Content uploaded by Sedigheh Amir Ali Akbari
Author content
All content in this area was uploaded by Sedigheh Amir Ali Akbari on Oct 03, 2014
Content may be subject to copyright.
Journal of Research in Medical Sciences | July 2014 |
629
Effects of menthol essence and breast milk
on the improvement of nipple fissures in
breastfeeding women
Sedigheh Amir Ali Akbari, Seideh Hanieh Alamolhoda, Alireza Akbarzadeh Baghban1, Parvaneh Mirabi2
Department of Reproductive Health and Midwifery, Faculty of Nursing and Midwifery, 1Department of Basic Sciences, School of Rehabilitation,
Shahid Beheshti University of Medical Sciences, Tehran, Iran, 2Department of Midwifery, Zanjan Branch, Islamic Azad University, Zanjan, Iran
Background: Nipple fi ssure is a common disorder during breastfeeding. With high prevalence of nipple fi ssures and its impacts on
breastfeeding, as well as the existence of evidence in favor of the application of peppermint as an antiinfl ammatory and antiinfection
herb, the purpose of this study is to determine the eff ect of Menthol essence on improving nipple fi ssures in the primiparous
breastfeeding women. Materials and Methods: is study was conducted using a clinical trial method. Samples were divided
randomly into two groups of 55 women. e women in the peppermint group applied four drops of Menthol essence on their nipple
and areola after each feeding. e control group applied four drops of their own milk on the nipple and areola after each feeding.
en, the two groups were studied on days 10 and 14 postpartum. For intensity of pain, the visual analog scale (0-10 cm) and to
measure the severity of damage, Amir scale (1-10cm) were applied and the existence or lack of nipple discharge was also recorded.
e data were analyzed using SPSS 17 software. Results: e mean intensity of pain and nipple fi ssure before treatment (8.55 ± 1.74)
and day 10 after delivery (4.26 ± 1.57) and before treatment and day 14 after delivery in the case group (1.32 ± 1.02) had a signifi cant
diff erence (P < 0.001). Nipple discharge between the two groups, before treatment (%75.2) and day 10 after delivery (%31.6) and
before treatment and day 14 after delivery (%15.7), the case group had a signifi cant diff erence (P < 0.001). Conclusion: Menthol
essence can improve nipple fi ssures in the primiparous breastfeeding women.
Key words: Amir scale, menthol, nipple fi ssures, peppermint essence, visual analog scale
Address for correspondence: Ms. Seideh Hanieh Alamolhoda, Department of Reproductive Health and Midwifery, Faculty of Nursing and Midwifery,
Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail: alamolhoda.h@gmail.com
Received: 04-12-2012; Revised: 28-08-2013; Accepted: 11-05-2014
infant, which results in stretching the newborn makes
to remove the nipple, especially in the 1st day after
birth when the mother lacks enough milk and repeated
sucking occurs. Untreated nipple fi ssure can cause such
problems as severe pain and bleeding.[1] Nipple fi ssures
can act as a portal for bacteria and can lead to mastitis.[3]
Creams, lotions, and ointments are used for prevention
and treatment of nipple fi ssures, none of which has any
scientifi c basis.[4] Due to having anti-infl ammatory and
anti-microbial substances, breast milk is also used in
preventing and improving nipple fi ssures.[1] Renfrew
et al. have stated that there is no topical medicine for
the prevention and treatment of nipple fi ssures.[5] Some
studies have suggested that application of ointments
may be unnecessary and costly.[6] In recent years, due to
the failure of existing therapies researchers have inclined
to use herbal medicines. Today, herbs like peppermint,
Aloe vera, meadowsweet and hypericum are used widely
throughout the world and sale of medicinal herbs has
increased exponentially.[7] One of the plants used in long
ago is peppermint with the scientifi c name of menthe
piperitha. Of its medicinal properties, antispasmodic
INTRODUCTION
Despite the fact that 98% of women are physiologically
capable of breastfeeding, nowadays many mothers avoid
breastfeeding after delivery. One of the most common
causes of this problem is nipple fi ssure experienced
by breastfeeding women in the 1st days after delivery
and is the second leading cause of early termination of
breastfeeding, the fi rst being the feeling of inadequacy
of milk by mothers, and the main reason to use bo le-
feeding.[1] A nipple fi ssure is an injury on the nipple of
breastfeeding women, which is accompanied by pain,
infl ammation and discharge. The highest incidence is
between days 3 and 7 after delivery. In some women, it
may take up to 6 weeks after delivery.[1] Since 1945, sore
nipple has been reported in papers and recorded as a
reason for ablactating of infants by mothers.[2] According
to the reports in the papers, 80% of breastfeeding mothers
experience nipple pain and injury which interfere
with breastfeeding.[2] Of the causes of nipple pain
and damage, reference can be made to inappropriate
breastfeeding techniques and bad positioning of the
ORIGINAL ARTICLE
How to cite this article: Amir Ali Akbari S, Alamolhoda SH, Bghban AA, Mirabi P. Effects of menthol essence and breast milk on the improvement of
nipple fi ssures in breastfeeding women. J Res Med Sci 2014;19:629-33.
