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Nipple pain and insufficient milk supply are major causes of early weaning. We have found that persistent nipple pain was associated with strong infant sucking vacuums during breastfeeding. Several studies indicate that nipple pain and abnormal infant sucking have the potential to reduce milk transfer. We aimed to determine whether women with persistent nipple pain had low milk supply. The 24-hour milk production and feeding characteristics of mothers with persistent nipple pain (n=21) were compared with those mothers without nipple pain (n=21). Milk productions were measured by test-weighing the infant before and after every feed from each breast over a 24-26-hour period. Comparisons were made using Student's t tests and linear mixed models as appropriate. Lower milk productions were associated with longer meal durations for mothers with pain. There were no significant differences in the average 24-hour milk production or any feeding characteristics between the groups. However, four women with persistent nipple pain had milk production levels below 500 mL/day. The majority of breastfeeding women experiencing persistent nipple pain were able to achieve normal milk production levels. Feeding duration and frequency were similar to those of women not experiencing pain. However, longer meal durations in the pain group were associated with lower levels of milk production. Further investigation is necessary to identify mothers most affected by maternal nipple pain.
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Original Article
Breastfeeding Frequency, Milk Volume, and Duration
in Mother–Infant Dyads with Persistent Nipple Pain
Holly L. McClellan, Anna R. Hepworth, Jacqueline C. Kent, Catherine P. Garbin,
Tracey M. Williams, Peter Edwin Hartmann, and Donna Tracy Geddes
Background: Nipple pain and insufficient milk supply are major causes of early weaning. We have found that
persistent nipple pain was associated with strong infant sucking vacuums during breastfeeding. Several studies
indicate that nipple pain and abnormal infant sucking have the potential to reduce milk transfer. We aimed to
determine whether women with persistent nipple pain had low milk supply.
Subjects and Methods: The 24-hour milk production and feeding characteristics of mothers with persistent
nipple pain (n=21) were compared with those mothers without nipple pain (n=21). Milk productions were
measured by test-weighing the infant before and after every feed from each breast over a 24–26-hour period.
Comparisons were made using Student’s ttests and linear mixed models as appropriate.
Results: Lower milk productions were associated with longer meal durations for mothers with pain. There were
no significant differences in the average 24-hour milk production or any feeding characteristics between the
groups. However, four women with persistent nipple pain had milk production levels below 500 mL/day.
Conclusions: The majority of breastfeeding women experiencing persistent nipple pain were able to achieve
normal milk production levels. Feeding duration and frequency were similar to those of women not experi-
encing pain. However, longer meal durations in the pain group were associated with lower levels of milk
production. Further investigation is necessary to identify mothers most affected by maternal nipple pain.
Although many cases of nipple pain can be resolved
with early treatment, pain and insufficient milk supply
are still common causes of early weaning.
Beyond the
experience-based advice of different positioning and at-
tachment techniques, few interventions exist for the treat-
ment of persistent nipple pain. In a recent study where
positioning and attachment, their infants were found to
apply stronger vacuums and transfer less milk during a
breastfeed compared with infants of mothers with no pain.
Furthermore, the time taken for the infant to feed from
one breast was similar for women experiencing pain and
those who were not.
Breastfeeding is a complex physiological process, and full
milk production is reliant upon adequate milk synthesis, se-
cretion, ejection, and removal from the breast.
During es-
tablished breastfeeding, milk synthesis rates are largely under
autocrine control, in that synthesis slows as breast fullness
Thus, ineffective milk removal will result in in-
complete breast drainage and down-regulation of milk syn-
thesis, which if prolonged may result in inadequate milk
production. Newton and Newton
demonstrated the poten-
tial for pain to interfere with breastfeeding; they found that
breastfeed volumes were significantly reduced by painful
distractions. This reduction was attributed to inhibition of the
milk ejection reflex, as the injection of oxytocin during the
distractions increased milk transfer to normal volumes.
It is
possible that the inhibition of milk ejection and strong sucking
vacuums may have contributed to the lower feed volumes
previously observed.
Because milk transfer may be lower in mothers with pain, it
is important to determine whether or not milk production is
consequently compromised. There is a large variation in milk
transfer between breastfeeds both within and between
mother–infant pairs, and the average volume of milk trans-
ferred during one breastfeed is inversely related to the num-
ber of breastfeeds over a 24-hour period.
Therefore, to
accurately estimate milk production it is imperative to mea-
sure milk transfer over a 24-hour period to take into account
the variations in feed volume and frequency.
This study aimed to investigate whether or not mothers
with persistent nipple pain had reduced 24-hour milk
School of Biomedical, Biomolecular, and Chemical Sciences, The University of Western Australia, Crawley, Western Australia, Australia.
Volume 0, Number 0, 2012
ªMary Ann Liebert, Inc.
DOI: 10.1089/bfm.2011.0117
production levels or altered feeding characteristics compared
with mothers without pain.
Subjects and Methods
All mothers were recruited from an ongoing study inves-
tigating infant sucking dynamics during breastfeeding. Upon
recruitment, mothers were invited to measure their milk
production levels at home. Nine of the 30 mothers in the
control group and 12 of the 30 mothers with persistent pain
agreed to measure milk production.
An additional 12 control
and nine pain mothers were recruited for this study.
The pain group consisted of mothers of healthy term in-
fants who were experiencing persistent nipple pain during
breastfeeding that had not resolved after assessment and
counseling by a lactation consultant (n=21). Mothers were
excluded from the study if a known clinical diagnosis for the
cause of their pain had been made, including either bacterial
or fungal nipple infection, nipple vasospasm, dermatitis, an-
kyloglossia, or torticollis. Women prescribed and taking ei-
ther steroids and/or antibiotics were excluded from the
study. The control group consisted of mothers breastfeeding
healthy term infants, who were content with their breast-
feeding relationship and not experiencing any pain during
feeding (n=21).
