CHAPTER I

1. INTRODUCTION
“Breast feeding is a mother’s gift to herself, her baby and the earth.”

By Pamela K. Wiggins
To become mother is the greatest joy and pride for a woman. Becoming a mother is an experience
which every woman cherishes. The bondage between them is not severed even after the life comes
out from her womb for she nourishes that life with a food which has found no substitute yet despite
advances in science and technology, that pristine food is called “Mother’s Milk”. A wealthy nation
is the one which has a healthy population, so to achieve that, all the physical, social and emotional
need of a postnatal mother should be met properly.(1)
Breast feeding is very important for the health and well-being of infants and mothers. It has been
traditional way of feeding newborn in our country and is one of the most natural and beneficial
acts a mother can do for her child. Dramatic health benefits have been proven to pass from mother
to child through breast milk. It is a common belief that breast feeding is a natural phenomenon and
proceeds smoothly and uneventfully1.
Every mother who has to breast feed her baby is likely to come across various difficulties and
problems. One among them is sore nipples. Two main causes of sore nipples are either the baby is
not positioned and latched properly or the baby is not sucking properly or both. Fungal infection
(due to candida albicans) may also cause sore nipples.
A newborn baby has only three demands. They are warmth in the arms of its mother, food from
her breasts and security in the knowledge of her presence. Breastfeeding satisfies all three. While
breastfeeding may not seem the right choice for every parent, it is the choice for every baby
because it fulfils the physical needs as well as psychotic complementary of the child.3
Breastfeeding is a special gift from a mother to her baby. It not only provides a natural opportunity
for bonding but also supports the growth and development of the new born. Many newborn lives
are saved because breast milk provides important nutrients and protection against illness and
infection. If every baby were exclusively breastfeed from birth, about 1.5 million lives would be
saved each year.

Breast milk is a high quality nourishment for babies which accommodate almost all the require
nutrients for their growth and safety. The World Health Organization and United Nations
Children's Fund have commend just breastfeeding in the first 4 to 6 months of infancy and its
continuation until 2 years along with additional feeding. According to the contemporary
calculation of WHO, although 98% of the world women are physiologically able to breastfeed, but
only 35% of the world babies are breastfed between their birth and fifth months.
In India within an hour of birth 96% of new-borns rate is 37%. In India within an hour of birth
96% of new-borns are breast fed of that urban population is 29% and rural are breast fed of that
urban population is 29% and rural population is 21 %. In India 4.9% of population is 21 %. In
India 4.9% of postnatal women face breast engorgement, flat or inverted postnatal women face
breast engorgement, flat or inverted nipple or mastitis nipple or mastitis.
The advantages of breastfeeding for mothers and newborns have been well recorded. It has been
estimated that 80 to 90 percent of women who are breastfeeding experience soreness of nipple and
up to one-third of mothers who experience symptom of soreness of nipple stop the breast feeding
within the first six weeks of postnatal period. (2)
Sore or painful nipples are a common complaint of breastfeeding women and frequently a reason
for cessation of breastfeeding in the first postpartum month.Premature discontinuation of breast-
feeding contributes to disappointment, feelings of failure, and guilt for many women. To prevent
occurrence of this problem and to ease discomfort, various measures have been tried, including
restricting the length of each nursing, or the frequency of feeding, particularly during initiation of
breastfeeding.(3)
Two main sources of nipple pain can be suggested on the basis of incorrect or physiological
mechanisms of attachment and milk transfer:--
1. Frictional trauma. 2. Suction lesions.
These may not be independent and correcting the source of one may automatically benefit the
other.If inadequate amounts of breast tissue are presented to the baby for 'stripping' (e.g. by the
mother's fingers impinging on the areola when the breast is offered) then insufficient tissue will
be formed into a teat. Such a teat does not extend well into the mouth but is repeatedly drawn in
and out of the mouth, between the tongue and gums, by the cyclical application of suction, and
frictional damage to the nipple may be incurred by this process. If clearly mothers with inverted
or retracted nipples will have difficulty in initially forming an adequate teat from their breast tissue.
Valuable Babies with relatively small mouths (e.g. premature infants) or those with even slightly
recessive chins may also have difficulty taking in adequate breast tissue. Babies, i.e. babies for
whom one would not assume smallness of ‘gape' to be a contributory factor.
Suction lesions
The assumption that larger babies can exert a more 'vigorous' sucking action may lead to the
inference that nipple trauma is brought about by excessive negative pressure. Large babies have a
'healthier' appetite, and this may manifest itself in the tendency to persist in sucking at the breast
beyond the point at which available milk is depleted. Many mothers experience transient
discomfort at the start of a feed. This can be explained in terms of the pressure exerted by the baby.