Amir Ali Akbari, et al.: Effect menthol essence and breast milk on nipple fi ssures
Journal of Research in Medical Sciences
| July 2014 | 630
Figure 1: Flow of participants through the clinical trial study
properties, including antivomiting and cooling can be
mentioned.[8] Peppermint is one of the world’s most
consumed medicinal plants with annual consumption of
about 7000 tons. Menthol essence has an ingredient called
Menthol whose antimicrobial activity on microorganisms
has been identifi ed.[9] Menthol essence (Menthol) aff ects the
cell membrane. These compounds a ack the cytoplasmic
membrane of microorganisms and infl ammatory factors and
degrade their membrane, leading to release of intracellular
components (ribose, sodium glutamate, etc.). In addition,
it plays a role in degradation of electron transfer activity,
absorption of nutrients, nucleic acid synthesis and Atpase
enzyme activity, which in turn leads to protection of cells
and loss of microorganisms and thus prevention of damage
to the tissue cells.[10] In studies conducted using the essence
of this herb no complications, adverse eff ects or allergies
has been reported. It is considered safe even in pregnancy
and lactation. It is classifi ed in group (A) in Australia and
permi ed by the American Food and Drug Administration
to be added to foods category.[11,12] Accordingly, this
study was designed to evaluate the effect of Menthol
essence in treatment of nipple fi ssure in the primiparous
breastfeeding women visiting healthcare centers of Tehran
during 2011-2012.
MATERIALS AND METHODS
In this clinical trial study, eff ects of menthol essence and breast
milk on the improvement of nipple fi ssures in breastfeeding
women were investigated. The study was held during
September 2010 until November 2011. Participants of the study
were all lactating women with nipple fi ssures who visited the
selected healthcare centers of Shahid Beheshti University of
Medical Sciences on their 3rd day after delivery. All parturient
women should have visit in health care centers for their
newborn’s thyroid screening tests as a routine national program
in Iran. The inclusion criteria was having term pregnancy,
singleton neonate, and lack of abnormality in breasts and being
primiparous. Women who had postpartum fever or breast
infection (mastitis) or their newborns had oral infections, and
infants with Short Frenulum tongue were excluded [Figure 1].
The sample was estimated to be 110 people, with 95% of
confi dence level and an error probability of 5%. First, the
study purpose and the conduction manner were explained
to lactating women. If they consented to participate in
the study, their wri en informed consent was taken. ()
Random allocation was done based on random numbers
table. Women who participating in the study were divided
in two groups of peppermint and control (placebo) data
were collected applying an observational checklist in order
to examine the intensity of nipple damage and presence
of purulent secretion of fissure. The Amir scale[13] for
severity of damage was used to determine the severity of
nipple damage and visual analog scale for pain intensity
was used to measure the pain. Obstetric and demographic
characteristics of participants were collected with a
researcher made questionnaire.
For each group, 50 people were considered and with a 10%
probability of determent, the number was increased to 55
people for each group. Therefore, the study was conducted
on a total number of 110 lactating women. In the fi rst phase
before treatment, the fi rst part of the check list was fi lled
out and the check list 2 and 3 related to pain, injury rate of
nipple and the existence of nipple discharge were completed
in two stages (days 10 and 14 postpartum) by the researcher.
In order to determine the validity and reliability of the data
form, content validity and test-retest techniques were applied
respectively and r was estimated 0.9 (r = 0.9). The pain was
measured using visual analog scale (over the 10 cm tape).
In this scale, numbers 1-3 refl ects mild pain, 4-7 moderate
pain and 8-10 represents severe pain. To check the amount
of damage of the nipple and areola, Amir et al. scale was
applied. Based on this scale 1-2 mm refl ects minor, 3-9 mm
medium, and 10 mm and more represents severe damage.
Menthol essence in the form of Menthol drop that is
produced by Poursina Co. in 15 mL packages was used.
