الفهرس 
Theoretical and operational definitionsOnly 14 pages are availabe for public view
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Abstract
Egypt Demographic and Health Survey (EDHS) 2014 shows that among infants under
two months of age, 71 percent are receiving only breast milk. However, the proportion of
exclusively breastfed drops off rapidly among older infants. By age 4-5 months, only around
1 in 8 children were being exclusively breastfed. Breastfeeding can be challenging, especially
in the early days. Many women who start out breastfeeding stop before the recommended
minimum of exclusive breastfeeding for six months. Often women stop because common
problems interfere with their ability to breastfeed (Farag et al., 2020).
Several studies have shown that women with breast and nipple complications reported that it affects their success and continuation of breastfeeding. In a survey in New York City,35% of nursing mothers stopped breastfeeding after one week due to the pain of cracked nipples (Elagamy et al., 2019). Thirty percent stopped breastfeeding between week one and three. Another survey of breastfeeding mothers in Brazil reported that there was a 25% higher nrisk of interruption of exclusive breastfeeding when the women had cracked nipples.Normally, nipples are kept supple from the secretions of the Montgomery tubercles in the areola. They can become sore when they are excessively dry or wet, which makes them crack or fissure (Ismail et al., 2019). Nipple pain can be classified as acute pain because, usually, it occurs in the first week postpartum. The most common cause is inadequate positioning and attaching of the infant to the breast, which can lead to damage to the skin of the nipple and pose a major challenge for breastfeeding women, as they need to breastfeed around eight times a day in the early postpartum period. Frequent incorrect feeding hampers the tissue repair process and can lead to further damage (Coca et al., 2019).Maternity nurses play a crucial role in providing physical, psychological, and emotional support and necessary information to women. The nurse caring for the vbreastfeeding mother should help the women achieve independence and success in her feeding efforts prepared with knowledge of the anatomy and physiology of the breast and lactation, the component and positive effects of breast milk, and the techniques of breastfeeding. The nurse can help women and their families by using their own resources to achieve a successful experience (Piro & Ahmed, 2020).The purpose of the current study was to investigate the effect of peppermint water versus expressed breast milk on cracked nipple among lactating women. The study was carried out in postnatal ward and postnatal clinics at four settings in Menoufia governorate:Menoufia University Hospital, Shebin El-Kom Teaching Hospital, Sirs-Elian Hospital, and Menouf Hospital. A quasi-experimental design was used in carrying out the study.Purposive sample of that consists of (90(lactating women with cracked nipple who did not start any treatment was selected. The participants were divided randomly into three groups. Each of the 90 women was asked to pick a piece of paper containing a number (1, 2,and 3). Those who selected number 1 were assigned to G1, those who selected number 2 wereassigned to G2, and those who selected number 3 were assigned to G3.1- The first study group which included (30) women who were instructed to apply expressed breast milk after each feeding.2- The second study group included (30) women who were instructed to apply peppermint water on the nipples and areola after each feeding.3- The control group which included (30) women who were left for the routine postnatal
hospital care Inclusion and exclusion criteria of the study participants:Both groups have the following criteria:
Inclusion criteria:- Lactating mothers with cracked nipple did not start any treatment.- Free from any medical diseases which interfere with breastfeeding (infectious disease as active pulmonary tuberculosis).- Delivery of a viable healthy newborn (without cleft lip or cleft palate).- Accept to participate in the study.- Accept the follow up contact after discharge from the hospital.Exclusion criteria:- Women with diagnosed chronic diseases, for example, diabetes, mental disorders,autoimmune diseases, and severe anemia.- Women suffering from diseases or conditions affecting breastfeeding, including infectious mastitis, ductal infections, flat or inverted nipples, nipple or sub areola bscess, and fungal infection on the breast.Throughout the course of the present study, data were collected using these instruments. These instruments were as follows:Instrument I: A structured interviewing questionnaire: that included socio-demographic data, previous obstetric history, assessment of women’s knowledge regarding the cracked nipple definition, causes, signs, and symptoms, complications, preventive measures as well as its management.Instrument II: Breastfeeding Observation Checklist: It was adapted from World Health
