Prevention of Nipple Cracks with Peppermint Water versus Breast Milk in Lactating Primiparous Women Hala A

Prevention of Nipple Cracks with Peppermint Water versus Breast Milk in Lactating Primiparous Women
Hala A. Thabet (1) Manal A. Mourad (2), Abdulrahaman M. Alahadal (3), Samira Alsenany (4), Amer Alsaif (5).

Faculty of Nursing, El-Mansoura University (1) Medicine College King Abdul Aziz University (2) Faculty of
Pharmacy King Abdulaziz university (3) Faculty of Nursing, Public Health Department, king Abdulaziz university
(4) Physical Therapy, Physical Therapy Department, Faculty of Applied Medical sciences, King Abdulaziz University
(5).

ABSTRACT: Introduction: Sore nipples associated with breastfeeding are a common problem, with an incidence ranging from 11% to 96%, and may lead to premature weaning. (1, 2) This frequently occurs due to suction trauma to the nipple secondary to incorrect positioning at the breast. (3, 8) Objective: To formulate peppermint water and to evaluate the efficacy of peppermint water versus breast milk application in the prevention of nipple cracks associated with breastfeeding. Setting & Design: Experimental research design was utilized in this study to compare the above formulation with expressed breast milk. This study was carried out in post-partum wards in the Maternity and Child Health Hospital and the Azazia Maternity Hospital, Jeddah. Material/Methods: One hundred fifty primiparous participants were assigned randomly to three experimental groups. Group 1, the peppermint water group, was instructed to put soaked gauze with peppermint water on and around the nipples and areola after washing the nipples with water following every breastfeed from day 1 to day 14 and washing before the next feed. The same instruction was given to Group 2, the expressed breast milk group, with the difference that breast milk was used to soak nipples. Group 3 did nothing but keep their nipples clean and dry. Each woman was followed for up to 3 visits or telephone calls within 15 days and then by the telephone call at 30 days postpartum. The frequency of the nipple and areola crack and the pain was evaluated. Results: In the present study, the application of peppermint water was found to be an effective method to prevent nipple cracks. The relative risk of the overall nipple and areola cracks in the control group (48% & 56%) and expressed breast milk group (32% & 32%) was higher than in the peppermint water group (4% & 2%) at 15 and 30-day postpartum. (p < 0.001). In addition, at 15 and 30 days, it was observed that women in the peppermint water group were less likely to report no cracks (n = 2) than women in the expressed breast milk group (n = 6 & 8) and control group (n = 24 & 28). Women in the peppermint water group experienced mostly no pain (92% & 96% respectively) compared to those in the expressed breast milk group and the control group (64% & 68%, 44% & 40% respectively) (p < 0.001). Conclusions: Peppermint water in breastfeeding lactating women is associated with fewer cracks nipple and is more effective than expressed breast milk. It could be recommended, along with teaching better breastfeeding technique at the initiation of breastfeeding, for preventing cracks nipple. Hala A. Thabet, Manal A. Mourad, Abdulrahaman M. Alahadal, Samira Alsenany, Amer Alsaif. Prevention of Nipple Cracks with Peppermint Water versus Breast Milk in Lactating Primiparous Women. Life Sci J 2013; 10(4):2010-2017. (ISSN:1097-8135). http://www.lifesciencesite.com. 266
Key words: breastfeeding ?nipple crack ?peppermint water
1. Introduction
Sore nipples associated with breastfeeding are a common problem, with a prevalence ranging from 11% to 96%, and may lead to early weaning. 1-2
This commonly happens from suction trauma to the nipple secondary to inappropriate positioning at the breast. 3-4
The positioning of the baby’s body is essential for good attachment and successful breastfeeding. Most problems can be prevented totally if good attachment and positioning are done at the first and early feeds. 4 An effective sucking technique is reflected significant to establish breastfeeding, to ensure milk transfer, and to prevent breastfeeding difficulties.5, 6
It is a dream for most mothers to have comfort in breastfeeding, but sore nipples are still a common problem and pain or cracks frequently occur after
Breastfeeding.7-8 when the nipples hurt, breast feeding is in trouble. It is estimated that 80 to 90% of breastfeeding women experience some nipple soreness, with 26% developing to cracks and extreme nipple pain. 9-10. Up to be one- third of the women who experience these symptoms may change to replacement methods of infant nutrition within the first six postnatal weeks. 11-12 On the other hand, very sore, cracked, blistered or bleeding nipples are abnormal. 7
Several techniques of healing sore and nipples cracked have been used, containing the use of woman breast milk, tea bags, Masse’s cream, A and D ointment, lanolin cream, and breast shells. A common therapeutic approach to sore nipples 4,13-14 presently contains dried-on human milk, modified lanolin (medical grade), and the wearing of breast shells (hard plastic devices that provide an air barrier
to protect the skin from brushing and/or pressure from an overlying dress and other contacts). In none of the published studies, 15-16 however, has any method been totally efficacious, and sore nipples stay a frustrating clinical dilemma. This encouraged us to investigate other treatment methods and to test their safety and efficacy.

