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Raynaud's - Help With Keeping Warm

Raynaud's

Raynaud's of the nipple is the name given when women are affected by nipple vasospasms. Vasospasm is the constriction of blood vessels, cutting off the blood supply. During this phase the nipple turns white. The nipple then typically turns purple and then pink as blood low in oxygen, and then high in oxygen enters the nipple. As different blood vessels can constrict for different lengths of time, it can be possible to see all three colours in the nipple at once. Pain typically occurs as blood re-enters the nipple, at the end of the event, with the pain lasting up to several minutes.

I have found that damage to the nipple can occur if a child latches onto a constricted nipple during a vasospasm event. The constricted nipple does not stretch well, and the internal, and sometimes external, damage can cause high levels of pain during latching and sometimes also with milk let down. Any such internal damage can take a week or so to heal and become pain free. Raynaud's can also cause a mild, continuous pain, or breast sensitivity, which sometimes starts a few days before the vasospasm events start to occur.

After the first vasospasm event, vasospasm is likely to continue to occur with each feeding or exposure to the cold, with treatment typically taking a week or two for the events to subside. Vasospasm events may last from a few minutes to continuously if the nipple is not warmed. Pain can be described as being in either the nipple or the whole breast.

Vasospasm most commonly occurs on both nipples, but I have found that it may be limited to one, and which nipple is affected may change over time. It can be triggered solely by the cold, extreme changes in temperature (such as going outside on a cold day), high emotions, leaving nipples to air-dry after breastfeeding, damage to the nipple caused by poor latch or similar, or a combination of factors. Raynaud's can recur with subsequent pregnancies and breastfeeding. Some medications have been associated with vasospasm including oral contraceptives. "Fibromyalgia, rheumatologic diseases (eg, systemic lupus erythematosus or rheumatoid arthritis), endocrine diseases (eg, hypothyroidism or carcinoid), and prior breast surgery have also been associated with Raynaud's phenomenon." (kellymom webpage).

Raynaud's is often misdiagnosed as poor latch, as pain can occur when feeding, external damage may be present, and it may not hurt every time you breastfeed. This can be a very frustrating diagnosis for the mother, as trying to repeatedly latch the baby to get the 'perfect latch' can result in intense pain every time. Raynaud's is sometimes also misdiagnosed as thrush, and I have had nipple damage misdiagnosed as a milk bleb. Broken capillaries and ducts due to Raynaud's can bleed into the surrounding tissue. When a milk duct is damaged a white ring can form around the duct, looking like a milk bleb. These "bleb's" do not need to be opened up or cleared, but can be left to heal.

Raynaud's of the nipple most commonly affects breastfeeding women, with onset typically occurring sometime in the first month, or during the first winter of breastfeeding. However, Raynaud's also occurs in pregnant women, and may also affect women who have never been pregnant. It is more common in cold climates, and can be hereditary. Women who have Raynaud's of the fingers and toes will often develop Raynaud's of the nipple when they start to breastfeed. Raynaud's occurs in up to 22% of women (Olsen and Nielson, 1978).

If the vasospasms are due to the cold only the term Raynaud's disease is used, and if they are secondary to another condition then the term Raynaud's phenomenon is used. If the vasospasms are due to poor latch only then the condition is not Raynaud's, but is just described as nipple vasospasm or blanching.

Management of Raynaud's

Raynaud's disease is a condition that is typically managed, not cured. I've listed all sensible management options that I am aware of below. No single option will work for every woman. Many women will use a range of management options, with methods used changing with the season, how badly they are being affected, pregnancy, and breastfeeding of a newborn or an older child.

The number of supplements and medications suggested to help with Raynaud's is significant, and I've only included the options that studies have shown to work for some women, or are widely accepted to help some women. Even this reduced list is extensive, mothers should try options that they consider appropriate for themselves, and not everything at once. All women should discuss all medical, herbal, and supplement management options with their health provider first.

Keeping Warm

General Suggestions

Remedies

B6 vitamin supplements help some women. There are no studies supporting this, but it does appear to help (DrJackNewman website). The recommended dosage is 150-200 mg/day for four days, reducing to 25 mg/day until the mother has been pain free for several weeks. Any improvements generally occur within the first few days of taking this supplement. Vitamin B6 can affect milk supply in some women, making this option most suitable for women with an established milk supply (baby older than three months) or an oversupply of milk. Women with a young baby or a low milk supply should feed their baby on demand and monitor wet and dirty nappies for the first week or so after starting these supplements.

If vitamin B6 does not work then nifedipine tablets, a prescription drug, may be considered (Kahan 1982). Nifedipine is typically used to treat raised blood pressure, and prevents vasospasm occurring by reducing smooth muscle tone in arteries. Treatment is usually a two-week dose of 15 to 30 mg per day, either taken over the day or using slow release tablets once a day. Future attacks can be treated with an additional course of tablets. Some women who suffer from regular repeat attacks may wish to take a continuous low dose treatment. Treatment can be unsuitable for women with low blood pressure, and side effects can include headaches. Women may need to reduce the dosage to avoid headaches, or increase it to treat the Raynaud's. Nifedipine does cross into breastmilk, however no harmful effects to the infant are known.

