Journal of Tropical Pediatrics, 2016, 62, 63–68
doi: 10.1093/tropej/fmv056
Advance Access Publication Date: 1 September 2015
Brief Report
BRIEF REPORT
Factors Associated with Nipple Lesions
in Puerperae
by Taciana Maia de Sousa,1 Luana Caroline dos Santos,2
Érika Freitas Peixoto,3 Leonardo Motta Costa Lopes,3
Luiza Barroso de Andrade,3 Marcelo Cançado Frois,3
Michelle Amanda Santiago,3 and Maria Cândida Ferrarez Bouzada4
1
Universidade Federal de Minas Gerais, Minas Gerais, Brazil
Departamento de Nutrição, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
3
Universidade Federal de Minas Gerais, Minas Gerais, Brazil
4
Departamento de Pediatria, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
Correspondence: Taciana Maia de Sousa, Departamento de Nutrição, Escola de Enfermagem. Avenida Professor Alfredo Balena, 190, sala 324,
Belo Horizonte/MG. CEP: 30130-100. E-mail <[email protected]>
2
ABSTRACT
This retrospective cross-sectional study aimed to evaluate the factors associated with nipple lesion
development in puerperae. Analyses were performed using the Poisson regression with robust variance. The level of significance was set at 5% (p < 0.05). We evaluated 1270 puerperae, among
whom 193 (15.4%) presented with nipple lesions. The condition was more prevalent among the
mothers who did not receive information about breastfeeding [PR, 1.69; 95% confidence interval
(CI), 1.19–2.42], those who underwent cesarean delivery (PR, 1.48; 95% CI, 1.02–2.16), those who
used a pacifier (prevalence ratios (PR), 2.04; 95% CI, 1.05–3.95), those who used baby formula
only (PR, 1.61; 95% CI, 4.82–5.36) and those who used baby formula combined with breastfeeding
(PR, 1.61; 95% CI, 1.06–2.45). A lower incidence of nipple lesions was observed among those who
did not receive information on hand expression of breast milk (PR, 0.65; 95% CI, 0.46–0.93) and
those who did not breastfeed in the first hour of life (PR, 0.61; 95% CI, 0.38–0.97).
K E Y W O R D S : Nipple pain, Risk factors, Maternal health, Breastfeeding.
BACKGROUND
Exclusive breastfeeding during the infant’s first 6
months of life is extremely important for nutrition
and adequate development [1]. However, this practice may be prematurely interrupted because of several factors such as the absence of guidance on
breastfeeding, the use of a pacifier, the mother’s
need to return to work and the occurrence of pain
and nipple lesion [2–5].
Nipple lesion is a common complication among
women who breastfeed and can present with intense
pain [5–7]. Furthermore, this injury can be recurrent, lead to a reduced epithelization rate and delay
C The Author [2015]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
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63
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Factors Associated with Nipple Lesions in Puerperae
scarring, which hinders treatment and the continuity
of breastfeeding [8, 9].
Several authors have suggested that this complication is associated with incorrect positioning and
latching on of the baby during breastfeeding, which
reinforces the importance of providing adequate
guidance to women during gestation [3, 10, 11].
However, in some cases, incorrect positioning during
breastfeeding was not observed, which suggests the
contribution of other factors [9].
Time to first feeding, the use of a feeding bottle,
the infant’s bite, nipple pigmentation and shape, exposure to cold and family/medical team support during the breastfeeding process include the likelihood
that a woman may develop nipple lesions [12].
However, studies on this topic are limited [9, 11,
13]. Therefore, this study aimed to evaluate the factors associated with nipple lesion development in
puerperae who were receiving assistance from a reference hospital.
distribution using the Kolmogorov–Smirnov test.
Descriptive statistics included the distribution of frequencies for qualitative variables, mean 6 SD values
of parametric quantitative variables and median
[95% confidence interval (CI)] for the remaining
variables. Chi-square tests were used to estimate
the association between two qualitative variables;
the Student t-test and Mann–Whitney U-test were
used to compare the means and medians,
respectively.
