INTRODUCTION:

Many women avoid breast feeding their newborns simply because they are afraid they will suffer from nipple sores.¹Sore nipple is a condition in which there is a crack across the nipple or at the base of the nipple or it means any persistent pain in the nipples that lasts throughout the breastfeeding or hurts between feedings.²

It is a dream for most of the mothers to have comfort in breastfeeding and nipple sores are common problem, and pain or cracks frequently occur after breastfeeding.

It is estimated that 80-90% of breastfeeding women experience nipple soreness, with 26 percent progress into cracking or intense pain.³

Faulty technique of delatching is also one of the important causes of nipple sore among lactating mothers.⁴Providing anticipatory guidance to postnatal mothers about the etiology and prevention of nipple sore may increase the likelihood of initiating and maintaining breastfeeding. Through the guidance related to prevention of nipple sore, the incidence of other complications like breast engorgement and mastitis will also decrease, that result in a healthy mother/ infant relationship and promotion of breast feeding.⁵

A sore nipple associated with breast-feeding is a common problem, with an incidence ranging from 11% to 90% and may lead to premature weaning. This frequently results from incorrect positioning at the breast. In addition, sore nipples can readily become infected with bacteria or yeast, the presence of which can delay healing, even when positioning and latching on are corrected.⁶

Coca KP et al (2009) carried out a case control study to identify causative factors associated with nipple sores in women breastfeeding exclusively in a maternity unit. The sample was 146 recently-delivered mothers in rooming-in and were tested daily for a diagnosis of nipple injury, identified using a magnifying glass. The study concluded that primiparity, poor knowledge about breast feeding techniques and turgid /or engorged breasts are associated with nipple sores.⁷

Nipple sore during the first week of breastfeeding is common. Some studies report prevalence as high as 96%.⁸ Sore nipples have been identified as an important factor in a woman’s decision to discontinue breastfeeding. Preventing or treating it is important not only to increase individual woman’s comfort but also to promote breastfeeding generally. Breastfeeding provides significant health benefits for infants and mothers which is hampered due to nipple sores, which further lead to breast complications like mastitis and breast engorgement.⁹

Nipple sore is the most common reason for early weaning, surpassed only by the mother’s perception of insufficient milk supply. In a study of 100 breastfeeding mothers, up to 95% of women experienced sore nipples during the first week of breastfeeding their infants, with the majority of those mothers reaching pain ratings of moderate to intense. The psychological stress of chronic pain associated with nursing can lead to a disruption in the mother/infant relationship.¹⁰

The International Lactation Consultant Association states that nipple sore is often the result of ineffective positioning and latch. The group recommends anticipatory guidance to prevent nipple sore. Additionally, education related to clinical assessment of the nipple should be provided to rule out other causes, such as bacterial or fungal infection.¹¹

It is important to deal with problems faced by mothers during breastfeeding as they may frequently result in the stoppage of breastfeeding or addition of supplements of animal milk or commercial infant formula. It is found that nipple soreness has been reported by 33-96% lactating women.¹²

An intervention study on the treatment of sore nipple among 66 primiparous mothers in Turkey revealed that approximately 65% of the lactating women experienced sore nipples. Lesions were found on the areola and nipple during immediate postpartum.¹³

A study on the early enhancement of successful breast feeding was undertaken in Sweden. 52 healthy mother infant pairs were referred to the pediatric clinic of Malmo general hospital because of nursing problems. Observations of nursing behavior showed that almost all the problems were connected to pain during feeding which is related to nipple sores.¹⁴

The investigator during her clinical posting at postnatal ward observed that postnatal mothers are not feeding properly to their babies due to pain during feeding. So the investigator selected this problem statement to educate the postnatal mothers on knowledge regarding prevention of nipple sore to reduce the incidence of nipple sore in GianSagar Medical College and Hospital.

MATERIALS AND METHODS:

Research design:

A pre experimental design and one group pre-test and post testwas used for the study.

Setting of the study:

The study was conducted in obstetric ward of GianSagar Medical College and Hospital, Ram Nagar, Rajpura, Punjab.

Population:

The population of the study consisted of postnatal mothers admitted in obstetric ward of GianSagar Medical College and Hospital, Ram Nagar, Rajpura, Punjab.