Breast milk contains nutrients that are vital for the infant in the first few months. Research has
demonstrated that mothers require active support for establishing and sustaining appropriate
breastfeeding practices. Malnutrition kills one out of three infants in India. 66% of these deaths
occur during the first year of life and is often caused by inappropriate feeding practices. According
to WHO, breastfeeding is absolutely crucial in the first six months and should continue up to two
years along with regular food. Sadly, across the world only one out of three children is breastfed
during this period.5
UNICEF says that despite compelling evidence that exclusive breastfeeding prevents diarrhoea
and pneumonia, global rates of breastfeeding have remained relatively stagnant in the developing
world, growing from 32% in 1995 to 39% in 2010. ”If breastfeeding were promoted more
effectively, we would see more children survive, with lower rates of disease and lower rates of
malnutrition and stunting,” said UNICEF executive director Anthony Lake.5
Sore nipples are common reason for the avoidance or termination of breast feeding. According to
World Health Organization’s recommendation, all babies should be exclusively breast fed for six
months, followed by the introduction of appropriate weaning foods which are given in conjunction
with breast feeding until two years of age6
Nipple soreness is one of the most common reasons new mothers give for discontinuing
breastfeeding, often during the first week of nursing. This is quite unfortunate, for nipple soreness
is almost always a short-term problem, and can usually be corrected in a matter of days.
Breastfeeding is encouraged in current obstetrical practice which is not supposed to hurt,
eventhough most of the mothers are experiencing some degree of soreness during the early stages
of nursing. The degree of soreness varies greatly, with some mothers experiencing slight
tenderness, and others bleeding and cracked nipples.6

The promotion and support of breastfeeding is a global priority and an important child-survival
intervention and the World Health Organization (WHO) advocates exclusive breastfeeding for six
months. In reality many mothers are unable to practice exclusive breastfeeding due to lack of
confidence in mother’s ability to breastfeed, problems with the infant latching or sucking, breast
pain and sore nipples. Sore nipples associated with breastfeeding are a common problem, with an
incidence ranging from 11% to 96% and may lead to premature weaning. This frequently occurs
from suction trauma to the nipple secondary to incorrect positioning at the breast.7
It is common to feel some discomfort when the baby first latches on especially in the first days
after birth before the milk has come in. This type of soreness will usually ease up after the first
few sucks especially after the milk lets down and flows freely. Women in primitive societies whose
breasts were exposed to air and sunlight constantly, experienced fewer problems with soreness.7
Many women avoid breast feeding their newborns simply because they are afraid they will suffer
from sore nipples. The most difficult period of nursing is during the first few days and weeks as
mothers are forming a relationship with their newborn. They are most likely tired from the lack of
sleep and if this is their first breastfeeding experience, they could be struggling to find the right
positioning for their baby during feeding time. One of the best method to prevent sore nipple is
properly positioning the baby during breastfeeding. There are several different positions,
regardless of which position they choose; there is a need to be sure that both are in a comfortable
position.8 5
Nipple soreness will usually begin during the first days of nursing, will peak on the fourth or fifth
day and then ease off each day after that. Soreness should lessen greatly on days 7-10 and by the
time the baby is 2 weeks old, nursing should be pain free.8
Sore nipples occur so commonly in developed countries that many health professionals believe
them to be inevitable. The causes are almost always from the baby’s mouth and tongue, which
results from incorrect attachment of the baby to the breast, retracted nipples, formation of the crust
over the nipples etc. Correcting this will provide immediate relief from pain and will also allow
rapid healing to take place.8
Sore nipples are prevented by frequent short feedings rather than the prolonged feeding. Because
of these sore nipples many mothers decide not to breastfeed their babies. As with uptake, trends in
breast feeding duration appear to be associated with factors such as social class and maternal age.

