Evidence has shown that breast milk alone is sufficient for infant nutrition in the first 6 months of life (Butte et al, 2002). The World Health Organization (WHO, 2024) recommends that babies should be put to the breast within the first hour after birth and be exclusively breastfed for the first 6 months. It is recommended to continue breastfeeding up to 2 years of age or beyond, and implement complementary foods only after 6 months (Butte et al, 2002).
Despite the well-established evidence supporting these recommendations, exclusive breastfeeding rates remain low (WHO, 2024). According to the WHO (2023) fact sheet, only 44% of infants are exclusively breastfed globally. In the UK, only 1% of mothers maintain exclusive breastfeeding to 6 months (Department of Health, Social Services and Public Safety, 2013; UNICEF, 2017). Across the UK, rates of exclusive breastfeeding to 6 weeks vary, with 24% reported in England, 17% in Wales, 32% in Scotland and 13% in Northern Ireland (D'Cruz, 2018; UNICEF, 2024). A study by the Scottish government in 2017, showed an increase in the proportion of infants receiving breastmilk at 6 months to 43%, from 32% in 2010 (D'Cruz, 2018). Approximately 80% of breastfeeding mothers in the UK do not meet their breastfeeding desires as a result of breastfeeding-related pain and other maternal, infant or social challenges (UNICEF, 2017; Wray and Garside, 2018).
Although it is acknowledged that some level of nipple discomfort is generally inevitable, nipple pain and injury persist as one of the most common reasons for ceasing breastfeeding (Ziemer et al, 1990; Morland-Schultz and Hill, 2005; Dennis et al, 2014). Breastfeeding-related pain has been reported as a cause of concern by 74% of mothers (McCann et al, 2007; Wagner et al, 2013; UNICEF, 2017). Despite evidence-based recommendations, there are no consistent recommended practices to help new mothers overcome this challenge (Buck et al, 2014).
Care pathways use multidisciplinary guidelines to incorporate current best practices into management plans for specific conditions (Coffey et al, 1992; Rosenberg and Donald, 1995; Kitchiner and Bundred, 1996; Sackett et al, 1996). Care pathways are also designed to reduce undue variations in the approach to management of patients with similar conditions (Teisberg et al, 2020; Payedimarri et al, 2021). While numerous interventions have been proposed to reduce nipple pain in breastfeeding mothers, a critical evaluation failed to reveal any irrefutable intervention, leading to differences in recommended approaches (Dennis et al, 2014). Given variations in recommended practices, an expert-validated, evidence-based nipple care pathway can provide a standardised, best practice approach for managing breastfeeding-related nipple injuries.
The Delphi methodology is a structured group communication process where experts use an iterative approach to evaluate complex issues with conflicting or incomplete data and reach consensus. The primary purpose of the technique is to generate a reliable consensus opinion from a group of experts by an iterative process of questionnaire interspersed with controlled feedback (Dalkey and Helmer, 1963; Nasa et al, 2021). This method has been used in healthcare for many purposes, including development of care pathways and to improve support for maternal outcomes (Harwood et al, 2021; Payedimarri et al, 2021).
This study's aim was to validate the complex breastfeeding research evidence and translate it into simple but effective mother-facing guidance to help in the prevention, identification and management of breastfeeding-related nipple injuries.
Methods
Figure 1 illustrates the nipple care pathway development process. A scoping review extracted recommended practices from selected databases. Flowcharts based on evidence and other recommendations were created and compiled into statements. Maternal health experts, including breastfeeding-experienced mothers, formed a Delphi panel to review and provide feedback on the statements. The statements were amended, clarified or adopted based on experts' feedback.
Scoping review
This study used the 5-stage scoping methodology framework proposed by Arksey and O'Malley (2005). This includes:
- Stage 1: identifying the research question
- Stage 2: identifying the relevant studies
- Stage 3: study selection
- Stage 4: charting the data
- Stage 5: collating, summarising and reporting.
The optional stage of ‘consultation exercise’, which involves consulting end users and professionals, was accomplished during the Delphi process (Arksey and O'Malley, 2005).
