Effective interventions for treating nipple trauma resulting from breastfeeding: a systematic review

Silva, Jéssica Iohanna da; Chagas, Ana Larysa Galdino das; Sena, Bárbara de Oliveira; Lima, Camila Almeida de; Santos, Giulia Viana dos; Campelo, Maria Carolina Dantas; Medeiros, Lays Pinheiro de; Araújo, Rhayssa de Oliveira e

doi:10.37689/acta-ape/2022AR00013677

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Acta Paulista de Enfermagem

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Review Article • Acta Paul Enferm 35 • 2022 • https://doi.org/10.37689/acta-ape/2022AR00013677 copy

Effective interventions for treating nipple trauma resulting from breastfeeding: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To identify interventions based on effective scientific evidence for treating nipple trauma due to breastfeeding.

Methods

This is a systematic review, carried out in the MEDLINE^®/PubMed^®, Scopus, CINAHL, Web of Science, Cochrane and LILACS databases, between August and September 2020. The descriptors nipple* AND wound and injuries OR trauma AND therapeutic OR treatment AND breastfeeding were used. Intervention studies, without language and time restriction, full text and that did not address nipple trauma not related to breastfeeding were included. Effective interventions were considered those with positive outcome for tissue repair and/or pain. The searches were in pairs, and the quality of the trials was assessed by the Jadad scale and by the Grading of Recommendations Assessment, Development and Evaluation.

Results

The final sample was composed of seven articles, found in the CINAHL, Web of Science and Scopus databases. The effective interventions found involved chamomile ointment, use of highly purified lanolin, low-level laser photobiomodulation, honey, millefeuille and breast milk. Each intervention found was used in different situations and in different ways, which should be considered for clinical practice. Guidance on the handle was present in association with most effective interventions.

Conclusion

The interventions evidenced may contribute to reduce difficulties in breastfeeding, in the reduction of pain and injury tissue repair.

Nipples; Wounds and injuries; Therapeutics; Breast feeding; Nursing care

Design	Risks of bias	Inconsistency	Indirect evidence	Inaccuracy	Certainty	Importance
Study 1: Nayeri et al.⁽¹²⁾
Triple-blind clinical trial	Non-severe	Non-severe	Non-severe	Non-severe	⨁⨁⨁⨁ High	Critical
Study 2: Jackson et al.⁽¹³⁾
Simple randomized blind trial	Very severe^*	Severe^*	Non-severe	Very severe^*	⨁⨁〇〇 Low	Important
Study 3: Mariani Neto et al.⁽¹⁴⁾
Randomized clinical trial	Non-severe	Non-severe	Non-severe	Non-severe	⨁⨁⨁⨁ High	Critical
Study 4: Coca et al.⁽¹⁵⁾
Experimental study	Severe	Non-severe	Non-severe	Non-severe	⨁⨁⨁⨁ High	Important
Study 5: Abou-Dakn et al.⁽¹⁶⁾
Blind simple controlled clinical trial	Non-severe	Non-severe	Non-severe	Non-severe	⨁⨁⨁⨁ High	Critical
Study 6: Coca et al.⁽¹⁷⁾
Triple-blind randomized clinical trial	Non-severe	Non-severe	Non-severe	Non-severe	⨁⨁⨁⨁ High	Critical
Study 7: Firouzabadi et al.⁽¹⁸⁾
Randomized clinical trial	Non-severe	Non-severe	Non-severe	Non-severe	⨁⨁⨁⨁ High	Critical
Study 8: Abdoli et al.⁽¹⁹⁾
Randomized clinical trial	Non-severe	Non-severe	Non-severe	Non-severe	⨁⨁⨁⨁ High	Critical
Study 9: Brent et al.⁽²⁰⁾
Randomized clinical trial	Severe†	Severe†	Non-severe†	Severe†	⨁⨁〇〇 Low	Important