Ethics approval for the study was granted by the Human
Research Ethics Committee of The University of Western
Australia, and all participants supplied written, informed
consent to participate in the study.
Participant characteristics
Participant demographic and pain characteristics were
collected via a questionnaire. Variables recorded included
infant birth weight and gestational age, maternal age, preg-
nancy and postpartum complications, nipple pain, nipple
shield use, and frequency of feeding expressed breastmilk and
artificial formula. Maternal pain intensity was assessed im-
mediately after the monitored breastfeed of the breast with
the worst pain using the Visual Analogue Scale.
The duration
of pain was calculated by subtracting the reported day that
pain was initially experienced from the infant’s age.
Measurement of milk production
Each mother measured the volume of each feed from each
breast over a 24–26-hour period using the infant-test weight
Mothers recorded the start and finish timesof the
feed and their infant’s weight before and after every breast-
feed for 24–26 hours on a Medela electronic BabyWeigh scale
(Medela AG, Baar, Switzerland). Feed volumes were calcu-
lated by subtracting the prefeed weight from the postfeed
weight. Expression volumes were calculated by weighing the
collection bottle before and after expressing.
Feeds were defined as a breastfeed from one breast. Feed
durations were calculated by subtracting the reported start
time from the reported end time. If a second feed started
within 30 minutes of the previous feed ending, then the two
feeds were classed as paired. If a third feed started within 30
minutes of the second feed ending, the three feeds were
paired breastfeed, two paired breastfeeds, or three clustered
Meal durations were calculated by summing the
duration of all contributing feeds, excluding between-feed
Measurement of sucking vacuum
Intra-oral vacuum was measured for an entire breastfeed
via a small Silastic(Dow Corning) tube attached to a pres-
sure transducer (Cobe Laboratories, Frenchs Forest, Aus-
tralia) taped alongside the nipple as previously described.
The pressure transducer was then connected via an inter-
connect cable (Cobe Laboratories) to the bridge amp (ADIn-
struments, Castle Hill, Australia) that was connected to a
Power Lab (ADInstruments), and data were analyzed using
the software package Chart version 5.0.2 (ADInstruments).
Average baseline and peak vacuums for the entire feed were
calculated for each infant.
Statistical analysis
Based on milk production data from Kent et al.,
it was
determined that this study had a power of 0.8 to detect a true
difference in milk productions of 130 g.
All analyses were performed using R version 2.9.0 for Mac
The additional packages nlme
and lattice
used for linear mixed modeling and lattice plots, respectively.
Data are presented as mean SD values except where the data
were not normally distributed, in which case the median (first
quartile, third quartile) is presented. Values of p<0.05 were
considered significant.
Total milk production was defined as the sum of the
amount of milk removed from both breasts, through breast-
feeding and breast expression, over the entire period, nor-
malized to 24 hours.
Breastfeeding variables defined for each
breast and normalized to a 24-hour period included milk
production, total feed duration, number of feeds, mean feed
duration, and mean feed volume.
Groups were compared on continuous variables using
Student’s ttest, with the Welch modification for unequal
variances used when Bartlett’s test of equality of variance
indicated heteroscedasticity. Distributions of milk production
levels in the two groups were compared with the two-sample
Kolmogorov–Smirnov test. Categorical variables were as-
sessed for group differences using Fisher’s exact test. Uni-
variate associations between measured variables and 24-hour
milk production have been assessed using either ttests or
linear regression as appropriate.
Relationships among 24-hour milk production, group, and
feeding characteristics were tested using regression models
with milk production as the response and measured variables
and group as predictors. All variables with a significant or
near significant ( p<0.1) univariate relationship to milk pro-
duction were included as predictors in the full regression
model, with the exception of confounding variables. Stepwise
selection was used, removing the least significant variable
until all included variables had a pvalue of <0.1.
No systematic differences were detected between the
two groups for any of the participant characteristics tested
(Table 1).
Pain characteristics
Women with persistent pain reported experiencing bilat-
eral pain for a median length of 66 (43, 89) days. The pain
intensities were lower for women who measured their 24-
hour milk production compared with those who did not:
measured, 22/100 (14, 44); not measured, 50/100 (36.5, 62.5)
Breastfeeding alternatives
Women in the pain group were significantly more likely to
feed expressed breastmilk ( p=0.043) (Table 1), although re-
ported daily pumping frequencies were not significantly dif-
ferent ( p=0.296). A low number of women expressed during
the monitored period (control, n=2; pain, n=4), and thus the
effect of expressing on milk production was not assessed.
Nipple shields
Nipple shield use was only reported in the pain group, with
five women regularly using a nipple shield ( p=0.048). When
low supply was defined as <500 g, there was a higher rate of
low supply in those using nipple shields ( p=0.028) within the
pain group.
Feeding characteristics
Feeding volume, frequency, and duration were similar for
the persistent pain and control groups, when either feeds or
meals were considered (Table 2) ( p>0.4 for all). In a 24-hour
period, the infants had an average of six meals of approxi-
mately 110 g, and feeding patterns for both groups are shown
in Figure 1.
Sucking vacuum
There was a trend for mothers in the control group to
measure milk production if their infant transferred less milk
during intra-oral vacuum measurement (measured,
55.1 25.6 g, n=9; not measured, 78 30.7 g, n=21 [p=0.085]).