Search strategy
The PubMed, Science Direct, Medline-Ovid and Cochrane databases were searched for literature. The following search strings were used in different combinations: ‘sore nipples’, ‘nipple fissure’, ‘breastfeeding nipple pain’, ‘sore nipple prevention/treatment’, ‘nipple fissure prevention/treatment’ and ‘nipple pain prevention/treatment’. The websites for the National Institute of Health and Care Excellence (NICE), NHS and WebMD were also searched for relevant guidance documents and information. Searches were performed on 21 and 30 June 2022.
Screening process
Of the 1982 returned studies, four non-English studies and 305 duplicates were excluded. After abstract screening, 1172 studies were further excluded and an additional 448 were excluded in the eligibility review. Full details are shown in Figure 2.
Study eligibility
A total of 405 studies were assessed for suitability based on the criterion of a conclusion recommending specific practices for identifying, preventing or managing breastfeeding-related nipple injuries. No specific timeframe was set for eligible literature. After assessment, 53 publications were retained, and recommended nipple care practices were extracted.
The scoping review revealed diverse options for preventing or treating breastfeeding-related nipple injuries, categorised into education, practices, dressings, breast shield/shells, breast milk and non-pharmacological topical ointments. The complete findings of the review are currently under peer review for separate publication.
Creating the Delphi item list
Extracted recommendations were categorised according to their target; prevention, identification or treatment of breastfeeding-related nipple injuries. Collected recommendations from the NICE, NHS and partner sites were categorised on the Delphi item list. Flowcharts, combining recommendations for various stages of breastfeeding, were created by the authors and added to the list for expert review.
Recruitment of relevant experts
UK-based maternal healthcare professionals and mothers who had breastfed for 1 month or more in the year before data collection (2022) were invited to the Delphi expert panel. They were recruited through professional contacts and networks, as well as online advertisements, from diverse areas of the UK. While maternal healthcare professionals may not be academic experts in breastfeeding, they serve as primary care providers for breastfeeding mothers in the UK, with their clinical expertise deemed valuable in this study. Continuous academic programmes contribute to their knowledge, making their experience considered ‘expert’. The final panel was composed of 26 breastfeeding mothers and professionals, including GPs, gynaecologists, midwives, lactation consultants, community pharmacists, doulas and health visitors.
The Delphi study process
A modified online Delphi technique validated evidence-based recommendations through three rounds of expert surveys following a virtual welcome meeting. Study rounds were specified as three, with exclusion and inclusion criteria, as well as feedback on why items were dropped or added, clearly stated (Diamond et al, 2014).
The Jisc online survey was used for data collection, where participants could rate the statements and flowcharts on the Delphi item list and leave comments or feedback. Surveys were open for 7 days, with reminders sent on the 4th day to encourage expert participation. Experts who did not respond were reinvited in subsequent rounds. Data were collected over 5 weeks between September and October 2022.
Data were extracted and analysed via Microsoft Excel. In accordance with improved reporting standards, consensus was defined a priori as 80% expert agreement. Basic quantitative analysis using percentages in Excel was done to determine consensus, while qualitative recommendations were categorised thematically by the authors.
First round
For the first round, a link to the web-based Delphi questionnaire was emailed to all participants to decide if the recommendations, including the generated flowcharts, should be adopted into the nipple care pathway. Participants were also invited to optionally leave a comment in support of their choices.
If an item achieved 80% agreement, it was recorded and excluded from further rounds. Items lacking consensus were revised based on feedback for the second round. Feedback beyond the study scope was recorded but excluded from the survey in subsequent rounds.
Second round
For the second round, a link to the modified Delphi questionnaire was emailed to all participants to review and feedback. Responses were collated and analysed, as per the first round. Recommended practices not reaching consensus from the two previous rounds were modified according to respondents' comments.
Third round
The final round replicated previous steps, reviewing all recommendations that gained consensus in the first two rounds. Flowcharts from the first round were modified based on earlier feedback and included for final review.
