Infants of mothers with persistent nipple pain exert strong sucking vacuums

Characterization of parameters for the analysis of objective measures of non-nutritive sucking of newborns

PURPOSE

To propose a methodology for analyzing data generated by an instrument measuring non-nutritive sucking pressure in newborns.

METHODS

An analytical observational study was developed, with a cross-sectional design, considering the data collected from 24 full-term newborns without complications. Three collections from each neonate were analyzed, with duration of 2 minutes and a 2-minute interval between them. The defined parameters were extracted using a program developed in Matlab®. The results were obtained by analyzing and comparing 12 variables at a 5% confidence level. Comparison of manual and computerized analyzes was also carried out using the intraclass correlation coefficient.

RESULTS

The multiple comparison between the three collection moments showed that the significant statistical differences occurred between collections one and two and two and three. When analyzing and comparing each variable separately, it was noted that the second collection showed: greater number of sucking groups, greater number of suctions, less time to start the sucking groups, longer time of sucking groups, less number of sporadic suctions, higher mean pressure values and with less standard deviation, more number of pauses with shorter time of pauses. The intraclass correlation coefficient revealed almost perfect agreement for the 12 evaluated parameters.

CONCLUSION

The 12 variables analyzed are relevant, especially in the second collection. The Matlab® program proved to be viable and effective in extracting and analyzing parameters, showing high agreement when compared to manual evaluation.

Application of Statistical Analysis and Machine Learning to Identify Infants' Abnormal Suckling Behavior

OBJECTIVE

Identify infants with abnormal suckling behavior from simple non-nutritive suckling devices.

BACKGROUND

While it is well known breastfeeding is beneficial to the health of both mothers and infants, breastfeeding ceases in 75 percent of mother-child dyads by 6 months. The current standard of care lacks objective measurements to screen infant suckling abnormalities within the first few days of life, a critical time to establish milk supply and successful breastfeeding practices.

MATERIALS AND METHODS

A non-nutritive suckling vacuum measurement system, previously developed by the authors, is used to gather data from 91 healthy full-term infants under thirty days old. Non-nutritive suckling was recorded for a duration of sixty seconds. We establish normative data for the mean suck vacuum, maximum suck vacuum, suckling frequency, burst duration, sucks per burst, and vacuum signal shape. We then apply computational methods (Mahalanobis distance, KNN) to detect anomalies in the data to identify infants with abnormal suckling. We finally provide case studies of healthy newborn infants and infants diagnosed with ankyloglossia.

RESULTS

In a series of case evaluations, we demonstrate the ability to detect abnormal suckling behavior using statistical analysis and machine learning. We evaluate cases of ankyloglossia to determine how oral dysfunction and surgical interventions affect non-nutritive suckling measurements.

CONCLUSIONS

Statistical analysis (Mahalanobis Distance) and machine learning [K nearest neighbor (KNN)] can be viable approaches to rapidly interpret infant suckling measurements. Particularly in practices using the digital suck assessment with a gloved finger, it can provide a more objective, early stage screening method to identify abnormal infant suckling vacuum. This approach for identifying those at risk for breastfeeding complications is crucial to complement complex emerging clinical evaluation technology.

CLINICAL IMPACT

By analyzing non-nutritive suckling using computational methods, we demonstrate the ability to detect abnormal and normal behavior in infant suckling that can inform breastfeeding intervention pathways in clinic.Clinical and Translational Impact Statement: The work serves to shed light on the lack of consensus for determining appropriate intervention pathways for infant oral dysfunction. We demonstrate using statistical analysis and machine learning that normal and abnormal infant suckling can be identified and used in determining if surgical intervention is a necessary solution to resolve infant feeding difficulties.

A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series

BACKGROUND

Lactation consultants frequently advise adjustments to fit and hold (or positioning and attachment) with the aim of optimising intra-oral nipple placement. However, approaches to fit and hold vary widely, with limited evidence of benefits, and effects of fit and hold on infant tongue movement have not been examined. The aim of this preliminary study was to investigate whether a gestalt breastfeeding intervention alters tongue movement, using measurements from ultrasound imaging to determine nipple placement and intra-oral nipple and breast tissue dimensions.

METHODS

Ultrasound measurements were conducted in five breastfeeding dyads, infants aged 4-20 weeks, while feeding in their usual or 'standard' position and again after brief application of gestalt principles of fit and hold. Four of the mother-baby pairs, who had received comprehensive lactation support, reported persisting nipple pain. Three of these infants had difficulty latching and fussed at the breast; three had been diagnosed with oral ties. A fifth pair was breastfeeding successfully.

RESULTS

Ultrasound demonstrated that the distance from nipple tip to junction of the hard and soft palate decreased, intra-oral nipple and breast tissue dimensions increased, and nipple slide decreased after a brief gestalt intervention.

CONCLUSION

These preliminary findings suggest that changes in fit and hold impact on infant tongue movement and contour. Further research investigating short- and long-term outcomes of a gestalt breastfeeding intervention in larger cohorts is required.