Jadad assessment	Study 1 - Nayeri et al. ⁽¹²⁾	Study 2 - Jackson et al. ⁽¹³⁾	Study 3 - Mariani Neto et al. ⁽¹⁴⁾	Study 4 - Coca et al. ⁽¹⁵⁾	Study 5 - Abou-Dakn et al. ⁽¹⁶⁾	Study 6 - Coca et al. ⁽¹⁷⁾	Study 7 - Firouzabadi et al. ⁽¹⁸⁾	Study 8 - Abdoli et al. ⁽¹⁹⁾	Study 9 - Brent et al. ⁽²⁰⁾
Was the study described as randomized?	1	1	1	1	0	1	1	1	1
Has randomization been described and is it adequate?	1	1	1	1	0	1	1	1	1
Was the study described as double blind?	1	0	0	0	0	1	0	1	1
Has blinding been described and is it appropriate?	1	1	0	0	1	1	0	1	1
Have the losses and exclusions been described?	1	1	1	1	1	1	1	1	1
Total	5	4	3	3	2	5	3	5	5

Control group	Intervention group	Follow-up	Results	Comments
Study 1: Nayeri et al.⁽¹²⁾
53 subjects used lanolin ointment (20g tubes) 1g, 3 times/day in areola and nipple + observation of breastfeeding and guidance on the correct latch on. The women evaluated were between 3 and 7 days postpartum	53 subjects used chamomile ointment 1.5%, 1g, 3 times/day in areola and nipple + observation of breastfeeding and guidance on correct latch on. The women assessed were between 3 and 7 days postpartum	3 and 7 days	Pain assessment by the Visual Analogue Scale showed significantly less pain in the intervention group on the 3rd (p<0.001) and 7th day (p<0.001). Symptom assessment by the Storr scale showed significantly less severity in the intervention group on the 3rd (p<0.001) and 7th day (p=0.041)	Chamomile was more effective in reducing pain and symptoms
Study 3: Mariani Neto et al.⁽¹⁴⁾
90 women used breast milk at the end of each feeding, applying a thin layer of breast milk to the site of pain and nipple trauma, waiting to dry naturally +guidelines on the positioning of the baby and proper latching on to the nipple-areola region + guidelines on washing the breasts and bra daily with water and neutral soap and not using additional care. Women were still included in the maternity ward, but the exact period of recruitment of participants after childbirth was not specified	90 women used highly purified lanolin (Lansinoh Laboratories, Inc) applying a thin layer to the painful and traumatized nipple area, waiting to dry naturally + guidelines on positioning the baby and proper latching on to the nipple-areola region during breastfeeding + guidelines on washing the breasts and bra daily with water and neutral soap and not using additional care. Women were still included in the maternity ward, but the exact period of recruitment of participants after childbirth was not specified	2 and 7 days	Pain assessment by the numeric and verbal pain assessment scale showed significantly less pain in the intervention group (p<0.001). Nipple trauma assessment by the Nipple Trauma Score showed significantly less severity in the intervention group on the 2nd day (p=0.667) and 7th day (p=0.025)	Lanolin was more effective in reducing pain and improving the score of nipple-areolar injuries
Study 4: Coca et al.⁽¹⁵⁾
26 women received guidance on positioning and correct latch on + guidance on the use of breast milk before and after breastfeeding at the site of injury. Women were recruited while still in the maternity ward, but the exact postpartum period was not specified.	24 women made topical use of anhydrous lanolin ointment by applying a thin layer on the nipple region and the injury, awaiting natural drying + guidance on positioning and correct latch on. Women were recruited still in the maternity ward, but the exact postpartum period was not specified	24 hours	Nipple-areolar injury assessment was performed by measuring the injury size, which showed a significantly greater decrease in the injury in the intervention group (p<0.001)	Lanolin was more effective in decreasing the size of nipple-areolar injuries
Study 5: Abou-Dakn et al.⁽¹⁶⁾