Conversely, mothers in the pain group with higher milk
transfer during intra-oral vacuum measurement were more
likely to measure milk production (measured, 52.8 37.5 g,
n=12; not measured, 34.0 24.6 g, n=18 [p=0.021]). Infants in
the pain subgroup (n=21) of this study applied higher base-
line (pain, –91.5 57.2 mm Hg; control, –38.4 25.4 mm
Hg [p=0.003]) and peak (pain, –204.9 61.8 mm Hg; control,
–151.7 45.7 mm Hg [p=0.004]) vacuums during the moni-
tored feed compared with the control group (n=21). In the
women who measured 24-hour milk production, no
Table 1. Infant and Maternal Characteristics
pain Control
Age (days) 75 (43, 96) 62 (43, 90) 0.547
age (weeks)
39.0 (38, 39.4) 38.7 (38, 40.1) 0.466
Birth weight (kg) 3.25 (2.99, 3.85) 3.59 (3.1, 3.9) 0.375
Birth length (cm) 51.0 (48.5, 52) 51 (49, 53) 0.895
Apgar score 9 (9, 9) 9 (9, 9) 0.808
Time to first
1 (0.25, 1.5) 0.6 (0.5, 2) 0.971
Sex female 10/21 11/21 1
Birth mode
10/18 10/18 1
Expressed breastmilk
Daily 5/18 3/18 0.043
Weekly 2/18 3/18
Occasionally 6/18 0/18
Never 5/18 12/18
Daily 4/18 1/18 0.113
Weekly 0/18 3/18
Occasionally 0/18 0/18
Never 14/18 14/18
Mostly 2/18 4/18 0.443
Sometimes 10/18 10/18
Never 6/18 3/18
Age (years) 32 (28.5, 34) 33 (29.5, 38) 0.143
Marital status
married/de facto
19/21 18/19 0.490
Parity primiparous 13/18 12/18 0.822
High school 2/19 0/18 0.250
Trade certificate/
1/19 0/18
College diploma 4/19 2/18
University degree 12/19 16/18
nipples yes
13/19 5/19 0.063
Low supply yes 7/19 2/19 0.128
Engorgement yes 13/19 7/19 0.179
Mastitis yes 6/19 15/19 0.228
Data are presented as median (lower quartile, upper quartile) or
Significantly different, p<0.05.
Table 2. Daily Feed Volume and Characteristics
for the Persistent Pain and Control Groups
pain Control
Number 12 (10, 12) 10 (10, 12) 0.694
Mean duration
18.7 (12.0, 24.7) 16 (13.0, 23.6) 0.441
Mean volume (g) 61 (48, 75) 61 (52, 77) 0.568
% feeds paired 100 (57.1, 100) 93.3 (54.5, 100) 0.874
Number 6 (6, 7) 6 (6, 7) 0.641
Mean duration
32.2 (22.9, 39.0) 31.3 (23.6, 40) 0.760
Mean amount (g) 108 (81, 138) 117 (94, 135) 0.654
Feed duration
214 (143, 262) 188 (151, 249) 0.935
Total milk
production (g)
738 (612, 905) 704 (615, 826) 0.957
Left breast (g) 363 (228, 413) 372 (281, 433) 0.518
Right breast (g) 350 (312, 518) 355 (269, 472) 0.614
Data are presented as median (lower quartile, upper quartile).
difference in milk intake was seen for the monitored feed:
pain, 70 (38, 88) g; control, 68 (38, 80) g ( p=0.916).
Milk production
Although the range of 24-hour milk production measured
in the pain group (276–1,136 mL) was lower than that ob-
served for the control group (510–1,324 mL), there were no
significant differences in either the distribution ( p=0.603) or
the mean milk production ( p=0.957) between the pain and
control groups. Characteristics for the four women in the
pain group with 24-hour milk production levels below the
range seen in the control group ( <500 mL) are shown in
Table 3.
FIG. 1. The 24-hour milk intake patterns by breast for two control group (A and B) and two pain group (C and D) infants.
Feed volume transferred from the left (LB) and right breasts (RB) over a 24-hour period was measured using the infant test-
weigh method and plotted against the feed time and duration (rectangles). (A) and (C) demonstrate both paired and unpaired
feedings, whereas consistent paired feeds are shown for (B) and (D).
Table 3. Milk Production and Feeding Characteristics of Four Mothers with Persistent
Pain and Low Milk Production
Milk production (g) 275 434 437 486
Feeds/day 10 16 11 7
Mean feed amount (g) 16.4 27.2 59.4 69.5
Mean feed duration (minutes) 29.1 25.6 23.6 24.5
Meals/day 5 8 7 5
Mean meal amount (g) 36 59.4 59.7 99.7
Mean meal duration (minutes) 77.3 56.9 38.1 38
Vacuum (mm Hg)
Baseline -251.0 -57.3 -49.8 -93.4
Peak -318.1 -218.4 -161.0 -142.1
Expression frequency 5/breast/day <1/day 3/breast/day <1/day
Formula Yes No Yes Yes
Use of nipple shield Yes Yes Yes No
Significant univariate predictors of higher 24-hour milk
productions were higher average feed ( p<0.001) and meal
volumes ( p<0.001) and shorter average meal duration
(p=0.008). Trends to higher milk production were demon-
strated with increased infant age ( p=0.066), vaginal delivery
(p=0.078), and shorter average feed durations ( p=0.054).
There was no association between 24-hour milk production
and baseline ( p=0.589), peak vacuum ( p=0.443), or infant sex
(p=0.449). No significant univariate associations were de-
tected between any of the remaining variables and 24-hour
milk production.
There were different relationships seen between meal
duration and 24-hour milk production for the two groups
(Fig. 2). Although there was no relationship between meal
duration and milk production for the control group
(p=0.801), in the pain group an increase of 1 minute in meal
duration was associated with a decrease of around 9 mL in
milk production ( p=0.017). Thus, in the pain group, short
meal durations had higher milk productions than those with
similar meal durations in the control group, those with meal
durations of approximately 33 minutes had similar produc-
tions, and those with long meal durations had lower milk
productions than the control group.
When all measured variables were considered, the best
linear regression model took into account meal duration and
volume and mode of delivery, with shorter meal durations
(p=0.011), greater meal volumes ( p<0.001), and vaginal de-
livery ( p=0.048) being significant predictors of higher 24-
hour milk production.
