador de Trauma Mamilar retrata a assistência prestada em aleitamento materno mostrando-se como uma importante ferramenta para a construção desse indicador de qualidade.

Aleitamento materno; Mamilos; Ferimentos e lesões; Indicadores de qualidade em assistência à saúde

RESUMEN

Objetivo

evaluar la adecuación del instrumento Indicador de trauma del pezón, implementado en la maternidad de un Hospital Universitario, como indicador de la calidad.

Método

estudio exploratorio, descriptivo y retrospectivo; que analizó el instrumento Indicador de Trauma del pezón, en 1691 madres admitidas de junio a noviembre de 2012. Los dados fueron presentados como frecuencias absolutas y porcentajes, con pruebas de asociación.

Resultados

el promedio del índice de trauma del pezón fue del 55,5%, el trauma más frecuente fue la excoriación (62,2%); su principal causa, la fijación incorrecta del recién nacido (44%). Se presentaron los factores neonatales y maternos asociados con el trauma.

Conclusión

el instrumento Indicador de trauma del pezón retrata la atención en lactancia materna contribuyendo a la construcción del este indicador del calidad.

Lactancia materna; Pezones; Heridas y traumatismos; Indicadores de calidad de la atención de salud

INTRODUCTION

Early and exclusive breastfeeding up to the sixth month of the child’s life is considered a key practice to reduce neonatal and infant mortality, and is highly recommended by the Ministry of Health (11. Ministério da Saúde (BR). II Pesquisa de prevalência de aleitamento materno nas capitais brasileiras e Distrito Federal. Brasília: Ministério da Saúde; 2009.) and the World Health Organization, as well as continued breastfeeding up to 2 years of age or more, for it has a protective effect against diabetes and obesity (22. Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva: World Health Organization; 2013.). Large-scale breastfeeding promotion has the potential to prevent an estimated 11.6% of infant deaths and improve mother-child global health (33. Pérez-Escamilla R, Curry L, Minhas D, Taylor L, Bradley E. Scaling up of breastfeeding promotion programs in low- and middle-income countries: the “breastfeeding gear” model. Adv Nutr. 2012 Nov;3(6):790-800.).

The status of breastfeeding in Brazil significantly improved after three decades of implementation of the National Breastfeeding Policy, but differences between the regions and capitals of the country persist, and despite the efforts of several national and international organizations, breastfeeding rates, especially exclusive breastfeeding, are below the recommended levels (11. Ministério da Saúde (BR). II Pesquisa de prevalência de aleitamento materno nas capitais brasileiras e Distrito Federal. Brasília: Ministério da Saúde; 2009.). According to several authors, pain and nipple trauma are, among other factors, related to early weaning (4-8).

Nipple trauma is defined as a macroscopic traceable cutaneous lesion in the area of the mammilla and areola (44. Abou-Dakn M, Fluhr JW, Gensch M, Wockel A. Positive effect of HPA lanolin versus expressed breastmilk on painful and damaged nipples during lactation. Skin Pharmacol Physiol. 2011;24(1):27-35.), or else as vascular lesions that can cause change in color, texture and shape of the skin (99. Cervelini MP, Gamba MA, Coca KP, Abrão ACFV. Lesões mamilares decorrentes da amamentação: um novo olhar novo para um problema conhecido. Rev Esc Enferm USP. 2014;48(2):346-56.).

Breastfeeding management following the prevention of nipple trauma is one of the main activities to be developed in the rooming in system, care model adopted to promote care to the mother-child binomial. According to the Brazilian Ministry of Health, this practice allows healthy babies to remain with their mothers 24 hours a day after birth until hospital discharge (1010. Ministério da Saúde (BR). Portaria nº 1016 de 26 de agosto de 1993. Aprova as normas básicas para a implantação do sistema “Alojamento Conjunto”. Diário Oficial [da] República Federativa do Brasil. 1993 set 1, 131(167 Seção 1):13066-7.).

The health professionals who provide care to patients in rooming in intervention play a key role in the success of the breastfeeding experience, identifying and correcting any factors that may lead to nipple injury, contributing to mitigate pain and ensuring appropriate breastfeeding.