Re-thinking lactation-related nipple pain and damage

Nipple pain is a common reason for premature cessation of breastfeeding. Despite the benefits of breastfeeding for both infant and mother, clinical support for problems such as maternal nipple pain remains a research frontier. Maternal pharmaceutical treatments, and infant surgery and bodywork interventions are commonly recommended for lactation-related nipple pain without evidence of benefit. The pain is frequently attributed to mammary dysbiosis, candidiasis, or infant anatomic anomaly (including to diagnoses of posterior or upper lip-tie, high palate, retrognathia, or subtle cranial nerve abnormalities). Although clinical protocols universally state that improved fit and hold is the mainstay of treatment of nipple pain and wounds, the biomechanical parameters of pain-free fit and hold remain an omitted variable bias in almost all clinical breastfeeding research. This article reviews the research literature concerning aetiology, classification, prevention, and management of lactation-related nipple-areolar complex (NAC) pain and damage. Evolutionary and complex systems perspectives are applied to develop a narrative synthesis of the heterogeneous and interdisciplinary evidence elucidating nipple pain in breastfeeding women. Lactation-related nipple pain is most commonly a symptom of inflammation due to repetitive application of excessive mechanical stretching and deformational forces to nipple epidermis, dermis and stroma during milk removal. Keratinocytes lock together when mechanical forces exceed desmosome yield points, but if mechanical loads continue to increase, desmosomes may rupture, resulting in inflammation and epithelial fracture. Mechanical stretching and deformation forces may cause stromal micro-haemorrhage and inflammation. Although the environment of the skin of the nipple-areolar complex is uniquely conducive to wound healing, it is also uniquely exposed to environmental risks. The two key factors that both prevent and treat nipple pain and inflammation are, first, elimination of conflicting vectors of force during suckling or mechanical milk removal, and second, elimination of overhydration of the epithelium which risks moisture-associated skin damage. There is urgent need for evaluation of evidence-based interventions for the elimination of conflicting intra-oral vectors of force during suckling.

Osteopathic manipulative treatment to improve exclusive breast feeding at 1 month

OBJECTIVE

Previous studies have assessed breastfeeding-support programmes. Among these, osteopathic manipulative treatment (OMT) is a frequently used approach, although without strong evidence of efficacy.

METHODS

A double-blind randomised controlled trial was conducted between July 2013 and March 2016. Breastfed term infants were eligible if one of the following criteria was met: suboptimal breastfeeding behaviour, maternal cracked nipples or maternal pain. The infants were randomly assigned to the intervention or the control group. The intervention consisted of two sessions of early OMT, while in the control group, the manipulations were performed on a doll behind a screen. The primary outcome was the exclusive breastfeeding rate at 1 month, which was assessed in an intention-to-treat analysis. Randomisation was computer generated and only accessible to the osteopath practitioner. The parents, research assistants and paediatricians were masked to group assignment.

RESULTS

One hundred twenty-eight mother-infant dyads were randomised, with 64 assigned to each group. In each group, five infants were lost to follow-up. In the intervention group, 31 of 59 (53%) of infants were still exclusively breast fed at 1 month vs 39 of 59 (66%) in the control group, (OR 0.55, 95% CI 0.26 to 1.17; p=0.12). After adjustment for suboptimal breastfeeding behaviour, caesarean section, use of supplements and breast shields, the adjusted OR was 0.44 (95% CI 0.17 to 1.11; p=0.08). No adverse effects were reported in either group.

CONCLUSION

OMT did not improve exclusive breast feeding at 1 month.

TRIAL REGISTRATION NUMBER

NCT01890668.

25 Years of Research in Human Lactation: From Discovery to Translation

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.

Nipple shield use does not impact sucking dynamics in breastfeeding infants of mothers with nipple pain

Nipple shields (shield) may reduce pain during breastfeeding, but the impact on infant sucking dynamics is not known. We examined the effects of shield use on sucking dynamics, milk removal and nipple pain in two groups of breastfeeding dyads: pain group (PG): shield used for nipple pain; comparison group (CG): no breastfeeding difficulties. Twenty PG (6 ± 4 weeks postnatal) and 28 CG dyads (8 ± 6 weeks postnatal) attended 2 monitored breastfeeding sessions with shield use randomised. Within-subject outcomes were compared. PG: shield use did not affect intra-oral vacuum (peak p = 0.17, baseline p = 0.59), sucking frequency (p = 0.20) or milk transfer (40 mL vs 48 mL, p = 0.80; percentage of available milk removed (PAMR) 55% vs 57%, p = 0.88), and reduced McGill pain scores (p = 0.012). CG: shield use increased non-nutritive sucking (10% more, p = 0.049), and reduced nutritive sucking (18% less, p = 0.017) and milk transfer (63 mL vs 31 mL p < 0.001, PAMR 65% vs 36% p < 0.001). For both groups, feeding duration increased by 2 min (p < 0.0001) and non-nutritive portions of the feed increased with shield use.Conclusion: Nipple shield use improved maternal comfort and did not impact milk removal or sucking strength in PG, but significantly reduced milk transfer and nutritive sucking in CG. What is Known: • Mothers report that nipple shields reduce nipple pain and enable continued breastfeeding. • Concerns that nipple shield use may reduce milk transfer and alter infant sucking patterns are based on limited published evidence. What is New: • Nipple shield use is associated with a 25% reduction in pain scores in breastfeeding mothers with chronic nipple pain. • Milk transfer is not reduced in dyads that regularly use a shield for chronic nipple pain. • Intra-oral vacuums are not impacted by nipple shield use in mothers experiencing pain.