Need for the study

Motherhood is a boon for every woman, it brings along with it some ailments that come as a total
surprise for the new mom, one among them is sore nipple. The resultant discomfort or pain often
causes the mother to discontinue the breast feeding. Studies have shown that 80 -90 % of breast
feeding women experiences some nipple soreness, with 26% progressing to cracking and extreme
nipple pain. Sore nipples associated with breast feeding are still a common problem. Many studies
show that breast milk does appear to have healing properties that can prove beneficial when it
comes to treating minor illness and injuries. This is because of the antibodies that the breast milk
contains.9
Health promotion goals include increasing the duration of breast feeding because of its irrefutable
advantages to the mother and baby, society and the environment.

However many mothers experience painful, sore nipples during breast feeding and stops nursing
before they intended. The reported incidence of nipple pain and trauma varies between 34% and
96% of breast feeding women. Characteristics associated with nipple pain include crack, sore,
bleeding, oedematous, erythemic, blistered nipples that may have fissures. Several researchers
have identified poor infant positioning or latch or both as the most common causes of sore
nipples.9
An intervention study on the collagenase treatment of sore nipples among 66 primiparous mother
in Turkey showed that approximately 65% of the lactating women experienced sore nipples.
Lesions were found on the areola and nipple during immediate postpartum.10
A descriptive study was conducted on breastfeeding problems in the first six months of life in rural
Karnataka of 420 mother-infant pairs showed that the onset of breastfeeding problems occurred in
31.7% of women during the first month of life and 76.9% in the first week, 7.7% in second and
15.4% in the third week respectively. Insufficient milk was reported by 53.6% while 23%of the
mothers had other problems like sore nipple, mastitis and breast engorgement. The study
concluded that the onset of breastfeeding problems was alarmingly high in neonatal period.11
A descriptive study on the breastfeeding practices and problems related to breastfeeding among
327 rural women in Jammu and Kashmir revealed that about one-quarter of mothers had lactational
problems. The study found that 28.4% had initial suckling problems, 8.6% had sore nipple,
8.6%had breast engorgement, 9.8% had mastitis and abscess and 3.7% had no milk.12
There is an importance to deal with problems faced by mothers during breastfeeding as they may
frequently result in the stoppage of breastfeeding or addition of
supplements of animal milk or commercial infant formula. It is found that about 33-96% lactating
women have sore nipples, 3% Korean women have nipple inversion and 73-92% women are
having inverted nipple.13
Sore nipples are usually due to one or both of two causes. Either the baby is not positioned and
latched properly, or the baby is not suckling properly or both. Incidentally, babies learn to suck
properly by getting milk from the breast when they are latched on well.Fungal infection (due to
Candida albicans), may also cause sore nipples.14
The pain from the fungal infection goes on throughout the feed and may continue even after the
feed is over. Women describe knifelike pain from the first two causes. The pain of the fungal
infection is often described as burning, but may not have this character. A new onset of nipple pain
when feedings had previously been painless is a tip off that the pain may be due to a yeast infection,
but the pain may be superimposed on pain due to other causes. Cracks may be due to a yeast
infection. Dermatologic conditions may also cause late onset nipple pain. Painful nipples are a
common reason for cessation of breastfeeding.14
Currently, about 55.5% of women in the United States breast feed their infants in the hospital,
though this proportion has been decreasing slightly over the past few years, mainly because of the
increasing number of births to women under 20 who are least likely to breastfeed. Of women who
breast-feed, 42% - 60% encounter substantial problems that lead to early weaning.14
An experimental study was conducted in America to identify an effective preparation method for
breastfeeding and to develop measurement tools for nipple tenderness and breast engorgement
which will be useful for assessing the severity. 25 subjects served as their own controls by
preparing one nipple and massaging one breast,
either the left or right, but not the other breast or nipple. Nipple tenderness and breast engorgement
were recorded on five-point scales. Analysis of the data revealed that tenderness and engorgement
were decreased in the prepared, massaged breast15.
The investigator with her observation analyzed that sore nipples are common among the post-natal
mothers and the breast milk application helps to the better healing of sore nipples. Many doctors,
researchers, and scientists agree that breast milk does appear to have healing properties that can
prove beneficial when it comes to treating minor illnesses and injuries. This is because of the
antibodies that breast milk contains and it also be effective in reducing pain and healing cracks
and also it doesn’t have any side effects. This view motivated the investigator to conduct a study
to find the effectiveness of breast milk application on sore nipples.

STATEMENT OF THE PROBLEM:

“A study to assess the effectiveness of application of breast milk in the prevention of sore
nipple among postnatal mothers admitted in selected hospital of Ambala Haryana”.