If you go to see your doctor to talk about Nifedipine, it may pay to go prepared, as many doctors are unaware of this condition, and its treatment, and are reluctant to prescribe it to breastfeeding mothers. I recommend you take a printout of this page with you: http://www.ncbi.nlm.nih.gov/pubmed/15060268 Which is the research that supports the use of nifedipine. The prescription for nifedipine is usually subsidided in New Zealand.

Calcium (2000mg per day) and magnesium (1000mg per day) supplements can help some women if they are deficient in these minerals (Belch et al, 1985).

Pain relief tablets such as Ibuprofen may help, however they should not be taken continuously over long periods of time.

Half a glass of red wine a day can help some women, however it should be noted that heavy alcohol use is associated with an increase in Raynaud's. The link to this research is here: http://www.arthritis.org/smoking-raynauds.php Women wanting to try this treatment should try half a glass of red wine, once a day, just after feeding your baby, at a time when you know you won’t need to feed your baby for half an hour at a minimum, or one hour if you are smaller than average. This delay will allow your body to process the alcohol.

Given that moderate consumption is the key, the benefit may be derived from giving the blood vessels a rest. Some mothers find that their nipples seem to progressively constrict, with each episode getting worse, as it builds on the last vasospasm. Having a rest, a chance to relax and heal, is just what they need.

For pregnant women, the current recommended safe limit of alcohol is no alcohol at all. If a pregnant woman wanted to try this remedy, I would strongly suggest they consult with their Doctor first. This remedy may not be suitable for women whose babies feed very frequently, women with a history of alcohol abuse, or women suffering postnatal depression.

Some herbs help stimulate circulation; these include ginger, cayenne pepper, and cinnamon. Herbal preparations such as "winter warmth", tablets, or simply including these ingredients in your cooking helps some women. Ginkgo Biloba may also be of help (Muir et al 2002). The suggested dosage of ginkgo as a tea is one tablespoon per cup, and 2-3 cups a day. You should check with your Doctor before taking ginkgo, as it may reduce clotting, so isn't recommended if there is any potential bleeding for mother or baby, and it should never be combined with blood thinners, aspirin, ibuprofen, coumadin or arthritis medications. I also note that ginkgo may prevent ovulation.

Recommended websites:

http://www.kellymom.com/bf/concerns/mom/nipple-blanching.html

http://www.breastfeedingonline.com/articles.shtml

Your midwife, lactation consultant, or a la leche league leader can provide further help for women with Raynaud’s.

If you have suffered from Raynaud's I would love to hear from you as to what treatment methods you have tried, and what has worked for you, so this article can be added to over time. I can be contacted at tara@summerwarmth.co.nz.

References

Drjacknewman webpage (2009): http://www.drjacknewman.com/help/Vasospasm%20and%20Raynaud%E2%80%99s%20Phenomenon.asp

Kellymom webpage (2009): http://www.kellymom.com/bf/concerns/mom/nipple-blanching.html

Nbci webpage (2009): http://www.nbci.ca/index.php?option=com_content&view=article&id=52:vasospasm-and-raynauds-phenomenon&catid=5:information&Itemid=17

Belch JJF, Shaw B, O'Dowd A, Saniabadi P, Lieberman P, Sturrock Rd. et al. (1985) Evening Primrose Oil (Efamol) in the Treatment of Raynaud's Phenomenon : A Double Blind Study. Thrombosis and Haemostasis. 54(2): 490-494

Kahan A, Weber S, Amor B, Saporta L, Hodara M, Degeorges M (1982). [Controlled study of nifedipine in the treatment of Raynaud's phenomenon] (in French). Rev Rhum Mal Osteoartic 49 (5): 337-43.

Olsen N, Nielson SL. (1978) Prevalence of Primary Raynaud's Phenomenon in Young Females. Scand J Clin Lab Invest; 37:761-76

Suter LG, Murabito JM, Felson DT, Fraenkel L (2005) The incidence and natural history of Raynaud's phenomenon in the community. Arthritis and Rheumatism 52 (4): 1259-63.

Muir AH, Robb R, McLaren M, Daly F, Belch JJ (2002) The use of Ginkgo biloba in Raynaud's disease: a double-blind placebo-controlled trial. Vasc Med 7 (4): 265-7.

This information was adapted from an article written by Tara Hills for Mosaic, April 2010.

Disclaimer:

Information provided by Summer Warmth is not meant as a substitute for professional help from your health care professional. Please seek advice from your health care professional if you are having problems with breastfeeding or if you have continuing concerns.

Mother’s Stories

This section currently just has my story, if you would like to write your story for this page I’d love for you to send it in.

