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Association of Nipple Piercing With Abnormal Milk Production and Breastfeeding

Association of Nipple Piercing With Abnormal Milk Production and Breastfeeding Letters Section Editor: Robert M. Golub, MD, Senior Editor. To the Editor: Body piercing has become increasingly popular and socially accepted throughout all age groups; it is particularly prevalent in the adolescent population.1 Current information states that nipple piercing is generally not deemed to be detrimental to maternal milk supply.2 However, irritation or trauma may predispose a nipple-pierced breast to infant attachment problems or blocked ducts.3 We present 3 patients with lactation difficulties suggesting that nipple piercings can lead to complications and that these complications can be associated with breastfeeding difficulties. Methods Patients were lactating women referred to the Human Lactation Research Group at the University of Western Australia for unilateral breast engorgement or poor milk supply. The ethics committee of the University of Western Australia provided approval for this study, and all participants gave informed consent for publication of these data. Histories were obtained from the patients. All women were given advice regarding positioning and attachment of the infant to the breast. All women also attempted to increase breast-milk supply by expressing after feeds; in particular, mother-infant dyad 1 expressed immediately at secretory activation (lactogenesis II). Expressing was performed to assess whether lack of milk flow was due to nonuse of the breast. In addition, dyads 2 and 3 had been prescribed a galactagogue (domperidone). Breastfeed volumes were measured by the test weight method.4 Mammary blood flow was measured by Doppler ultrasound. Breast anatomy and milk ejection were assessed by ultrasound. Results History, breastfeeding assessment, and management of the mother-infant dyads are presented in the Table. All women reported clinical signs of secretory activation in both breasts. However, they reported and we observed that their infants, when fed from the pierced breast, were extremely unsettled compared with feeding from the contralateral breast. Table. Table. Characteristics of 3 Mother-Infant Dyads Referred for Difficulties With Lactation in Which the Women Had Healed Nipple Piercing View LargeDownload On examination, the nipple piercings were completely healed, with no milk leakage. None of the breasts appeared hypoplastic. For dyads 1 and 2, minimal milk was expressed or removed by the infant from the pierced breast. There was a marked reduction in blood flow to the pierced breast. Septa were clearly visible with ultrasound in the milk ducts of the pierced breast of dyad 3. Milk ejection was confirmed by visualization of duct dilation. A decrease in the volume of complementary feeds was achieved after postfeed expression and the administration of domperidone in dyads 2 and 3. Comment These cases indicate that nipple piercing may cause complications leading to duct obstruction so that only negligible amounts of milk can be removed from the breast during lactation. Ineffective milk removal from the breast causes a decrease in milk supply due to local feedback.5 These women expressed minimal amounts of milk from their pierced breasts despite frequent breast pumping. The reduction in mammary blood flow is consistent with low milk production because a positive relationship between milk production and blood flow has been shown in animals.6 Although ductal obstruction is difficult to prove, ductal septa were confirmed in 1 woman. Although a ductogram might have shown ductal patency, the test is limited to 1 ductal system; moreover, catheterization of the nipple duct may be inhibited by scar tissue and carries a risk of infection. Although the possibility of a spurious association exists, this potential complication should be recognized. Dyad 1 illustrates that with management of lactation, unilateral breastfeeding is possible. Many women have successfully breastfed with a nipple piercing, so it is likely that only a small percentage of women may encounter difficulties during lactation subsequent to the procedure. Because these patients suggest that nipple piercing may in some cases lead to duct obstruction and impaired lactation, further