OBJECTIVES:

1. To assess and compare occurrence of sore nipple among postnatal mothers in experimental and
comparison group.

2. To find out the association of sore nipple score with selected demographic variables.

HYPOTHESIS

• Following hypothesis will be tested at 0.05 level of significance:

• H1: There will be significant difference in mean post-test score of sore nipple soreness among
postnatal mothers after application of breast milk in experimental and comparison group.
• H2: There will be significant association of occurrence of sore nipple score among postnatal
mothers with their selected demographic variables.

OPERATIONAL DEFINITIONS:
• EFFECTIVENESS: In this study effectiveness refers to the efficacy of breastmilk to have
desired effect in terms of prevention of sore nipple in postnatal mothers as evident from the
scores of nipple soreness scale.
• BREAST MILK: In this study breast milk refers to hind milk of the mother which is applied
to on nipples of postnatal mothers four times in a day after feeding the baby.

• SORE NIPPLE: In this study sore nipples refers to any redness, persistent pain, tenderness
and cracks in the nipples that lasts throughout the entire breastfeeding or painful even between
feeds as measured by sore nipple scale.
• POSTNATAL MOTHERS: In this study postnatal mothers refers to the mothers admitted in
postnatal wards of selected hospital of Ambala Haryana.

ASSUMPTIONS

• In this study it is assumed that:

• Post-natal mothers may suffer from sore nipple.

• LATCH scale is appropriate tool for the breast feeding assessment of baby.

• Nipple soreness scale is appropriate tool in the assessment of sore nipple.

• Sore nipple is a preventable phenomenon.

DELIMITATIONS:

• The study will be delimited to:

• Intervention will be delivered for mothers only for first four days in postnatal period.

• Assessment of sore nipple will be done at the time of discharge or on 5th day whichever is
earlier but not before 3rd postnatal day.

• Sore nipple will be assessed one time only.

CONCEPTUAL FRAMEWORK
• Conceptual framework deals with concepts assembled together by the writer for their relevance
to the research problem which provides a certain frame of reference for clinical practice,
research, and education. The conceptual framework used in this study was based on Orlando’s
Nursing Process Theory (1972).
The present study aims at application of breast milk for the prevention of sore nipples
among postnatal mothers in a selected Hospital Mullana Ambala haryana.
• Orlando’s theory focuses on the patient as an individual. Each person, in each situation is
different. Nursing is concerned with individuals who suffer or anticipate a sense of
helplessness. According to Orlando’s theory, patient behavior stimulates a nurse’s reaction,
which makes the beginning of the nursing process disciplined. This reaction is comprised of
five sequential parts. The reaction of a nurse towards nipple sore healing is given in the
pictorial representation below.
• In the present study, application of breast milk on sore nipples and the posttest assessment of
sore nipples.

Figure 1: Schematic representation of conceptual framework based on Ida Jean Orlando’s

Nursing Process Theory
SUMMARY:
This chapter dealt with the background of the study, need for the study, and statement of problem,
objectives, hypothesis, operational definition, assumption, delimitations and conceptual
framework.
OUTLINE OF THE REPORT
Further report of the study follows in four chapters besides the preceding
Chapter II would be presenting the review of literature related to the present study.
Chapter III will deals with the detailed methodology of the study and plan for data analysis.
Chapter IV will deals with the analysis, interpretation of the data, its major findings and
discussion.
Chapter V would be devoted to summary of the study, study findings, conclusion and limitations
of the study as well as its implications and recommendations.

This chapters ends with selected references, annexure and an abstract of the study
 CHAPTER II
REVIEW OF LITERATURE
“Review your work. You will find, if you are honest, that 90% of the trouble is traceable to
loafing.”
Ford Frick
Review of literature is a systematic identification, location, scrutiny and summary of written
materials that contain information on the research problem. Review of literature is an essential task
in the research process. It brings clarity and focus to the research problem, improves the
methodology and broadens the knowledge base in the research area.
Literature review is based on an extensive summary of books, journals and international nursing
indices. It provides basis for future investigation, justifies the need for the study, reveals contents
of data collected and relates the findings from one study to another with the hope to establish a
comprehensive study of scientific knowledge in a professional discipline, from which valid and
pertinent theories may be developed.
The review of literature has been organized and presented under the following headings:
Studies related to:
2.1. Breast milk and its advantages.

