AT THE AAD SUMMER ACADEMY 2015
NEW YORK (FRONTLINE MEDICAL NEWS) – The “perfect storm” of pregnancy and lactation can throw breastfeeding moms into a painful deep freeze.
Almost 25% of women with lactation pain may actually be experiencing symptoms of Raynaud’s, Dr. Honor Fullerton Stone said at the American Academy of Dermatology summer meeting.
“Breastfeeding mothers are in a perfect storm,” of physical developments that predispose them to this vasoconstrictive phenomenon, said Dr. Fullerton Stone, who practices dermatology in Menlo Park, Ca. “Estrogen increases the alpha-adrenergic receptors on smooth muscle. Nerve irritation from constant breastfeeding upregulates those receptors. And emotional stress – crying baby, anyone? – increases epinephrine, which contributes further to vasoconstriction.”
She conducted a review of 88 of her own patients with nursing-related breast pain. Of these, about a quarter ended up with a diagnosis of nipple vasoconstriction. None of the women had a history of Raynaud’s disease.
Pain during a nursing session is the presenting complaint, but breastfeeding pain is incredibly nonspecific as a symptom. It’s the quality of the pain, Dr Stone said, that should ring a bell.
“There’s let-down pain, which occurs at latch and then comes on again later, with refill. There’s pain from candidiasis, which is dramatic at latch, like a radiating heat, but goes away rapidly after a few days of antifungals,” she noted. But with Raynaud’s, “the pain is persistent. It’s throbbing, which makes sense since it’s vascular. And it’s constant,” lasting through every nursing session, which she said is the kind of experience that makes mothers stop breastfeeding.
Since pain is such a pervasive symptom in breastfeeding complaints, women with vasoconstriction of the nipple are often misdiagnosed. They can go for months trying to improve latch technique or receiving antifungal therapy with no improvement, she said.
Dr. Stone considers a diagnosis of Raynaud’s if two of the following criteria are met:
• Color change of nipple, cold sensitivity, or color change of acral surfaces with cold exposure.
• Chronic deep breast pain for 4 or more weeks.
• Failure of oral antifungals and or antibiotics.
Treatment is both supportive and systemic and avoiding cold is key. She recalled a young mother who arrived in her office bundled up in a down parka on a warm California spring day. “I don’t know why, but this really seems to help,” she said.
“I suggest taking two hot showers a day and all the better if they can be right before nursing. Hot pads and compresses are not going to help. You need to warm up the entire body to calm this vascular reactivity.”
Women should also avoid consuming anything that can cause vasoconstriction, including caffeine and tobacco, she advised.
Nifedipine is a very effective medication, and is safe for nursing infants, Dr. Stone said. The sustained-released 30 mg/day dose is typically recommended, but she has changed her thinking on this a bit.
Her internal study showed that, although 83% responded very well to the drug, about a third of them also had a vasodilation-related side effect.
“For this reason, I usually now start with the 10 mg nonsustained form, and warn about things like headache, dizziness, postural hypotension, and fainting,” she said. Typically, patients adjust well to the drug’s effects and then the dose can be individually titrated.
Dr. Fullerton Stone had no relevant financial disclosures.
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