Impact of Nipple Shield Use on Milk Transfer and Maternal Nipple Pain

Background: Nipple pain is a common cause of early cessation of breastfeeding. A nipple shield (shield) is often used to improve breastfeeding comfort. There are concerns that shield use may limit milk transfer. The aims of this study were to determine whether shield use reduces milk transfer and maternal nipple pain. Methods: A within-subject study of two groups of breastfeeding dyads (infants <6 months) was conducted; Control Group (CG): no breastfeeding difficulties; Pain Group (PG) shield used for nipple pain. There were two monitored sessions where shield use was randomized. Test weights and pain questionnaires were completed, and percentage of available milk removed (PAMR) was calculated. Results: Twenty-five PG (6 ± 4 postnatal weeks) and 34 CG (9 ± 6 postnatal weeks) had similar 24-hour milk production (PG: 676 ± 239 mL, CG: 775 ± 162 mL, p = 0.083). PG mean milk transfer volume and PAMR did not differ with shield use (no shield: 46 mL, 59%; shield: 40 mL, 53%, volume p = 0.38, PAMR p = 0.64). CG mean volume and PAMR were reduced with shield use (no shield: 65 mL, 64%; shield: 31 mL, 33%, volume p < 0.001, PAMR p < 0.001). PG pain scores were similar with and without shield use (Visual Analog Scale p = 0.44, McGill p = 0.97). Conclusions: Shield use did not impact either milk production or milk transfer in breastfeeding women experiencing nipple pain.

Effect of nipple shield use on milk removal: a mechanistic study

BACKGROUND

Concerns about reduced milk transfer with nipple shield (NS) use are based on evidence from studies with methodological flaws. Milk removal during breastfeeding can be impacted by infant and maternal factors other than NS use. The aim of this study was to control electric breast pump vacuum strength, pattern and duration across multiple study sessions to determine if NS use reduces milk removal from the breast.

METHODS

A within-subject study with two groups of breastfeeding mothers (infants < 6 months) were recruited; Control Group (CG): no breastfeeding difficulties; Pain Group (PG) used NS for persistent nipple pain. Mothers completed three randomised 15 min pumping sessions using the Symphony vacuum curve (Medela AG); no NS, fitted NS, and a small NS. Sessions were considered valid where the applied vacuum was within 20 mmHg of the set vacuum. Milk removal was considered as pumped milk volume, and also percentage of available milk removed (PAMR), which is calculated as the pumped volume divided by the estimated milk volume stored in the breast immediately prior to pumping.

RESULTS

Of 62 sessions (all: n = 31 paired sessions) a total of 11 paired sessions from both PG (n = 03) and CG (n = 08) were valid (subset) with and without a fitted NS. Only 2 small shield sessions were valid and so all small shield measurements were excluded. Both pumped volumes and PAMR were significantly lower with NS use for all data but not for subset data. (All: Volume and PAMR median: no NS: 76.5 mL, 69%, Fitted NS: 32.1 mL, 41% respectively (volume p = 0.002, PAMR p = 0.002); Subset: Volume and PAMR median: no NS: 83.8 mL, 72%; Fitted NS: 35.2 mL, 40% (volume p = 0.111 and PAMR p = 0.045). The difference in PAMR, but not volume, was statistically significant when analysed by linear mixed modelling. A decrease of 10 mmHg was associated with a 4.4% increase in PAMR (p = 0.017).

CONCLUSIONS

This experimental data suggests that nipple shield use may reduce milk removal. Close clinical monitoring of breastfeeding mothers using nipple shields is warranted.

Latch-related nipple pain in breastfeeding women: the impact on breastfeeding outcomes

Background

Nipple pain is a common issue experienced by breastfeeding mothers and if not resolved, can contribute to early cessation of breastfeeding.

Aims

To investigate mothers experiences of nipple pain, the solutions used to manage their issues, and the perceived impact on breastfeeding outcomes with particular focus on latch-related nipple pain with no clear underlying cause (LRNP).

Methods

Data was collected via an online survey of UK-based women (n=1084).

Findings

LRNP was the most common issue as experienced by 52% of mothers surveyed. Various solutions were utilised to try to manage LRNP. Use of Highly Purified Anhydrous (HPA) Lanolin to manage LRNP was associated with a substantial increase in breastfeeding duration (average 33.2 weeks compared to 26.5 weeks for those who didn't report using HPA Lanolin).

Discussion

HPA Lanolin is a key solution used by mothers in the management of latch-related nipple pain and one which they perceive as having a significant positive effect on the physical symptoms and pain associated with nipple trauma. Use of HPA Lanolin was also associated with a substantial increase in breastfeeding duration which ultimately aids women in meeting their personal breastfeeding goals and improves overall breastfeeding rates.