Ethical considerations
Ethical approval for this study was granted by the University of Leeds ethics review board (reference: HREC 21-016). The study aims and participants' involvement were fully discussed with all participants, who were thenasked to sign an informed consent form. Research data were managed in line with the university's research data management policy.
Results
A total of 26 experts completed the first round (22–28 September 2022), 22 in the second (3–9 October 2022), and 23 in the third (14–20 October 2022). All identified disciplines were represented in every round. Overall, 32 statements were assessed in the first round, 17 in the second and 11 in the third (Table 1).
Table 1. Summary of consensus process and experts' engagement
| Round | Partcipating experts (%) | Opening items | Items reaching consensus | New items added for review in next round |
|---|---|---|---|---|
| 1 | 26/35 (74.3) | 32 | 18 | 3 |
| 2 | 22/26 (84.6) | 17 | 11 | 5 |
| 3 | 23/26 (88.5) | 11 | 10 | - |
Consensus recommendations were categorised into support and education-related recommendations (Table 2); technique-related recommendations (Table 3); and nipple care-related recommendations (Table 4).
Table 2. Support and education-related recommendations
| Guidelines statement | Round where consensus reached | Agreement (%) |
|---|---|---|
| First-time mothers in the UK are generally unprepared for breastfeeding and its associated challenges | 1 | 80.8 |
| One-to-one breastfeeding classes should be integrated as part of the routine in-person antenatal care services for all expecting mothers | 1 | 92.3 |
| Group breastfeeding sessions are an adequate alternative where one-to-one sessions are not available or accessible | 2 | 90.9 |
| Pregnant women intending to breastfeed would be more likely to succeed if they had a better understanding of the physiological discomfort and hypersensitivity that are commonly associated with the early stages of breastfeeding | 1 | 96.3 |
| Healthcare professionals should schedule the first postpartum in-person breastfeeding training on positioning and attachment within the first 2 hours of birth | 1 | 84.6 |
| It is essential that every mother receives in-person professional support to achieve good positioning and attachment at their first attempt at breastfeeding | 2 | 95.5 |
| To prevent recurrence, breastfeeding mothers with cracked nipples should seek face-to-face breastfeeding education sessions as part of their treatment/recovery plan | 1 | 92.3 |
| Commercially available nipple care products are important tools supporting mothers in early stages of breastfeeding and play a significant role in supporting breastfeeding in the UK | 1 | 80.8 |
Table 3. Technique-related recommendations
| Guideline statement | Round where consensus reached | Agreement (%) |
|---|---|---|
| Ensuring babies take as much of the areola as possible in their mouths during feeding is important in preventing breastfeeding-related nipple injuries | 1 | 88.4 |
| Gently expressing some breast milk, to soften the breast before breastfeeding, is effective in improving latch | 3 | 91.3 |
| It is important for breastfeeding mothers to gently break latch if milk flow is not established within 2 minutes (as evidenced by rhythmic sucks and regular swallowing movements) | 2 | 81.8 |
Breast pumping is recommended to a breastfeeding mother when she is:
|
2 | 95.586.481.8 |
Table 4. Nipple care-related recommendations
| Guideline statement | Round where consensus reached | Agreement (%) |
|---|---|---|
| Presence of nipple pain during or after a feed could be an early sign of a problem and advice from a healthcare professional should be sought as soon as possible | 1 | 96.2 |
| Breastfeeding mothers should examine their nipples for whiteness, abnormal shape and contour (looking pinched or flattened on one side) after every feed to identify early signs of nipple problems | 1 | 96.2 |
| Mothers with nipple pain should consider expressing breast milk by hand, if necessary, when nipple pain becomes unbearable | 1 | 96.2 |
| I will recommend the application of lanolin to prevent breastfeeding-related nipple injuries | 1 | 88.5 |
| The principles of moist wound healing, where an occlusive barrier protects the injured tissue and provides optimal environment for wound healing, can be applied to breastfeeding mothers with nipple injuries (cracked or severely damaged nipples) | 1 | 96.2 |
| Frequent lanolin application and short-term use of a nipple shield while feeding is an effective measure for mothers with breastfeeding-related nipple injuries who want to continue breastfeeding while their nipples heal | 1 | 96.2 |