The women in the peppermint group were asked to apply
4 drops of Menthol essence on the nipple and areola after
each feeding (every 2 h). The women in the control group
were requested to apply 4 drops of their own milk on their
nipple and areola after each feeding. The participants in
both groups were asked to refer to relevant center on days
10 and 14 after delivery to check the severity of pain, injury
and nipple discharge. If any women refused to a end the
Amir Ali Akbari, et al.: Effect menthol essence and breast milk on nipple fi ssures
Journal of Research in Medical Sciences | July 2014 |
631
center for any reason, a researcher would visit them at their
homes and would examine their fi ssures.
In this study, the data have been analyzed using version 17 of
the SPSS software (IBM Corporation, NY, USA). Descriptive
statistical methods including frequency distribution table,
mean index, and standard deviation were used to describe
the individual characteristics of the subjects. Then, with due
consideration to the ranking nature of the response variable
and the abstract nature of the data, fi rst the intensity of
pain and severity of damage during 3 days were compared
using Friedman test. The responses (results) of medicine
and placebo groups were compared using Mann-Whitney
test. In addition, in cases where the Mann-Whitney test was
signifi cant, cycles of treatment were compared two-by-two
with alpha correction using Wilcoxon test. The signifi cance
was considered level 0.05. For examining nipple discharge,
the existence or lack of discharge in 3 days was compared
using Cochran test. Then, the responses of the medicine
and placebo groups were compared using Chi-square test.
RESULTS
The study was conducted on 110 primiparous lactating
women with nipple fi ssures in two groups of medicine
and placebo with 55 people in each group. The two groups
were homogeneous in terms of age, education, duration of
pregnancy, and delivery method meaning that the members
of the two groups did not have a signifi cant diff erence in
these regards [Table 1].
In comparison of the diff erence in pain intensity score
before treatment and day 10 after delivery, as well as the
pain intensity score before treatment and day 14 after
delivery, the two groups showed a statistically signifi cant
diff erence [Table 2].
In comparison of the diff erence in damage severity score
in two groups, damage severity score before treatment
and day 10 after delivery, as well as damage severity score
before treatment and day 14 after delivery, the peppermint
and breast milk groups showed a statistically signifi cant
diff erence [Table 3].
In comparison of the diff erence in the existence or lack of
nipple discharge before treatment and day 10 after delivery,
as well as the pain intensity score before treatment and day
14 after delivery, the two groups of peppermint and breast
milk showed a statistically signifi cant diff erence [Table 4].
DISCUSSION
The fi ndings of this study indicated that Menthol essence
(Menthol) improves nipple fi ssures. In a study conducted
by Melli et al. in 2007 under the title of “The Eff ect of
Peppermint water in the Prevention of Nipple fi ssures,”
the results suggested that nipple fi ssures in the intervention
group were signifi cantly fewer than those in the control
group (relative risk = 3.6, 95% confi dence interval = 2.4-
4.3). The results of that study were consistent with those of
our study. However in Sayah’s study, Menthol essence has
Table 1: Comparison of demographic and midwifery
characteristics of the peppermint and breast milk
groups in the primiparous lactating women
Variable Breast milk
(n = 55)
Peppermint
(n = 55)
P value
Age (years) 23.76±2.52 23.8±1.80 NS
Having job (women) % 70.5 70 NS
Education (women) 67.2 65 NS
Husband age 25.84±1.91 25.74±1.78 NS
Having job (husband) % 67.5 68 NS
Husband education (high school) % 69.5 70.5 NS
Delivery mode (cesarean section) % 76.2 70 NS
Marriage age (years) 2±1.07 3±0.88 NS
The results are presented as mean (SD) or number (%); SD = Standard deviation
Table 2: Comparison of pain intensity before and after
treatment in the peppermint and breast milk groups
(mean ± SD) in the primiparous lactating women
Groups 3 days after
delivery
(n = 55)
10 days after
delivery
(n = 55)
14 days after
delivery
(n = 55)
P value*
Peppermint 8.55±1.74 4.26±1.57 1.32±1.02 <0.001
Breast milk 8.41±2.15 6.67±9.42 4.32±3.14 <0.001
P value** 0.34 0.002 0.001
*Friedman; **Mann-Whitney; The results are presented as mean ± SD; SD = Standard
deviation
Table 3: Comparison of nipple fi ssure damage severity
before and after treatment in the peppermint and breast milk
groups (mean ± SD) in the primiparous lactating women