Interchanging Breast Pump Kit Brands Alters Breast Pump Suction Pressure

Background: Postpartum mothers express and store breast milk using a hospital-grade pump and manufacturer-specific kit (flanges, bottles, tubing, valves, and membranes). After hospital discharge, mothers may attempt to interchange kits from different manufacturers. The objective of this study is to determine whether pump performance is affected by the use of a different manufacturer's kit. Materials and Methods: Suction pressure was tested using kits and six pumps from three manufacturers (Ameda, Medela, and Spectra). Pump settings (speed and vacuum strength) simulated maximum, minimum, and commonly used median settings. Suction pressure (mmHg) was measured using an analog gauge and repeated six times for each pump-kit combination. Measurements were compared using repeated measures analysis of covariance (ANCOVA) to determine whether kit was an independent predictor of suction pressure. Results: The kit type was a significant independent predictor (p < 0.05) of suction pressure for all at medium vacuum strength and many at maximum and minimum vacuum strengths. Upon further analysis interchanging kits resulted in both significantly increased and decreased suction pressures compared to the manufacturer-specific kit. Conclusion: Breast pump kits generate variable suction pressures when interchanged between pumps from different manufacturers. Interchanging combinations of kits and breast pumps could potentially lead to low milk expression due to ineffective suction pressure or increased discomfort from excessive pressure. The results of this study emphasize the importance of maternal education regarding the use of manufacturer-specific kits and breast pumps.

Nipple Deformation and Peripheral Pressure on the Areola During Breastfeeding

Breastfeeding is a complex process where the infant utilizes two forms of pressure during suckling, vacuum and compression. Infant applied compression, or positive oral pressure, to the breast has not been previously studied in vivo. The goal of this study is to use a methodology to capture the positive oral pressure values exerted by infants' maxilla (upper jaw) and mandible (lower jaw) on the breast areola during breastfeeding. In this study, the positive and negative (vacuum) pressure values are obtained simultaneously on six lactating mothers. Parallel to the pressure data measurements, ultrasound images are captured and processed to reveal the nipple deformations and the displacements of infants' tongues and jaw movements during breastfeeding. Motivated by the significant differences in composition between the tissue of the breast and the nipple-areola complex, the strain ratio values of the lactating nipples are obtained using these deformation measurements along with pre- and postfeed three-dimensional (3D) scans of the breast. The findings show an oscillatory positive pressure profile on the breast under both maxilla and mandible, which differs from clinical indications that only the mandible of an infant moves during breastfeeding. The strain ratio varies between mothers, which indicates volume changes in the nipple during feeding and suggests that previous assumptions regarding strain ratio for nonlactating breasts will not accurately apply to breast tissue during lactation.

Moving toward a better understanding of the experience and measurement of breastfeeding-related pain

Purpose: Despite how commonly breastfeeding-related pain is experienced in the postpartum period, and its frequent implication in breastfeeding cessation, this unique type of pain is not well evaluated nor assessed. The purpose of this study was to gain a comprehensive description and understanding of breastfeeding-related pain among postpartum breastfeeding women. Methods: This study employed a mixed methods approach using a descriptive-interpretive qualitative approach, in addition to administering the Short-Form McGill Pain Questionnaire, second version, to comprehensively gain both quantitative and qualitative descriptors of breastfeeding-related pain. Fourteen partnered and educated women living in Southern Ontario with experience of breastfeeding-related pain took part in this study. Results: The results from this study suggest that breastfeeding-related pain is often experienced as severe and distressing, and comprises various elements of pain including continuous, intermittent, neuropathic, and affective components. Conclusion: Breastfeeding-related pain is multidimensional and can be severe and distressing for women. Current measurement tools may not adequately reflect the multidimensional components of this unique type of pain, which may limit the effectiveness of health care providers to help with its identification and management.

Preterm Infant Feeding: A Mechanistic Comparison between a Vacuum Triggered Novel Teat and Breastfeeding

The goal for preterm infants is to achieve full oral feeds quickly and ultimately progress to full breastfeeding. Supplementary oral feeds are often given when the mother is not available to breastfeed. Bottles typically deliver milk in a different fashion compared to breastfeeding, which is thought to hamper transition to full breastfeeding. The aim of this study was to compare the sucking dynamics of preterm infants fed at the breast to feeding with an experimental novel teat (NT) designed to release milk only upon the application of vacuum. Simultaneous ultrasound imaging of the infant oral cavity and measurement of intra-oral vacuum was performed during a breastfeed and a feed with the NT. Test weighs were used to measure milk intake. Linear mixed effects models were performed to investigate differences by feed type, and simultaneous linear regression was performed to investigate individual patterns. Tongue movement was not different between breastfeeding and the NT. Intra-oral vacuums (median (interquartile range: IQR)) were significantly lower with the NT (Baseline vacuum: -5.8 mmHg (-11.0, 0.1); Peak: 40.0 mmHg (-54.6, -27.1)) compared to breastfeeding (Baseline: -31.1 mmHg (-60.0, -12.7); Peak: -106.2 mmHg (-153.0, -65.5)). Milk intake was significantly higher with the NT (33 mL (22.5, 42.5)) compared to the breastfeed (12 mL (3, 15.5)). The novel teat encouraged a similar tongue action to breastfeeding, and infants transferred a greater volume of milk with the novel teat. Intra-oral vacuums were lower in strength with the novel teat compared to the breast. Use of the novel teat for the training of sucking dynamics in preterm infants has the potential to improve breastfeeding success and requires further investigation.