Sample size\Sampling technique:

50 postnatal were selected by purposive sampling technique from postnatal mothers admitted in obstetric ward of GianSagar Medical College and Hospital, Ram Nagar, Rajpura, Punjab.

Development and description of the tool

The structured knowledge interview schedule was used for present study after obtaining approval from the medical and nursing experts in the field of Obstetrics and Gynecology. The reliability of the tool was checked by conducting pilot study on 8 postnatal mothers in GianSagar Medical College and Hospital and the reliability was found as r = 0.8.

Intervention

Planned teaching programme on prevention of nipple sore.

The Planned Teaching Programme on prevention of nipple sores was prepared for postnatal mothers. It includes the detail information about definition, causes and clinical features of nipple sore, measures for maintenance of breast hygiene, ways of maintenance of proper latching, demonstration on different positions for breast feeding, other advices and let down reflex which help in the prevention of nipple sore, timing, duration and frequency of breast feeding for prevention of nipple sores, signs of correct and incorrect attachment of newborn to breast, technique of de latching and complications of nipple sores. Total duration of Planned Teaching Programme was 30 minutes and it was administered with the help of charts, flashcards and demonstration to postnatal mothers.

Data collection procedure

The investigator had obtained written permission from concerned authorities before data collection. The data was collected in month of February and March from 25/2/2013 to 23/3/2013. The subjects were approached individually in the obstetric ward. Purpose of the study was explained and consent was taken from the subjects. On the first day pretest was taken and then same day Planned Teaching Programme was administered. Post test was conducted after 5 days.

RESULTS:

Research findings were organized under the following sections

Section A: Analysis of sample characteristics.

Section B: Assessment of knowledge regarding prevention of nipple sore among postnatal mothers.

Section C: Effectiveness of planned teaching programme.

Section D: Association of knowledge regarding prevention of nipple sore among postnatal mothers with selected demographic variables.

Section – A

Analysis of sample characteristics

Table 1 Frequency and percentage distribution of sample characteristics

Socio- demographic characteristics	Frequency (f)	%
Age (in years)
18-23	35	70
24-29	15	30
Religion
Hindu	16	32
Muslim	1	2
Christian	1	2
Sikh	32	64
Type of family
Nuclear	16	32
Joint	33	66
Extended	1	2
Educational status
No formal education	7	14
Up to Primary	17	34
Up to Secondary	21	42
Graduate and above	5	10
Occupation
House wife	43	86
Self employed	8	4
Pvt. Employ	3	6
Resident
Urban	11	22
Rural	39	78
Source of information
Mass media	4	8
Health worker	12	24
Family and Friends	34	68
Monthly income
<5000 - 10,000	17	34
10,001 – 15,000	27	54
15,001 and above6 12

N = 50

Section – B

Assessment of knowledge regarding prevention of nipple sore among postnatal mothers.

Table 2. Range, Mean, Median and Standard Deviation of knowledge regarding prevention of nipple sore among postnatal mothers. N=50

Variable	Range	Mean	Median	SD
Knowledge	4-17	11.58	12	2.928

Table 2 depicts mean knowledge scores of postnatal mothers. The mean knowledge score was 11.58 with the SD 2.928.

Table 3 Percentage distribution of subjects as per their level of pre-test knowledge. N=50

Level of Knowledge	%
Poor (0 – 10)	28%
Average (11 – 20)	72%
Good (21 – 30)	0%

Table 3 represents that 28% subjects had poor knowledge followed by 72% who had average knowledge while none of subjects had good knowledge regarding prevention of nipple sore.

Fig 1: Bar diagram showing distribution of subjects as per their level of pretest knowledge.

Fig 1 represents that more than half of the subjects had average knowledge scores i.e. 72% followed by 28% subjects had poor knowledge regarding prevention of nipple sore and none possessed good knowledge regarding prevention of nipple sore.

Section – C

Effectiveness of Planned Teaching Programme

This section analyzes the effectiveness of Planned Teaching Programme on knowledge regarding prevention of nipple sore.

Table 4. Range, Mean, Median and Standard Deviation of pre- test and post test knowledge scores. N=50

Test

Range

Mean

Median

Pre-test

Post-test

4-17

11 – 25

11.58

18.72

2.928

3.110

Table 4 shows the mean pre- test and posttest knowledge score of postnatal mothers regarding prevention of nipple sore. The mean score in pre-test was 11.58 with SD 2.928 and mean post test score was18.72 with SD 3.110.

