The effectiveness on health education to prevent nipple trauma from breastfeeding: a systematic review

Oliveira, Flávia Silva; Vieira, Flaviana; Cecilio, Jessica Oliveira; Guimarães, Janaína Valadares; Campbell, Suzanne Hetzel

doi:10.1590/1806-93042020000200002

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REVIEW • Rev. Bras. Saude Mater. Infant. 20 (2) • Apr-Jun 2020 • https://doi.org/10.1590/1806-93042020000200002 copy

The effectiveness on health education to prevent nipple trauma from breastfeeding: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives:

to analyze the effectiveness on health education to prevent nipple trauma in breastfeeding compared to other interventions.

Methods:

systematic literature review was carried out in January 2019, according to PRISMA recommendations. The searches were conducted in Cinahl, PubMed, Web of Science, Scopus, and in the references cited in the selected articles. The studies were assessed for quality and level of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

Results:

twelve studies were selected, all conducted at the maternities. The interventions were classified in two categories: health education on breastfeeding and the use of nipple covers. Health education on breastfeeding presents a moderate level of evidence on the prevention of nipple trauma. There is a moderate to high level of evidence on the positive effects of guaiazulene, gel or peppermint water applied in the postpartum period to prevent nipple trauma.

Conclusion:

health education on breastfeeding with clinical demonstration is an important strategy to prevent nipple trauma and requires more than one educational approach. The use of nipple covers requires some consideration, since they must be removed prior to breastfeeding. All interventions were conducted in the postpartum period, which points out for the necessity of clinical research to prevent nipple trauma in prenatal care.

Key words:
Breastfeeding; Wounds and injuries; Health education; Systematic review

Author, Year, Country	Proposal	Method	Outcome	Level of evidence	Conclusion
S1. Duffy et al.¹⁴14 Duffy EP, 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 (4): 189-96. 1997, Australia	Investigate the effect of a group teaching session for nulliparous women in the third trimester of pregnancy	Randomized experimental study with 75 primiparous women intending to breastfeed, conducted during the prenatal follow-up. EG^* * EG = experimental group; (n=37): received prenatal education intervention. CG^† † CG = control group; (n=38): received regular prenatal education. Followed up to the 4th postnatal day for evaluation of breastfeeding and nipple pain and trauma (NTI^‡ ‡ NTI= nipple trauma index; ). In the 6th week, the maintenance of breastfeeding was verified.	The intervention group had higher overall NTI score (M^§ § M = mean; = 132.85, SD^\|\| \|\| SD = standard deviation. = 5.5), indicating less nipple trauma p<0.001;	Moderate	Practice training delivered to prenatal group effectively reduced nipple pain and trauma in nulliparous women and increased breastfeeding rates.
S2. Henderson et al.,²⁸28 Henderson A, Stamp G, Pincombe J. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth. 2001; 28 (4): 236-42. 2001, Australia	Evaluate the effectiveness of a standardized educational intervention in breastfeeding	Randomized clinical trial with 160 primiparous women intending to breastfeed. EG (n=80): received health education on standardized and individual breastfeeding with verbal, visual, and written approach within 24 hours postpartum. CG (n=80): received the regular care of the unit. The groups were evaluated after 6 weeks, 3 and 6 months.	There was no significant difference between the groups in the incidence of nipple trauma.	Moderate	Intervention cannot be recommended as regular practice.
S3. Oliveira et al.²⁹29 Oliveira LD, Giugliani ER, Espirito Santo LC, França MC, Weigert EM, 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, Brazil	Evaluate the impact of a breastfeeding technique intervention on the exclusive breastfeeding rate and on related breast problems in the first month postpartum.	Randomized clinical trial with 211 mother-child pairs. EG (n=74): guidelines with the use of educational material on the technique of breastfeeding. CG (n=137): conventional guidelines of the unit. The evaluation was performed at the maternity, at 7^th and 30t^h days postpartum.	There was no significant difference (p>0.05) between the groups regarding the frequency of nipple trauma in the maternity hospital (EG = 43.2% x CG=43.8%), on the 7th day (EG = 43.2% x CG=48.9%) and the 30th day (EG=8.5% x CG=9.1%).	High	One session in the maternity hospital to reinforce the proper breastfeeding technique was insufficient to improve the breastfeeding technique or reduce the occurrence of breast problems resulting from poor technique.
S4. Eksioglu et al.¹⁵15 Eksioglu A, Yesil Y, Gungor DD, Turfan EC. The effects of different breastfeeding training techniques for primiparous mothers before discharge on the incidence of cracked nipples. Breastfeed Med. 2017; 12 (5): 311-5. 2017, Turkey	Investigate the effects of different pre-discharge breastfeeding training techniques for primiparous mothers on the subsequent incidence of nipple trauma.	Controlled intervention study with 90 primiparous women. G1 (n=30): routine care. G2 (n=30): provision of package leaflet. G3 (n=30): demonstration-based training.	In the 2^nd week postpartum, the rate of nipple trauma was 63.3% in G1, 56.7% in G2, and 20.0% in G3 (p=0.001). In the 4^th week postpartum, the rate of nipple trauma was 30.0% in G1, 10.0% in G2, and 6.7% in G3 (p=0.026).	Moderate	Demonstration-based training was an effective method to prevent nipple trauma.