| The following practices are recommended to breastfeeding mothers with nipple soreness: seek lactation support from midwife and health visitor, apply lanolin, continue breastfeeding as normal and take oral analgesics | 2 | 86.4 |
| The following practices are recommended to breastfeeding mothers with painful, cracked nipple(s): seek lactation support from midwife and lactation consultant, apply lanolin, continue breastfeeding as normal, take oral analgesics and use nipple shield | 2 | 86.4 |
| The following practices are recommended to breastfeeding mothers with severely damaged nipple(s): seek lactation support from midwife and lactation consultant, apply lanolin, take oral analgesics and discontinue breastfeeding from affected nipple | 2 | 81.8 |
The majority (80.8%) of participants believed that UK first-time mothers lacked preparation for breastfeeding, with 96.3% emphasising the importance of understanding early breastfeeding challenges. Experts highlighted the significant role of nipple care products (80.8%) and advocated for integrating one-to-one breastfeeding classes in routine antenatal care services (92.3%). If this was not feasible, 90% suggested group sessions as alternatives. In round three, unanimous expert agreement resulted in a consolidated statement on preparing pregnant women for breastfeeding.
Pregnant women should be provided with prenatal breastfeeding education that is open and realistic about potential challenges encountered when breastfeeding; offers a problem-focused approach to monitor breastfeeding; and explains clearly when, how and where to get further information, advice and support.
Recommended techniques to improve breastfeeding experience for mothers included ensuring that babies take as much of the areola as possible in their mouths (88.4%), gently massaging the breasts to soften them before feeding (91.3%), gently breaking the latch if milk flow is not established within 2 minutes (81.8%) and considering breast pumping in certain situations (81.8–95.5% across three situations).
Among the many recommended practices to help nursing mothers care for their nipples, 88.5% of participants recommended applying lanolin to prevent nipple injuries. Almost all agreed on moist wound healing for cracked and severely damaged nipples (96.2%), and endorsed frequent lanolin use and short-term nipple shield use for breastfeeding mothers with injuries (96.2%).
Flowcharts
Figure 3 outlines a breastfeeding flowchart to reduce the risk of nipple injuries. The chart highlights the importance of a good latch, steps to achieve optimal latch and infant positioning, and signs of successful infant to reduce the risk of breastfeeding-related nipple injuries and enhance breastfeeding confidence. Figure 4 shows a prevention tool designed to aid new mothers in identifying breastfeeding complications, offering guidance and clinical indications. Consensus on both flowcharts was achieved in the third round following input from the first round.
Discussion
Breastfeeding related nipple injuries stand out as a prominent postpartum maternal concern. Existing studies, including clinical trials, have produced inconsistent and conflicting data. Furthermore, certain study designs and a notable gap between academia and practical application render some recommendations impractical (Agbedia et al, 2014; Leach and Tucker, 2018). Using a modified Delphi consensus method to develop a self-management guide for mothers may be one way to mitigate this challenge (McMillan et al, 2016). This study harnessed the knowledge and experiences of multidisciplinary maternal health experts to generate effective and practicable support material.
Educational and technique recommendations
The present study found that experts believed that initiating prevention of breastfeeding-related nipple injuries should involve practices before childbirth, underscoring the significance of including one-to-one breastfeeding classes in routine antenatal care. Pregnant women with disabilities or situations that may affect breastfeeding should explore all options, accessories and support to help personalise their experience. Seeking peer support is also recommended prenatally. This further emphasises the role of prenatal education or counselling in reducing breastfeeding complications (Karaçam and Sağlık, 2018; Gao et al, 2022).
Many studies highlight the importance of proper latch and positioning in preventing nipple injuries among nursing mothers (Cadwell et al, 2004; Morland-Schultz and Hill, 2005). In line with WHO (2022) recommendations, experts advise initiating breastfeeding within an hour of birth, with ongoing healthcare professional support until the mother feels comfortable with handling and positioning for a proper latch. Early initiation and supervision are crucial for mothers to achieve their breastfeeding goals.