2.2. Incidence and problems of sore nipples.

2.3. Treatments for sore nipples.

2.1 Studies related to breast milk and its advantages

A quasi experimental study was conducted in the Neonatal Intensive Care Unit of Imam Reza
Hospital in Mashhad , Iran. The sample size was 225 mothers with sore nipples. The patients were
randomly divided into 3 groups. The first group rubbed the hind milk on the nipples and the second
group used Lanolin locally on the nipple 3 times a day and the third group did not use anything.
The patients were re-examined on the consecutive days. Data was collected by means of an
interview and physical examination by using a questionnaire. Data analysis was done by using the
SPSS version 11.5 software and the used tests were Chi-Square test, Mann-Whitney test and
Kruskal-Wallis test. The healing time was different in these 3 groups (p=0.038).The healing time
in the lanolin group was longer than the breast milk group (p=0.029) and the control group
(p=0.028).The study result concluded that breast milk application on sore nipples is more effective
than topical application of lanolin21.

A study was conducted to compare the effectiveness of application of expressed breast milk or
colostrums with that of hydrous lanolin to woman’s nipples after breast feeding for prevention or
reduction of nipple pain and trauma during the first 5 postnatal days. Each of the 23 subjects was
her own control, applying lanolin to one nipple and expressed breast milk or colostrum to the other.
After every feeding, mothers rated nipple pain for each breast on a 4-point scale. On postpartum
days 0-5, the nipple condition was assessed by investigators who were “blind “to the intervention
used on each nipple. Nipple pain and trauma experienced by the women were similar for the two
interventions. The study concluded that both breast milk and lanolin are effective in reduction of
nipple trauma.22

A study mentions about the benefits of breast milk. Breast milk is sterile, antibacterial and has
many healing properties. It can be used to treat a variety of ailments and can be applied topically
for eye and ear infections, minor skin injuries, sore or cracked nipples, diaper rash, sore throat and
stuffy noses. It is also known to boost up the immunity in adult cancer patients who have
immunosuppression due to chemotherapy. A research also says that HAMLET, a protein in breast
milk was seen to kill cancer cells. It was used to successfully treat virally infected warts which
reduced by 75 percent with an ointment containing this protein.23

An experimental study was conducted to compare the effectiveness of three techniques on the
prevention or reduction of nipple pain and cracked nipples during the first five days postpartum.
The methods applied were to apply warm compresses, expressed breast milk or to give no
treatment other than keeping the nipples dry and clean. The number of cases with nipple pain was
less in the group that applied warm compresses and breast milk24.

A study was conducted by Iran Mashhad University of Medical Sciences to compare the
effectiveness of topical application of breastmilk and dry cord care on bacterial colonization in
umbilical cord of neonates. A population based sample of 118 newborns and their mothers were
investigated. Bacterial colonization in breast milk group was shorter than dry cord care group
(p=0.016).The study result concluded that topical application of breast milk on umbilical cord care
leads to reduced bacterial colonization and it can be used as easy, cheap, non injury methods for
umbilical cord care.25

A randomised control study was conducted regarding umbilical cord care at birth using five
different methods including colostrum. In this study 500 newborns were studied (100 in each
group). The newborns were randomised at birth into five groups and cord care was given as per
the group parameters till the time of cord separation. Umbilical cord separation time ranged from
4-13 days. The mean duration of umbilical cord separation in the “NO CARE” or natural drying
was 7-14 days. Sterile water and alcohol seemed to be effective in cord healing and reduction in
bacterial colonisation rates. In this study, colostrum application was seen to show reduction in
colonisation when compared with ‘NO CARE’ group. Colostrum can be used on a mass scale in
the developing countries as an easily available effective intervention in reducing the cord
colonization.
An experimental study was conducted in the postoperative ward of Government Lady Goschen
Hospital, Mangalore, to determine the effectiveness of selected modalities for cord healing among
newborns. The selected modalities were application of breast milk, sterile water and natural drying
on umbilical cord .Purposive sampling with random assignment to group 1, group 2 and group 3
was done and sample size was 100 newborns. The study result concluded that application of breast
milk reduced cord separation time. 27