Author, Year, Country	Proposal	Method	Outcome	Level of evidence	Conclusion
S5. Hewat et al.³⁸38 Hewat RJ, Ellis DJ. A comparison of the effectiveness of two methods of nipple care. Birth. 1987; 14 (1): 41-5. 1987, Canada	Evaluate whether breast milk or colostrum, applied to the nipples after breastfeeding, is superior to hydrated lanolin in preventing nipple pain and trauma	Randomized clinical trial with 23 primiparous women evaluated until the 10^th day postpartum. G1 (n=10) applied expressed breast milk or colostrum on the right nipple and lanolin on the left after each feeding. G2 (n=13) reversed the procedure. Each participant was her own control.	All the women experienced nipple trauma. There was a positive and significant correlation between nipple trauma and engorgement (r=0.43; p<0.02).	Low	Breast milk was not superior to lanolin in the prevention or reduction of nipple trauma in the first 10 days postpartum.
S6. Centuori et al.³⁰30 Centuori S, Burmaz T, Ronfani L, Fragiacomo M, Quintero S, Pavan C, et al. Nipple care, sore nipples, and breast-feeding: a randomized trial. J Hum Lact. 1999;15(2):125-30. 1999, Italy	Determine whether the duration of breastfeeding and the incidence of nipple trauma and pain are affected by the use of ointments and creams.	Randomized clinical trial with 219 postpartum women followed-up in four moments until the third month postpartum. CG^* * EG = experimental group; (n=96): followed hospital routines. EG^† † CG = control group; (n=123): did not use physical, chemical, and mechanical methods in nipple care.	There was no difference between the two groups regarding breast and nipple problems. Bottle and pacifier use were associated with nipple trauma (p<0.05) after hospital discharge and two weeks postpartum.	Moderate	Special cleaning with distilled water and sterile gauze, and the use of creams and spray on the nipples proved to be unnecessary.
S7. Api et al.²⁵25 Api M, Sivri D, Api O, Görgen H, Çetin A, Yayla M. Prevention of Nipple Cracks With Guaiazulene Versus Breast Milk in Nursing Mother: A Randomized, Controlled, Double-Blind Trial. J Turkish German Gynecol Assoc. 2005; 6 (4): 279-84. 2005, Turkey	Evaluate the effectiveness of guaiazulene cream compared to breast milk in the prevention of nipple pain and trauma during breastfeeding.	Randomized, controlled, double-blind clinical trial with women of vaginal delivery in the puerperium. EG (n=76): used guaiazulene ointment 0.05% after each feeding. Breast cleaning was recommended before feeding CG (n=77): used breast milk after each feeding. The women were evaluated 15 and 30 days after delivery for nipple pain and trauma.	The total incidence of nipple trauma was 31.4% at 30 days postpartum, 18.4% in EG and 44.2% in CG (p= 0.001, RR^‡ ‡ RR = relative risk; EVOO = extra virgin olive oil. = 0.42, CI95%=0.24-0.71).	High	The application of guaiazulene was effective to reduce nipple trauma.
S8. Melli et al.²³23 Melli MS, Rashidi MR, Nokhoodchi A, Tagavi S, Farzadi L, Sadaghat K, Tahmasebi Z, Kazemi AM. A randomized trial of peppermint gel, lanolin ointment, and placebo gel to prevent nipple crack in primiparous breastfeeding women. Med Sci Monit. 2007; 13 (9). 2007, Iran	Investigate the preventive effect of peppermint gel on nipple trauma, compared to modified lanolin and placebo	Double-blind randomized clinical trial with 216 primiparous women evaluated on days 4, 7, 14, and 42 postpartum. G1 (n=72): purified lanolin G2 (n=72): peppermint gel. G3 (n=72): placebo gel. The intervention was applied to the areola and nipple after each feeding and cleaned before the next feeding. All the women received guidelines on breastfeeding prior to breastfeeding.	Nipple trauma was less common when using peppermint gel (3.8%) than when using lanolin ointment (6.9%) or placebo (22.6%) (p=0.01), on the 14th day postpartum. The relative risk of trauma in the lanolin group (RR= 2.41, CI95%=1.20-3.01) was higher than in the peppermint group (RR=1.85, CI95%=1.64-3.10).	High	Peppermint gel formulated as a natural remedy was effective in preventing nipple trauma. The application of the gel was suggested as prophylaxis for nipple trauma with proper instruction at the start of breastfeeding.