Such support to breastfeeding implies high quality care and can be measured objectively by performance indicators, including the nipple trauma indicator. The first step of the implementation of this indicator requires the construction of an “instrument for the management of nipple trauma”, according to the needs of each health service (1111. Mendonça CTA, Silva LIMC. Indicador de trauma mamilar. In: Viana DL, Leão ER, Figueiredo NMA, organizadores. Especialização em enfermagem: atuação, intervenção e cuidados de enfermagem. São Paulo: Yendis; 2010. vol. 1, p. 106-12.). The administration of this instrument would provide objective data on the frequency and characteristics of the lesions, risk factors for the onset of nipple trauma, the measures adopted and assessment of the actions implemented to heal these injuries (1111. Mendonça CTA, Silva LIMC. Indicador de trauma mamilar. In: Viana DL, Leão ER, Figueiredo NMA, organizadores. Especialização em enfermagem: atuação, intervenção e cuidados de enfermagem. São Paulo: Yendis; 2010. vol. 1, p. 106-12.).

Therefore, periodic assessment of the instrument allows a more accurate account of maternity care practices related to breastfeeding through the measurement of the nipple trauma index, which is obtained by dividing the number of mothers with nipple trauma by the total number of mothers who breastfed times 100(1111. Mendonça CTA, Silva LIMC. Indicador de trauma mamilar. In: Viana DL, Leão ER, Figueiredo NMA, organizadores. Especialização em enfermagem: atuação, intervenção e cuidados de enfermagem. São Paulo: Yendis; 2010. vol. 1, p. 106-12.).

In view of the aforementioned, in order to improve care quality, the nursing team that provide care to mothers in the rooming-in facility of the Teaching Hospital of the University of São Paulo proposed, in 2012, the implementation of a quality indicator for breastfeeding as a tool to promote objective assessment of the care delivered. The first step to reach this goal involved constructing a tool for sore nipple management called Nipple Trauma Index and conducting a pilot study(1212. Shimoda GT, Aragaki IMM, Lima AAP, Bertoni GC, Piran RC, Aquino SRCS. Relato de experiência sobre a implantação do indicador de trauma mamilar no Alojamento Conjunto do HU-USP. São Paulo; 2011. [Resumo expandido apresentado no V Fórum para Técnicos e Auxiliares de Enfermagem: a enfermagem no cuidado e na segurança do paciente; São Paulo: HU-USP;2011].), during which the tool was administered for one month and reshaped after analysis of the results obtained.

After the nurses were trained in the use of this tool, it was administered to all the women who had recently given birth admitted to the rooming-in at the Teaching Hospital of the University of São Paulo, from May 1st, 2012. However, a few months later some operational difficulties in the implementation of this care quality indicator were detected, as well as the need for further modifications in the adopted instrument. Thus, a broader assessment of the results obtained was needed to provide a critical analysis of the tool, in order to answer the following guiding question: “Does the Nipple Trauma Index developed accurately portray the quality of care delivered to mothers and infants associated to breastfeeding?

Thus, the general objective of the research was to assess the suitability of the instrument Nipple Trauma Index administered in the rooming in facility of a teaching hospital, as a care quality indicator. For this purpose, the following specific objectives were established: assessing the nipple trauma index at the rooming in facility of the Teaching Hospital of the University of São Paulo over a six-month period; assessing the frequency of the types and causes of nipple trauma; identifying maternal and neonatal factors associated with nipple trauma; identifying conformities and non - conformities related to completion of the Nipple Trauma Index instrument and finally proposing adjustments to the referred tool, according to the results obtained.

METHOD

Exploratory, descriptive, retrospective and quantitative study extracted from an end-of course paper of the Specialization Course in Obstetric Nursing (1313. Cirico MOV. Indicador de trauma mamilar em alojamento conjunto [monografia]. São Caetano do Sul: Universidade Municipal de São Caetano do Sul, Curso de Especialização em Enfermagem Obstétrica; 2013.), developed in the Rooming in unit of the university hospital of the University of São Paulo.

The site of the study is a teaching hospital, which provides secondary care, with rooming in facilities that prioritize breastfeeding and that has been a Baby Friendly Accredited Hospital” (1414. Ministério da Saúde (BR). Portaria n. 1.153 de 22 de maio de 2014. Redefine os critérios de habilitação da Iniciativa Hospital Amigo da Criança (IHAC), como estratégia de promoção, proteção e apoio ao aleitamento materno e à saúde integral da criança e da mulher, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União [da] República Federativa do Brasil. 2014 mai 28;151(100 Seção 1):43-5.) since 2006.

