>Any other suggestions for causes, prevention or treatment?
Judith, here is what I have in my files on Vasospasm of the nipple. It
seems to me that since she is working on *preventing* the problem this
time, she could begin immediately to use the Ca/Mag and/or Primrose
Oil/Fish Oil supplements, all of which have no side effects and appear to
address the cause, instead of waiting until the problem arises and going to
the drugs.
I have had good luck with Ca/Mag and Primrose oil with my clients.
Pat Gima, IBCLC
Milwaukee, Wisconsin
________________________________
Dear Lactneters,
Do many of you use Calcium and Magnesium supplements to treat nipple
vasospasm in breastfeeding women? An article by Mayer (1988, An Overview of
solutions to breastfeeding and sucking problems, La Leche League
International, Illinois) suggests using calcium (2000mg per day) and
magnesium (1000mg per day) to treat this problem.
A review of the mainstream medical literature failed to refer to the use of
calcium or magnesium to treat vasospasm affecting any other organ.
I was fascinated when I was again doing a literature search on this topic
the other night when I found an article measuring the magnesium
concentration in erythrocytes in a group of 30 women with the vasospasm of
primary Raynaud's phenomenon compared to a group of controls. The women
with primary Raynaud's phenomenon had a significantly lower magnesium
concentration in erythrocytes during winter (when you would expect
vasospasm to be at its worse) than did the controls. (Leppert J, Aberg H.
et al, The concentration of magnesium in erythrocytes in female patients
with primary Raynaud's phenomenon; fluctuation with the time of year,
Angiology 45: 283-288 1994). So there does seem to be a rationale for the
use of magnesium to treat this problem. So what do you use?
Laureen Lawlor-Smith
South Australia
The following is part of a paper I will be presenting at the NMAA
conference in October. It summarises the treatment of Raynaud's phenomenon
affecting the nipples of breastfeeding women. I hope you find it of use.
The management of Raynaud's phenomenon in the lactating woman is limited by
the need to ensure the safety of any treatment not only for herself but
also for her breastfeeding infant.
Avoiding cold stress is the mainstay of treatment of Raynaud's phenomenon.
It is of interest that not only the affected part but the whole body needs
to be kept warm to avoid reflex sympathetic vasoconstriction (Coffman
1990). Patients should therefore be advised to breastfeed in a warm
environment, to wear warm clothing and to avoid cold exposure at all times.
Once painful vasospasm has occurred warming the nipples (for example by
using warm compresses) may be helpful.
Smoking should be avoided in patients with Raynaud's phenomenon. Smoking as
little as two cigarettes per day has been shown to increase vascular
resistance by 100% and decrease cutaneous blood flow by 40% (Cardelli and
Kleinsmith 1989). Smoking may therefore potentiate Raynaud's phenomenon.
Caffeine may exacerbate Raynaud's phenomenon in some patients and should
therefore be avoided. Although it is a vasodilator, its use may be
associated with rebound vasoconstriction through central mechanisms thereby
precipitating symptoms of Raynaud's phenomenon (Adee 1993).
Moderate aerobic exercise has been shown to be of benefit in Raynaud's
phenomenon and may be worth a trial in the breastfeeding patient (Cardelli
and Kleinsmith 1989).
The use of calcium (2000mg per day) and magnesium (1000mg per day) has been
reported anecdotally as a treatment for nipple vasospasm (Maher 1988).
There is no scientific evidence to date however to support the efficacy of
this regimen.
Evening primrose oil (Belch et al 1985) and fish oil (Digiacomo et al 1989)
have individually been found to be of benefit to patients with primary
Raynaud's phenomenon. Both agents are certainly safe for the lactating
woman and her baby. However large doses of these agents are required to
improve symptoms - 12 capsules per day of evening primrose oil equivalent
to 540mgs of gamma linoleic acid or 12 fish oil capsules per day
equivalent to 3.96gms of eicosapentanoic acid and 2.64gms of docosahexanoic
acid. Furthermore it takes 6 weeks to get any significant clinical response
with either of these agents and they are therefore not useful in the short
term. A lactating woman presenting with acute nipple pain secondary to
vasospasm is therefore likely to require more immediate relief at least in
the interim.
Of all drugs investigated thus far for the treatment of Raynaud's
phenomenon, nifedipine, a calcium channel blocker of the dihydropyridine
group has been the most effective (Wollersheim and Van Zweiten 1993). In
primary Raynaud's' phenomenon nifedipine is associated with reductions in
attack frequency between 50 and 91% ( Rodheffer et al 1983, Corbin et al
1986 and Kahan et al 1983). When given to a lactating woman less than 5% of
the total dose of nifedipine appears in her breast milk (Ehrenkranz et al
1989). The administration of nifedipine does not alter breast milk
composition (Ehrenkranz et al 1989). Treating a breastfeeding woman with
nifedipine therefore appears to pose no risk to her infant.
Nifedipine appears therefore to be a safe and rational choice for the
treatment of Raynaud's phenomenon affecting the nipples of lactating
women. The successful use of nifedipine in treating this condition has
recently been described in five breastfeeding patients (Lawlor-Smith and
Lawlor-Smith 1997).
Side effects to nifedipine are said to occur in approximately one third of
patients and are usually secondary to peripheral vasodilatation. These may
include headache, flushing, dizziness, reflex tachycardia and peripheral
oedema (Cooke and Nicolaides 1990). Side effects may be minimised by either
starting at a small dose such as 5mg three times per day and slowly
increasing until an optimal clinical response is achieved (Cooke and
Nicolaides 1990) or by using a slow release preparation to avoid the peak
blood levels associated with standard therapy (Belch 1991). Side effects
occurred in three of five breastfeeding patients treated for nipple
vasospasm. Side effects settled in one patient spontaneously and in the
remaining two with a change in dose (Lawlor-Smith and Lawlor-Smith 1997).
The reference for the use of nifedipine to treat affected nipples is
Lawlor-Smith LS, Lawlor-Smith CL. Raynaud's Phenomenon of the Nipple: A
preventable cause of breastfeeding failure? MJA 1997;166:448.
I would start this patient on 30mg of slow-release nifedipine as a single
daily dose and then assess response.
Laureen Lawlor-Smith
South Australia
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