Nurses are often the primary providers who interact with the women during the antenatal period and are best positioned to guide women’s through the avoidance and solving of breastfeeding difficulties. Although many problems may be “common”, failure to therapy conditions that cause pain, frustration, and anxiety can lead to premature weaning and the prevention of breastfeeding of subsequent children. 17
With the resurgence of interest in breast feeding, there is an increasing request for natural therapies for minor problems that accompany nursing, yet the efficiency of these therapies is inadequately documented. Despite a large number of preparations found to be effective, there is still a continuous search for finding extra preparations with increasing specificity. 18 It is essential to do something about nipple soreness before it becomes worse and nipples develop painful cracks. In a previous study, we found that simple self-administered ordinary remedies, such as peppermint water, are effective in the avoidance of sore nipples. 19
Peppermint (Mentha piperita), which is used as a popular flavoring for gum, toothpaste, and tea, has a relaxing and numbing result and has been used to release skin irritations. 20 It also has an antiseptic influence and increases tissue flexibility, making tissues resistant to cracks. 21 The present study, peppermint water was formulated, and its effects on the prevention of nipple cracks related to breastfeeding were compared with that breastmilk.

Subjects and Methods:
Research design:
An experimental research design was carried out in this study to compare the effect of two methods to prevent the nipple cracks.

Study setting:
The study was carried out at the Maternity and Child Health Hospital and the Azazia Maternity Hospital, Jeddah.

Study sample:
The study sample consisted of 150 prim parous women with normal nipples who were breastfeeding after a vaginal delivery at 38 or more weeks of gestation .who were consecutively chosen from the previously mentioned setting. They were randomized into two intervention groups and one control group. Group 1, the peppermint water group, was instructed to place gauze saturated with peppermint water on and around the nipples and areola after washing the nipples with water subsequent each breastfeed from day one to day fourteen. The same instruction was given to Group 2 concerning using expressed breast milk to soak the nipples. Group three did nothing but keep their nipples clean and dry. Each participant was followed for up to three visits or telephone calls within fourteen days and then by the telephone call at week six postpartum. The data were collected from Sept. 2009 to Jan. 2010; the sample of this study constituted only women’s with healthy full-term babies. Women discharged before the interview or who had a preterm birth, post-partum high temperature, breast infection, and nipple abnormalities, had twins, took medicines at night, did not have a telephone line or were illiterate or less than 18 years of age, were excluded. In addition, infants that were fed infant formula or used a pacifier, or who had a mouth infection were excluded from the study sample.

Data were collected concerning women’s personal characteristics and to ensure their suitability for the research purpose. All selected women received comprehensive hospital breastfeeding instruction before the infant began breastfeeding. After taking the women history, the researcher carried out a physical examination of the infant and the mother’s breasts and evaluated the breastfeeding technique for all women
After giving informed consent, all women groups were given adequate written and verbal instructions on breastfeeding. The involved groups were requested to do their distributed intervention with peppermint water or expressed breast milk 4 times a day after breastfeeding. Outcomes were evaluated on days one to seven.

Tool for data collection:
The present study, the researchers were used three tools for data collection based on review of relevant updated literature to accomplish the aim of the study.

Three tools were used for this study.
An interview questionnaire sheet was used for women to collect data: consists of two parts: Part I. Demographic characteristics of women: This section was developed to assess the general characteristics of women such as the age of the mother, level of education, occupation and marital status Part II. Concerned with the women’s information regarding breastfeeding .This part was designed to assess knowledge regarding frequency and duration of breastfeeding and nipple cracks within 24 hours after birth.

