An Evaluation of the Signs of Nipple Trauma Associated With Breastfeeding: A Delphi Study

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Background: No consensus on the definitions of nipple trauma has been reported. Thus, different individuals assess identical events inconsistently. Research Aims: To establish clear definitions for the seven signs of nipple trauma related to breastfeeding-erythema, swelling, scabbing, blistering, fissure, purpura, and peeling-and to reach consensus among multiple specialists. Methods: We implemented a longitudinal, prospective survey design using a 3-step Delphi method. In the first survey we targeted specialists in breastfeeding, dermatology, and cosmetics, and we presented images as representative cases during a set of semi-structured interviews. In the second and third surveys, we questioned midwives who were certified as "advanced midwives" through mail, using a questionnaire prepared based on the results of the first survey. The agreement criteria of this study were as follows: (1) a median of 2.0 or below; (2) an interquartile range of 1.0 or below; and (3) at least 51% showing responses of either "strongly agree" or "agree." Results: Based on the responses of the 42 experts, we reached a consensus on 48 items: eight related to erythema, 10 to swelling, nine to scabbing, seven to blistering, seven to fissure, four to purpura, and three to peeling. We then classified these items based on the condition or possible mechanism of the wound. Finally, we developed an observation tool: "seven signs of nipple trauma associated with breastfeeding," along with images. Conclusions: Application of this tool for breastfeeding support could improve objectivity in observing and evaluating nipple trauma.

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