Characterisation of sucking dynamics of breastfeeding preterm infants: a cross sectional study

BACKGROUND

Full breastfeeding is the ultimate aim for preterm infants to ensure they receive the full benefits of human milk however, preterm infants face a number of challenges associated with their immaturity and associated morbidities. In order to facilitate oral feeding, it is essential to have a sound knowledge of the sucking dynamics of the breastfed infant. The aim of this study was to measure and describe the sucking dynamics of the preterm breastfeeding infant.

METHODS

A prospective cross sectional observational study was carried out at King Edward Memorial Hospital, Perth. 38 mothers and their preterm infants (birth gestation age: 23.6-33.3 weeks; corrected gestation age 32.7 to 39.9 weeks) were recruited. Intra-oral vacuum levels, tongue movement and milk intake for a single breastfeed was measured. Statistical analysis employed linear regression and linear mixed effects models.

RESULTS

Synchronised ultrasound and intra-oral vacuum measurements show that the preterm infant generates vacuum by lowering their tongue in a parallel fashion, without distortion of the nipple/nipple shield. Baseline (B), mean (M) and (P) peak suck burst vacuums weakened over the course of a feed (B: p = 0.015; M: p = 0.018; P: p = 0.044) and mean and peak vacuums were weaker if the mother fed with a nipple shield (M: p = 0.012; P: p = 0.021). Infant milk intakes were higher when infants sucked for longer (p = 0.002), sucked for a greater proportion of the feed (p = 0.002), or had a greater sucking efficiency (p < 0.001).

CONCLUSIONS

Breastfeeding preterm infants generated intra-oral vacuum in the same manner as term infants. Nipple shields were associated with weaker intra-oral vacuums. However, vacuum strengths were not associated with milk intake rather time spent actively sucking was related to milk volumes. Further research is required to elucidate factors that influence preterm infant milk intake during breastfeeding.

Efficacy of an Osteopathic Treatment Coupled With Lactation Consultations for Infants' Biomechanical Sucking Difficulties

BACKGROUND

Despite well-known recommendations from national and international bodies including the World Health Organization, few mothers achieve the goal of breastfeeding exclusively for 6 months. Half of mothers stop breastfeeding due to biomechanical issues in the first month, despite increasing support from lactation consultants. Osteopaths worldwide work with these babies, but there is little empirical evidence for this type of treatment. Research aim: This study aimed to determine the efficacy of an osteopathic treatment coupled with usual lactation consultations on infants' ability to latch. Secondary objectives included assessment of nipple pain and mothers' perceptions of the effect of treatment.

METHODS

We conducted a single blind, randomized controlled trial at a mother-to-mother support group between January and December 2015. Data were collected at four different times over a 10-day period (T0-T10) from 97 mother-infant dyads using the LATCH assessment tool, a visual analog scale (VAS) to document mothers' nipple pain, and a de novo questionnaire for breastfeeding management and potential treatment side effects.

RESULTS

There were consistent statistical and clinical differences in the mean LATCH scores between the treatment and the control groups ( p < .001). However, no significant differences in the VAS scores were reported over time ( p = .713). Mothers reported no serious or unexpected side effects during the follow-up period.

CONCLUSION

This study is one of the first to bring together lactation consultants and osteopaths to address infants with biomechanical sucking difficulties. Findings support the hypothesis that the addition of osteopathy to regular lactation consultations is beneficial and safe.

Lactation in the Human Breast From a Fluid Dynamics Point of View

This study is a collaborative effort among lactation specialists and fluid dynamic engineers. The paper presents clinical results for suckling pressure pattern in lactating human breast as well as a 3D computational fluid dynamics (CFD) modeling of milk flow using these clinical inputs. The investigation starts with a careful, statistically representative measurement of suckling vacuum pressure, milk flow rate, and milk intake in a group of infants. The results from clinical data show that suckling action does not occur with constant suckling rate but changes in a rhythmic manner for infants. These pressure profiles are then used as the boundary condition for the CFD study using commercial ansys fluent software. For the geometric model of the ductal system of the human breast, this work takes advantage of a recent advance in the development of a validated phantom that has been produced as a ground truth for the imaging applications for the breast. The geometric model is introduced into CFD simulations with the aforementioned boundary conditions. The results for milk intake from the CFD simulation and clinical data were compared and cross validated. Also, the variation of milk intake versus suckling pressure are presented and analyzed. Both the clinical and CFD simulation show that the maximum milk flow rate is not related to the largest vacuum pressure or longest feeding duration indicating other factors influence the milk intake by infants.