The Rooming in facilities are composed of 52 beds, 43 of which are destined to the mother-child binomial. The minimum hospitalization time is 60 hours, irrespective of the type of delivery. During hospitalization, the mother is invited to participate in daily group activities promoted by the nurse, where themes related to newborn care, the postpartum period and breastfeeding are addressed. The nursing team also provides individualized assistance to the mothers and infants, supporting the breastfeeding process throughout the hospitalization. Monitoring of mother-infant binomial also includes assessment of breastfeeding, checking of breasts and nipples and completion of the nipple trauma index tool.

Data were collected from the Nipple Trauma Index tool containing all the e answers of the women admitted to the rooming in facilities of the Teaching Hospital of the University of São Paulo. Admission occurred between the first day of June and on November 30, 2012.

Data were transcribed in Microsoft Excel® electronic spreadsheet and later entered into the statistical program SPSS® (Statistical Package for Social Sciences) version 17.0 and presented as absolute and percentage frequencies. In order to identify maternal and neonatal factors associated with nipple trauma caused by breastfeeding the statistical tests like the Chi-square test or Fisher’s exact test (when the expected frequency was less than 5) were applied, assuming a probability of 5% of occurrence of type 1 error.

The study was approved by the Research Ethics Committee of São Paulo’s University Teaching Hospital under number 167660. Anonymity of participants and confidentiality of data were ensured, according to the provisions of Resolution CNS 466/12. Free informed consent form was waived because it is not needed in retrospective studies.

RESULTS

From June to November 2012, 1,723 deliveries were conducted in the Teaching Hospital of the University of São Paulo, with an average of 287 births a month. Thirty-two (32) women were excluded from the study sample, as follows: 19 women who did not breastfeed their babies, two women who gave birth two stillborn babies, one woman who gave birth to a stillborn baby who died in the last month of intrauterine gestation and 10 who did not meet the Nipple Trauma Index tool. Thus, for the purposes of analysis and data treatment, a total number of 1,691 women was obtained.

Regarding the characterization of the sample, most mothers were adults (85.7%), i.e., over 19 years (according to the classification of the World Health Organization) primiparous (48.9%) or had delivered their second children (31, 2%), mulatto (53.9%), with dark brown nipple-areola region (59.6%), had protruding nipple (67.0%), vaginal delivery (47.2%) or by forceps (16.3%), received spinal anesthesia (61.4%) and breastfed their children in the delivery room (61.8%). Most non-primiparous women (50.3%) had experienced nipple trauma during breastfeeding in previous pregnancies. Regarding the newborns, most were full-term (58.2%), appropriate for gestational age (78.8%) and remained in rooming in with their mothers (80.7%).

Regarding the number of assessments recorded at the Nipple Trauma Index by the nurse during hospitalization, of the 1, 691 (100%) women who delivered babies, most of them: 970 (57.4%) were assessed three times, followed by 364 (21.5%) mothers assessed twice, a period that corresponds to the minimum hospital stay of 60 hours established by the institution. There were 309 (18.3%) mothers who were assessed more than three times because their hospital stays were longer than usual for different reasons, 44 (2.6%) mothers who were assessed only once during hospitalization and for 4 (0.2%) mothers no assessments were recorded.

The instruments completed by the mothers that did not include information on the presence or absence of nipple trauma (19 to 1.1%) were not considered for data analysis from that section on, totaling 1,672 instruments for further assessments.

Regarding the frequency of nipple trauma, of the 1,672 (100%) participants, 928 (55.5%) had some type of nipple trauma, and 744 (44.5%) did not have nipple trauma.

Figure 1 includes nipple trauma index calculation in the period of June-November 2012.

Figure 1
– Nipple trauma Index (%), June-November 2012, at the Rooming-in facility of the Teaching Hospital of the University of São Paulo - Brazil 2012

Regarding the classification of types of nipple trauma, of the 928 (100%) mothers affected, 687 women (74.0%) had single lesions and 239 (25.8%) had multiple lesions, and 2 (0.2%) women did not include this information on the instrument. The types of trauma reported were, as follows: 740 (62.2%), erythema 227 (19.1%), fissure 145 (12.2%), blisters 50 (4.2%), erosion, 7 (0.6%) and other lesions (whitening, ecchymosis and areolar edema) 21 (1.7%). It should be stressed that the total number of the variable is greater than the total number of lesions because there were mothers with multiple lesions.