Finally, prevalence ratios (PR), with nipple lesion
as the outcome, were estimated with the respective
95% CIs using the Poisson regression analysis with
robust variance. The multivariable model included
the variables with p < 0.20 in the univariate analysis.
The stepwise backward method was used to insert
the variables, and the goodness-of-fit test was used
to adjust the final model. The latter only comprised
the variables that remained significant at a level of
5% (p < 0.05).
METHODS
This study was a retrospective cross-sectional research. Puerperal records, collected between
October 2012 and June 2013 through use of medical
records and a structured questionnaire, were reviewed retrospectively for purposes of this study.
The study was approved by the ethics committee of
the Universidade Federal de Minas Gerais and was
conducted according to the guidelines of resolution
466 promulgated by the National Health Council on
12 December 2012.
Data on the presence and onset of fissure were
collected, as well as the potential associated factors
such as age of the mother, infant’s weight at birth,
number of prenatal consultations, information
received on breastfeeding and hand expression of
breast milk, support from the medical team, birth
route, time to first feeding, diet of the newborn, use
of a pacifier and presence of an accompanying person in the ward. The infants’ weights at birth were
classified according to the criteria of the World
Health Organization (WHO) [14].
The data were analyzed using the Statistical
Package for the Social Sciences version 19 (SPSS
Inc.) and the Stata version 11 software. The quantitative variables were evaluated for normal
RESULTS
During the study, 1270 puerperal records were reviewed retrospectively. The median age was 26.71
years (95% CI, 26.29–27.11 years). Of these women,
15.4% (n ¼ 193) exhibited a nipple lesion.
Approximately 97% (n ¼ 188) of them were able to
report the time of onset of the lesion, and 38.3%
(n ¼ 72) reported that the lesion occurred up to
24 h after delivery.
The median number of prenatal consultations
was 8.13 (95% CI, 4.87–18.14). Of the puerperae,
52.5% (n ¼ 650) stated having received information
on breastfeeding, and 42.2% (n ¼ 333) were informed about the practice of hand expression of
breast milk. The prevalence of vaginal delivery was
70.8% (n ¼ 887), and 75.0% of the women breastfed
in the first hour of life.
With regard to newborns, 39.5% (n ¼ 348) had
low (n ¼ 97) or insufficient birthweight (n ¼ 251)
and 87.5% (n ¼ 1096) were exclusively breastfed.
The remaining results regarding sample characterization are shown in Table 1.
Nipple lesions were more prevalent among the
mothers who did not receive information on breastfeeding (17.3 vs. 13.7%; p ¼ 0.046), those who had a
cesarean delivery (18.3 vs. 14.2%; p ¼ 0.042), those
Factors Associated with Nipple Lesions in Puerperae
Table 1. Characteristics of puerperae who
received assistance from a reference hospital
(Belo Horizonte/MG) between October 2012
and June 2013
Characteristics
N
Age of the mother (years)
<20
199
20 and 40
1047
40
23
Number of prenatal consultations
<4
63
4–6
226
7
694
Birth route
Vaginal
902
Cesarean
368
Time to first feeding
1 h
815
>1 h
271
Information on breastfeeding
Yes
652
No
593
Information on hand expression of breast milk
Sim
334
Não
458
Support from the medical team
Yes
1077
No
163
Accompanying person in the ward
Yes
927
No
329
Use of a pacifier
Yes
58
No
1194
%
15.7
82.5
1.8
6.4
23.0
70.6
71.0
29.0
75.0
25.0
52.4
47.6
42.2
57.8
86.9
13.1
73.8
26.2
4.6
95.4
who used a pacifier (28.7 vs. 14.9%; p ¼ 0.009) and
those who breastfed in the first hour of life (17.0 vs.
11.4%; p ¼ 0.016). In contrast, nipple lesions were
less prevalent among the women who did not receive
information about hand expression of breast milk
(12.6 vs. 17.4%; p ¼ 0.022; Table 2).