Suck-Swallow-Breathe Dynamics in Breastfed Infants

Despite the importance of the suck-swallow-breathe reflex during breastfeeding, a large proportion of our understanding is derived from bottle-feeding studies. Given the differences in the delivery of milk during breast and bottle feeding, it is imperative that a more general view of the suck-swallow-breathe and milk removal process during breastfeeding is available. This systematic review aimed to assess the evidence for the mechanism of milk removal during breastfeeding; evaluate how the term infant coordinates sucking, swallowing, breathing (SSwB) and cardiorespiratory patterns; and how these patterns change with maturation during breastfeeding. A literature search of PubMed and MEDLINE was performed to assess the mechanism of milk removal and patterns of sucking, swallowing, breathing, and cardiorespiratory control during breastfeeding in healthy term infants. Seventeen studies were selected and a narrative synthesis was performed. Nine studies assessing the infant sucking mechanism consistently provided evidence that vacuum is essential to milk removal from the breast. The limited data on swallowing and breathing and cardiorespiratory control showed mixed results. Overall, results highlighted the high variability in breastfeeding studies and suggested that swallowing, breathing, and cardiorespiratory patterns change with maturation, and within a breastfeed. These findings show potential for devising breastfeeding interventions for populations at risk of SSwB problems. However, consistent methods and definitions of breastfeeding parameters are required before interventions can be adequately developed and tested.

Ultrasound Imaging of Breastfeeding--A Window to the Inside: Methodology, Normal Appearances, and Application

Ultrasound imaging has been employed as a noninvasive technique to explore the sucking dynamics of the breastfeeding infant over the past 40 years. Recent improvements in the resolution of ultrasound images have allowed a more detailed description of the tongue movements during sucking, identification of oral structures, and measurements of nipple position and tongue motion. Several different scanning planes can be used and each show sucking from a different perspective. Ultrasound techniques and image anatomy are described in detail in this review and provide the basis for implementation in the objective assessment of breastfeeding.

Vacuum characteristics of the sucking cycle and relationships with milk removal from the breast in term infants

BACKGROUND

The importance of an infant's intra-oral vacuum in milk removal from the breast has been established. However, the relationship between the vacuum curve and milk transfer is not well understood.

AIMS

To investigate the parameters of the infant suck cycle in relation to the volume of milk removed from the breast.

STUDY DESIGN

Cross-sectional study to elucidate the role of infant intra-oral vacuum in efficient milk removal from the breast.

SUBJECTS

Nineteen fully breastfed term infants.

METHODS

Intra-oral vacuum was recorded during monitored breastfeeds using a pressure transducer. Ultrasound imaging (milk flow) and respiratory inductive plethysmography (swallowing) were used to determine the nutritive sucking (NS) portion of the feed. Milk intake was determined by weighing infants before and after feeds. Vacuum traces of the first and next 2min of NS from the first breast were analysed.

RESULTS

The volumes of milk removed during both NS periods were negatively associated with peak vacuum (p<0.001) and rate of vacuum application (p<0.001), and positively related to area under first half of the suck cycle (p<0.001). Most parameters changed significantly from the first 2min of NS to the next 2min including significant reduction in peak vacuum and area under first half of the suck cycle.

CONCLUSION

These results further support the role of intra-oral vacuum, specifically optimal peak vacuum, in effective and efficient milk removal during breastfeeding. It also appears that infants modify their sucking dynamics to adapt to changes in milk flow during milk ejection as the breast empties.

Nipple Shields

Mothers have used nipple shields for centuries for various breastfeeding issues and problems. Shield use has become controversial, but many clinicians recommend the use of nipple shields under varying circumstances despite the absence of any professionally peer-reviewed or generally agreed-upon guidelines, protocols, policies, or clinical algorithms. Judicious use of nipple shields can salvage the breastfeeding process, and most mothers have found them to be helpful. However, some mothers and studies have reported problems with shields. There remain many questions regarding the effect of nipple shield use on infant feeding behaviors relative to the imprinting that may be affected by presenting a superstimulus to an infant during a sensitive or critical period of time. This raises more questions than answers.

Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments

Background: Persistent nipple pain is one of the most common reasons given by mothers for ceasing exclusive breastfeeding. We aimed to determine the frequency of nipple pain as a reason for consultation, the most common attributed aetiologies, and the effectiveness of the advice and treatment given. Methods: All consultations at the Breast Feeding Centre of Western Australia (WA) were audited over two six-month periods in 2011 (n = 469) and 2014 (n = 708). Attributed cause(s) of nipple pain, microbiology results, treatment(s) advised, and resolution of pain were recorded. Results: Nipple pain was one of the reasons for consultation in 36% of cases. The most common attributed cause of nipple pain was incorrect positioning and attachment, followed by tongue tie, infection, palatal anomaly, flat or inverted nipples, mastitis, and vasospasm. Advice included correction of positioning and attachment, use of a nipple shield, resting the nipples and expressing breastmilk, frenotomy, oral antibiotics, topical treatments, and cold or warm compresses. Pain was resolving or resolved in 57% of cases after 18 days (range 2–110). Conclusion: The multiple attributed causes of nipple pain, possibly as a result of a cascade of events, suggests that effective early lactation management for prevention of nipple pain and early diagnosis and effective treatment are crucial to avoid early weaning.

