Access KeysSkip to MenuSkip to ContentSkip to Footer

8.2 Nipple Pain

Nipple pain is a common early postpartum concern.

It causes mothers

Nipple pain can be caused by several factors:

Transient nipple pain is common during the first week postpartum, peaking at day 3 and decreasing by day 7. 5 There is no damage evident and the pain disappears within a short time of commencing the feed (ie, about 30 seconds).

Technique factors

Historically, an intervention to try to prevent nipple damage was to limit the number of feeds and length of time on the breast. A Cochrane Review 6 concluded that this practice was associated with an increased incidence of sore nipples, engorgement and the need to give additional (formula) feeds, and is therefore not recommended.

One study noted that 94% of women with breastfeeding problems had babies who had a "superficial, nipple-sucking" technique. 7

Many authors implicate a poorly latched baby as being the major culprit of nipple damage. 8 9 10

It has also been noted that there is a correlation between the early use of bottles and/or pacifiers and a disorganized suck and nipple damage. 7 11

From this body of work it is clear that the most common cause of nipple pain and nipple damage is preventable by:

  • teaching correct positioning and latching techniques, and
  • avoiding artificial nipples (teats/pacifiers/dummies) during the learning period.

Back to basics

Poor latch (whether from maternal technique or infant ability) may exist in the presence of other factors mentioned above.
In assisting the mother, go back to basic principles of position and latch FIRST to obtain a clearer picture of the other factors.

Quality assurance activity

Would you and a small group of colleagues be able to organize an audit of all cases of nipple damage on discharge from your maternity unit over a one-month period?
It may be as simple as just an incident report, though trying to determine a cause for each would be useful. You may like to discuss with your colleagues the significance of this data once collected. Together you could work on ways to reduce the incidence before surveying again.

Maternal anatomy issues

General tips:

  • Always start any 'difficulty latching' attempt to breastfeed with a well positioned baby in skin-to-skin contact with mother.
  • Gentle touch or massage, or a cold cloth over the nipple will stimulate the erectile tissue.
  • Compress the breast to hold the shape, ensuring the compression points on the breast coincide with where the baby's bottom and top jaws will be. Some mothers find it helpful to maintain this hold for a minute or two until sucking well established.
  • While the breast is still soft prior to lactogenesis II is the best time for the baby to learn to breastfeed from his mother's breasts. If an artificial teat, whether it be a bottle nipple or a nipple shield, is introduced before giving the baby this opportunity the baby is more likely to require the 'super' stimulation of a formed shape at the posterior hard palate to stimulate sucking for all future feeds.

Workbook Activity 8.3

Complete Activity 8.3 in your workbook.

Inverted or non-protractile nipples

Non-protractile or inverted nipples are difficult to draw out. Attempt to shape the breast well and hold that shape until infant is well established on the breast.

Some devices may assist:
Syringe on right modified for mother to gently draw out non-protractile or inverted nipple.

Syringe on right modified for mother to gently draw out non-protractile or inverted nipple.
Photograph © Health e-Learning

Devices such as the modified syringe, or commercially available devices have assisted mothers to draw their nipples out to enhance baby's ability to latch. Using a hand pump for a minute or so can also draw out the nipple. Some mothers may find it more comfortable if her partner is able to suck the breast/nipple into a teat shape immediately before feeding the baby.

These techniques are not always necessary though as many babies latch well to the breast regardless of nipple protractility.

Remember it is breastfeeding, not nipple feeding.


Infant well-latched to nipple shield.

Infant well-latched to nipple shield.
© B. Wilson-Clay IBCLC

Sometimes a nipple shield may be successful. A risk:benefit assessment needs to be thoroughly explored first. Short-term benefits may lead to long-term complications for the breastfeeding dyad. In the past, nipple shields have been associated with decreased milk transfer, infant weight loss and decreased milk supply.12 13 14 Even with modern, thin nipple shields their use has been associated with premature weaning15 yet one study of preterm infants showed increased milk transfer over two consecutive feeds.16

Milk transfer via a shield, before lactogenesis II, will be negligible and therefore shields are not started until mother has established a good milk supply.

Note: Once a nipple shield has been introduced, observe for a good deep latch and nutritive sucking pattern. Follow-up assessment of infant condition and maternal milk supply is very important with the aim to weaning off the shield when the initial problem has resolved.




Infant anatomy issues

Ankyloglossia (tongue tie)

Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.

Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.
© Dr E. Jain

Ankyloglossia is a membranous attachment between the inferior aspect of the tongue and the anterior floor of the mouth, just beneath or directly onto the posterior alveolar ridge. This short or tight lingual frenulum may prevent the baby from extending the tongue over the bottom gum line or elevating the tongue (a very essential action for breastfeeding).


Presentation

80% of cases of poor latch as a result of ankyloglossia presented at 2 days postpartum; whereas 60% of women with nipple pain from ankyloglossia presented after day 2.17

If not treated the most common outcomes include:

  • poor latch
  • nipple pain
  • severe nipple damage
  • constantly feeding
  • infant failure to thrive (inadequate milk transfer)

Treatment

Several factors need to be considered. Adequate tongue movement and function is essential for breastfeeding. Mild anomalies may have minimal effect on tongue function. However, when tongue-tie is noted, it must always be considered as causative of any breastfeeding problems until proven otherwise.

Frenotomy
This is a simple surgical procedure to release the restriction and provide greater movement.