Tara’s story

My experience with Raynaud’s started when my son, Olly, was just a few weeks old. I quickly noticed my white nipples, googled it, and found out that it was probably Raynaud’s. My midwife agreed, and I made a booking to see my doctor to see if I could take nifedipine. Meanwhile I started using a large heated wheat pack after each feed. My doctor considered nifedipine to be unsuitable for me due to my low blood pressure, and advised me to keep warm. My large wheat pack obviously wasn’t a practical long-term solution, I brought a herbal tonic that I couldn’t drink, and had such low milk supply that I was supplementing, so didn’t want to take vitamin B6. So I went back to the internet where I found out about breastwarmers and ordered some from Australia. These made a huge difference for me.

However the breastwarmers I had were very large, and not that practical, therefore I never used them as much as I should, and would eventually end up with vasospasms again when they weren’t being used during times of cold weather. I had particular trouble with my left side, which once every three or so months, would get damaged with what appeared to be a leak from one of the milk ducts, causing intense pain with latching.

Olly was weaned when he was two years old and I was three months pregnant. Soon after this I began having trouble with vasospasms again. They would always be heralded a few days beforehand by very sensitive ‘tingly’ nipples. I really didn’t want to use my existing breastwarmers all the time due to their bulk, so I figured out how to make some myself that were smaller and more discrete, and found them to be very effective at getting rid of the ‘tingly’ feeling. They never really felt like they were doing anything, but whenever I stopped using them the sensitive nipples came back, and this is a comment that some of my testers also made.

After having my second child, Emma, I was so sure that I had my Raynaud’s under control that I never even bothered to tell my midwife about it. I was sure that if I was extra careful, never let my nipples air-dry and always used my breastwarmers, I would be fine. I guess I forgot about how with a newborn you are regularly waving your nipple in front of them for minutes at a time, in the middle of the night, trying to latch them. This scenerio was no match for my current management of Raynaud’s. I started having vasospasms about a week after Emma was born. These were particularly bad on my right side, and I also started having had intense latching pain on this side, moderate pain during feeding, and some external damage. My midwife and I both figured this was all due to poor latching on this side, and I watched all the latching video clips I could, and reread the latching information I had. Nothing I did would gaurentee a pain free latch though. I felt like such a failure that I couldn't latch properly and feed pain free.

With every latch words like "bitch", and "how could you do this to me", would spring into my mind. I was horrified that these words could be associated with my beautiful, loved, daughter. Emma had had a beautiful birth, followed by days of continuous skin-on-skin contact, and demand breastfed. We were strongly bonded to each other, yet these awful words somehow found their way into our lives. Latching was torture. Way worse than childbirth. However, I was completely determined to breastfeed, knowing the huge benefits that it had given Olly and I. I was also completely sure that whatever was causing my pain was something that I could work through.

The vasospasms and painful latching lasted for a few weeks. I used my breastwarmers all the time, and tried many ways of keeping my wheat packs warm at night so I didn't have to go to the kitchen to heat them up.

I had a second bout of Raynaud's a few months later, during fine weather in December. I had vasospasms as well as excurating pain during latching. The pain during latching had a distinct starting point, after I had latched while my nipple was constricted, and this had caused me internal and external damage, causing me ongoing pain with each latch. My constricted nipple wouldn't stretch, and a baby’s suck is very strong, and something had to give. After realising this, with every latch I would gently squeeze the nipple to check it wasn't constricted. If it was, I would squeeze/massage it for a few moments was all it usually needed to become stretchy again. If a vasospasm occurred I would also squeeze and massage to make sure the blood returned to the nipple as soon as possible to stop the pain and prevent tissue damage.

I knew that latching trama to the nipple was believed to be associated with Raynaud's. But it damage due to latching of a constricted nipple seems to me to be a better fit to women's description of an "intense pain regardless of perfect latching". Usually when the problem is poor latch, if the latch is corrected then the latch will be painfree, leading to the advice that "breastfeeding shouldn't hurt, if it does, take the baby off the breast and try relatching". For a woman who is going to have intense pain with every latch, advice like this is terrible information. I remember latching Emma again and again, trying to obtain pain free breastfeeding. In hindsight I think I was probably doing more damage than good, as really I knew Emma was well latched.

I started using disposable hand warmers during this eposide of Raynaud's. I put these inside a cover to keep me and the warmers dry, and to make sure neither Emma or I could come into direct contact with them and get too hot. I had finally found the solution that worked for me - the bliss of having eight hours continuous heat at night. Emma slept with me, so this solution meant I didn't have to get out of bed at all at night. It only took a few nights for me to have my vasospasms under control, and the pain at latching took a week or so to go. Using the warmers gave me lots of milk in my right breast, but this was a problem that I could easily manage by block feeding, or expressing when I needed to. Using cold cabbage leaves to reduce engorgement was one solution I was happy to leave to those without Raynaud's.

Breastfeeding is now going great. Emma is currently at that incredibly cute stage where she comes off the breast every few minutes to look at me, smile, and then bury her head into me again. I so look forward to all the other breastfeeding stages we will be able to go through together, and consider myself so lucky to have been able to manage this condition and to be able to breastfeed my children.