Multivariable analysis showed that the variables
associated with a high incidence of nipple lesions
included the following: lack of information on
breastfeeding, guidance on hand expression of breast
65
Table 2. Results of the univariate analysis of the
association between the occurrence of nipple
lesion and the other variables studied
Variable
Number of prenatal consultations
<4
4–6
7
Birthweight
Low weight
Insufficient weight
Adequate weight
Excessive weight
Information on breastfeeding
Yes
No
Professional who gave the
information
Physician
Nurse
Other
Birth route
Vaginal
Cesarean
Information on hand expression
of breast milk
Yes
No
Time to first feeding
1 h
>1 h
Presence of accompanying person
Yes
No
Kinship of accompanying person
Partner
Family member
Other
Diet of the newborn
Exclusive breastfeeding
Exclusive breastfeeding þ
baby formula
Baby formula
Medical team support
Yes
No
Use of a pacifier
Yes
No
%
p value
0.421
16.1
14.3
17.3
0.729
19.6
14.7
15.2
21.9
0.046
13.7
17.3
0.407
14.3
11.7
18.7
0.042
14.2
18.3
0.022
17.4
12.6
0.016
17.0
11.4
0.238
15.0
16.8
0.161
12.6
17.4
11.9
0.143
14.5
24.4
4.5
0.384
15.5
14.2
0.009
28.7
14.9
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Factors Associated with Nipple Lesions in Puerperae
Table 3. Results of the Poisson regression
analysis for the association between the
variables and the occurrence of nipple lesion
Variable
Information on breastfeeding
Yes
No
Information on hand
expression of breast milk
Yes
No
Birth route
Vaginal
Cesarean
Time to first feeding
1 h
>1 h
Diet of the newborn
Exclusive breastfeeding
Exclusive breastfeeding
þ baby formula
Formula
Use of a pacifier
No
Yes
PR
95% CI 95
1.00
1.69
–
1.19–2.42
1.00
0.65
–
0.46–0.93
1.00
1.48
–
1.02–2.16
1.00
0.61
–
0.38–0.97
1.00
1.61
–
1.06–2.45
1.61
4.82–5.36
1.00
2.04
–
1.05–3.95
milk, cesarean delivery as birth route, breastfeeding
in the newborn’s first hour of life, not exclusive
breastfeeding and use of a pacifier (Table 3).
DISCUSSION
Nipple lesions were more frequent among the nursing mothers who did not receive guidance on breastfeeding, those who had a cesarean delivery, those
who were not exclusively breastfeeding and those
who used a pacifier for the newborn. Meanwhile,
nipple lesions were less prevalent among the puerperae who did not receive guidance on hand expression of breast milk and did not breastfeed in the first
hour after delivery.
Guidance on breastfeeding is recommended in the
‘Ten steps for successful breastfeeding’, established by
the WHO and the United Nations Children’s Fund
with the aim of informing pregnant women and
puerperae about the benefits and adequate management of breastfeeding [15]. Several studies have reported an association between the development of
nipple lesions and lack of information on breastfeeding [3, 16]. Guidance has been suggested to emphasize adequate positioning of the newborn and latching
on of the infant to the nipple-areola region to allow
effective feeding and reduce the risk of complications
such as breast engorgement, nipple lesions, low milk
production and breast infections [17, 18].
Cesarean delivery as the birth route has also been
described in other studies as a factor associated with
inadequate breastfeeding and the development of
nipple lesions [19, 20]. This association may be
related to a higher intensity of pain after childbirth
and consequent difficulty in correctly positioning the
newborn for breastfeeding [9, 21]. Undergoing an
elective cesarean delivery can extend hospitalization
time, increase the risk of infections after delivery,
lead to complications in subsequent deliveries and
hinder breastfeeding. These factors highlight the importance of normal delivery [22].
Another factor that was associated with nipple lesion was the use of a pacifier, a practice that interferes with the child’s latching on to the mother’s
breast and may alter the suction pattern, thus contributing to the development of lesions [23, 24]. A
pacifier is still used; however, it is not recommended
by the WHO because it interferes with mastication,
suction and deglutition, causing alterations in the
muscles of the phonoarticulatory organs and dental
occlusion. Moreover, it is a source of oral contamination, which compromises breastfeeding [25, 26].