Fig. 2: Bar diagram showing mean pre-test and post-test knowledge score of postnatal mothers regarding prevention of nipple sore.

In order to find out the statistical inference paired t- test was used. The following hypothesis was stated.

H₁: There is significant difference in the mean pre and posttest knowledge score regarding prevention of nipple sore among postnatal mothers.

Table 5 Mean, Standard deviation, mean difference and t- test value of pre-test and post-test knowledge scores. N=50

Assessment	Mean	SD	Mean difference	t-test
Pre-test	11.58	2.928	7.14	19.88*
Post-test	18.72	3.11

*Significant (p<0.05), df-49

Table‘t’ value = 2.01

Table 5 reveals that there was significant difference in mean pre test and post test knowledge scores of the subjects, moreover there was significant increment in average post test score i.e. 18.72 with SD 3.110 from the pre test average score of 11.58 with SD 2.928. As the calculated ‘t’ value (19.88) is more than table value (2.01),so H₁ hypothesis was accepted at 5% level of significance.

Section D: Association of knowledge regarding prevention of nipple sore among postnatal mothers with selected demographic variables.

In order to determine the association between knowledge and demographic variables chi square test was used and the following hypothesis was stated:

H_2: There is significant association between the knowledge regarding prevention of nipple sore with selected demographic variables. N=50

Sr. no	Variable	Level of knowledge			Chi square value	df		Table value	Level of significance
		Good	Average	Poor
1 2 3 4 5 6 7 8	Age (in years) 18-23 24-29 Religion Hindu Muslim Christian Sikh Type of family Nuclear Joint Extended Educational status No formal education Up to Primary Up to Secondary Graduate and above Occupation House wife Self employed Pvt. Employ Resident Urban Rural Source of information Mass media Health worke Family and Friends Monthly income <5000 - 10,000 10,001 – 15,000 15,001 and above		25 11 11 1 1 23 13 22 1 1 12 19 4 31 3 2 8 28 4 9 23 12 20 4	10 4 5 0 0 9 3 11 0 6 5 2 1 12 1 1 3 11 0 3 11 5 7 6	0.043 0.513 0.776 11.608	1 3 2 3		3.841 7.815 5.991 7.815 5.991 3.841 5.991 5.991	NS NS NS S NS NS NS NS
					0.395 0.102 0.625 0.977		2 1 2 2

S- Significant (p<0.05), NS- Non Significant (p>0.05)

Table 6 shows the computed chi square value of association between the knowledge regarding prevention of nipple sore with selected demographic variables. The results revealed that there was significant association found between the educational status and knowledge regarding prevention of nipple sore. There was no significant association found with the age, religion, type of family, occupation, resident, source of information and monthly income. Hence H₂hypothesis was accepted at 5% level of significance for educational status and rejected in case of other mentioned socio demographic variables.

DISCUSSION:

The postnatal mothers had poor knowledge (28%) on different aspects of prevention of nipple sore. No even a single postnatal mother had good knowledge prior to the implementation of knowledge intervention in the form of demonstration and planned teaching programme whereas the postnatal mothers had good knowledge (26 %) after the intervention and none of them had poor knowledge regarding all the aspects of prevention of nipple sore. These findings was supported by Sheety M who also reported that after attending the this kind of intervention knowledge and practices of postnatal mothers improved regarding breast feeding problems and its management as indicated by value i.e. 21.51 was more than the table value and decrease the chances of breast feeding problems and other complications.¹⁵this intervention is also supported by Percival P who revealed that educational teaching session on position and attachment of the baby on the breast had an significant effect on postnatal nipple pain, nipple trauma and breast feeding duration.¹⁶

RECOMMENDATIONS:

1. Similar study can be conducted with large sample size to generalize the findings.

2. A similar study can be conducted by true experimental approach.

3. Comparative study can be conducted among primipara and multipara postnatal mothers.

4. A follow up study can be conducted to evaluate the Effectiveness of Planned Teaching Programme.

REFERENCES:

1. Kaur B. Breastfeeding practices of urban, rural women. NNT Jan 2011; 6(10): 12- 5. Available from : URL:http:// www.rguhs.ac.in/05_N189_29824.doc [Accessed Jan 20 2013]