A study was conducted to compare the effect of topical application of human milk, ethyl alcohol
96%, and silver sulphadiazine on umbilical cord separation time in newborn infants. Of the 373
singleton near- to full-term newborns enrolled in the study, 312 completed the study. Newborns
from birth were randomised to mother’s milk group, alcohol group, silver sulphadiazine group,
and control (no treatment) group. Mother’s milk for Group 1, ethyl alcohol for Group 2, and silver
sulphadiazine ointment for Group 3 were applied to the umbilical stump three hours after birth and
control group and they received dry cord care only. Significant difference was observed in the
mean cord separation time among the four groups. No significant complications were observed in
any group. The suggestion was that breast milk could be substituted for other topical agents for
umbilical cord care.28

A randomised clinical trial on the effects of topical application of breast milk and dry cord care on
bacterial colonisation and umbilical cord separation time in 118 neonates was conducted in York
Hospital. Children requiring immediate attention were excluded from the study. Parents were
provided a pamphlet about umbilical cord care and signs and symptoms of omphalitis within three
hours after delivery. There were no significant differences between the two groups in cord
colonisation rate before and after the intervention, but Staphylococcus epidermis normal flora of
skin in the breast milk group was more significant than in the dry cord care group. The mean cord
separation time in breast milk was ( 6.35- 2.03)was significantly shorter than in the dry cord care
group(7.31-2.44) no cases of complication such as sepsis or omphalitis were seen in any of the
groups.29

A study was conducted to compare the incidence of omphalitis among three groups, each using a
different type of newborn cord care: povidone-iodine, dry care, and topical human milk. The
design used was case control design. Participants included were 150 healthy, full-term newborns
and their mothers. The study concluded that there were no significant differences between the three
groups in terms of omphalitis occurrence. Two cases of omphalitis were observed (one in the
human milk group, one in the povidone-iodine group). Interestingly, babies in the dry care or
topical human milk group had shorter cord separation times than those in the povidone-iodine
group. The cultural practice of applying human milk to the umbilical cord stump appears to have
no adverse effects and is associated with shorter cord separation times than are seen with the use
of antiseptics.30
A randomised control study selected 565 newborns and subjected them into two groups: 327 who
received topical breast milk application to the eyes prior to each breastfeeding for the first ten days
of life, and 328 who received no treatment. The results showed that conjunctivitis appeared in
9.1% of the newborns in Group1 and 25.6% of the newborns in Group 2 (P < 0.001).31

A retrospective study was conducted on switch from antibiotic eye drops to instillation of mothers’
milk drops as a treatment of infant epiphora on 65 newborns. Among them, 20 were subjected to
conventional treatment on antibiotics and 45 newborns underwent an alternative treatment or
topical mothers’ milk application. The findings showed that the babies in the group with mother’s
milk had spontaneous and shorter time of resolution when compared to antibiotic group. This study
emphasized the relief of mild symptoms of infection.32

A study conducted on breast milk immunology revealed that breast milk has anti-microbial factors
like lactoferrin, lysozyme and secretory Ig A. It was discovered that antibodies in breastmilk were
specifically directed against microorganisms present in intestinal tract or in her respiratory system.
In addition, anti-inflammatory substances in human milk play an indirect anti-inflammatory role
by promoting the growth and differentiation of epithelial barriers which prevent penetration of
microorganisms. There is growing epidemiological evidence that breast feeding is protective
against Type 1diabetes mellitus and crohn’s disease. Thus, it was concluded that breastmilk helps
in the development as well as maturation of immune system of the newborn.33

