Discussion The health benefits of breastfeeding for women and baby are well-documented

Discussion
The health benefits of breastfeeding for women and baby are well-documented. 17, 21, 22 One of the main difficulties in lactating women at the beginning of breastfeeding is nipple cracks, and this may represent an obstacle to successful breastfeeding, leading to a reduction in milk production. 23
In the first weeks of breastfeeding, sore nipples are most often produced by a poor latch by the feeding infant. The latch can best be evaluated by somebody experienced in lactation observing a feeding. 25
No one topical agent has shown superior results in the release of nipple discomfort. The best essential factor in diminishing the prevalence of nipple pain is the providing of teaching in relation to appropriate breastfeeding technique and latch-on as well as protective guidance about the high occurrence of early postpartum nipple pain. 26 With sufficient support and good information on avoiding some of the common difficulties related to breastfeeding, a woman chance of effectively breastfeeding her new baby is significantly improved. There are a number of experimental studies with different treatments and treatment mixtures to prevent nipple pain and injury in breastfeeding women. 27 Bearing in mind the health threats associated with not breastfeeding and the fact that sore nipples are not predictable during the early days of breastfeeding 7, 11, it is logical to generate healthy, flexible tissue that is very resistant to cracks.

In the present study, the use of peppermint water was noticed to be an effective technique to avoid nipple cracks. Also, no areola crack was witnessed in the peppermint water group. In our previous study 19, the use of peppermint water was found to be three times more effective than expressed breast milk EBM; 27% vs. 9%. This study showed a significant decrease in the occurrence of nipple pain and cracks in breastfeeding women wherever peppermint water was useful after breastfeeds. These effects could be attributed to the sedative and numbing effects and the antibacterial action of peppermint water leading to the decrease of irritation and nipple discomfort. Additionally, painful feeding could be the cause of the decrease of the frequency and duration of feeds in the expressed breast milk group.
Concerning the amount of nipple crack in the current study in women in the peppermint water group, at fifteen and threaten days, they were more likely to report no cracks (n = 2) than were women in the expressed breast milk group (n = 6 & 8) and the control group (n = 24 & 28). Regarding areola crack (p < 0.001), women in the control group were more likely to state severe nipple crack (18% & 20%) than were women in the expressed breast milk group (8% & 8 % respectively) , but the majority of women in the peppermint water group were likely to report no nipple crack (44% & 46% respectively) (p < 0.001). The control group had a greater chance of suffering overall nipple and areola crack (24 % & 28%) than had the expressed breast milk group (16%&16% respectively),which is relatively fewer than the rate of 9% found in our previous study for the level of nipple crack in peppermint water users. 19
As regards pain intensity at fifteen and thirteen days, women in the peppermint water group felt mostly no pain (92% & 96 respectively ) compared to those in the expressed breast milk group and the control group (64% & 68%, and 44% & 40% respectively) (p < 0.001). These results are supported by the findings of Akkuzu and Ta?kin (2000) 28, who illustrated that applying warm compresses or expressed breast milk was found to be less effective in avoiding nipples cracked than simply preserve the nipples clean & dry. There were a smaller amount of cases with nipple pain in the group that applied expressed breast milk. Ideally, additional studies should be done to increase more insight into the efficiency of peppermint water because the applying of a cream or an ointment is easier than a solution, and in order to recommend a constant amount of peppermint water, planning a randomized trial comparing peppermint lotion/cream to no action could be the subsequent step.

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Conclusions and recommendations:
The results presented that the formulated peppermint water as a natural remedy is more effective in the avoidance of nipple cracks than expressed breast milk. To our knowledge; this is the second study reporting the influence of peppermint water on nipple and areola pain and cracks. Daily use of peppermint water is associated with an increase in the duration and amount of feeds, and less nipple pain compared to the use of expressed breast milk alone. Recommendations: Based on the present findings, peppermint water application could be suggested as a prophylaxis of cracks nipple; in addition, proper instruction at the initiation of breastfeeding and education program are needed to improve women' awareness concerning prevention of cracked nipples
Acknowledgement
We gratefully acknowledge the willing assistance given by the women in our study, the hospital midwife staff working in the Maternity and Child Health Hospital and the Azazia Maternity Hospital. We also thank Dr. Basam Eldek for helping with the final analysis.

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