Persistent Nipple Pain in Breastfeeding Mothers Associated with Abnormal Infant Tongue Movement

Background: Infants of breastfeeding mothers with persistent nipple pain have been shown to apply stronger vacuums to the breast and transfer less milk during one monitored feed. This may be associated with differences in the movement of the tongue. The aim was to analyse the intra-oral nipple shape and movement of the tongue of infants of mothers with and without nipple pain. Methods: Breastfeeding infants of mothers with or without nipple pain were monitored using ultrasound and intra-oral vacuum during one breastfeed. From cine clips of the ultrasound scans measurements were made of the depth of the intra-oral space between the hard-soft palate junction (HSPJ) and the mid-tongue; the distance of the tip of the nipple to the HSPJ; and nipple diameters from the tip to the base. Results: During nutritive sucking, tongue movements of infants of mothers with nipple pain resulted in a smaller intra-oral space (p = 0.040) and restricted nipple expansion compared to controls (p < 0.012). Stronger baseline and peak vacuums compared to controls were confirmed (p = 0.002). Conclusion: In these mothers, nipple pain was associated with restricted infant tongue movement. Ultrasound may complement measurement of intra-oral vacuum in monitoring treatment strategies in breastfeeding women experiencing nipple pain.

Case report of nipple shield trauma associated with breastfeeding an infant with high intra-oral vacuum

BACKGROUND

Nipple pain is associated with early cessation of breastfeeding and may be caused by high intra-oral vacuum. However identification of high intra-oral vacuum is typically restricted to the research setting. This is the first reported case of an infant with high intra-oral vacuum that was clinically identified through a specific pattern of nipple trauma associated with nipple shield use. Knowledge of clinical signs associated with high intra-oral vacuum may facilitate early recognition of this unusual breastfeeding challenge.

CASE PRESENTATION

The mother of an exclusively breastfed 3 month old infant had severe bilateral nipple pain with minimal trauma that persisted from birth. The nipples were not misshapen immediately after breastfeeding and adjustments to infant attachment at the breast did not attenuate the pain. Examination of the infant's oral anatomy was unremarkable with no ankyloglossia present. Microbiological cultures of nipple swabs and breast milk were negative for bacterial and fungal growth, and prescribed antimicrobial treatments did not reduce the nipple pain. Mild blanching and erythema of the nipples were occasionally observed, and were not consistent with nipple vasospasm. Nipple shields were used regularly as they modified the pain, although this resulted in blisters that corresponded with the nipple shield holes. Measurement of infant intra-oral vacuum during breastfeeding confirmed intra-oral vacuum up to 307 % higher than reference values. Breastfeeding gradually became less painful, and after 6 months was completely comfortable.

CONCLUSIONS

High intra-oral vacuum is difficult to assess in the clinical setting and is likely an under-reported cause of early weaning that is not well understood. This original case report highlights high intra-oral vacuum as at differential diagnosis to be considered by health professionals when evaluating mothers experiencing strong nipple pain during the initiation of breastfeeding. A clinical screening tool is needed to enable prompt identification of these infants.

Nipple pain, damage, and vasospasm in the first 8 weeks postpartum

BACKGROUND

Nipple pain and damage are common in the early postpartum period and are associated with early cessation of breastfeeding and comorbidities such as depression, anxiety, and mastitis. The incidence of nipple vasospasm has not been reported previously. This article describes nipple pain and damage prospectively in first-time mothers and explores the relationship between method of birth and nipple pain and/or damage.

SUBJECTS AND METHODS

A prospective cohort of 360 primiparous women was recruited in Melbourne, Australia, in the interval 2009-2011, and after birth participants were followed up six times. The women completed a questionnaire about breastfeeding practices and problems at each time point. Pain scores were graphically represented using spaghetti plots to display each woman's experience of pain over the 8 weeks of the study.

RESULTS

After birth, before they were discharged home from hospital, 79% (250/317) of the women in this study reported nipple pain. Over the 8 weeks of the study 58% (198/336) of women reported nipple damage, and 23% (73/323) reported vasospasm. At 8 weeks postpartum 8% (27/340) of women continued to report nipple damage, and 20% (68/340) were still experiencing nipple pain. Ninety-four percent (320/340) of the women were breastfeeding at the end of the study, and there was no correlation between method of birth and nipple pain and/or damage.

CONCLUSIONS

Nipple pain is a common problem for new mothers in Australia and often persists for several weeks. Further studies are needed to establish the most effective means of preventing and treating breastfeeding problems in the postnatal period.

A feasibility evaluation of oral pressure therapy for the treatment of obstructive sleep apnea

Objective:

This feasibility study examined the initial-use safety and potential utility of a novel noninvasive oral pressure therapy (OPT) system designed to reduce airway obstruction during sleep.

Methods:

This was a single-center, proof-of-concept, single-treatment-night study in which subjects with obstructive sleep apnea (OSA) underwent a baseline polysomnography (PSG) study followed by PSG during use of an OPT system. The OPT system is composed of a bedside console, a polymer mouthpiece, and a flexible tube connecting the mouthpiece to the console. The console contains a pump that creates vacuum intended to pull the soft palate anteriorly and stabilize the tongue to reduce obstruction during sleep.

