Sue Huml, LLLL, IBCLC
Lansinoh Laboratories
The post from Cindy Church really caught my attention as I recently read Dr.
Mary Ziemer's latest study, published in the Nov/Dec 95 issue of Nursing
Research.- Evaluation of a Dressing to Reduce Nipple Pain and Improve Nipple
Skin Condition in Breast-feeding Women-   As I have personally been exploring
the feasability of creating the moist healing environment (used on other more
serious wounds in the body) for traumatized/injured nipples. I  have followed
Dr. Ziemer's research over the last five years with great interest.
I had long thought that applying a wound film dressing to damaged nipples would
have a positive effect for the nursing mother but had also felt that the
application of the dressing itself would be problematic (because of the size and
shape of the nipple, and the need for frequent access to the breast by the
nursing baby).
I was thrilled to see that Dr. Ziemer had completed a study using a specially
designed dressing (Blisterfilm, Sherwood Medical) a 3 inch circular polyethylene
film dressing with a 0.25-in perimeter adhesive system.
Cindy posted that "It didn't work, by the way but the authors still think this
medical approach is important" However, reading directly from the study - the
abstract reports that  -  scores indicated significant reduction in the amount
of eschar (scabbing) on the surface of the nipple.  There was no difference in
erythema intensity or fissure severity.  Use of a dressing significantly reduced
nipple pain during the study period."   The study did report that there was some
problem with the adhesive system and 66% of the participants found the dressing
to be uncomfortable.  However, the results were that creating the moist healing
environment using a dressing DID reduce scabbing and significantly reduced
nipple pain.
In Dr. Ziemers previous study (JOGNN Voll 22 No 3 May/June 93) she found that
Skin changes in the nipple were visible in 100% (20) of the sample, and 65% has
severe skin damage and 90% reported pain.  (she did NOT offer positioning or
latch-on advice).  Many have said her study is not an accurate portayal of the
average breastfeeding mother, however, there are still the majority of women
(worldwide) who get no LC help or advice at all upon the initiation of
breastfeeding, so perhaps her women in the study are more representative of the
normal breastfeeding woman that we would like to think.  Other studies since the
1950's right up until the mid 90's  have consistently reported that 80-95% of
women report some degree of nipple pain and 25-27% progress to severe pain and
fissuring.  The longevity and consistency of these statistics reinforce one very
important issue, sore nipples remain a major reason for the discontinuance of
breastfeeding.  The endless scientific examination of why must not be allowed to
obscure our ultimate mutual goal - to establish a successful breastfeeding
relationship.
Whenever this relationship is at risk, regardless of the reason, it is incumbent
on the breastfeeding specialist to treat the issues of 1) investigating and
correcting the underlying cause, and 2) offering symptomatic relief as two
separate and equally important issues.  No where in the healing arts is pain
relief witheld regardless of the underlying cause of the discomfort. Dr. Ziemers
exploration of pain relief methods for the breastfeeding mother should be
welcomed with open arms (or should I say open flaps!)
If any measure of relief can be offered - as long as it does no harm- then it
should be offered to then allow for a thorough assessment of the condition and
development of an appropriate treatment plan.  It is time that we acknowledge
that individuals are as different (and as beautiful) as snowflakes and that
nipples are skin!
If a mother says she is in pain then she is in pain.  She should not be made to
feel that it is all in her mind or that she is doing something wrong.  We owe it
to her to offer her comfort and pain relief so that she may proceed, gently and
patiently, with mastering the womanly art of breastfeeding.
On the topic of "Are there any studies to PROVE that positioning and latch-on
correction improve breastfeeding outcomes"  I am not aware of any, but then how
would you go about that, other than having a group where every b/f is observed
and judged correct and another group where there is no observation or advice....
Those of us in the lactation field agree that  outcomes are so much better when
positioning and latch-on are good.         I know I'm going to take some flack
for this as there are some of you who believe that ALL sore nipple problems are
caused by faulty positioning or improper latch-on.  I happen to believe that
there are many many causes of sore or damaged nipples, positioning and latch-on
being important ones to look at.  But, how many of you have seen women where
everything looked perfect BUT still the woman confounds you with cracked
bleeding nipples (even rulling out thrush)  Some women have very very dry skin
and it is prone to cracking, especially with all that skin expansion of the
breast going on during pregnancy.  Very often there may be three four or maybe
five things going on at one time.  Some women have the beginnings of cracked
nipples, even BEFORE their baby is born, just last week I heard about a woman in
last trimester with terribly sore "grazed" nipples.     And, here we have been
telling women for decades now to drop their flaps and expose the nipples to air
(or even hair dryers and sun lamps) to help to heal them.  I always say, if you
had cracked bleeding lips, you wouldn't even dream of exposing them to air, a
hair dryer or a heat lamp to heal them, yet this is what we told women for years
to do to their nipples.
Obviously one of my buttons have been hit but I have to say that I have found
Dr. Ziemers work to be very interesting, thorough and based in science.  I have
never had the pleasure of meeting her but have spoken to her  from time to time.
She was and has been one of the first to view breastfeeding mothers' nipples as
skin.
Phew! I feel better now!
Sue Huml, LLLL (for 20 years this month) and IBCLC