This study has shown that despite experiencing pain dur-
ing breastfeeding, mothers with persistent nipple pain are
able to achieve a full milk production. Furthermore, these
women fed with similar duration and frequency as women
not experiencing pain. The feed characteristics and milk pro-
ductions of these mothers are similar to those of other cohorts
of breastfeeding women not experiencing pain.
The similar
feeding characteristics suggest that pain does not result in
lower 24-hour milk production as a consequence of fewer or
shorter feeds and does not require more frequent or longer
feeds. It is possible that the professional assistance received by
mothers with pain may have contributed to this outcome.
Also, the mothers recruited for this study had a high socio-
demographic status, which is associated with longer length of
Thus, these women were likely to be
highly motivated to breastfeed despite experiencing pain.
As the volume of milk transferred during a 24-hour period
was similar for both groups, it is unlikely that the milk ejection
reflex was adversely affected by the pain experienced during
breastfeeding. Presumably, if the milk ejection reflex were
impaired, milk transfer rates during feeding would have been
lower for these women. In the study of Newton and Newton,
painful distractions resulted in decreased milk transfer for one
feed, and the volume of milk received by the infant could be
increased by the injection of oxytocin, the hormone that
stimulates milk ejection. It is interesting that distractions that
reduce milk transfer have been found to have less impact over
time, as the mother becomes conditioned to the stimuli.
Therefore, it is conceivable that the women in this study may
have become conditioned to experiencing pain over time.
Previously, we found that feed volumes were reduced in
infants with strong sucking and mothers with persistent
In this study, neither the mean baseline nor peak vac-
uum levels were related to milk production. Similarly, no
relationships were detected between feed/meal durations
and baseline/peak vacuums. This suggests that although
strong sucking vacuums are applied neither milk synthesis
nor removal rates are affected.
FIG. 2. Relationship between 24-hour milk
production and average meal duration for the
pain and control groups. Regression lines for
the relationship between meal duration and 24-
hour milk production are shown for each group
(pain =triangles, control =circles). The trend for
infants in the pain group represents higher
volumes at low meal durations and lower vol-
umes at higher meal durations. The regression
lines of the two groups intersect at approxima-
tely 33 minutes, indicating average meal dura-
tions longer than 33 minutes were associated
with lower 24-hour milk production levels in
the pain group.
In the final regression model to predict 24-hour milk pro-
duction volume, higher mean meal volume, shorter mean
meal duration, and vaginal delivery were significantly asso-
ciated with higher milk production. Thus it may be worthy to
investigate the affect of mode of birth on established milk
production levels in a larger cohort. Mode of birth has been
recently shown to be associated with delayed onset of lacta-
and reduced breastmilk transfer from Days 2 to 5
compared with vaginal deliveries. Thus ce-
sarean section may be a barrier to breastfeeding success and
worthy of further consideration.
Clinically, the only predictor of lower milk production was
meal durations lasting longer than 33 minutes in the women
with persistent nipple pain, and longer meal durations were
not associated with lower milk productions in the control
group. Reasons for long meal durations could be due to either
maternal opinion of minimum feeding durations or that the
infant may not appear to be settled and satiated at the end of
the feed. Thus, it may be useful to monitor milk transfer in
women who report long meal durations. It is interesting that
in this study we did not find a relationship between infant
sex and milk production, which differs from the previous
findings of significantly higher milk productions ( p=0.036)
between mothers of boys (831 187 g) and those of girls
(755 151 g).
Caution is required when applying these results to all
mothers with persistent pain, as recruited mothers who
measured their milk production differed from those who did
not in two respects. First, those women who measured their
milk production reported lower pain intensities than those
who did not. The task may have been too onerous for those
experiencing higher-intensity pain. Breastfeeding character-
istics, such as feeding duration or expression frequency, may
be different in women with high pain intensity as interference
levels are likely to be higher. Also, it is unknown whether
higher pain intensities affect oxytocin release, and subse-
quently milk transfer volume. Second, unlike our previous
study of infant sucking vacuum,
milk transfers for the
monitored feed were not different between the two groups
(p=0.916). Women in the control group tended to measure
their milk production if milk transfer during the monitored
feed was lower, possibly for reassurance, whereas women in
the pain group with higher milk transfer during the moni-
tored feed were more likely to measure milk production.
These tendencies may explain the more homogeneous spread
of monitored milk intakes between groups in this study.
Therefore, further investigation of a larger cohort of women
with pain, especially those with high-intensity pain and low
feed transfer, is necessary to determine which breastfeeding
dyads may experience low milk production.
In this study, breastfeeding mothers with pain were more
likely to use nipple shields and feed expressed breastmilk
than breastfeeding mothers without pain as a means of re-
ducing the level of their pain. Three of the five women expe-
riencing pain and using nipple shields had low milk
production ( <500 mL). Nipple shields are not generally re-
commended as an intervention for nipple pain unless moni-
tored by a knowledgeable health professional. Studies of the
effect of nipple shields on milk transfer are conflicting. Early
studies have associated nipple shields with reduced milk
whereas more recent research in preterm and
term infants suggests that ultrathin nipple shields do not af-
fect milk transfer.
Because it is not known whether the
low milk production measured in mothers who were using
nipple shields in this study was due to the shield itself or other
factors that might potentially influence supply such as pain or
low prolactin levels, monitoring of mothers using shields is
strongly supported. Because of the small numbers of mothers
using shields in this study, further research is required into the
effect of nipple shields on milk transfer in term infants whose
mothers experience pain.
It is possible that with professional support, breastfeeding
women experiencing low-intensity persistent nipple pain can
achieve a full milk production despite their infants applying
strong vacuums. Those women who had difficulty reaching
full milk production were not breastfeeding less frequently and
were more likely to have long breastfeeding meal durations.
