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    <meta name="author" content="Denise Fisher" />
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      <h1 id="top">5.2 Factors causing nipple damage</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study E</h3>
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			Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
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		<dl><dt><a href="topic_5-1.html"><cite>Topic 5.1: Sore nipples</cite></a></dt><dd class="topic-paragraph">Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.</dd></dl>
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			What other conditions may contribute to nipple damage occurring in the first week postpartum?
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		<dl><dt><a href="topic_5-2.html"><cite>Topic 5.2: Factors causing nipple damage</cite></a></dt><dd class="topic-paragraph">Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.</dd></dl>
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			What other conditions may contribute to nipple damage occurring in the first week postpartum?
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		<div class="captionBox"><img width="400" height="257" src="images/nipple_damage.jpg" alt="Nipple damage" /><p>Nipple damage caused by poor latch. <br />&copy;  S.Cox IBCLC</p></div>
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      <div class="section" id="Engorgement"><h2>Engorgement</h2>
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			As the breasts become full with the onset of copious milk production (usually day three or four), they tend to loose their elasticity, the nipples become flatter and some infants have difficulty attaching properly to the breast. This is a common time for nipple damage to occur. Relieving breast fullness before commencing a feed by expressing a small amount of milk usually allows the infant to attach well and prevents or relieves further nipple trauma (see Case C).
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      <div class="section" id="Anatomical_variations_of_mother"><h2>Anatomical variations of mother</h2>
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			There are many variations in the size and shape of mothers' nipples and breasts, with most not interfering with breastfeeding. As long as the infant can draw sufficient breast into his/her mouth to form a teat so that the nipple area is near the junction of the hard and soft palate, breastfeeding can proceed normally. When the infant attaches but is unable to draw the nipple/breast far enough into his/her mouth, the nipple may become sore and cracked/traumatised.
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			Concern is often expressed regarding the ability to breastfeed, with flat or inverted nipples that were described in Case A. No specific treatment has been shown to "improve" nipple protractility antenatally (<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup>), although flat nipples often become more elastic and flexible during pregnancy.
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			Infants find it easiest to attach to breasts with flat or inverted nipples when their reflexes are at their peak and the breasts are soft, usually within the first hour of birth. Being very careful about correct positioning and attachment from the first feed is important. Firm nipple substitutes such as bottle teats and dummies are a different shape and texture to the breast, and their use before the infant has had an opportunity to attach and breastfeed independently often leads to ongoing attachment difficulties. Devices, including breast pumps, the Avent Niplette™<sup><a href="#note3">3</a></sup> and modified disposable syringes<sup><a href="#note4">4</a></sup>, can help draw out the nipple prior to a breastfeed. Some women also use these devices antenatally. Nipple shields may also provide protection to the nipple and a firm surface for the infant to attach to if he/she cannot attach unaided<sup><a href="#note5">5</a></sup>.
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		<div class="columns"><div class="column" style="width: 50%">
				<div class="captionBox"><img width="200" height="300" src="images/modified_syringe.jpg" alt="A Modified Syringe" /><p>A Modified Syringe. <br />&copy;  Health e-Learning</p></div>
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				<div class="captionBox"><img width="250" height="167" src="images/well_latched_bwc.gif" alt="Using a nipple shield" /><p>Using a nipple shield. <br />&copy;  Breastfeeding Atlas</p></div>
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      <div class="section" id="Anatomical_variations_of_the_infant"><h2>Anatomical variations of the infant</h2>
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			Tongue-tie (ankyloglossia) and a high arched palate (genetic) or other palatal abnormalities from intubation (particularly in premature infants) can cause sore and traumatised nipples.
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			<div class="captionBox"><img width="435" height="300" src="images/tongue_tie_BI.jpg" alt="Ankyloglossia" /><p>Ankyloglossia. <br />&copy;  B.Ingle, IBCLC</p></div>
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			Between 3.2 and 4.6 percent of infants are born with a tongue-tie (<sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup>). Tongue movement, such as the ability to protrude the tongue over the lower gum, cup a finger or the breast<sup><a href="#note8">8</a></sup> or to generate a normally shaped peristaltic wave may be limited when the sub-lingual frenulum extends further towards the tip of the tongue than normal. The degree to which breastfeeding is affected will depend on the movement restriction, the shape of the infant's mouth and the elasticity and shape of the mother's breast and nipple. In some situations (but not all), ankyloglossia results in ongoing severe nipple trauma that is not improved with corrections to positioning and attachment, and poor breast drainage<sup><a href="#note9">9</a></sup>. Frenotomy (division of the tongue-tie) provides almost instantaneous pain relief, no further nipple trauma and improved attachment of the infant (<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup>). The Hazelbaker Assessment Tool for Lingual Frenulum Function is an objective method of assessing the impact of a tongue tie on breastfeeding effectiveness and can be useful in deciding whether a frenotomy is necessary<sup><a href="#note10">10</a></sup>.