Regarding the sucking pattern of the newborns, of the total 2,616 (100%) assessments, 1,229 (47.0%) showed an appropriate standard and 719 (27.5%) an inappropriate standard. For 668 (25.5%) newborns, the sucking pattern was not assessed.

As for the causes of nipple trauma recorded by the nurses in the Nipple Trauma Index instrument, it was found that of the 928 (100%) mothers, 472 (50.9%) had a single cause, 258 (27.8%) had multiple causes, and in 198 (21.3%) the cause of nipple trauma was not identified.

Table 1
– Frequency distribution of nipple trauma causes recorded by the nurses - Brazil 2012

The variables type of delivery (normal, cesarean section or forceps) anesthesia (spinal, epidural, local, general, double block or no anesthesia), having or not breastfed in the delivery room and the classification of the newborn for weight (small for gestational age, appropriate for gestational age or large for gestational age) showed no statistically significant association for the occurrence of nipple trauma.

The other maternal and neonatal variables significantly associated with the presence of nipple trauma (p = 0.05) are shown in Table 2.

Table 2
– Maternal and neonatal variables significantly associated with the presence of nipple trauma - Brazil, 2012

Since some mothers had anatomical malformations in their right and left nipples we decided to conduct statistical association test by chi-square test, separately for each type of nipple, and the results are shown in Table 3. Please note that the total number of mothers with injury for each type of nipple is different. Also, one woman had only the left breast.

Table 3
– Distribution of the mothers regarding the presence of nipple trauma in different types of left and right nipples - Brazil 2012

As for the assessment of the adequacy of the instrument Nipple Trauma Index, some nonconformities were detected in the completion of the tool by the nurses and some relevant information for the diagnosis and management of this complication was missing.

The main nonconformities identified were as follows: discrepancies in assessments between reviewers (nurses), lack of several records and errors in the records. The main gaps in the instrument were no room to record the supply of milk supplement to the newborns and no standardization of the words used to describe the causes of nipple trauma and the actions conducted or recommended by the nursing staff. Based on the results obtained, some adjustments were proposed to the tool used in this study. The tool before and after these adjustments is shown in the Appendix.

DISCUSSION

The social determinants involved in early weaning in the postpartum period are pacifier use, limited number of night feedings, mother with extra home work, lack of support of the partner regarding breastfeeding, child gender and nipple trauma(1515. Vieira TO, Vieira GO, Oliveira NF, Mendes CM, Giugliani ER, Silva LR. Duration of exclusive breastfeeding in a Brazilian population: new determinants in a cohort study. BMC Pregnancy Childbirth. 2014;14:175.). In addition, nipple injuries are associated with a 2.4 fold increased risk of discontinuing breastfeeding before six months (1515. Vieira TO, Vieira GO, Oliveira NF, Mendes CM, Giugliani ER, Silva LR. Duration of exclusive breastfeeding in a Brazilian population: new determinants in a cohort study. BMC Pregnancy Childbirth. 2014;14:175.). Nipple pain and insufficient milk supply are the main causes of early weaning, and persistent nipple pain was associated with strong sucking of the newborn during breastfeeding (55. McClellan HL, Hepworth AR, Kent JC, Garbin CP, Williams TM, Hartmann PE, et al. Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain. Breastfeed Med. 2012;7(4):275-81.),. Such data is corroborated in the present study.

Regarding the nipple trauma index calculated during the six months of assessment, it ranged from 52.0% to 59.2%. There are no standardized nipple trauma indexes in the literatures. However, the reviewed studies contain indexes that can be used for comparison purposes.

A study conducted in two “Baby Friendly Accredited Hospitals” in Berlin, Germany (44. Abou-Dakn M, Fluhr JW, Gensch M, Wockel A. Positive effect of HPA lanolin versus expressed breastmilk on painful and damaged nipples during lactation. Skin Pharmacol Physiol. 2011;24(1):27-35.),, identified a 90% percentage of occurrence of nipple trauma in 84 mothers assessed. In Australia (1616. Buck ML, Amir LH, Cullinane M, Donath SM, CASTLE Study Team. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeed Med. 2014;9(2):56-62.) despite the high motivation of women regarding breastfeeding and access to education in the Baby Friendly Hospital, with intensive support in the postpartum period, 79% of the women reported nipple pain, and 58% had nipple trauma during the first week of breastfeeding. In a systematic review (1717. Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Syst Rev. 2014(12):CD007366.) some studies reported incidence of pain and nipple trauma ranging from 34% to 96% of women who breastfeed, and this condition reduced the duration of breastfeeding. Another study showed decrease of 16.9%, from 41.5% to 24. 6% in the nipple trauma index before and after certification of professionals as consultants in lactation (IBCLC - International Board Certified Lactation Consultants) (1818. Chiurco A, Montico M, Brovedani P, Monasta L, Davanzo R. An IBCLC in the maternity ward of a mother and child hospital: a pre- and post-intervention study. Int Environ Res Public Health. 2015;12(8):9938-51.).