investigation of potential effects of nipple piercing is necessary to identify factors that might contribute to lactation difficulties. Back to top Article Information Author Contributions: Ms Garbin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Garbin, Deacon, Rowan, Geddes. Acquisition of data: Garbin, Deacon, Rowan, Geddes. Analysis and interpretation of data: Garbin, Deacon, Rowan, Hartmann, Geddes. Drafting of the manuscript: Garbin, Deacon, Rowan, Hartmann, Geddes. Critical revision of the manuscript for important intellectual content: Garbin, Deacon, Rowan, Hartmann, Geddes. Statistical analysis: Garbin, Deacon, Rowan, Geddes. Obtained funding: Hartmann. Study supervision: Hartmann, Geddes. Financial Disclosures: None reported. Funding/Support: The research was funded by Medela AG, Baar, Switzerland. Role of the Sponsor: The funding organization had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. References 1. Kaatz M, Elsner P, Bauer A. Body-modifying concepts and dermatologic problems: tattooing and piercing. Clin Dermatol. 2008;26(1):35-4418280903PubMedGoogle ScholarCrossref 2. Armstrong ML, Caliendo C, Roberts AE. Pregnancy, lactation and nipple piercings. AWHONN Lifelines. 2006;10(3):212-21716792708PubMedGoogle ScholarCrossref 3. Meltzer DI. Complications of body piercing. Am Fam Physician. 2005;72(10):2029-203416342832PubMedGoogle Scholar 4. Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics. 2006;117(3):e387-e39516452357PubMedGoogle ScholarCrossref 5. Peaker M, Wilde CJ. Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia. 1996;1(3):307-31510887504PubMedGoogle ScholarCrossref 6. Prosser C, Davis S, Farr V, Lacasse P. Regulation of blood flow in the mammary microvasculature. J Dairy Sci. 1996;79(7):1184-11978872713PubMedGoogle ScholarCrossref To the Editor: Body piercing has become increasingly popular and socially accepted throughout all age groups; it is particularly prevalent in the adolescent population.1 Current information states that nipple piercing is generally not deemed to be detrimental to maternal milk supply.2 However, irritation or trauma may predispose a nipple-pierced breast to infant attachment problems or blocked ducts.3 We present 3 patients with lactation difficulties suggesting that nipple piercings can lead to complications and that these complications can be associated with breastfeeding difficulties. Patients were lactating women referred to the Human Lactation Research Group at the University of Western Australia for unilateral breast engorgement or poor milk supply. The ethics committee of the University of Western Australia provided approval for this study, and all participants gave informed consent for publication of these data. Histories were obtained from the patients. All women were given advice regarding positioning and attachment of the infant to the breast. All women also attempted to increase breast-milk supply by expressing after feeds; in particular, mother-infant dyad 1 expressed immediately at secretory activation (lactogenesis II). Expressing was performed to assess whether lack of milk flow was due to nonuse of the breast. In addition, dyads 2 and 3 had been prescribed a galactagogue (domperidone). Breastfeed volumes were measured by the test weight method.4 Mammary blood flow was measured by Doppler ultrasound. Breast anatomy and milk ejection were assessed by ultrasound. History, breastfeeding assessment, and management of the mother-infant dyads are presented in the Table. All women reported clinical signs of secretory activation in both breasts. However, they reported and we observed that their infants, when fed from the pierced breast, were extremely unsettled compared with feeding from the contralateral breast. Dyad 1 Dyad 2 Dyad 3 History Maternal age, y 37 33 25 Age at piercing, y 28 26 18 Breast pierced and piercing type Right, ring Right, barbell Right, ring Complications of piercing None Barbell migration, allergy to metal Ring torn out with resultant scar and loss of nipple sensation Duration jewelry in place, y 3 2.5 3 Timing of jewelry removal before this pregnancy, y 7, at first pregnancy 4.5 4.5 Previous lactation 1, breastfed exclusively for 6 mo, left breast only, 6 y ago 0 0 Infant age at presentation, d 3 28 32 Reason for referral Unresolved right breast engorgement Poor milk supply, right breast Poor milk