Mothers separated from their babies are encouraged to consider other options including manual hand expressing and/or breast pumping to ensure their babies continue to get breastmilk, especially colostrum, which is crucial for their development (Grueger et al, 2013; WHO and UNICEF, 2014). The Delphi panel agreed on other evidence-based practices, such as gently massaging the breast to soften it and improve latch, ensuring babies take as much of the areola as possible in their mouths, and gently breaking a latch if milk flow is not established within 2 minutes.
Suggestions on how to help mothers meet their breastfeeding goals revolved around providing open and honest discussions on breastfeeding and more efficient support for breastfeeding mothers, as well as normalising breastfeeding to improve mothers' experiences. Statements such as ‘get on with it’ and ‘if you are doing it right, it shouldn't hurt’ were acknowledged as common but unacceptable remarks made by professionals providing lactation support. Breastfeeding is often projected as a problem-free process for mothers, making mother unduly worried at the first experience of discomfort. Providing honest and open information empowers mothers to make well-informed decisions about breastfeeding, equipping them to handle common challenges on their breastfeeding journey. Many studies, including a qualitative exploration of mothers' breastfeeding experiences (Powell et al, 2014), have supported the importance of professionals providing honest information about breastfeeding expectations.
In-person support for breastfeeding is crucial. Acknowledging practical challenges, 92.3% of experts proposed integrating ‘one-to-one’ breastfeeding classes into routine antenatal care, with 90.9% endorsing group sessions as a viable alternative. This supports UNICEF's (2024) suggestion that the provision of face-to-face support in local communities is a key aspect of improving breastfeeding rates in the UK.
To normalise breastfeeding, it is crucial to enhance its visibility in public, media and school education, especially in ethnic minority groups. Many studies have shown that breastfeeding mothers feel uncomfortable feeding when they are out of the comfort of their homes because of public reception (Boyer, 2012), triggering them to discontinue breastfeeding when they have to return to work or leave home more frequently (Amir, 2014).
Nipple care recommendations
In the UK, the NHS (2022; 2024) and NICE (2022) recommend the application of breast milk on the nipple and areola complex to prevent and manage breastfeeding-related nipple injuries. The Delphi panel did not achieve consensus on using breast milk for preventing or treating breastfeeding-related nipple injuries. However, consensus was reached on the significance of commercially available nipple care products in supporting early-stage breastfeeding in the UK (80.8% agreement).
For breastfeeding mothers with nipple-related concerns, recommendations, including which healthcare professional to see, vary depending on severity. The categorisation of nipple injuries into sore, cracked and severely damaged (shown in Table 4) is descriptive, given that symptoms can differ. However, experts recommended lanolin for all levels of nipple injuries, despite current guidelines (NHS, 2022; NICE, 2022). This recommendation correlates with published data on the benefit of lanolin to improve breastfeeding experience (Jackson and Dennis, 2017; Mariani et al, 2018; Silva et al, 2022). However, the disconnect between practice guidelines and the clinical recommendation on this issue is notable and may suggest that the guidelines are not reflective of up-to-date practice.
The nipple injury identification tool (Figure 4) is intended to help mothers identify causes of nipple-related injury and suggest next steps. While oral analgesics are recommended, in line with NHS (2023) guidance, practices such as support contacts differed based on injury severity. Promptly directing mothers based on their needs will prevent tertiary delay in receiving assistance (Combs Thorsen et al, 2012; Papali et al, 2015). Additionally, breastfeeding mothers with nipple injuries may use lanolin and take oral analgesics. Those with cracked nipples could consider a short-term nipple shield, while severe damage may require discontinuing feeding from the affected breast and exploring pumping or manual expression.
