Application of cabbage leaves compared to gel packs for mothers with breast engorgement: Randomised controlled trial
Introduction
Breast milk is considered the most desirable food for babies. There has been extensive research in various countries providing evidence that breastfeeding has short-term and long-term benefits to both mothers and infants. Most new mothers who breastfeed find it a deeply satisfying experience, both physically and emotionally (Lawrence and Pane, 2011). The World Health Organisation (WHO, 2002) has emphasised the importance of breastfeeding for a duration of greater than six months, and most countries, including Singapore, promote exclusive breastfeeding. In Singapore, 50% of the mothers breastfeed their infants exclusively when they are discharged from the hospital (Chua and Win, 2013).
Breast engorgement is a common physiological problem for lactating mothers, which can be due to the rate of secretion that exceeds the rate of the ejection of milk and/or poor/shallow latching from the baby. The reported incidence of breast engorgement varied among studies, ranging from 20% to 77% (Spitz et al., 1998, Walker, 2000). Based on an internal survey at the private hospital where the current study was conducted, the incidence was about 20%.
There are numerous consequences of breast engorgement: painful swelling breasts associated with sudden increase in milk volume, lymphatic and vascular congestion, and interstitial oedema during the first congestion (Lawrence and Pane, 2011, Lawrence and Lawrence, 2011). Studies have reported that poor management of breast engorgement leads to the failure of milk production during the early postpartum period, resulting in an early cessation of breastfeeding (Lawrence and Pane, 2011, Snowden et al., 2001, Walker, 2000). The major reason for an early cessation of breastfeeding is due to the pain caused by breast engorgement (Foo et al., 2005). If breast engorgement is not managed effectively, it can lead to mastitis and breast abscess (Olds et al., 2000).
The main aim of the management of breast engorgement is to successfully establish and maintain the flow of breast milk and empty the breast milk effectively via the baby or expression to prevent engorgement (Lawrence and Pane, 2011). Current approaches involve a combination of pharmacotherapy (Snowden et al., 2001) such as pain medications and non-pharmacological management such as direct massage to the areas with blocked ducts (Snowden et al., 2001, Walker, 2000), cold cabbage leaves (e.g. Arora et al., 2008, Nikodem et al., 1993, Roberts et al., 1995), cold gel packs (Roberts, 1995), cabbage leaves extract (Roberts et al., 1995), gua-sha as a form of Chinese massage (Chiu et al., 2010), acupuncture (Kvist et al., 2007), therapeutic ultrasound (Mclachlan et al., 1993), and breast binding (Swift and Janke, 2003).
Non-pharmacological treatments for breast engorgement are becoming increasingly popular. The use of cabbage leaves is a popular non-pharmacological method used in managing breast engorgement and it can reduce the discomfort, tenderness, and swelling of breasts (Arora et al., 2008, Roberts et al., 1995). The cabbage leaves contain enzymes such as sinigrin and rapine (Joy, 2013) and have proven to be a good source of antioxidants (Nilnakara et al., 2009). The sulphur compound in cabbage leaves has antiseptic, disinfectant, anti-bacterial, and anti-inflammatory properties (Hatfield, 2004), which will support their use to relieve pain and swelling. The temperature of cabbage leaves has an impact on its effectiveness (Rosier, 1988). In the study hospital, non-pharmacological methods of massage, cold cabbages, and cold gel packs were used to treat mothers with breast engorgement. A systematic review was conducted on the effectiveness of cabbage leaf application on pain and hardness in breast engorgement and its effect on the duration of breastfeeding (Wong et al., 2012). The review found that cabbage leaves can potentially help to reduce the pain and hardness of engorged breasts and increase the duration of breastfeeding, but the results were inconclusive. Nikodem et al. (1993) reported that when compared to mothers in the control group, 18% more mothers who received the cabbage leaf intervention were exclusively breastfeeding at six weeks postpartum. From the literature, only one study has been conducted to compare the effectiveness between gel packs and cabbage leaves (Roberts, 1995). Roberts’ (1995) study showed a reduction in pain with the breast engorgement post-intervention with both gel packs and cabbage leaves, but there was no significant difference in pain scores between the two groups.
Although a few studies have found that the cabbage leaf treatment and cold gel packs can potentially reduce symptoms caused by breast engorgement, the findings from these studies were inconclusive. Furthermore, a review of the literature identified gaps such as a lack of control group used in the design, small sample sizes, a lack of blinding technique, a lack of follow-ups, and inconsistency in the duration of the application of cold cabbage leaves and cold gel packs. Hence, our study aimed to examine the effectiveness of cold cabbage leaves and cold gel packs in improving mothers’ outcomes of pain, hardness of breasts, temperature, duration of breastfeeding, and satisfaction using a randomised controlled trial. The hypotheses were:
- (1)
When compared with those in the control group, mothers using cold cabbage leaves or cold gel packs will report lower levels of pain, hardness of breasts, and body temperatures with statistically significant differences over time in the first and second hour after the two applications, as well as at each post-test time point;
- (2)
When compared with those in the cold gel packs group, mothers receiving cold cabbage leaves application will report lowers level of pain, hardness of breasts, and body temperatures with statistically significant differences at each post-test time point.
- (3)
When compared with those in the control group, mothers in the two treatment groups will have longer durations of breastfeeding at 3-month and 6-month follow-ups with statistically significant differences.
- (4)
When compared with those in the control group, more mothers will be satisfied with the treatment of breast engorgement in the two treatment groups with statistically significant differences.
Section snippets
Study design
A randomised controlled three-group pre-test and repeated post-test study design was adopted. Mothers were randomly assigned into intervention group 1 (cold cabbage leaves application plus routine care), intervention group 2 (cold gel packs application plus routine care), or the control group (routine care only).
Setting and sampling
Mothers with breast engorgement were recruited on their day of discharge from a private maternal and children’s hospital, which has an average of 768 deliveries per month, in Singapore.
Results
Among the 240 mothers approached, 228 were recruited in the study. All 228 mothers completed the baseline data collection, but one mother from the cold gel pack group dropped out before the commencement of the intervention as her baby had severe jaundice. Therefore, a total of 227 were eligible for final data analysis. Five out of these 227 mothers were uncontactable at the 3-month follow-up, and two mothers out of 164 who were still breastfeeding at the 3-month follow-up were not contactable
Discussion
This is the first study that used a rigorous design to compare the effectiveness of cold cabbage leaves and cold gels packs for mothers with breast engorgement, with clear descriptions of the duration of application and six post-intervention follow-ups. The majority of our participants were over 30 years old (mean 32.9 years), Chinese, with Bachelor degree or higher education levels, and with total family monthly incomes of over S$5000. The sample was a representation of the participating
Conclusions
Cold cabbage leaves helped to relieve pain and hardness in breast engorgement at all post-intervention time points while cold gel packs only helped to relief pain at all post-intervention time points. Mothers who received the cold cabbage leaves intervention reported to be most satisfied with the treatment, followed by those who received the cold gel packs intervention. There was no difference in the durations of breastfeeding among the three groups. While both cold cabbage leaves and cold gel
Author contributions
Study Design: WBB, HHG, SKSL, CYS.
Data Collection and Analysis: WBB, CYH, LY, HHG.
Manuscript Preparation: WBB, HHG, ML, CYH, LY, SKSL, CYS.
Funding statement
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgements
We appreciate the nurses from the study venue who helped with the data collection. We appreciate the doctors from the study hospital who provided great support to this study. We thank all mothers who took time to participate in this study. We appreciate the Medical Publications Support Unit of the National University Health System, Singapore, for assistance in language editing of this manuscript.
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