Compared to the referred studies, the nipple trauma index obtained in this study is close to the expected. However, comparison to the results obtained in a survey conducted in 2005 (1919. Shimoda GT, Silva IA, Santos JLF. Características, frequência e fatores presentes na ocorrência de lesão de mamilos em nutrizes. Rev Bras Enferm. 2005;58(5):529-34.) in this same scenario, which showed 52.75% prevalence of this lesion, indicates that there was no significant improvement in care quality related to breastfeeding. It should be stressed that during the 2005 study, the Teaching Hospital of the University of São Paulo was not yet accredited as “Baby - Friendly Hospital”. Thus, it is necessary to create or improve the existing strategies for decrease the incidence of nipple trauma in this health service.

Lower frequency of nipple trauma was found in protruding nipples compared to other nipple shapes, such as pseudo-inverted, flat and semi-protruding nipples. Such data support the findings of other studies (1212. Shimoda GT, Aragaki IMM, Lima AAP, Bertoni GC, Piran RC, Aquino SRCS. Relato de experiência sobre a implantação do indicador de trauma mamilar no Alojamento Conjunto do HU-USP. São Paulo; 2011. [Resumo expandido apresentado no V Fórum para Técnicos e Auxiliares de Enfermagem: a enfermagem no cuidado e na segurança do paciente; São Paulo: HU-USP;2011]., 1919. Shimoda GT, Silva IA, Santos JLF. Características, frequência e fatores presentes na ocorrência de lesão de mamilos em nutrizes. Rev Bras Enferm. 2005;58(5):529-34.). This can be explained by the different individual anatomical characteristics observed that affect infant sucking and often make latching difficult for the babies.

Regarding the frequency of the different types of trauma, this study corroborated data from a previous research conducted in the same institution, and the same gradient(1212. Shimoda GT, Aragaki IMM, Lima AAP, Bertoni GC, Piran RC, Aquino SRCS. Relato de experiência sobre a implantação do indicador de trauma mamilar no Alojamento Conjunto do HU-USP. São Paulo; 2011. [Resumo expandido apresentado no V Fórum para Técnicos e Auxiliares de Enfermagem: a enfermagem no cuidado e na segurança do paciente; São Paulo: HU-USP;2011].).

The main cause of nipple trauma, as well as in other studies (55. McClellan HL, Hepworth AR, Kent JC, Garbin CP, Williams TM, Hartmann PE, et al. Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain. Breastfeed Med. 2012;7(4):275-81.,77. Ingram J, Johnson D, Copeland M, Taylor HJ. The development of a new breast feeding assessment tool and the relationship with breast feeding self-efficacy. Midwifery. 2015;31(1):132-7.-88. McClellan HL, Kent JC, Hepworth AR, Hartmann PE, Geddes DT. Persistent nipple pain in breastfeeding mothers associated with abnormal infant tongue movement. Int J Environ Res Public Health. 2015;12(9):10833-45.,1717. Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Syst Rev. 2014(12):CD007366.,1919. Shimoda GT, Silva IA, Santos JLF. Características, frequência e fatores presentes na ocorrência de lesão de mamilos em nutrizes. Rev Bras Enferm. 2005;58(5):529-34.) was latch-on problems (44.0%), demonstrating the importance of appropriate nursing staff levels and satisfactory work conditions in these services to ensure adequate supervision of breastfeeding in order to prevent this complication. Therefore, since nipple trauma often results from incorrect positioning and latch on problems, mothers should receive professional care immediately after delivery to prevent pain and nipple trauma (1717. Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Syst Rev. 2014(12):CD007366.).