S9. Melli et al.²⁴24 Melli MS, Rashidi MR, Delazar A, Madarek E, Maher MHK, Ghasemzadeh A, Sadaghat K, Tahmasebi Z. Effect of peppermint water on prevention of nipple cracks in lactating primiparous women: a randomized controlled trial. Int Breastfeed J. 2007; 2 (7). 2007, Iran	Evaluate the effectiveness of a topical preparation of peppermint water in comparison with expressed breast milk for the prevention of nipple trauma in nursing primiparous women.	Randomized clinical trial with 196 women, followed-up in three visits or phone calls within 14 days and one phone call within the sixth week postpartum. EG (n=98): application of peppermint water after each feeding. CG (n=98): application of breast milk after each feeding. All mothers received standardized breastfeeding education with demonstrations before starting breastfeeding.	The occurrence of nipple trauma was lower in the group using peppermint water (p<0.01) EG=7%, CG=23%. In the EG, trauma occurred on the 7th day postpartum (6.2 ± 1.9) and in the CG, on the 4^th day postpartum (3.8 ± 0.9). Peppermint water reduced the risk of trauma compared to the other group (RR=3.6, CI95%=2.9, 4.3).	Moderate	Peppermint water was effective in preventing nipple pain and trauma compared with breast milk.
S10. Atan e Sirin.²⁷27 Atan SÜ, Sirin A. Prevention of nipple problems in primipara breastfeeding mothers: A pilot study. Healthmed. 2012; 6 (12): 4258-66. 2012, Turkey	Compare the effectiveness of breast milk, warm wet compress, and tea compress in the prevention of nipple problems in primiparous women.	Experimental study with 105 primiparous women. G1 (n=35): tea compress G2 (n=35): warm wet compress G3 (n=35): breast milk Health education on the benefits and success of breastfeeding was provided, together with a brochure to support this education. Visits on the 5^th and 14^th day postpartum.	The highest rate of nipple trauma (34.3%) occurred on the 3^rd day postpartum. On the 6^th and 7^th days postpartum, fewer nipple problems were identified in the warm wet compress group (p>0.023). On the 14^th day postpartum, there was no significant difference between the groups, p=609 (G1=54.3%, G2=42.9%, and G3=49.5%).	Low	Midwives and nurses can teach mothers in the hospital about warm wet compresses to prevent nipple pain and trauma and continue the practice after discharge.
S11. Thabet et al.²⁶26 Thabet HA, Mourad MA, Alahadal AM, Alsenany S, Alsaif A. Prevention of Nipple Cracks with Peppermint Water versus Breast Milk in Lactating Primiparous Women. Life Science J. 2013;10(4): 2010-7. Disponível em: http://www.lifesciencesite.com/lsj/life1004/266_21318life1004_2010_2017.pdf. http://www.lifesciencesite.com/lsj/life1... 2013, Saudi Arabia	Compare the effect of peppermint water compared to breast milk for the prevention of nipple injuries.	Experimental study with 150 primiparous women breastfeeding after vaginal delivery with 38 or more weeks of gestation, from the 1^st to the 14^th day postpartum. G1(n=50): peppermint water applied after each feeding with a gauze on the nipples and areolas after washing the nipples with water. G2 (n=50): expressed breast milk after each feeding. CG (n=50): nipples were kept clean and dry. All the women received comprehensive hospital education on breastfeeding before the start of breastfeeding.	Women in the peppermint water group were more prone to intact nipples and areolas at 15 and 30 days (88% and 92%) than women in the breast milk group (60% and 64%) and CG (44% and 40%) (p<0.001).	Low	Peppermint water was more effective in preventing nipple trauma and pain than breast milk. Proper instructions at the beginning of the breastfeeding program are required.
S12. Cordero et al.⁴⁰40 Cordero MJA, Villar NM, Barrilao RG, Cortés MEC, López AM. Application of Extra Virgin Olive Oil to Prevent Nipple Cracking in Lactating Women. Worldviews on Evid Based Nurs. 2015; 12 (6): 364-9. 2015, Cuba	Evaluate the effectiveness of extra virgin olive oil (EVOO) in the relief and prevention of sore nipples in nursing mothers compared to the use of breast milk.	Experimental, prospective, randomized trial with 300 nursing mothers. G1 (n=150): EVOO on the nipple after each feeding G2 (n=150): drops of milk after each feeding. Clinical evaluations were performed in the first two weeks of treatment and after the first month of breastfeeding.	The occurrence of nipple trauma in the EVOO group: 2.7%. In the group that used breast milk: 44.0%. Nipple trauma was related to poor posture during feeding (p<0.001)	Low	EVOO was important in the prevention of nipple trauma, with a positive result even with inadequate posture during feeding.

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[1] Authors' contribution

Oliveira FS and Vieira F participated in the study design, selection of articles, interpretation and discussion of data, as well as in the writing of the article. Cecilio JO selected the articles to be included in the study. Guimaraes JV and Campbell SH conducted a critical review of the manuscript. All authors approved the final version of the article.