Further research is required to determine if mothers with high-
intensity nipple pain have compromised milk production.
Financial support in the form of a Ph.D. scholarship and
unrestricted research grant was received from Medela AG,
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Donna T. Geddes, D.M.U., PostGrad Dip. (Sci.), Ph.D.
School of Biomedical, Biomolecular, and Chemical Sciences
The University of Western Australia
M310, 35 Stirling Highway
Crawley, WA 6009, Australia
... Sample size determination was based on the primary endpoint of the primary study, that is, the total milk volume transferred during breastfeeds with and without a nipple shield in groups of participants with and without nipple pain, using the data source of McClellan, Hepworth, Kent, et al. (2012) that included 24-hour milk production and milk transfer volumes as well as the estimated volumes of milk available in the breast for groups of participants with nipple pain (n ¼ 21) and without nipple pain (n ¼ 21). Our biostatistician used a bootstrap approach that considered two feeds and added the effect of a shield in one of the feeds, assuming that nipple shield use reduces milk transfer. ...
... McClellan, Hepworth, Kent, et al. (2012) reported similar proportions in women with persistent nipple pain, where 80% (n ¼ 17) of women had full milk production, and 19% (n ¼ 4) had 24-hour production of less than 500 ml. Evidence from older studies of term breastfeeding dyads indicated that frequent milk removal in the early postpartum period drives subsequent adequate milk production (de Carvalho et al., 1982;Yamauchi & Yamanouchi, 1990). ...
... Therefore, our results must be interpreted with caution. Our finding of adequate milk production in most participants with persistent nipple pain concurs with that of McClellan, Hepworth, Kent, et al. (2012) and suggests that further research is needed to investigate the etiologies and support needs of women with coexisting persistent nipple pain and low milk supply. ...
Objective To examine relationships between nipple pain scores and 24 h milk production volumes, breastfeeding and pumping frequencies, and breastfeeding duration in women using nipple shields for persistent nipple pain. Design Secondary outcome analysis of a prospective cohort study. Setting Research laboratory (monitored feeds) and participants’ homes (milk production). Participants Twenty-five breastfeeding women (6±4 weeks postpartum) using nipple shields for persistent nipple pain. Methods A randomized trial was conducted to investigate the primary outcome of milk transfer with and without nipple shield use in participants with and without nipple pain. Here we report secondary outcomes of associations between 24 h milk production, breastfeeding and pumping frequencies, breastfeeding durations and intake in participants using a nipple shield for nipple pain. Participants completed demographic, health and breastfeeding questionnaires, and at two monitored breastfeeding sessions completed the pain visual analogue scale (VAS), and Brief Pain Inventory – Short Form (BPI-SF total, and subcategory scores for pain interference with general activity, mood, sleep, and breastfeeding). Milk production (mL/24 h), feed volumes, and percentage of available milk removed (PAMR) were calculated from data and milk samples obtained by participants over one 24 h period and at study visits. Participants logged 24 h data on a customised research website. We used descriptive statistics, simple and multiple linear regression for analyses. Results Milk production and feeding duration were not associated with nipple pain scores (VAS p = .80; BPI-SF p = .44). An increase in BPI-SF breastfeeding subcategory score of one unit, indicating pain interference with breastfeeding, was associated with a 0.28 decrease in breastfeeding frequency (p = .02), and an 18.8 mL decrease in 24 h breastfeeding intake (p = .04). Conclusion We found no association between nipple pain intensity and milk production or feed duration. Persistent nipple pain was associated with reduced breastfeeding frequency, therefore continuing professional support is required to ensure adequate milk removal and pain management.
... El dolor persistente en el pezón es una de las etiologías más comunes entre las madres lactantes. Afecta a la calidad y al volumen de la lactancia materna, pudiendo originar el abandono de la misma [7,8]. Un artículo demuestra que el 41% de las grietas se producen en el centro hospitalario (entre las primeras 48 y 120 horas) [9]. ...
... No se aprecian diferencias estadísticamente significativas entre la media de la integridad tisular del pezón izquierdo al inicio ni al final del estudio. Sin embargo, se observa que la media del tiempo de cicatrización vuelve a ser inferior en el grupo intervención (4,9) frente al grupo control (5,8), con una probabilidad de 0,099. ...
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Introducción. Las grietas en los pezones y el dolor constituyen uno de los principales motivos para el abandono de la lactancia materna. Por ello es necesario encontrar productos que ayuden a mejorar esta situación tanto para los sanitarios como para las pacientes. Objetivo. El objetivo de este estudio es comparar la eficacia de este apósito frente a la lanolina, en el control del dolor y la cicatrización de las heridas en los pezones a los siete días postparto. Metodología. Se realizó un ensayo clínico aleatorizado ciego simple con mujeres gestantes del Hospital Viamed Montecanal de Zaragoza. El grupo de intervención fue tratado con el apósito Nursicare® y el grupo control con lanolina, para el tratamiento de las grietas en los pezones. Se obtuvo la aprobación del Comité de Ética de la Investigación de la Comunidad de Aragón. Participaron 106 mujeres, 53 en el grupo intervención y 53 en el de control. Resultados. Se observaron diferencias estadísticamente significativas en el tamaño de la lesión tras aplicar el tratamiento y el tiempo de cicatrización, siendo menor en el grupo de intervención. El nivel de dolor se redujo de una forma mayor en el grupo de intervención que en el control, con una diferencia estadísticamente significativa. Conclusión. El apósito Nursicare® ha demostrado efectos positivos estadísticamente significativos en el tratamiento de grietas en los pezones, siendo más eficaz que la lanolina en el tratamiento de las heridas en los pezones, acelerando el proceso de curación y disminuyendo el dolor.