supply, right breast Formula supplement, mL/24 h 0 240 280 Baseline Assessment Test weigh breastfeed, ga Right, 0 Left, 54 Right, 4 Left, 84 Right, 4 Left, 76 Postfeed expression, g Right, 0 Left, not assessed Right, 2 Left, 45 Right, not assessed Left, not assessed Mammary blood flow, L/24 hb Right, 3.6 Left, 356 Right, 3.3 Left, 84 Right, 4.4 Left, 340 Milk ejection, duct dilation Positive Positive Positive Duct anatomy, ultrasound Normal Normal Septa, right breast 24-h milk production, gc Not assessed Right, 8 Left, 442 Not assessed Recommended Management Interventions Express right breast after feeds. Consider therapeutic ultrasound. Ibuprofen 400 mg for engorgement and pain. At presentation had been taking domperidone 10 mg 3 times daily for the last 3 wk. Recommended increasing dose to 20 mg 3 times daily. Double express after feeds. At presentation had been taking domperidone 20 mg 3 times daily for the last 4 wk. Recommended continuing regimen. Double express after feeds. 4-wk Follow-up Formula supplement, mL/24 h 0, exclusive breastfeeding with left breast 150 180 Domperidone use NA Increased dosage for 2 wk, then gradually reduced dosage. At 4 wk no longer medicated. Continued regimen for 2 wk, then gradually reduced dosage. At 4 wk no longer medicated. Abbreviation: NA, not applicable. aNormal (SD), 76 (12.6) g. bNormal (SD), right, 197 (206) L/24 h; left, 170 (112) L/24 h. cNormal (SD), 788 (169) g. On examination, the nipple piercings were completely healed, with no milk leakage. None of the breasts appeared hypoplastic. For dyads 1 and 2, minimal milk was expressed or removed by the infant from the pierced breast. There was a marked reduction in blood flow to the pierced breast. Septa were clearly visible with ultrasound in the milk ducts of the pierced breast of dyad 3. Milk ejection was confirmed by visualization of duct dilation. A decrease in the volume of complementary feeds was achieved after postfeed expression and the administration of domperidone in dyads 2 and 3. These cases indicate that nipple piercing may cause complications leading to duct obstruction so that only negligible amounts of milk can be removed from the breast during lactation. Ineffective milk removal from the breast causes a decrease in milk supply due to local feedback.5 These women expressed minimal amounts of milk from their pierced breasts despite frequent breast pumping. The reduction in mammary blood flow is consistent with low milk production because a positive relationship between milk production and blood flow has been shown in animals.6 Although ductal obstruction is difficult to prove, ductal septa were confirmed in 1 woman. Although a ductogram might have shown ductal patency, the test is limited to 1 ductal system; moreover, catheterization of the nipple duct may be inhibited by scar tissue and carries a risk of infection. Although the possibility of a spurious association exists, this potential complication should be recognized. Dyad 1 illustrates that with management of lactation, unilateral breastfeeding is possible. Many women have successfully breastfed with a nipple piercing, so it is likely that only a small percentage of women may encounter difficulties during lactation subsequent to the procedure. Because these patients suggest that nipple piercing may in some cases lead to duct obstruction and impaired lactation, further investigation of potential effects of nipple piercing is necessary to identify factors that might contribute to lactation difficulties. Author Contributions: Ms Garbin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Garbin, Deacon, Rowan, Geddes. Acquisition of data: Garbin, Deacon, Rowan, Geddes. Analysis and interpretation of data: Garbin, Deacon, Rowan, Hartmann, Geddes. Drafting of the manuscript: Garbin, Deacon, Rowan, Hartmann, Geddes. Critical revision of the manuscript for important intellectual content: Garbin, Deacon, Rowan, Hartmann, Geddes. Statistical analysis: Garbin, Deacon, Rowan, Geddes. Obtained funding: Hartmann. Study supervision: Hartmann, Geddes. Financial Disclosures: None reported. Funding/Support: The research was funded by Medela AG, Baar, Switzerland. Role of the Sponsor: The funding organization had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Association of Nipple Piercing With Abnormal Milk Production and Breastfeeding