Follow up Questionnaire: Questionnaire was used to determine the presence and severity of nipple damage and pain lactating primiparous women. Each mother scored her own pain during breastfeeding. Rating scales were used to determine the level of pain as follows: no pain, mild (discomforting), moderate (distressing), and severe (excruciating). Data were recorded and follow-up of all mothers during the study period by telephone or by arranging an appointment for the visit
An opinionnaire Questionnaire: was designed to evaluate mothers’ attitude toward the applied measures to prevent cracked nipples.
Ethics approval
The Medical Ethics Committee of the Ministry of Health at Jeddah approved the research study; all participants were given adequate information, and consent was obtained from each woman.
Data collection
Demographic and antepartum information was abstracted from the medical records. An interview was conducted during the postnatal stay. The follow-up telephone interviews were conducted by a trained midwife at days four, eight and fourteen postnatal. All mothers were asked about the frequency and duration of breastfeeding at 24 hours, and the data were recorded. A follow-up visit was organized for both groups 1 week after recruitment (day 8) or at any time during the trial course in the circumstance of nipple cracks or pain. A telephone interview was conducted with all women at week six. A questionnaire was used to determine the presence and severity of nipple damage and pain. Each woman scored her own pain during breastfeeding. Rating scales were used to determine the level of pain as follows: no pain, mild (discomforting), moderate (distressing), and severe (excruciating). 10 The main outcome measures include responses to questions about nipple pain at week six and objective outcomes from the physical examination at each visit. An opinionative was designed to assess mothers’ acceptance of measures to prevent nipples cracked.

Operational design:-
A pilot study was conducted on 5 women from each group to assess the validity and reliability of tools according to the statistical analysis of the pilot results. The necessary modifications were made (included in the sample).

Administrative design:-
A letter of a proposal was written and presented to the Chairman of the Obstetrics and Gynecology Department to obtain his approval to conduct this study.

Results
Part (A): Characteristics of the study sample
Table (1) Shows that most women in all interventions (using expressed breast milk ; peppermint water ); control groups were age – matched (20 to 29 years, respectively ) difference between groups as a regard educational status, employment ; marital status were not statistically significant (p=0.055,p=0.13,p=0.55 respectively.

Part (B) knowledge of women concerning breastfeeding
shows that knowledge of women in intervention groups (using expressed breast milk ; peppermint water) ; control group was mostly satisfactory (88%, 90% . and 76%, respectively) . However, their knowledge about breastfeeding positions mostly satisfactory in an expressed breast milk group than other groups (peppermint group ; control group) were statically significant (P=0.015*) respectively. The difference between intervention group ; control group regard the knowledge about causes of cracked nipple were not statistically significant (p=0.12) All women (100%) in the group of breast milk had unsatisfactory knowledge about options will help to resolve the cracked nipple. Difference between groups as a regard these items of knowledge was statically significant (P=.002 respectively.

Table (III) Shows that at 15 ; 30-day women in the peppermint water group were less likely to report no cracked (n = 2) than women in the expressed breast milk group (n =6 ; 8) ; control group ( 24 ; 28 ) regards areola crack (p ; 0.001). Women in the control group were more likely to report severe nipple crack (18 ;20) than women in the expressed breast milk group (8 ; 8) respectively .While the majority of women in the group of using peppermint water were likely to report no nipple crack (44 ; 46 respectively) ( p ; 0.001). The control group had a higher odd of experiencing overall nipple ; areola crack (24; 28) than the expressed breast milk group (16 ;16 respectively). Differences between groups as regard areola crack, nipple crack ; Overall areola ; nipple crack were extremely significant (p=;0.001).

Table (IV) Shows that as regard pain intensity at 15 ;30 days felt by women in the peppermint water group was mostly no pain (92%;96 respectively ) compared to those in expressed breast milk group ; control group (64%, 68% ; 44%;40% respectively ).( p ; 0.001). Severe pain was experienced significantly further more among women in control group and breast milk group at15 ; 30 days ( 40%,40%, 28%,20% )respectively than the group of peppermint water (4%,4% ) respectively.( p ; 0.001)
Table (V) illustrated that on the 15 ; 30 days, we found significant differences in intact nipples and areola between the two intervention groups ; control group. The group using peppermint water showed an increase intact nipple and areola (88% ; 92%) than the group using expressed breast milk (60% ; 64% and control group 44%;40% )respectively, Painless feeding began to increase in the group using peppermint water at 15 ; 30 days (92% ; 96%, than the group using expressed breast milk (52% ;56%), while in the control group, painless feeding initially reduced and peaked on the thirteen days postpartum (48% ; 40% ) respectively. The difference in self-reported painless feeding between the three groups reached statistically highly significance on all days (p = ;0.001). Most of the participants (92% ;92%) in group using peppermint water continued to breastfeed at 15 ; 30 days. While 44% ; 40% of the women in the expressed breast milk group and 56% ; 52% in the control group used infant formula in addition to breast milk. Differences between groups as a regard full breast feeding were highly significant (p=;0.001).