The second leading cause of nipple trauma was frequent infant sucking (23.7%), similar to a finding from a 2011 study, in which the author (1212. Shimoda GT, Aragaki IMM, Lima AAP, Bertoni GC, Piran RC, Aquino SRCS. Relato de experiência sobre a implantação do indicador de trauma mamilar no Alojamento Conjunto do HU-USP. São Paulo; 2011. [Resumo expandido apresentado no V Fórum para Técnicos e Auxiliares de Enfermagem: a enfermagem no cuidado e na segurança do paciente; São Paulo: HU-USP;2011].) explains that frequent sucking impacts the nipple-areola skin tissue, contributing to the trauma, and this can be observed in cases of mothers with reduced colostrum production or infants with latching problems who obtain an insufficient amount of milk. Lower milk production was associated with longer breastfeeding times in women with nipple pain. However, most women with persistent nipple pain were able to produce normal levels of milk (55. McClellan HL, Hepworth AR, Kent JC, Garbin CP, Williams TM, Hartmann PE, et al. Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain. Breastfeed Med. 2012;7(4):275-81.).

Another cause of nipple trauma reported in this study was strong sucking by the newborn, as in other studies (77. Ingram J, Johnson D, Copeland M, Taylor HJ. The development of a new breast feeding assessment tool and the relationship with breast feeding self-efficacy. Midwifery. 2015;31(1):132-7.-88. McClellan HL, Kent JC, Hepworth AR, Hartmann PE, Geddes DT. Persistent nipple pain in breastfeeding mothers associated with abnormal infant tongue movement. Int J Environ Res Public Health. 2015;12(9):10833-45.). Analysis of ultrasound images showed that newborns from women with nipple pain had reduced movements of the tongue compared to the infants from women in the control group, confirming that infants of mothers with nipple pain exert a stronger pressure (88. McClellan HL, Kent JC, Hepworth AR, Hartmann PE, Geddes DT. Persistent nipple pain in breastfeeding mothers associated with abnormal infant tongue movement. Int J Environ Res Public Health. 2015;12(9):10833-45.). However, with professional support, breastfeeding by women with low milk production and persistent nipple pain can be improved and achieve an optimal milk production, despite the strong sucking of the babies (55. McClellan HL, Hepworth AR, Kent JC, Garbin CP, Williams TM, Hartmann PE, et al. Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain. Breastfeed Med. 2012;7(4):275-81.).

As for the trauma-related factors, primiparous women had a higher frequency of nipple trauma (60.2%), which can be justified by their lack of experience regarding breastfeeding techniques, and because they are exposing the nipple-areola area to infant sucking for the first time, as already reported by other studies (1919. Shimoda GT, Silva IA, Santos JLF. Características, frequência e fatores presentes na ocorrência de lesão de mamilos em nutrizes. Rev Bras Enferm. 2005;58(5):529-34.-2020. Essa MS, Ebrahim EM. Effect of breast milk versus therapeutic honey (Apicare) on cracked nipples’ healing. Life Science J, 2013;10(1):2137-47.). In addition to the inexperience of primiparous women, some authors point out that many of these women are not well informed on care to the breasts and related to breastfeeding during the prenatal period, which aggravates the incidence of nipple trauma(2020. Essa MS, Ebrahim EM. Effect of breast milk versus therapeutic honey (Apicare) on cracked nipples’ healing. Life Science J, 2013;10(1):2137-47.).

White women had a higher frequency of nipple trauma (62.6%) as well as women with pink nipples (70.3%). Darker nipples had lower incidence of nipple trauma, which is consistent with data from another study (1919. Shimoda GT, Silva IA, Santos JLF. Características, frequência e fatores presentes na ocorrência de lesão de mamilos em nutrizes. Rev Bras Enferm. 2005;58(5):529-34.),), that reported that women with greater amount of nipple-areolar pigmentation were more resistant to trauma caused by baby sucking.

Preterm newborns also showed a statistically significant inverse relationship with the presence of nipple trauma, as previously reported(1212. Shimoda GT, Aragaki IMM, Lima AAP, Bertoni GC, Piran RC, Aquino SRCS. Relato de experiência sobre a implantação do indicador de trauma mamilar no Alojamento Conjunto do HU-USP. São Paulo; 2011. [Resumo expandido apresentado no V Fórum para Técnicos e Auxiliares de Enfermagem: a enfermagem no cuidado e na segurança do paciente; São Paulo: HU-USP;2011].),), in a study where mothers with term newborns had a higher frequency of nipple trauma compared to mothers of preterm babies, with 58.6% and 32.9%, respectively. Preterm infants may have weaker sucking, which results in a lower impact on the nipple tissue as well as postponement of the first feeds until clinical stabilization (2121. Soares JPO, Novaes LFG, Araújo CMT, Vieira ACC. Amamentação de prematuros sob a ótica materna. Rev CEFAC. 2016 jan-fev;18(1):232-41.).