2. Brent N, Sherrill JR, Thomas E, Lillian A. Infant feeding. Arch Paediatric Adolescent Medicine1998; 152:1077-82.Available from: URL: http:// www.rguhs.ac.in/.../05_N076_13729.doc. [Accessed March 05 2012]

3. Melli MS, Rashidi MR, Nokhoodchi A, Tagavi S, Farzadi L, Sadaghat T et al. A randomnized trail of peppermint gel, lanolin ointment and placebo gel to prevent nipple crack in primiparous breastfeeding women. MedSciMoint. 2007; 13 (9): 406 -11. Availablefrom:URL:http://www.mediscimoint.com/fulltxt.php?IDMAN-10163.[Accessed Jan 20 2013]

4. Sore-cracked-nipples. Australian Breastfeeding Association. Oct 2011. Available from https://www.breastfeeding.asn.au/bf-info/common-concerns–mum/sore-cracked-nipples. [Accessed Nov 25 2012]

5. Tait P. Nipple pain in breastfeeding women: causes, treatment, and prevention strategies. J Midwifery and Women Health 2000; 45:212-15. Available from: URL: http://www.ncbi.nih.gov/m/pubmed/10907330/. [Accessed Jan 16 2012]

6. Anitha J. Effectiveness of structured teaching programme about breast feeding techniques on knowledge and practice in prevention of nipple sore among primipara mothers.2008 Available from: URL: http:// www.rguhs.ac.in/.../05_N043_4718.doc. [Accessed Feb 05 2012]

7. Coca KP, Gamba MA, Souza SR, Cristina A, Abrao FV. Case control study to identify causative factors associated with nipple sores in women breastfeeding exclusively in a maternity unit. J Pediatr 2009; 85:4. Available from: URL: http://www http://www.academia.edu/1335125 [Accessed Feb 06 2013]

8. Shialja V, Veen K. Goldentips for breast feeding. The journal of health action 2009; 22:232-34.

9. Page T, Lockwood C, Guest K. Management of nipple pain and/or trauma associated with breastfeeding: a systematic review. JBI Rep 2003; 1:127–47. Available from: URL: http: // www. joannabriggslibrary .org /index. php/ jbisrir/article/view/384 .[Accessed Jan 16 2012]

10. Amir L, Dennerstein L, Garland S, Fisher J, Farish S. Psychological aspects of nipple pain in lactating women. J PsychosomObstetGynecol 1996; 17(1):53– 8. Available from: URL: http:// www .libra .msra .cn/Publication /31673920. [Accessed April 06 2012]

11. Raleigh, NC. Clinical Guidelines for the Establishment of Exclusive Breastfeeding: International Lactation Consultant Association.2005 Available from:URL: http://www.guideline.gov/summary/summary.aspx?doc. [Accessed Oct 05 2012]

12. Riordan J. Breastfeeding and human lactation. 3^rd ed. Jones and Bartlett Publications; 2005. Available from: URL: http://www.gogglebooks.com [Accessed April 05 2012]

13. Kusku NK, Koyunchu F. Treatment of sore nipples. International J gynaecology and obstetrics 2002; 76:81-2. Available from: URL: http:// www. 119.82.96.8080/…Nur Malathi.pdf/[Accessed April 08 2012]

14. Righard L. Early enhancement of successful breast feeding in Sweden. World Health Forum 1996; 17(1): 92 -7. Available from: URL: http://www. ncbi. nlm.nih.gov/pubmed/8820155 [Accessed Feb 22 2012]

15. Sheety M. Effectiveness of planned teaching programme on breast feeding problems and its management among primigravida postnatal mothers at Manglore. Journal of health action 2009; 22: 35- 8.

16. Percival P. Whether an antenatal teaching session on position and attachment of the baby on the breast had an effect on postnatal nipple pain, nipple trauma and breast feeding duration. 1997 Available from: URL: http://www.ncbi.nlm.nih.gov/pubmed/9511686 [Accessed Feb 25 2012]

Received on 08.09.2014 Modified on 18.09.2014

Asian J. Nur. Edu. and Research 5(1): Jan.-March 2015; Page 67-71

DOI: 10.5958/2349-2996.2015.00015.4

Effect of Planned Teaching Programme on Knowledge regarding Prevention of Nipple Sore among Postnatal mothers in Gian Sagar Medical College and Hospital, Ram Nagar, Rajpura, Punjab.