Organization & United Nations Children‟s Fund (1993). Breastfeeding observation checklist was used to observe the breastfeeding process for 5 minutes. It was containing: the mother’s and newborn‟s positions as well as the infant’s attachment to the breast.Instrument III: Numerical rating scale (NRS): It is a subjective self-reported scale developed by Lafoy and Goden (2000) for describing the mother‟s self-rating of pain. The scale was used to assess the intensity of nipple pain.Instrument IV: Nipple soreness rating scale (NSR):It was adapted from Storr, to assess the healing of the nipple soreness.Instrument V: Nipple Trauma Score (NTS):It was adapted from AbouDakin to evaluate the depth and extent of nipple trauma.An approval from the committee of Hearing and Ethics was obtained from the Faculty of Nursing, Menoufia University on 8/1/2020. Approaches to ensure ethics were considered in the study regarding confidentiality and informed consent. The researcher introduced herself to the participants and explained the purpose of the study in order to obtain their acceptance to be recruited in the study as well as to gain their cooperation Confidentiality was achieved by the use of locked sheets with the names of the participants replaced by numbers. All participants were informed that the information they
provided during the study would be kept confidential and used only for statistical purposes.After finishing the study, the findings were presented as a group data with no personal participant’s information remaining. After explanation prior to enrollment in the study, informed consent had been obtained from all women. Each woman had informed that participation in the study was voluntary and each woman could withdraw from the study whenever she decided to do so. Each woman was allowed to freely refuse the participation. They were free to ask any question about the study details.Upon the completion of data collection, each answer was coded and scored. The researcher coded the data into a coding sheet so that data could be prepared for computer use.Data was statistically analyzed using (Statistical Package for the Social Sciences, version 22,SPSS Inc. Chicago, IL, USA).The findings of this study supported the three study hypotheses. Lactating women with cracked nipple who apply peppermint water have lower scores of pain intensity and tenderness than lactating women who receive routine care. Lactating women with cracked nipple who apply expressed milk secretion have lower scores of pain intensity and tenderness
than lactating women who receive routine care. Lactating women with cracked nipple wh apply expressed milk secretion have lower scores of pain intensity and tenderness than lactating women who apply peppermint water.
The findings of the present study showed that:● There was no statistical significant difference among the study participants regarding the age, residence, occupation, and level of education● The majority of the study groups had poor knowledge regarding cracked nipple (70.0%,73.3%, and 60 %) in the control, peppermint water, and expressed breast milk groups,respectively.● There was no statistically significant difference among the study participants regarding using the correct breastfeeding position and correct attachment with the newborn during breastfeeding.● There was no statistically significant difference among the study groups regarding the pain intensity before the intervention. While there was a very highly statistically significant difference between control & peppermint water groups regarding the pain intensity and there was a very highly statistically significant difference between control & expressed breast milk groups while there was statistically significant between peppermint water & expressed milk groups after the intervention (posttest & follow-up).● There was no statistically significant difference among the study groups regarding the nipple soreness before the intervention (pretest). While there was a highly statistically significant difference between control & peppermint water groups regarding the nipple soreness and there was a very highly statistically significant difference between control & expressed breast milk groups while there was a highly statistically significant difference between peppermint water & expressed milk groups after the intervention (posttest & follow-up). There was no statistically significant difference among the study groups regarding the nipple trauma before the intervention (pretest).While there was a very highly statistically significant difference between control & peppermint water groups regarding the nipple trauma and there was a very highly statistically significant difference between control & expressed breast milk groups while there was highly significant between peppermintb water & expressed milk groups after the intervention (posttest & follow-up). According to the findings of the present study, it can be concluded that there was a highly statistically significant difference after using expressed breast milk on the reduction of the cracked nipple in terms of pain, nipple soreness, and nipple trauma than those who use routine care. This supported the first study hypothesis. Also, the present study showed that there was a highly statistically significant difference after using peppermint water on the reduction of the cracked nipple in terms of pain, nipple soreness, and nipple trauma than those who use routine care. This supported the second study hypothesis. In addition, the present study showed that expressed breast milk was more effective than peppermint water as it relieves cracked nipples in terms of pain, nipple soreness, and nipple trauma after its application. This supported the third study hypothesis. Based on the present findings; the study hypotheses were all accepted.Based on the findings of the current study, the following recommendations are proposed: Incorporating preventive measures and taking care of cracked nipple within antenatal counseling to reduce cracked nipple after delivery. Nurses should encourage mothers to initiate and sustain exclusive breastfeeding with the correct position and technique to prevent cracked nipples. Encouraging the use of non-pharmacological measures expressed breast milk as it was safe and less expensive for those who have cracked nipple.