Mothers who stayed with their children in rooming in facilities during all the assessments showed a higher frequency of nipple trauma (57.8%), explained by the more frequent exposure of their nipples to sucking, as a result of the greater encouragement to breastfeeding.

Most newborns from mothers who experienced nipple trauma showed a pattern of inadequate suckling (70.1%) in at least one assessment in the rooming in facility, stressing the most frequently reported cause of nipple trauma.

Corroborating our study, a research conducted in Australia (1616. Buck ML, Amir LH, Cullinane M, Donath SM, CASTLE Study Team. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeed Med. 2014;9(2):56-62.) also failed to show a statistically significant association between type of delivery and incidence of nipple trauma.

Regarding the presence of nipple trauma at the different kinds of nipples, it was found that the lowest frequencies of nipple trauma occurred in protruding nipples, both in the left (46.7%) and in the right nipple (44.0%), and the opposite occurred in semi-protruding, flat, inverted or pseudo-inverted nipples, which showed the highest frequencies of nipple trauma, with a statistically significant association (p = 0.000). However, there are no studies demonstrating these relationships. So, further studies are needed.

Most of the women (78.9%) who participated in the study during their hospital stay were assessed through the the nipple trauma index tool two or three times, depending on the length of their stay. However, this result reflects the need to train nurses on the importance of starting completion of the instrument upon the admission of the patients in the unit, and conduct subsequent monitoring of daily progress, to allow a more accurate assessment of the breastfeeding process for 100% of the mothers admitted to the rooming in facility.

Assessment of the limitations observed in the format of the printed instrument and its use indicted the need for adjustments in this tool. Thus, a new Nipple Trauma Index was designed, which was more adapted to the reality of the rooming in facilities of the Teaching Hospital of the University of São Paulo. The new tool cannot be compared to any others because of the lack of studies in the area.

CONCLUSIONS

The Nipple Trauma Index proposed for use in the assessment of mothers in the rooming in facility of the Teaching Hospital of the University of São Paulo depicts the care provided to breastfeeding mothers in this health service, proving to be an important tool to monthly monitor nipple trauma levels and contributing to the construction of a care quality instrument in breastfeeding.

The results analyzed showed that the nipple trauma index in the period of June-November 2012, in the rooming in facility of the Teaching Hospital of the University of São Paulo ranged from 52 to 59.2%, reaching an average of 55.5% in the semester.

The most frequent type of nipple trauma was galling, followed by erythema, fissure, blister, other injuries and erosion, respectively. The main causes raised were infant’s incorrect mouth attachment (latch-on), frequent sucking, other various causes, strong sucking by the newborn and the use of breast pump.

The maternal and neonatal factors associated with nipple trauma were age, parity, skin color, color of the nipple-areola area, newborn prematurity, newborn length of stay in the rooming-in facility, trauma in previous experience of breastfeeding and inappropriate sucking pattern at some point during hospitalization.

Given the observed non-conformities, the Nipple Trauma index was adjusted and redesigned. Thus, the nurses who perform their duties in the rooming in facilities must be trained on the correct completion of this new tool, in order to minimize errors and standardize assessments.

One limitation of this study concerns the fact that other health centers may adopt different strategies and behaviors for the prevention and management of nipple trauma. However, after the necessary adjustments, the Nipple Trauma Index tool can be used in other health centers.