... It is well known that early cessation of breastfeeding impacts both long and short-term health outcomes for the infant and mother [1,2]. Nipple pain is one of the most common causes of mothers stopping breastfeeding earlier than planned [3][4][5]. The causes of nipple pain are varied and may be multifactorial, including suboptimal positioning and attachment, bacterial infection and vasospasm [6][7][8]. ...
... The primary endpoint of this study is total milk volume removed during pumping with and without a nipple shield. Sample size determination for this project was completed using the data source of McClellan et al. [5] where raw data was sourced from 21 women reporting nipple pain and compared with 21 mothers without nipple pain with regard to 24 h milk production, milk transfer volumes, and estimated milk available in the breast (mL). The sample size was calculated using a bootstrap approach where it considered two feeds and then added a nipple shield effect in one of the feeds. ...
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Abstract Background Concerns about reduced milk transfer with nipple shield (NS) use are based on evidence from studies with methodological flaws. Milk removal during breastfeeding can be impacted by infant and maternal factors other than NS use. The aim of this study was to control electric breast pump vacuum strength, pattern and duration across multiple study sessions to determine if NS use reduces milk removal from the breast. Methods A within-subject study with two groups of breastfeeding mothers (infants
... Oxytocin is a neurohypophysis hormone that links the causes and effects of positive social interactions. Oxytocin will induce the release of milk by myoepithelial contraction through the G protein receptors, activate phosphophilase and induce milk ejection so that the lactation inhibitor feedback decreases so that prolactin can be formed and milk production will increase for the next breastfeeding process (Anuhgera et al., 2019;Dewi et al., 2017;McClellan et al., 2012;Nugraheni & Heryati, 2017;Sari et al., 2017;Syukur et al., 2020;Wulandari & Mayangsari, 2019). ...
Background: Low milk production in the first few days after delivery becomes constraints in early breastfeeding. The purpose of this research is to find out effect of endorphin massage on milk production in postpartum mothers. Methods: Systematic review using the database: Google Scholar. The search results that meet the article criteria between 2017-2021, having minimum 20 sample, using keywords “massage, endorphin, ASI” are then analyzed for articles. Results: From 17 article extracted, it showed that milk production can be improved by massage techniques such as endorphin massage. Conclusion: To increased breast milk, it is advisable for postpartum mothers using massage therapy such as endorphin massage.
... Major advances have been made in the understanding breastfeeding and lactation, sucking dynamics and milk transfer however women experiencing nipple pain remain understudied despite it being a major cause of early cessation of breastfeeding [148]. Various causes of nipple pain have been identified yet treatment options are limited. ...
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Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.
... Other women, continue breastfeeding despite an excessive level of pain, being at higher risk of suffering from mastitis, sleep disorder, or even postpartum depression. [19][20][21] As health professionals, the first step in helping mothers manage pain is to recognize and anticipate the problem. 22 The active management of nipple soreness, including early detection and treatment, would help mothers recover in a 2-week period. ...
Background: Although most women start breastfeeding after delivery, difficulties often arise. One of the main reasons is nipple soreness, which contributes greatly to early cessation of breastfeeding. A soreness evaluation through validated scales, performed by health care professionals during the first few days, can contribute to improve breastfeeding and support for the mothers. Research Aim: Knowing the prevalence of nipple soreness during breastfeeding at 48 hours postpartum at the Infanta Cristina University Hospital (Madrid, Spain) through a cross-sectional descriptive study. Materials and Methods: The study took place between February and March 2019. A survey of 58 postpartum second day mothers was conducted including the Visual Analogue Scale (VAS) and Lactation Assessment Scale (LATCH) score for breastfeeding assessment. A descriptive analysis of secondary variables and subsequent bivariate inferential was performed for 95% confidence interval (CI). Results: The prevalence of nipple soreness observed is 97% (95% CI = 92–100%). It was found, significantly (p = 0.001), that the higher the score on LATCH, the lower the score on VAS and therefore the less pain. We found a relationship between women who were in skin-to-skin contact with their babies for 2 hours without interruption after birth and a higher pain score (p = 0.046). No other associations were found between VAS and other variables such as parity, type of birth, artificial milk supplements for the newborn, or using a pacifier. Conclusions: The high percentage of nipple soreness detected highlights that breastfeeding can be unpleasant in the first days after delivery. It is important to include in clinical practice the assessment of nipple soreness and the effectiveness of breastfeeding using validated scales.
... Menurut asumsi peneliti untuk memperlancar produksi ASI ibu dapat mengkonsumsi makanan bergizi seperti tumisan sayuran, selain mengkonsumsi tumisan sayuran ibu menyusui juga harus sesering mungkin menyusukan bayinya agar produksi ASI lancar, semakin sering bayi menyusu pada payudara ibu, maka produksi dan pengeluaran ASI akan semakin banyak. Konsistensi dalam menyusui akan membuat volume total produksi ASI ekslusif secara normal (McClellan et al., 2012). Hasil penelitian linear dengan pembuktian bahwa bahan dasar daun pepaya dapat meningkatkan pengeluaran ASI ibu (Tabel 3). ...