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      <div class="section" id="Neurological_issues_with_the_infant"><h2>Neurological issues with the infant</h2>
		<p>
			Neurological problems resulting in uncoordinated tongue movements, tonic bites or other abnormalities that preclude good attachment may present initially with sore/cracked nipples. Infants with these conditions require appropriate assessment and specialised assistance outside the scope of this resource<sup><a href="#note11">11</a></sup>.
		</p>
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      <div class="section" id="Inappropriate_use_of_lactation_aids"><h2>Inappropriate use of lactation aids</h2>
		<p>
			If the base of a nipple shield or the flange of a breast pump is too small for the nipple, pressure and friction can occur during use, exacerbating any nipple trauma already present. Different sized shields and pump flanges are available if needed. Pump pressure set too high can also prolong nipple pain.
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      <div class="section" id="High_intra-oral_pressure"><h2>High intra-oral pressure</h2>
		<p>
			Recent research indicates that the infants of some mothers who suffer from ongoing sore nipples without apparent cause generate much higher intraoral pressures than other infants<sup><a href="#note12">12</a></sup>. Other researchers have identified different sucking behaviours amongst infants that may have an effect on their mothers' nipples<sup><a href="#note13">13</a></sup>. Further research in this area will help elucidate further causes and treatments for nipple pain and trauma.
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            <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
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	{ c : '\n			<p>\n				<strong>Mary Jane is ready for hospital discharge on day three. She and the infant appear to be well, but she complains of painful nipples that are beginning to crack. What needs to be assessed to determine the cause of her sore nipples before she is discharged?</strong>\n			</p>\n		', r : '\n			<p>\n				Positioning and attachment of the baby at the breast must be assessed first as this would be the most likely cause of sore nipples. In addition, assessment should be made of Mary Jane\'s breasts and nipples (eg inverted or dimpled nipples) and the infant\'s oral anatomy (tongue-tie, high arched palate); sucking rhythm; and neurological competency.\n			</p>\n		' }
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<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('c');</script>
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        <h3>Notes</h3>
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          <li id="note1"><a href="references.html#alex92" title="See full details">#</a> Alexander JM et al. (1992) Randomised controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples.</li>
          <li id="note2"><a href="references.html#mcca95" title="See full details">#</a> McCandlish R et al. (1995) MAIN Trial Collaborative Group. Antenatal treatments for flat or inverted nipples: the MAIN Trial results</li>
          <li id="note3"><a href="references.html#mcge94" title="See full details">#</a> McGeorge DD (1994) The "Niplette": an instrument for the non-surgical correction of inverted nipples</li>
          <li id="note4"><a href="references.html#arse97" title="See full details">#</a> Arsenault G (1997) Using a disposable syringe to treat inverted nipples</li>
          <li id="note5"><a href="references.html#wils96" title="See full details">#</a> Wilson-Clay B (1996) Clinical use of silicone nipple shields</li>
          <li id="note6"><a href="references.html#mess00" title="See full details">#</a> Messner AH et al. (2000) Ankyloglossia: incidence and associated feeding difficulties</li>
          <li id="note7"><a href="references.html#ball02" title="See full details">#</a> Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad</li>
          <li id="note8"><a href="references.html#srin06" title="See full details">#</a> Srinivasan A et al. (2006) Ankyloglossia in breastfeeding infants: The effect of frenotomy on maternal nipple pain and latch</li>
          <li id="note9"><a href="references.html#lala03" title="See full details">#</a> Lalalea ML et al. (2003) Ankyloglossia: does it matter?</li>
          <li id="note10"><a href="references.html#amir06" title="See full details">#</a> Amir LH et al. (2006) Reliability of the hazelbaker assessment tool for lingual frenulum function</li>
          <li id="note11"><a href="references.html#lawr05a" title="See full details">#</a> Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession</li>
          <li id="note12"><a href="references.html#mccl08" title="See full details">#</a> McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums</li>
          <li id="note13"><a href="references.html#mizu04" title="See full details">#</a> Mizuno K et al. (2004) Sucking behavior at breast during the early newborn period affects later breast-feeding rate and duration of breast-feeding</li>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li>2.2 <a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li>2.3 <a href="topic_2-3.html">Management After Birth</a></li><li>2.4 <a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li>2.6 <a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li>3.1 <a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li>3.3 <a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li>4.3 <a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li class="current">5.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
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