Groups 3 days after
delivery
(n = 55)
10 days after
delivery
(n = 55)
14 days after
delivery
(n = 55)
P value*
Peppermint 8.31±3.47*** 6.51±2.78*** 2.24±1.03*** <0.001
Breast milk 8.02±4.16*** 7.39±3.43*** 5.76±3.27*** <0.001
P value** 0.44 0.001 0.001
*Friedma; **Mann-Whitney; ***Millimeter; The results are presented as mean ± SD;
SD = Standard deviation
Table 4: Comparison of nipple fi ssure discharge before
and after treatment in the peppermint and breast milk
groups (mean ± SD) in the primiparous lactating women
Groups 3 days after
delivery
(n = 55)
10 days after
delivery
(n = 55)
14 days after
delivery
(n = 55)
P value*
Peppermint % 75.2 31.6 15.7 <0.001
Breast milk % 74.5 53.7 29.8 <0.001
P value** 0.24 0.03 0.001
*cochran; **chi-square; SD = Standard deviation
Amir Ali Akbari, et al.: Effect menthol essence and breast milk on nipple fi ssures
Journal of Research in Medical Sciences
| July 2014 | 632
been used in the prevention of nipple fi ssures so that all
women in case group had received Menthol essence from
the very 1st day after delivery, while in the present study
Menthol essence was used as a medicine for treatment of
nipple fi ssures. Moreover, Melli et al.[14] conducted another
study in 2007 for examining the eff ects of peppermint gel,
lanolin ointment and placebo gel on the prevention of nipple
fi ssures. The results of that study were also consistent with
those of our study. Sayah’s study indicated that the incidence
of nipple fi ssures in the group receiving peppermint was
lower than that of other groups (P < 0.001).
In conducted surveys, no similar studies in which
peppermint herb is used for treatment of nipple fi ssures
were found but researchers have tried peppermint in other
cases of infl ammation and infection. For instance, Willis
et al.[15] suggest that Menthol essence (Menthol) reduces
infl ammation of respiratory tracts and prevents stimulating
eff ects of nicotine on smokers. Menthol interferes with the
functioning of transient receptor potential Melastatin-8
(TRPM8) and Ankirin-1 (TRPA1) receptors and the
stimulation channels; and this reduces infl ammation in
the tissue. Willis et al. claimed, inter alia, that Menthol
reduces infl ammation in smokers’ respiratory tracts through
interfering in the functioning of infl ammation receptors
(TRPM8) and (TRPA1). Alvandi et al.[16] suggested that
Menthol essence (Menthol) has strong anti-microbial eff ects
and that this property is more eff ective on Gram-positive
bacteria than Gram-negative ones. Alvandi et al. also stated
that, through aff ecting the microbes’ plasma membrane and
increasing the amount of some specifi c ions on or inside the
membrane, Menthol has a wide-range impact on protons’
driving force, the intracellular adenosine triphosphate and
the whole activity of microbial cells including pressure
control of living cells, and transport of soluble materials,
and regulating metabolism). Menthol also prevents bacteria
growth. Deans and Ritchi[17] have also expressed that
Menthol has strong antimicrobial properties particularly
on Gram-positive bacteria. They stated that Gram-positive
bacteria are more sensitive to the antibacterial action of
Menthol and that lower sensitivity of Gram-negative
bacteria is perhaps due to the external membrane of Gram-
negative bacteria, which limits the hydrophobic diff usion
of the essence to the lipo-polysaccharide layer of the cell.
Nipple fi ssure due to poor sucking by the infant is a suitable
environment for bacterial colonization especially infants’
oral fl ora. This increases the risk of parenchymal infection
of breasts (mastitis) and breast abscess after fi ssure. Menthol
essence (Menthol) attacks cytoplasmic membrane of
microorganisms and infl ammatory agents and destroys the
membrane. This leads to release of intracellular components
(ribose, sodium glutamate, etc.). It can also protect the cells
and destroy microorganisms and thus prevent damage
to tissue cells due to its role in degradation of electron
transport process, nutrients absorption, synthesis of nucleic
acid, and Atpase enzyme activity.[18]
ACKNOWLEDGMENTS
This paper is the result of a research project by Shahid Beheshti
University of Medical Sciences. Hereby, we appreciate the Chancellor,
Vice Chancellor and the Research Aff airs Department. We also
sincerely thank all the ladies participated in the study and wish them
good health given the fact that without their cooperation this study
was not possible. Our thanks should also go to all physicians and
midwives in the health centers-hospitals affi liated to Shahid Beheshti
University of Medical Sciences for their cooperation with researchers
in providing the necessary conditions for sample collection.