2.2 Studies related to incidence and problems of sore nipples

A descriptive study on the prevention and management of postnatal breast complications among
600 postnatal mothers at Allahabad showed that 20% of the mothers were found to have breast
complications. Breast engorgement (43.33%) was the most common complication followed by
cracked nipples (17.8%), retracted nipples (10%), cracked and sore nipples (8.33%), cracked and
retracted nipple (7.5%), failing lactation (7.5%) and breast abscess (3.33%).34
An experimental study was conducted in America to identify the level of perception of pain in
mothers with sore nipples. The study comprises of 94 breastfeeding women with sore nipples. 47
mothers received routine care and remaining 47 received glycerine gel application on sore nipples.
Nipple pain during breastfeeding was rated by the mothers on a 5-point verbal descriptor scale at
each visit, and pain at the start of treatment was compared to pain at the last visit. Analysis of
variance determined that no significant differences existed between the groups: F (2,86) = 1.34,
p>.05. Mothers in the glycerine gel group were more satisfied with their treatment method, but
this finding was not statistically significant. The study indicated that effective care and perinatal
education for nursing mothers with sore nipples should include assessment of breastfeeding
positioning and proper latching technique35.
A randomized controlled trial study was conducted in Iran (2007) to assess the efficacy and side
effects of purified lanolin (Lansinoh) in the prophylactics and treatment of sore nipples.The
samples were 57 women aged 20-35 years. Two groups of patients were formed: Group 1 – ten
women (17.5%) with no complaints applying the preparation with preventive aim and Group II –
forty seven (82.5%) women with sore nipples of different severity. In the first group of patients
due to the application of Lansinoh the skin remained smooth and elastic and breastfeeding was not
disturbed. In the II group, Lansinoh lead to a statistically significant difference in the nipple
attribute score before and after treatment.36
Priscilla Tait, CNM, MS (IBCLC) identified problems and conditions that contribute to
nipple pain during lactation and that may lead to early cessation or non-initiation of breastfeeding.
Signs and symptoms of poor latch-on and positioning, oral anomalies, and suckling disorders are
reviewed. Diagnosis and treatment of infectious agents that may cause nipple pain are identified.
Comfort measures for sore nipples and current treatment recommendations for nipple wound
healing are discussed. Suggestions are made for incorporating in-depth breastfeeding content into
midwifery education programs.37

A study was conducted to examine the relationship between breastfeeding latching process and
occurrence of breast problems and pain in a hospital in Latvia. Lactation assessment tool and five-
point verbal descriptor scale were used. Sample consists of 95 breastfeeding mothers with sore
nipples. The mothers were assessed and breastfeeding documented using Lactation assessment
tool. Four attribute categories were scored and examined as related to the pain levels of the mother:
the baby's face position; the baby's body position; the breastfeeding dynamic and the latching
process of the baby. The study revealed that there is no significant difference between the mother's
levels of reported pain and the assessed four attributes of the baby. Optimal latching process
behaviour of the baby were slightly
related to lower levels of reported pain (r (88) = -0.09, p>0.05). The researcher concluded that
assessment of breastfeeding techniques should be comprehensive and should begin before the
infant is at the breast which prevents the various breast problems and to improve the knowledge
and practices regarding breastfeeding.38

An experimental study was conducted on positive effects of an antenatal group teaching session
on postnatal nipple pain, nipple trauma and breast feeding rates in Australia. The study comprises
of 70 samples. At 6 weeks postnatally 31 out of the 35 women in the experimental group were
breast fed compared to 10 of the 35 women in the control group. Findings of the study revealed
that the women in the experimental group were better able to attach the baby on breast and had
significantly less nipple pain and trauma than control group. The study showed that the midwives
can help the mother through effective teaching strategy.39

2.3. Studies related to treatments for sore nipples

A randomized controlled trial study was conducted in America by American Medical
Association to assess the effectiveness of peppermint water on prevention of nipple cracks in
lactating primiparous women a randomized controlled trial among 196 primiparous breastfeeding
women. Women who were randomized to receive peppermint water were less likely to experience
nipple and areola cracks (9%) compared to women using expressed breast milk (27%; p <
0.01).Women who used the peppermint water on a daily basis were less likely to have a cracked
nipples than women who did not use peppermint water. Nipple pain in the peppermint water group
was lower than the expressed breast milk group. The study suggested that the peppermint water is
effective in the prevention of nipple pain and damage.40

A comparative study was conducted in Mercy Hospital of Pittsburgh, USA in 2004 to compare the
effectiveness of using breast shells with lanolin and hydrogel moist wound dressing in preventing
sore nipples in women who breastfeed. Researchers compared both treatments in a study of 42
breastfeeding women. The study suggested that both the treatments were effective, but breast shells
and lanolin were more effective than the wound dressing.41

A descriptive experimental study was performed in two Maternity Hospitals in Sao Paulo to
evaluate the effect of anhydrous lanolin-based ointment in the process of healing nipple injuries.
The random sample consisted of fifty puerperium women with nipple injuries. The size of the
injury in the control group reduced in 0.41 ± 0.11 cm (right breast) and 0.29 ± 0.06 cm (left breast)
compared to the experimental group, from the first to the second evaluation (p<0.001), showing to
be statistically significant. The study showed that lanolin is effective in treating nipple injuries.42

Summary
The literature collected from medical and nursing journals and websites consisted of
research studies and articles. Collected information was on effectiveness of breast milk, care of
sore nipples, which would provide valuable material for developing the tool, theoretical framework
and setting a suitable research design.