REFERÊNCIAS

  • 1
    Ministério da Saúde (BR). II Pesquisa de prevalência de aleitamento materno nas capitais brasileiras e Distrito Federal. Brasília: Ministério da Saúde; 2009.
  • 2
    Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva: World Health Organization; 2013.
  • 3
    Pérez-Escamilla R, Curry L, Minhas D, Taylor L, Bradley E. Scaling up of breastfeeding promotion programs in low- and middle-income countries: the “breastfeeding gear” model. Adv Nutr. 2012 Nov;3(6):790-800.
  • 4
    Abou-Dakn M, Fluhr JW, Gensch M, Wockel A. Positive effect of HPA lanolin versus expressed breastmilk on painful and damaged nipples during lactation. Skin Pharmacol Physiol. 2011;24(1):27-35.
  • 5
    McClellan HL, Hepworth AR, Kent JC, Garbin CP, Williams TM, Hartmann PE, et al. Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain. Breastfeed Med. 2012;7(4):275-81.
  • 6
    Berens PD. Breast pain: engorgement, nipple pain, and mastitis. Clin Obstet Gynecol. 2012;58(4):902-14.
  • 7
    Ingram J, Johnson D, Copeland M, Taylor HJ. The development of a new breast feeding assessment tool and the relationship with breast feeding self-efficacy. Midwifery. 2015;31(1):132-7.
  • 8
    McClellan HL, Kent JC, Hepworth AR, Hartmann PE, Geddes DT. Persistent nipple pain in breastfeeding mothers associated with abnormal infant tongue movement. Int J Environ Res Public Health. 2015;12(9):10833-45.
  • 9
    Cervelini MP, Gamba MA, Coca KP, Abrão ACFV. Lesões mamilares decorrentes da amamentação: um novo olhar novo para um problema conhecido. Rev Esc Enferm USP. 2014;48(2):346-56.
  • 10
    Ministério da Saúde (BR). Portaria nº 1016 de 26 de agosto de 1993. Aprova as normas básicas para a implantação do sistema “Alojamento Conjunto”. Diário Oficial [da] República Federativa do Brasil. 1993 set 1, 131(167 Seção 1):13066-7.
  • 11
    Mendonça CTA, Silva LIMC. Indicador de trauma mamilar. In: Viana DL, Leão ER, Figueiredo NMA, organizadores. Especialização em enfermagem: atuação, intervenção e cuidados de enfermagem. São Paulo: Yendis; 2010. vol. 1, p. 106-12.
  • 12
    Shimoda GT, Aragaki IMM, Lima AAP, Bertoni GC, Piran RC, Aquino SRCS. Relato de experiência sobre a implantação do indicador de trauma mamilar no Alojamento Conjunto do HU-USP. São Paulo; 2011. [Resumo expandido apresentado no V Fórum para Técnicos e Auxiliares de Enfermagem: a enfermagem no cuidado e na segurança do paciente; São Paulo: HU-USP;2011].
  • 13
    Cirico MOV. Indicador de trauma mamilar em alojamento conjunto [monografia]. São Caetano do Sul: Universidade Municipal de São Caetano do Sul, Curso de Especialização em Enfermagem Obstétrica; 2013.
  • 14
    Ministério da Saúde (BR). Portaria n. 1.153 de 22 de maio de 2014. Redefine os critérios de habilitação da Iniciativa Hospital Amigo da Criança (IHAC), como estratégia de promoção, proteção e apoio ao aleitamento materno e à saúde integral da criança e da mulher, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União [da] República Federativa do Brasil. 2014 mai 28;151(100 Seção 1):43-5.
  • 15
    Vieira TO, Vieira GO, Oliveira NF, Mendes CM, Giugliani ER, Silva LR. Duration of exclusive breastfeeding in a Brazilian population: new determinants in a cohort study. BMC Pregnancy Childbirth. 2014;14:175.
  • 16
    Buck ML, Amir LH, Cullinane M, Donath SM, CASTLE Study Team. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeed Med. 2014;9(2):56-62.
  • 17
    Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Syst Rev. 2014(12):CD007366.
  • 18
    Chiurco A, Montico M, Brovedani P, Monasta L, Davanzo R. An IBCLC in the maternity ward of a mother and child hospital: a pre- and post-intervention study. Int Environ Res Public Health. 2015;12(8):9938-51.
  • 19
    Shimoda GT, Silva IA, Santos JLF. Características, frequência e fatores presentes na ocorrência de lesão de mamilos em nutrizes. Rev Bras Enferm. 2005;58(5):529-34.
  • 20
    Essa MS, Ebrahim EM. Effect of breast milk versus therapeutic honey (Apicare) on cracked nipples’ healing. Life Science J, 2013;10(1):2137-47.
  • 21
    Soares JPO, Novaes LFG, Araújo CMT, Vieira ACC. Amamentação de prematuros sob a ótica materna. Rev CEFAC. 2016 jan-fev;18(1):232-41.

Publication Dates

  • Publication in this collection
    2016

History

  • Received
    02 Dec 2015
  • Accepted
    06 Oct 2016
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