39 women used breast milk, expressing and massaging the breast, applying drops of milk after each feeding, letting it dry naturally + guidelines on hand hygiene with soap and water before breastfeeding, correct breastfeeding practices and not using additional care. The postpartum period was not specified	45 women covered the areola with approximately 0.25g of highly purified lanolin on the nipple and areola, allowing it to dry naturally + guidelines on hand hygiene before breastfeeding, correct breastfeeding practices and not using additional care. The postpartum period was not specified	3, 7 and 14 days	Pain assessment by the Visual Analogue Scale showed significantly less pain in the intervention group on the 3rd (p=0.00), 7th (p=0.03) and 14th days (p=0.04). Nipple-areolar injury assessment by photographs and classification by Nipple Trauma Score showed significantly less severity in the intervention group on the 3rd (p=0.00) and 7th days (p=0.00). On the 14th day, there was no difference (p=0.16)	Lanolin was more effective in reducing pain and accelerating tissue repair of nipple-areolar injuries after 3 and 7 days of intervention
Study 6: Coca et al.⁽¹⁷⁾
29 women received 3 sessions of laser light irradiation in the powerless red spectrum (placebo) + guidance on proper position, correct latch on and breast care. Women were assessed during the first hours postpartum until hospital discharge	30 women received 3 sessions of low power laser therapy emitting continuous visible red light (660 nanometers) with an InGaAIP semiconductor and 40 milliwatts of power (action site size 4mm²), adjusted to an energy density of 5 Joules per cm² in 5 seconds (0.2 Joules per site). There was emission in 3 points (0.6 Joules in total), in the center of the injury, the right and left extremities + guidance on proper position, correct latch on and breast care. Women were assessed during the first hours postpartum until hospital discharge	0, 24 and 48 hours	Pain assessment by the Visual Analogue Scale showed pain reduction in the intervention group, with statistical significance after the second intervention (p = 0.016). After the first (p = 0.050) and the third intervention (p = 0.392), the results were not statistically significant. There was no statistical difference between groups after the third intervention	Photobiomodulation with low-power laser was more effective in the intragroup in reducing pain after 24 hours of intervention
Study 7: Firouzabadi et al.⁽¹⁸⁾
50 women used drops of breast milk 2 times/day after the end of breastfeeding 50 women coated the nipple with mountain honey, twice a day, after the end of breastfeeding 50 women washed their breasts with boiled millefeuille (30g + 1L water for 10 minutes) 2 times a day, after the end of breastfeeding All of them received advice on the correct breastfeeding technique. The postpartum period was not specified		1, 3 and 7 days	Symptom assessment by the Storr scale showed significantly less severity in the 3 groups over time (1, 3 and 7 days), with p<0.001 in each group. In the assessment between groups, there was no difference at any time	There was no difference in efficacy between the 3 interventions for improvement of pain-related symptoms and cracked nipple⁽¹⁸⁾
Study 8: Abdoli et al.⁽¹⁹⁾
40 women used breast milk on the nipple and areola after breastfeeding at least 4 times a day and letting it dry naturally + teaching the correct method of breastfeeding and distributing educational pamphlets. The postpartum period was not specified	40 women made topical use of a sachet of Achillea millefolium (millefeuille) tea, previously soaked in hot water, applied to the nipple and areola for 15 minutes, letting it dry naturally, at least 4 times a day + teaching the correct method of breastfeeding and distribution of educational pamphlets. The postpartum period was not specified	4, 8 and 14 days	Cracked nipple assessment by the Storr scale showed significantly less severity in the intervention group on the 4th (p<0.01), 8th (p<0.001) and 14th days (p<0.001). Pain assessment by the Visual Pain Scale showed significantly less pain in the intervention group on the 4th (p<0.001), 8th (p<0.001) and 14th days (p<0.001)	Millefeuille was more effective in reducing pain and lessening injuries.

Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
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[1] Corresponding author: Rhayssa de Oliveira e Araújo E-mail: rhayssaa@ufrn.edu.br