JAMA , Volume 301 (24) – Jun 24, 2009

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American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2009.877
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Abstract

Letters Section Editor: Robert M. Golub, MD, Senior Editor. To the Editor: Body piercing has become increasingly popular and socially accepted throughout all age groups; it is particularly prevalent in the adolescent population.1 Current information states that nipple piercing is generally not deemed to be detrimental to maternal milk supply.2 However, irritation or trauma may predispose a nipple-pierced breast to infant attachment problems or blocked ducts.3 We present 3 patients with lactation difficulties suggesting that nipple piercings can lead to complications and that these complications can be associated with breastfeeding difficulties. Methods Patients were lactating women referred to the Human Lactation Research Group at the University of Western Australia for unilateral breast engorgement or poor milk supply. The ethics committee of the University of Western Australia provided approval for this study, and all participants gave informed consent for publication of these data. Histories were obtained from the patients. All women were given advice regarding positioning and attachment of the infant to the breast. All women also attempted to increase breast-milk supply by expressing after feeds; in particular, mother-infant dyad 1 expressed immediately at secretory activation (lactogenesis II). Expressing was performed to assess whether lack of milk flow was due to nonuse of the breast. In addition, dyads 2 and 3 had been prescribed a galactagogue (domperidone). Breastfeed volumes were measured by the test weight method.4 Mammary blood flow was measured by Doppler ultrasound. Breast anatomy and milk ejection were assessed by ultrasound. Results History, breastfeeding assessment, and management of the mother-infant dyads are presented in the Table. All women reported clinical signs of secretory activation in both breasts. However, they reported and we observed that their infants, when fed from the pierced breast, were extremely unsettled compared with feeding from the contralateral breast. Table. Table. Characteristics of 3 Mother-Infant Dyads Referred for Difficulties With Lactation in Which the Women Had Healed Nipple Piercing View LargeDownload On examination, the nipple piercings were completely healed, with no milk leakage. None of the breasts appeared hypoplastic. For dyads 1 and 2, minimal milk was expressed or removed by the infant from the pierced breast. There was a marked reduction in blood flow to the pierced breast. Septa were clearly visible with ultrasound in the milk ducts of the pierced breast of dyad 3. Milk ejection was confirmed by visualization of duct dilation. A decrease in the volume of complementary feeds was achieved after postfeed expression and the administration of domperidone in dyads 2 and 3. Comment These cases indicate that nipple piercing may cause complications leading to duct obstruction so that only negligible amounts of milk can be removed from the breast during lactation. Ineffective milk removal from the breast causes a decrease in milk supply due to local feedback.5 These women expressed minimal amounts of milk from their pierced breasts despite frequent breast pumping. The reduction in mammary blood flow is consistent with low milk production because a positive relationship between milk production and blood flow has been shown in animals.6 Although ductal obstruction is difficult to prove, ductal septa were confirmed in 1 woman. Although a ductogram might have shown ductal patency, the test is limited to 1 ductal system; moreover, catheterization of the nipple duct may be inhibited by scar tissue and carries a risk of infection. Although the possibility of a spurious association exists, this potential complication should be recognized. Dyad 1 illustrates that with management of lactation, unilateral breastfeeding is possible. Many women have successfully breastfed with a nipple piercing, so it is likely that only a small percentage of women may encounter difficulties during lactation subsequent to the procedure. Because these patients suggest that nipple piercing may in some cases lead to duct obstruction and impaired lactation, further