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Pemberian ASI yang tidak optimal menyebabkan terhambatnya tumbuh kembang bayi dan salah satu faktor yang memicu terjadinya stres pada ibu menyusui. Salah satu solusi untuk menangani hal tersebut yaitu dengan mengonsumsi daun papaya yang mengandung laktagogum sehingga bermanfaat untuk membantu kelancaran pengeluaran ASI. Penelitian ini dilakukan untuk mengetahui pengaruh pemberian tumis daun pepaya terhadap produksi ASI pada ibu menyusui. Desain penelitian yang digunakan yaitu quasi-eksperiment dua kelompok (sebelum dan setelah perlakuan). Penelitian ini dilakukan di Klinik Permata Hati melibatkan tigapuluh ibu menyusui yang dibagi ke dalam dua kelompok intervensi dan kelompok kontrol. Pengujian yang dilakukan yaitu uji normalitas (Saphiro-wilk), analisis deskriptif nonparametric (Wilcoxon Signed-Rank Test) dan uji distribusi frekuensi terhadap data yang diperoleh. Terdapat perbedaan yang signifikan (p=0,000) terhadap perlakuan sebelum dan sesudah diberikan tumis daun papaya terhadap produksi ASI yang dihasilkan oleh ibu menyusui, sehingga dapat disimpulkan bahwa pemberian tumis daun pepaya dapat meningkatkan produksi ASI pada ibu menyusui. Penelitian ini diharapkan dapat menjadi dasar usulan agar para bidan dapat memberikan edukasi bagi ibu menyusui mengenai manfaat tumis daun pepaya dan cara pengolahannya untuk meningkatkan kelancaran produksi ASI. Catatan PenerbitPoltekkes Kemenkes Kendari menyatakan tetap netral sehubungan dengan klaim dari perspektif atau buah pikiran yang diterbitkan dan dari afiliasi institusional manapun. PendanaanPeneliti tidak menerima bantuan dana dari lembaga/institusi. Berbagi DataData hasil kajian ini disimpan pada repository Zenodo Kontribusi Penulis Para penulis tidak mendeklarasikan kontribusinya.
... Sample size determination was completed using the data source of McClellan et al. 20 where raw data were sourced from 21 mothers reporting nipple pain and compared with 21 mothers without nipple pain with regard to 24-hour milk production, milk transfer volumes, and estimated milk volume available in the breast. The sample size was calculated using a bootstrap approach where it considered two feeds and then added a shield effect in one of the feeds assuming that shield use decreases milk removal from the breast. ...
Background: Nipple pain is a common cause of early cessation of breastfeeding. A nipple shield (shield) is often used to improve breastfeeding comfort. There are concerns that shield use may limit milk transfer. The aims of this study were to determine whether shield use reduces milk transfer and maternal nipple pain. Methods: A within-subject study of two groups of breastfeeding dyads (infants <6 months) was conducted; Control Group (CG): no breastfeeding difficulties; Pain Group (PG) shield used for nipple pain. There were two monitored sessions where shield use was randomized. Test weights and pain questionnaires were completed, and percentage of available milk removed (PAMR) was calculated. Results: Twenty-five PG (6 ± 4 postnatal weeks) and 34 CG (9 ± 6 postnatal weeks) had similar 24-hour milk production (PG: 676 ± 239 mL, CG: 775 ± 162 mL, p = 0.083). PG mean milk transfer volume and PAMR did not differ with shield use (no shield: 46 mL, 59%; shield: 40 mL, 53%, volume p = 0.38, PAMR p = 0.64). CG mean volume and PAMR were reduced with shield use (no shield: 65 mL, 64%; shield: 31 mL, 33%, volume p < 0.001, PAMR p < 0.001). PG pain scores were similar with and without shield use (Visual Analog Scale p = 0.44, McGill p = 0.97). Conclusions: Shield use did not impact either milk production or milk transfer in breastfeeding women experiencing nipple pain.
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p>Objective: This project aimed to develop and update a dynamic three-dimensional (3D) graphic video learning object demonstrating a current knowledge of the anatomy and physiology of sucking and swallowing in newborns during breastfeeding. Method: To build and update the 3D computer graphics iconographies of the "Virtual Baby," we defined objectives for the learning object, created a literature review-based script, and organized a guide for structural (static) and functional (dynamic) graphical modeling for the designer. Results: Using 3D computer graphics, we produced a video with static images (anatomical structural) and dynamic sequences (most significant physiological and functional aspects and application of transparency to visualize the anatomical correlations between both). The video showed the anatomy and physiology of sucking and swallowing during breastfeeding. Its updates reflected additional scientific evidence as studies were published. Conclusion: Creation of the Virtual Baby provides a learning tool for visualizing the anatomy and physiology of sucking and swallowing in full-term newborns. The tool addresses the significant morphofunctional aspects of the breastfeeding process, supported by scientific literature, and can be used for student or professional training and in primary health care.<p
Objective Previous studies have assessed breastfeeding-support programmes. Among these, osteopathic manipulative treatment (OMT) is a frequently used approach, although without strong evidence of efficacy. Methods A double-blind randomised controlled trial was conducted between July 2013 and March 2016. Breastfed term infants were eligible if one of the following criteria was met: suboptimal breastfeeding behaviour, maternal cracked nipples or maternal pain. The infants were randomly assigned to the intervention or the control group. The intervention consisted of two sessions of early OMT, while in the control group, the manipulations were performed on a doll behind a screen. The primary outcome was the exclusive breastfeeding rate at 1 month, which was assessed in an intention-to-treat analysis. Randomisation was computer generated and only accessible to the osteopath practitioner. The parents, research assistants and paediatricians were masked to group assignment. Results One hundred twenty-eight mother–infant dyads were randomised, with 64 assigned to each group. In each group, five infants were lost to follow-up. In the intervention group, 31 of 59 (53%) of infants were still exclusively breast fed at 1 month vs 39 of 59 (66%) in the control group, (OR 0.55, 95% CI 0.26 to 1.17; p=0.12). After adjustment for suboptimal breastfeeding behaviour, caesarean section, use of supplements and breast shields, the adjusted OR was 0.44 (95% CI 0.17 to 1.11; p=0.08). No adverse effects were reported in either group. Conclusion OMT did not improve exclusive breast feeding at 1 month. Trial registration number NCT01890668 .
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The objective of this paper is to identify social and biomedical variables that influence the selection of methods of infant feeding in the United States and to provide guidelines for the choice of control variables in the design and interpretation of studies that examine the influence of breast-feeding on infant and child health. Data were drawn from a national household survey, the Child Health Supplement of the 1981 Health Interview Survey conducted by the National Center for Health Statistics. Relationships between demographic, socioeconomic, and health variables were studied for the total sample of children under age 5 y as well as for black and white women separately. The data provide evidence for the importance of both social and health variables as selection factors for breast-feeding in the United States.