Part(c): Satisfaction with breast milk ; peppermint water methods for Prevention of cracked nipple.

Table (VI) Shows that women in all intervention groups (using expressed breast milk ; peppermint water) were mostly satisfied with the used methods to prevent cracked nipple (45 ;46) respectively) and they indicated that they desired to use it in their future pregnancies (45% ; 46%). Differences between groups as regard satisfaction with methods and future use were not statistically significant (p=0.89, p=0.054, respectively)
Discussion
The health benefits of breastfeeding for women and baby are well-documented. 17, 21, 22 One of the main difficulties in lactating women at the beginning of breastfeeding is nipple cracks, and this may represent an obstacle to successful breastfeeding, leading to a reduction in milk production. 23
In the first weeks of breastfeeding, sore nipples are most often produced by a poor latch by the feeding infant. The latch can best be evaluated by somebody experienced in lactation observing a feeding. 25
No one topical agent has shown superior results in the release of nipple discomfort. The best essential factor in diminishing the prevalence of nipple pain is the providing of teaching in relation to appropriate breastfeeding technique and latch-on as well as protective guidance about the high occurrence of early postpartum nipple pain. 26 With sufficient support and good information on avoiding some of the common difficulties related to breastfeeding, a woman chance of effectively breastfeeding her new baby is significantly improved. There are a number of experimental studies with different treatments and treatment mixtures to prevent nipple pain and injury in breastfeeding women. 27 Bearing in mind the health threats associated with not breastfeeding and the fact that sore nipples are not predictable during the early days of breastfeeding 7, 11, it is logical to generate healthy, flexible tissue that is very resistant to cracks.

In the present study, the use of peppermint water was noticed to be an effective technique to avoid nipple cracks. Also, no areola crack was witnessed in the peppermint water group. In our previous study 19, the use of peppermint water was found to be three times more effective than expressed breast milk EBM; 27% vs. 9%. This study showed a significant decrease in the occurrence of nipple pain and cracks in breastfeeding women wherever peppermint water was useful after breastfeeds. These effects could be attributed to the sedative and numbing effects and the antibacterial action of peppermint water leading to the decrease of irritation and nipple discomfort. Additionally, painful feeding could be the cause of the decrease of the frequency and duration of feeds in the expressed breast milk group.

Concerning the amount of nipple crack in the current study in women in the peppermint water group, at fifteen and threaten days, they were more likely to report no cracks (n = 2) than were women in the expressed breast milk group (n = 6 ; 8) and the control group (n = 24 ; 28). Regarding areola crack (p ; 0.001), women in the control group were more likely to state severe nipple crack (18% ; 20%) than were women in the expressed breast milk group (8% ; 8 % respectively) , but the majority of women in the peppermint water group were likely to report no nipple crack (44% ; 46% respectively) (p ; 0.001). The control group had a greater chance of suffering overall nipple and areola crack (24 % ; 28%) than had the expressed breast milk group (16%;16% respectively),which is relatively fewer than the rate of 9% found in our previous study for the level of nipple crack in peppermint water users. 19
As regards pain intensity at fifteen and thirteen days, women in the peppermint water group felt mostly no pain (92% ; 96 respectively ) compared to those in the expressed breast milk group and the control group (64% ; 68%, and 44% ; 40% respectively) (p ; 0.001). These results are supported by the findings of Akkuzu and Ta?kin (2000) 28, who illustrated that applying warm compresses or expressed breast milk was found to be less effective in avoiding nipples cracked than simply preserve the nipples clean ; dry. There were a smaller amount of cases with nipple pain in the group that applied expressed breast milk. Ideally, additional studies should be done to increase more insight into the efficiency of peppermint water because the applying of a cream or an ointment is easier than a solution, and in order to recommend a constant amount of peppermint water, planning a randomized trial comparing peppermint lotion / cream to no action could be the subsequent step.

Conclusions and recommendations:
The results presented that the formulated peppermint water as a natural remedy is more effective in the avoidance of nipple cracks than expressed breast milk. To our knowledge; this is the second study reporting the influence of peppermint water on nipple and areola pain and cracks. Daily use of peppermint water is associated with an increase in the duration and amount of feeds, and less nipple pain compared to the use of expressed breast milk alone. Recommendations: Based on the present findings, peppermint water application could be suggested as a prophylaxis of cracks nipple; in addition, proper instruction at the initiation of breastfeeding and education program are needed to improve women’ awareness concerning prevention of cracked nipples
Acknowledgement
We gratefully acknowledge the willing assistance given by the women in our study, the hospital midwife staff working in the Maternity and Child Health Hospital