investigation of potential effects of nipple piercing is necessary to identify factors that might contribute to lactation difficulties. Back to top Article Information Author Contributions: Ms Garbin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Garbin, Deacon, Rowan, Geddes. Acquisition of data: Garbin, Deacon, Rowan, Geddes. Analysis and interpretation of data: Garbin, Deacon, Rowan, Hartmann, Geddes. Drafting of the manuscript: Garbin, Deacon, Rowan, Hartmann, Geddes. Critical revision of the manuscript for important intellectual content: Garbin, Deacon, Rowan, Hartmann, Geddes. Statistical analysis: Garbin, Deacon, Rowan, Geddes. Obtained funding: Hartmann. Study supervision: Hartmann, Geddes. Financial Disclosures: None reported. Funding/Support: The research was funded by Medela AG, Baar, Switzerland. Role of the Sponsor: The funding organization had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. References 1. Kaatz M, Elsner P, Bauer A. Body-modifying concepts and dermatologic problems: tattooing and piercing. Clin Dermatol. 2008;26(1):35-4418280903PubMedGoogle ScholarCrossref 2. Armstrong ML, Caliendo C, Roberts AE. Pregnancy, lactation and nipple piercings. AWHONN Lifelines. 2006;10(3):212-21716792708PubMedGoogle ScholarCrossref 3. Meltzer DI. Complications of body piercing. Am Fam Physician. 2005;72(10):2029-203416342832PubMedGoogle Scholar 4. Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics. 2006;117(3):e387-e39516452357PubMedGoogle ScholarCrossref 5. Peaker M, Wilde CJ. Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia. 1996;1(3):307-31510887504PubMedGoogle ScholarCrossref 6. Prosser C, Davis S, Farr V, Lacasse P. Regulation of blood flow in the mammary microvasculature. J Dairy Sci. 1996;79(7):1184-11978872713PubMedGoogle ScholarCrossref To the Editor: Body piercing has become increasingly popular and socially accepted throughout all age groups; it is particularly prevalent in the adolescent population.1 Current information states that nipple piercing is generally not deemed to be detrimental to maternal milk supply.2 However, irritation or trauma may predispose a nipple-pierced breast to infant attachment problems or blocked ducts.3 We present 3 patients with lactation difficulties suggesting that nipple piercings can lead to complications and that these complications can be associated with breastfeeding difficulties. Patients were lactating women referred to the Human Lactation Research Group at the University of Western Australia for unilateral breast engorgement or poor milk supply. The ethics committee of the University of Western Australia provided approval for this study, and all participants gave informed consent for publication of these data. Histories were obtained from the patients. All women were given advice regarding positioning and attachment of the infant to the breast. All women also attempted to increase breast-milk supply by expressing after feeds; in particular, mother-infant dyad 1 expressed immediately at secretory activation (lactogenesis II). Expressing was performed to assess whether lack of milk flow was due to nonuse of the breast. In addition, dyads 2 and 3 had been prescribed a galactagogue (domperidone). Breastfeed volumes were measured by the test weight method.4 Mammary blood flow was measured by Doppler ultrasound. Breast anatomy and milk ejection were assessed by ultrasound. History, breastfeeding assessment, and management of the mother-infant dyads are presented in the Table. All women reported clinical signs of secretory activation in both breasts. However, they reported and we observed that their infants, when fed from the pierced breast, were extremely unsettled compared with feeding from the contralateral breast. Dyad 1 Dyad 2 Dyad 3 History Maternal age, y 37 33 25 Age at piercing, y 28 26 18 Breast pierced and piercing type Right, ring Right, barbell Right, ring Complications of piercing None Barbell migration, allergy to metal Ring torn out with resultant scar and loss of nipple sensation Duration jewelry in place, y 3 2.5 3 Timing of jewelry removal before this pregnancy, y 7, at first pregnancy 4.5 4.5 Previous lactation 1, breastfed exclusively for 6 mo, left breast only, 6 y ago 0 0 Infant age at presentation, d 3 28 32 Reason for referral Unresolved right breast engorgement Poor milk supply, right breast Poor