Results:

Fifty-four men and 17 women, aged 53.2 ± 11.5 years (mean ± SD) had a baseline apnea–hypopnea index (AHI) greater than 5 events per hour. OPT was generally well tolerated with no serious adverse events. OPT significantly decreased AHI from 34.4 ± 28.9 events per hour (mean ± SD) at baseline to 20.7 ± 23.3 ( p < 0.001). Treatment produced an AHI less than 10 in 48% of the subjects. OPT significantly improved oxygen desaturation index ( p < 0.001) and increased the percentage of the night with oxygen saturation of 90% or greater ( p = 0.028). Stage-N1 sleep shifts, total sleep-stage shifts, awakenings and the percentage of sleep time spent in N1 sleep were significantly reduced with treatment.

Conclusion:

This proof-of-concept study suggests that OPT can produce clinically relevant relief of OSA in certain subjects who are readily identified by PSG during trial use of the noninvasive system. OPT shows promise as a new treatment option for OSA in appropriate patients.

Nipple pain during breastfeeding with or without visible trauma

BACKGROUND

Nipple pain is a major cause of early weaning. The causes of nipple pain are diverse, and most treatments involve experience-based assessment. There is little knowledge of the intensity or variation in pain experienced by breastfeeding women. Given the high breastfeeding initiation rates, it is important to evaluate pain experienced by lactating women in detail.

OBJECTIVE

To investigate and compare the pain experienced by breastfeeding women using objective measures.

METHODS

The type, effect, and severity of pain were measured using the McGill Pain Questionnaire, Brief Pain Inventory, and Visual Analogue Scale, respectively, for 2 groups of breastfeeding women. One group were experiencing persistent nipple pain despite treatment, and the other had obvious signs of nipple trauma.

RESULTS

Pain intensity and interference scores were highly variable for both groups. Mothers with nipple trauma reported significantly higher mean pain intensity and breastfeeding interference. Higher pain intensity scores were related to higher interference scores. After accounting for pain intensity, higher interference with general activity, mood, and sleep interference was related to longer duration of pain. There was no difference in MPQ class scores.

CONCLUSIONS

The ramifications of nipple pain extend far beyond the act of breastfeeding, particularly for women whose pain lasts several months. Given the lack of evidence-based treatments, it is not surprising that pain is a major contributor to premature weaning. Further research into the causes of nipple pain is necessary to enable the implementation of effective interventions, thus reducing further complications such as infection and postnatal depression. Detailed pain analysis may assist in assessing the success of these interventions.

Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain

BACKGROUND

Nipple pain and insufficient milk supply are major causes of early weaning. We have found that persistent nipple pain was associated with strong infant sucking vacuums during breastfeeding. Several studies indicate that nipple pain and abnormal infant sucking have the potential to reduce milk transfer. We aimed to determine whether women with persistent nipple pain had low milk supply.

SUBJECTS AND METHODS

The 24-hour milk production and feeding characteristics of mothers with persistent nipple pain (n=21) were compared with those mothers without nipple pain (n=21). Milk productions were measured by test-weighing the infant before and after every feed from each breast over a 24-26-hour period. Comparisons were made using Student's t tests and linear mixed models as appropriate.

RESULTS

Lower milk productions were associated with longer meal durations for mothers with pain. There were no significant differences in the average 24-hour milk production or any feeding characteristics between the groups. However, four women with persistent nipple pain had milk production levels below 500 mL/day.

CONCLUSIONS

The majority of breastfeeding women experiencing persistent nipple pain were able to achieve normal milk production levels. Feeding duration and frequency were similar to those of women not experiencing pain. However, longer meal durations in the pain group were associated with lower levels of milk production. Further investigation is necessary to identify mothers most affected by maternal nipple pain.

Oxygen Saturation and Suck-Swallow-Breathe Coordination of Term Infants during Breastfeeding and Feeding from a Teat Releasing Milk Only with Vacuum

Background. Vacuum is an important factor in milk removal from the breast, yet compression is the predominant component of milk removal from bottle teats. Since bottle-feeding infants have lower oxygen saturation, vacuum levels, and different suck-swallow-breathe (SSwB) coordination to breastfeeding infants, we hypothesised that when infants fed from a teat that required a vacuum threshold of -29 mmHg for milk removal, that oxygen saturation, heart rate, and suck-swallow-breathe (SSwB) patterns would be similar to those of breastfeeding. Study Design. Infants (n = 16) were monitored during one breastfeed and one feed from the experimental teat. Simultaneous recordings were made of oxygen saturation, heart rate, vacuum, tongue movement, respiration, and swallowing. Results. There were no differences in oxygen saturation and heart rate between the breast and the teat. Infants displayed fewer sucks and breaths per swallow during nutritive sucking (NS) compared to non-nutritive sucking (NNS). The number of sucks per breath was similar for NS and NNS although respiratory rates were slower during NS. These patterns did not differ between the breast and the teat. Conclusion. These results suggest that vacuum may be conducive to safe and coordinated milk removal by the infant during both breast and bottle-feeding.