Breastfeeding in the first hour of life was a variable
associated with the development of nipple lesions.
This practice is beneficial for both the newborn and
the mother, and is recommended by the Baby
Friendly Hospital Initiative, suggesting the importance
of skin-to-skin contact and breastfeeding in the first
hour of life as routine neonatal care to reduce child
mortality [27]. However, the present study showed a
higher prevalence of nipple lesions among women
who breastfed in the first hour of life. In 2009, Coca,
et al. [11] conducted a case-control study of the factors associated with nipple lesions, which included
146 puerperae, and found a similar correlation.
Nevertheless, the authors suggested nipple lesions
Factors Associated with Nipple Lesions in Puerperae
were not associated with breastfeeding in the first
hour of life but to the poor positioning and latching
on of the infant during breastfeeding in this period
[11]. Besides, women who do not breastfeed in the
first hour are likely to offer the breast less often, or
not even start breastfeeding, thereby they might have
less incidence of nipple soreness and lesions.
In addition to breastfeeding in the first hour of life,
unlike what was expected [28, 29], guidance on hand
expression of breast milk was also associated with the
development of lesions, probably because of difficulties in applying the recommendations. In a study with
70 women observed in a human milk bank, Sales,
et al. [30] observed that only 26% of puerperae who
were given guidance on hand expression of breast
milk knew the most appropriate method. In addition
to this hypothesis, the bias of temporality inherent to
the study design should be considered.
Furthermore, an association between nipple lesions
and the use of baby formula was observed. Puerperae
who abruptly interrupted breastfeeding and were not
given guidance on the appropriate hand expression of
breast milk technique may develop swollen and
engorged breasts, with an increased risk of developing
a nipple lesion [11, 30, 31]. Moreover, change in suction technique may occur in newborns receiving a
mixed diet of maternal milk and baby formula using a
feeding bottle, which also increases the risk of developing a lesion [25, 32]. Therefore, it is important
to encourage breastfeeding to prevent the development of nipple lesions [18].
The results obtained in this study suggest that
most variables associated with the development of
nipple lesions are justified by the incorrect positioning of the infant during breastfeeding. However, a
double mother/baby evaluation was not performed
at the time of feeding in this study; thus, it was not
possible to observe inadequate latching on and positioning, such as the tense shoulders of the mother,
misalignment of the baby’s trunk and chin, separation of the baby’s chin from the breast, insufficient
opening of the newborn’s mouth and no curl back of
the newborn’s lip, which have been described in
other studies [3, 33]. Other variables that were not
assessed were the type of nipple and nipple pigmentation, which are factors that, according to other authors, may also be associated with the development
of nipple lesions [11, 13].
67
Difficulty in diagnosing nipple lesions can also be
pointed out as a limitation of this study. However,
data in the literature on the adequate method for the
diagnosis and classification of lesions are scarce.
Another limitation is the retrospective design of the
study, which limited the assessment of some variables that were therefore not available. Despite these
limitations, the results identified an association between some preventable factors during the prenatal
and postnatal periods and nipple lesions. These data
are of great importance for the implementation of
more effective measures to promote breastfeeding,
and provide care and support for breastfeeding
mothers.
In this study, we observed an association between
nipple lesions and the lack of guidance on breastfeeding, use of a pacifier, cesarean delivery birth
route and use of baby formula. All these factors can
be controlled during prenatal and postnatal care.
Breastfeeding in the first hour of life and the provision of guidance on hand expression of breast milk
increased the prevalence of nipple lesion, which suggests the need for improvement of the currently
applied guidance methods.
The definition of factors associated with nipple lesions helps to identify those puerperae who are at
high risk for the development of this complication.
As a result, it is possible to prevent nipple lesion via
practices during the primary levels of assistance, such
as guidance on the advantages of normal delivery,
latching on, adequate positioning of the newborn
while feeding, negative effects of using a pacifier and
feeding bottle and the promotion of adequate
breastfeeding.
FUNDING
The authors state that this study received funding from PróReitoria de Pesquisa of Universidade Federal de Minas
Gerais.
ACKNOWLEDGEMENTS
The authors declare no conflicts of interest.
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