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The effect of a traditional (Mexican Hat) and of a new (Thin Latex) nipple shield on the sucking patterns and milk intake of 5-8-day-old babies was examined. Milk intake was determined accurately by test weighing using a Sartorius electronic balance with animal weighing keyboard, and sucking patterns by filming the mouth of the baby. The Mexican Hat reduced milk transfer by 58% (P is less than 0.01), and increased sucking rate (P is less than 0.05) and time spent resting (P is less than 0.01). The Thin Latex nipple shield reduced milk intake by a smaller amount (22%), and had no significant effect on sucking patterns.
The primary objective of the multi-site, international study was to examine trends in weight gain for term infants breastfed with and without ultra-thin silicone nipple shields to determine the effect of nipple shield use on infant weight gain over two months. Additionally, the study examined maternal satisfaction with nipple shield use using a structured survey. The nipple shield may facilitate successful breastfeeding outcomes when indicated. There has been question regarding infant weight gain with nipple shield use. A published pilot study using within-subject design indicated no significant difference in infant test weights and maternal prolactin levels when breastfeeding with and without nipple shields. The current study builds and expands upon the pilot study. Prospective, multi-site, non-randomised, between-subject study. Maternal-infant dyads (n = 54) who used a nipple shield for breastfeeding were studied. Results demonstrate no statistically significant difference in infant weight gain at two weeks, one month and two months between infants who breastfed with and infants who breastfed without a nipple shield. A majority (89.8%) of the women reported a positive experience with nipple shield use and 67.3% of the women reported that the nipple shield helped prevent breastfeeding termination. Infant weight gain was similar in maternal-infant dyads using nipple shields for two months compared to those not using the shields. Maternal positive report of nipple shield use lends to the clinical importance of nipple shield use when appropriately indicated. Nipple shield use may facilitate breastfeeding when clinically indicated in maternal-infant dyads without risk of decreased infant weight gain.
Plasma prolactin and cortisol levels were measured in mothers breast feeding with or without the use of a thin latex nipple shield, and in mothers wearing a nipple shield but who were not nursing. Suckling duration and milk transfer were also recorded. Suckling duration ranged between 6 and 31 min, being significantly correlated with prolactin levels 40 to 120 min after the feed started. At the latter time, baseline prolactin level and time spent nursing accounted together for most of the variance in prolactin levels: R2 was 0.79 and 0.82 at 90 min and 120 min respectively. Prolactin was released as usual when the shield was in place: levels were not significantly different from levels without the shield. Suckling duration was also unaffected by the shield, but milk transfer was significantly reduced. Cortisol was not released by using the shield, and the shield alone (without suckling) did not release prolactin. The thin latex nipple shield has therefore no untoward effect on the release of these hormones during nursing.
Infant test weighing and maternal test weighing are two independent methods for determining milk intake by the breast-fed infant. The sources of error in both these test weighing methods were examined with particular emphasis on the importance of evaluating and correcting for evaporative water loss (EWL). EWL ranged from 3 to 94% of the mother's change in weight after a single breast feed and from 3 to 55% of the infant's change in weight after a single breast feed. Correcting for EWL during a breast feed involved determining the time between the pre- and postfed weighings and measuring the rate of EWL after breast feeding. Significant correlations (p less than 0.001) were found between milk volume intake measured by test weighing the mother and correcting for maternal EWL, and milk volume intake measured by test weighing the infant and correcting for infant EWL. An improved method for measuring 24-h milk intakes by maternal test weighing using a sensitive electronic balance and correcting for EWL is described. The milk intakes, corrected for EWL, ranged from 690-1,041 g/24 h. If no correction for EWL was made then the average overestimate of milk intake by maternal test weighing was 14 +/- 6%.
Of the various methods for measuring pain the visual analogue scale seems to be the most sensitive. For assessing response to treatment a pain-relief scale has advantages over a pain scale. Pain cannot be said to have been relieved unless pain or pain relief has been directly measured.
The authors examined the breastfeeding duration and management of two groups of mothers with different exposures to services of a Certified Lactation Consultant (CLC). One group of mothers, at hospital H1 (n = 46), had access to a CLC, while mothers at hospital H2 (n = 115) did not. Results showed that: (a) mothers at H1 had significantly (t = 2.33, p < .02) longer durations of breastfeeding (M = 3.1 months, SD = 1.2) than peers at H2 (M = 2.4 months, SD = 1.2); (b) a significantly greater proportion of mothers at H1 attained their intended duration of breastfeeding compared to mothers at H2 (Mann-Whitney U, one-tailed test, Z = 1.94, p < .05); and (c) in a stepwise multiple regression analysis, intended length of breastfeeding accounted for 18% of the variance in duration of breastfeeding, mothers' age 9%, and mothers' education 3%. The results support the theory of reasoned action and the theory of patient education.
Objective: To examine the sociodemographic factors associated with the initiation and duration of breastfeeding. Method: Cross-sectional analysis of data from 3,120 women subjects in the 1990 Ontario Health Survey who reported having had a child in the previous year. Main outcome measures were if the last child was breastfed and if so, whether breastfeeding continued for four months or more. Multiple logistic regression was used to identify factors associated with initiation and duration. Results: The overall rate of breastfeeding initiation was 69.1% and among these women, 54.9% breastfed for four or more months. Major factors associated with initiation were older age, being a non-smoker, being employed, being married and greater education. Major factors associated with longer duration were being older, having been previously employed, being a non-smoker and greater education. Conclusions: Although overall rates of breastfeeding and duration are good, they could be higher. The sociodemographic factors can be used in the planning and targeting of educational interventions.