AUTHORS’ CONTRIBUTIONS
SAAA carried out the design and coordinated the study,
participated in most of the experiments and prepared the
manuscript. SHA provide assistance in the design of the
study, coordinated and carried out all the experiments
and participated in manuscript preparation. AAB and PM
provided assistance for all experiments. All authors have
read and approved the content of the manuscript.
REFERENCES
1. Cunni ngham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ,
Spong CY, et al. Williams Obstetrics. New York: MCGraw Hill; 2010.
2. Sayyah Melli M, Rashidi MR, Delazar A, Madarek E, Kargar
Maher MH, Ghasemzadeh A, et al. Eff ect of peppermint water on
prevention of nipple cracks in lactating primiparous women: A
randomized controlled trial. Int Breastfeed J 2007;2:7.
3. Goerg KJ, Spilker T. Effect of peppermint oil and caraway
oil on gastrointestinal motility in healthy volunteers: A
pharmacodynamic study using simultaneous determination of
gastric and gall-bladder emptying and orocaecal transit time.
Aliment Pharmacol Ther 2003;17:445-51.
4. Page T, Lockwood C, Guest K. Management of nipple pain and/
or trauma associated with breast-feeding. JBI Rep 2003;1:127-47.
5. Renfrew MJ, Woolridge MW, Ross McGill H. Enabling Women to
Breastfeed. London: The Stationary Offi ce; 2000.
6. Pugh LC, Buchko BL, Bishop BA, Cochran JF, Smith LR, Lerew DJ.
A comparison of topical agents to relieve nipple pain and enhance
breastfeeding. Birth 1996;23:88-93.
7. Ebadi M. Pharmacodynamic Basis of Herbal Medicine. 1st ed.
London: CRC Press; 2001.
8. Işcan G, Kirimer N, Kürkcüoğlu M, Başer KH, Demirci F.
Antimicrobial screening of Mentha piperita essential oils. J Agric
Food Chem 2002;50:3943-6.
9. Tylor VE. The Honest Herbal. Binghamton: Pharmaceatrial
Products Press; 1993.
10. Guedon DJ, Pasguier BP. Analysis and distribution of fl avonoid
glycosides and rosmarinic acid in 40 Mentha x piperita clones. L.
Agric Food Chem 1994;42:679-84.
11. de Smet P. Adverse eff ects of herbal medicines. Tafaghodi M,
Amiri R, Hossein Zadeh H, translators. 1st ed. Mashhad: Mashhad
University of Medical Sciences; 2006. p. 220.
12. Barnes J, Anderson LA, Phillipson JD, Newall CA. Herbal
Medicines: A Guide for Healthcare Professionals. 2nd ed. London:
Pharmaceutical Press; 2002. p. 468.
Amir Ali Akbari, et al.: Effect menthol essence and breast milk on nipple fi ssures
Journal of Research in Medical Sciences | July 2014 |
633
13. Amir LH, Lumley J, Garland SM. A failed RCT to determine
if antibiotics prevent mastitis: Cracked nipples colonized
with Staphylococcus aureus: A randomized treatment trial
[ISRCTN65289389]. BMC Pregnancy Childbirth 2004;4:19.
14. Melli MS, Rashidi MR, Nokhoodchi A, Tagavi S, Farzadi L,
Sadaghat K, et al. A randomized trial of peppermint gel,
lanolin ointment, and placebo gel to prevent nipple crack
in primiparous breastfeeding women. Med Sci Monit
2007;13:CR406-411.
15. Willis DN, Liu B, Ha MA, Jordt SE, Morris JB. Menthol a enuates
respiratory irritation responses to multiple cigarette smoke
irritants. FASEB J 2011;25:4434-44.
16. Alvandi K, Sharifan R, Aghazadeh A, Meshghi M. Study of
chemical composition and antimicrobial activity of peppermint
essential oil. Journal of Comparative Pathobiology 2010;7:355-64.
17. Deans SG, Ritchi G. Antibacterial properties of plant essential oils.
Int J Food Microbiol 1997;5:165-80.
18. Morland-Schul K, Hill PD. Prevention of and therapies for
nipple pain: A systematic review. J Obstet Gynecol Neonatal Nurs
2005;34:428-37.
Source of Support: This study is funded by Shahid Beheshti University
of Medical Sciences (Research project Number 25/12/566) IRCT number:
IRCT201206166807N5, Confl ict of Interest: None declared.
