NDC clinical guidelines: indications, contra-indications, and precautions for use of light therapy in treatment of persistent lactation-related nipple pain

What is the NDC definition of persistent lactation-related nipple pain?

Persistent nipple pain is caused by ongoing (chronic) inflammation of the nipple epithelium and/or nipple stroma, which causes nociceptic pain in the epithelium, and nociceptic and possibly neuropathic pain in the stroma. This chronic inflammation has been caused by repetitive mechanical microtrauma.

What are indications for light therapy in treatment of persistent lactation-related nipple pain?

NDC indications for use of light therapy

Light therapy may be indicated if nipple pain and inflammation persist after a period of time during which you've applied the NDC guidelines for nipple pain and damage.

The intent of light therapy is to tip the balance towards resolution of the chronic inflammatory state of the epithelium and stroma. This is because in some women, even once the application of mechanical forces is appropriately distributed over as much of the surface of the nipple-areolar complex intra-orally as possible, the normal mechanical pressures of breastfeeding perpetuate the inflammation or impede its healing.

You can find out more here about the theory which underlies the NDC Clinical Guidelines suggestion that laser therapy, whilst not supported by evidence, may be something that clinician discusses as an option with the patient.

In applying the NDC guidelines, you would only consider light therapy after

• You've been assisting the patient to optimise fit and hold with a gestalt intervention

• Considered treating with diflucan 150 mg stat, every second day for a week (total 3 doses), if there are indications for antifungal use. You can read about this here.

• Considered a trial of nipple shield use. You can read about this here.

The amount of time which passes before you suggest trying light therapy will be a clinical judgement which takes into account the complexity of your patient's unique presentation. It can take a fortnight or more for a gestalt intervention plus associated measures (not light therapy) to resolve nipple pain.

You can find the clinical steps of applying light therapy for lactation-related persistent nipple pain, starting here.

When is it not appropriate to recommend light therapy?

In applying NDC guidelines, light therapy is not indicated when

• There is nipple damage, such as cracks, blisters, visbile bruises, or ulcers. Epiethelial breaks and deeper visible haemorrhages require immediate steps to faciliate healing, which may, depending upon the extent of the wound, include rest from the mechanical stressors of direct breastfeeding and pumping. Steps for management of nipple pain and damage are here. Visible epithelial damage (not a contra-indication to light therapy in general but a sign that more direct strategies, such as resting the nipple, are required). Repetitive microtrauma acts against the resolution of inflammation, so that light therapy is unlikely to be helpful.

• The patient has not received previous intensive work with the gestalt method (at least three consultations: initial intervention, two follow-up consultations), in order to eliminate nipple and breast tissue drag a during breastfeeds. Repetitive microtrauma acts against the resolution of inflammation, so that light therapy is unlikely to be helpful.

• The patient is not continuing to work with the gestalt method as she breastfeeds her baby. Repetitive microtrauma acts against the resolution of inflammation, so that light therapy is unlikely to be helpful.

• The patient has not received in-clinic review of her use of mechanical milk removal, in order to eliminate repetitive mechanical microtrauma during pumping. Repetitive microtrauma acts against the resolution of inflammation, so that light therapy is unlikely to be helpful.

• The patient's nipples continue to be subject to overhydration and moisture-associated skin damage. This acts against the resolution of inflammation, so that light therapy is unlikely to be helpful.

Contraindications more broadly for use of a laser device

Contraindications for light therapy are

• Breast or other malignancy

• Light photosensitivity

What precautions need to be taken when using light therapy?

• Avoid eye contact with direct or reflected laser radiation

• Pregnant women who should not have the device applied in the vicinity of the womb

• The device should not be used in the vicinity of a pacemaker

• The device must be kept away from children

What are possible side-effects of light therapy?

In all studies and reviews assessing the safety and efficacy of photobiomodulation (or light) therapy, no adverse effects or contraindications in either animal models or human patients has been reported.

• A recent study by Barbara et al, investigated the side effects of light therapy on nipple pain, demonstrating that 31% of study participants received a tingling and/or prickling sensation post-treatment with light therapy over the nipple20. This effect was not considered harmful. Sensitivity to light was reported in 15% of trial participants, in the form of temporary effects such as reports of dizziness, temporary increase in pain, feelings of tiredness or euphoria23. These effects are not considered to be harmful in the long term.

Moreover, several studies have concluded no long-term adverse effects of PBM in vitro,24 in vivo including non-human primates,25 and in human models26,27.

We can conclude that photobiomodulation therapy is a safe, non-invasive and non-pharmacological method for treating pain and reducing inflammation.