milk supply, right breast Formula supplement, mL/24 h 0 240 280 Baseline Assessment Test weigh breastfeed, ga Right, 0 Left, 54 Right, 4 Left, 84 Right, 4 Left, 76 Postfeed expression, g Right, 0 Left, not assessed Right, 2 Left, 45 Right, not assessed Left, not assessed Mammary blood flow, L/24 hb Right, 3.6 Left, 356 Right, 3.3 Left, 84 Right, 4.4 Left, 340 Milk ejection, duct dilation Positive Positive Positive Duct anatomy, ultrasound Normal Normal Septa, right breast 24-h milk production, gc Not assessed Right, 8 Left, 442 Not assessed Recommended Management Interventions Express right breast after feeds. Consider therapeutic ultrasound. Ibuprofen 400 mg for engorgement and pain. At presentation had been taking domperidone 10 mg 3 times daily for the last 3 wk. Recommended increasing dose to 20 mg 3 times daily. Double express after feeds. At presentation had been taking domperidone 20 mg 3 times daily for the last 4 wk. Recommended continuing regimen. Double express after feeds. 4-wk Follow-up Formula supplement, mL/24 h 0, exclusive breastfeeding with left breast 150 180 Domperidone use NA Increased dosage for 2 wk, then gradually reduced dosage. At 4 wk no longer medicated. Continued regimen for 2 wk, then gradually reduced dosage. At 4 wk no longer medicated. Abbreviation: NA, not applicable. aNormal (SD), 76 (12.6) g. bNormal (SD), right, 197 (206) L/24 h; left, 170 (112) L/24 h. cNormal (SD), 788 (169) g. On examination, the nipple piercings were completely healed, with no milk leakage. None of the breasts appeared hypoplastic. For dyads 1 and 2, minimal milk was expressed or removed by the infant from the pierced breast. There was a marked reduction in blood flow to the pierced breast. Septa were clearly visible with ultrasound in the milk ducts of the pierced breast of dyad 3. Milk ejection was confirmed by visualization of duct dilation. A decrease in the volume of complementary feeds was achieved after postfeed expression and the administration of domperidone in dyads 2 and 3. These cases indicate that nipple piercing may cause complications leading to duct obstruction so that only negligible amounts of milk can be removed from the breast during lactation. Ineffective milk removal from the breast causes a decrease in milk supply due to local feedback.5 These women expressed minimal amounts of milk from their pierced breasts despite frequent breast pumping. The reduction in mammary blood flow is consistent with low milk production because a positive relationship between milk production and blood flow has been shown in animals.6 Although ductal obstruction is difficult to prove, ductal septa were confirmed in 1 woman. Although a ductogram might have shown ductal patency, the test is limited to 1 ductal system; moreover, catheterization of the nipple duct may be inhibited by scar tissue and carries a risk of infection. Although the possibility of a spurious association exists, this potential complication should be recognized. Dyad 1 illustrates that with management of lactation, unilateral breastfeeding is possible. Many women have successfully breastfed with a nipple piercing, so it is likely that only a small percentage of women may encounter difficulties during lactation subsequent to the procedure. Because these patients suggest that nipple piercing may in some cases lead to duct obstruction and impaired lactation, further investigation of potential effects of nipple piercing is necessary to identify factors that might contribute to lactation difficulties. Author Contributions: Ms Garbin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Garbin, Deacon, Rowan, Geddes. Acquisition of data: Garbin, Deacon, Rowan, Geddes. Analysis and interpretation of data: Garbin, Deacon, Rowan, Hartmann, Geddes. Drafting of the manuscript: Garbin, Deacon, Rowan, Hartmann, Geddes. Critical revision of the manuscript for important intellectual content: Garbin, Deacon, Rowan, Hartmann, Geddes. Statistical analysis: Garbin, Deacon, Rowan, Geddes. Obtained funding: Hartmann. Study supervision: Hartmann, Geddes. Financial Disclosures: None reported. Funding/Support: The research was funded by Medela AG, Baar, Switzerland. Role of the Sponsor: The funding organization had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Journal

JAMAAmerican Medical Association

Published: Jun 24, 2009

References