The nipple care pathway provides tailored alternatives for mothers to continue breastfeeding in specific situations. Despite extensive nipple injuries, some mothers value every opportunity to breastfeed and were recommended short-term nipple shield use by 96.2% of experts, highlighting a significant contrast with current UK guidelines. The strong consensus on the importance of commercial products, including nipple shields, contradicts NHS (2024) guidance that discourages their use. The reason behind the aversion to using products for breastfeeding support is unclear. One assumption is that breastfeeding accessories are often associated with infant formula, despite being designed to reduce the risk of switching to formula. The belief that breastfeeding should be easy and free for all mothers might contribute to resistance against the ‘commoditisation of breastfeeding’. This raises ethical concerns about healthcare practitioners and stakeholders failing to discuss available options with breastfeeding mothers, questioning their ability to make informed decisions. In the broader context, this reflects societal minimisation of women's pain, body autonomy and freedom of choice in healthcare decisions (O'Malley, 2021).
Implications for practice
The expert-validated nipple care pathway provides a standardised, evidence-based approach for preventing, identifying and managing breastfeeding-related nipple injuries, reducing undue variations in care. It emphasises tailored recommendations based on injury severity for personalised care. There is strong consensus on integrating one-to-one breastfeeding classes into routine antenatal care and early engagement with peer support groups are recommended to better prepare and support mothers. Providing open, honest and realistic information about breastfeeding expectations and challenges is advised to empower mothers' decision making. Overall, the study advocates for a more standardised, proactive, personalised and supportive approach to breastfeeding-related nipple injuries prevention and management.
Limitations
The Delphi method's reliability is debated because of factors such as personal biases. Healthcare professionals, while often primary sources of breastfeeding support, might lack expertise in human lactation. This was mitigated by involving diverse stakeholders active in breastfeeding support. The stringent 80% consensus threshold exceeds common Delphi standards. The panel's size may limit representation, and all experts were UK-based, impacting the generalisability of the study findings beyond the UK.
Conclusions
The Delphi panel achieved consensus on diverse recommendations for breastfeeding success and nipple issues, ensuring a consistent, data-driven standard of care for UK mothers. The need for tailored breastfeeding-related nipple injury management recommendations was emphasised to offer personalised care. The study presents an evidence-based, expert-validated nipple care pathway, a valuable self-care tool guiding prevention, identification and treatment of breastfeeding-related nipple injuries. However, occasional disparities between expert consensus and published guidance highlight the need for further research to align practices with recommendations, ensuring optimal support for breastfeeding goals.
Key points
- This study addressed the global challenge of low exclusive breastfeeding rates, emphasising the prevalence of breastfeeding-related nipple injuries as a significant factor in early cessation.
- The research, conducted through a mixed-method approach involving a scoping review and modified Delphi consensus technique, aimed to create an evidence-based nipple care pathway for new breastfeeding mothers.
- The study engaged UK-based maternal health experts and experienced breastfeeding mothers to reach consensus on key recommendations.
- Notable findings include the importance of one-to-one breastfeeding classes, early engagement in peer support groups, and the use of breastfeeding accessories for the prevention and management of breastfeeding-related nipple injuries.
- The study identified inconsistencies between expert consensus and published guidance, emphasising the need for better stakeholder engagement in policy development.
- The nipple care pathway offers a standardised approach for preventing, identifying and managing breastfeeding-related nipple injuries, providing valuable insights for improving breastfeeding support and outcomes.
CPD reflective questions
- How does the evidence-based nipple care pathway align with your current practice in supporting breastfeeding mothers, and what adjustments could enhance the care you provide?
- Considering the diverse recommendations for preventing and managing breastfeeding-related nipple injuries, how can you ensure inclusivity and personalised care, considering the unique needs and backgrounds of the breastfeeding mothers you support?
- Reflecting on the study's acknowledgement of occasional disparities between expert consensus and published guidance, how can you navigate ethical considerations in discussing available options with breastfeeding mothers, ensuring informed decision-making aligned with their preferences and goals?
- How can you incorporate the educational recommendations highlighted in the study, such as integrating one-to-one breastfeeding classes into routine antenatal care, to enhance breastfeeding preparedness and support for expectant mothers?
- Considering the technique-related recommendations, such as the importance of proper latch and positioning, what steps can you take to reinforce these practices in your interactions with breastfeeding mothers, particularly in the early stages of breastfeeding initiation?