The following outcomes of frenotomy have been achieved:
  • Where poor latch was their major complaint, 100% of women found latch was improved.17
  • Of those presenting with nipple pain, mean pain score reduced from 6.9 to 1.2 immediately after the procedure.17
  • A significant decrease in nipple pain score reported after frenotomy compared to after sham procedure.18
  • Ultrasound post-frenotomy demonstrated less nipple compression by the tongue and was associated with "better attachment, increased milk transfer and less maternal pain".19

Nipple infections

Fungal overgrowth (candidiasis, thrush, yeast)

Candida albicans is a fungus (a form of yeast), which exists normally on the mucous membranes of the gut and vagina and usually presents no problems to a healthy individual. Factors that cause an imbalance of the normal flora of the body often result in candidiasis - the condition caused by an overgrowth and change in form of the fungus as it infects the host tissue.

Factors often associated with nipple candidiasis are:

  • presence of vaginal candidiasis - up to 25% of women are affected by end of pregnancy 20
  • use of antibiotics 1
  • break in skin integrity of nipple
  • infant who has oral candidiasis (acquired during birthing or being introduced on fingers, etc)
  • infant use of pacifiers/dummies 21 22 - may also contribute to persistence of infant oral infection
  • use of bottles - 23% of lactating women who used bottles tested positive for Candida and 20% had nipple candidiasis. A risk factor for colonization of the mother was bottle use in the first 2 weeks postpartum. Of these women 57% had weaned by 9 weeks postpartum, compared to 31% who were negative for Candida . 23
Amongst women who reported breastfeeding associated pain, C.albicans is the most commonly cultured organism. 24

Presentation

Notice the shiny red areas around the nipple.

Notice the shiny red areas around the nipple.
© Goldfarb Breastfeeding Clinic

Nipple candidiasis commonly presents with the following signs and symptoms

  • acute breast/nipple pain after a period of pain-free feeding
  • deep shooting, burning, or stabbing pain in the breast
  • burning nipple pain, during and for some time after a breastfeed
  • nipple and/or areola may be red, shiny or flakey; though may show no changes
  • Candida may be obvious in the baby's mouth

Workbook Activity 8.4

Complete Activity 8.4 in your workbook.

Management

Observe a breastfeed to ensure latch is optimal, preventing further nipple damage.

Candida branches and multiples rapidly and exists in many different stages at the same time. Management is aimed at eradicating the pathogen and preventing re-infection. The mother's doctor will confirm the diagnosis and may prescribe a pharmaceutical antifungal agent.

Antifungal agents that have been found to be effective in treating nipple candidiasis include:

  • Gentian violet - painted on the nipples. This purple dye kills Candida on contact. (not readily available in some countries)
  • Pure coconut oil - rubbed into nipples and ingested for candida in other sites. 100% effective against candida albicans 25
  • Miconazole - cream applied sparingly to nipples, oral gel, and powder. Effective in 99% of cases. 26
  • Fluconazole - systemic agent, usually administered orally.
  • Nystatin cream, tablets and pessaries. Not usually the drug of first choice. Resistance has developed to this drug, only being effective in 54% of cases. 26

Educate the mother about the following supportive strategies that will enhance the antifungal treatment and prevent re-infection.

  • Meticulous attention to hygiene.
    • wash hands in warm, running soapy water before and after breastfeeding and any time when potentially infected areas have been touched, drying hands on a paper towel.
    • discard reusable gel breast pads if they were being used and don't recommence until infection is cured, and preferably not at all.
    • wash bras and cloth nursing pads daily and dry in direct sunlight if possible.
    • boil pacifiers or artificial teats/nipples daily and replaced frequently.
    • wash and thoroughly dry all toys, etc the baby puts in his mouth.
  • Rinse the nipples in a bicarbonate of soda solution to create an alkaline skin environment. Nipples may respond differently to traditional vaginal thrush soothing treatments.
  • Consider and treat all possible sources of recurring infection
    • trim the baby's finger nails to prevent Candida being harbored under the nail and transferred to the mouth.
    • the moist fold under the breasts of large breasted women
    • other children, maternal vaginal infection, sexual partner, a pet
  • Some women have reported faster resolution of symptoms when they eliminate simple sugars and yeasts from their diet and consume pure coconut oil, acidophillus and/or bacillo bifidus either in yoghurt form or in a commercially prepared capsule.
Treatment of the infant
The infant may be a source of a re-infection cycle. Check the infant's mouth mucosa carefully. It may be necessary to treat the mouth with an appropriate infant preparation such as miconazole gel.

Workbook Activity 8.5

Complete Activity 8.5 in your workbook.

Bacterial infection

Whenever nipple skin integrity is broken the risk of colonization with bacterial and fungal pathogens is significantly increased.
Staphylococcus aureus is the most common causative organism of bacterial infections on the nipple, though streptococcus may also be implicated.


© Goldfarb Breastfeeding Clinic

Management:
  • Treat the original cause of the break in nipple skin integrity.
  • Clean the nipple wound in a saline solution.
  • Apply antibiotic ointment as ordered by the doctor. A compound many find useful is a combination of betamethasone ointment, mupirocin ointment and miconazole powder making an anti-inflammatory, antibiotic and antifungal ointment. 27
    A doctor may prescribe this and a compounding pharmacy supply it.
  • It has been suggested that prophylactic oral antibiotics when nipple bacterial infection is diagnosed will prevent subsequent mastitis. 28
    However, in an unsuccessful attempt to replicate that study, the authors reported a significant number of women reluctant to take antibiotics prophylactically. 29

Supportive management of nipple damage

There is nothing to be achieved by treating sore or damaged nipples if you don't simultaneously treat the cause.

When the cause of the damage is treated (as above), the nipple will heal quickly even while the mother continues to breastfeed from the affected breast. After identifying the cause and initiating the appropriate action plan, the mother may also benefit from some other supportive measures.

Wound management

The damage on a nipple is a wound. However, unlike a wound on other parts of the body, a nipple wound has unique characteristics:
  • a large volume of a bodily secretion (ie breastmilk) must be allowed to flow past it frequently
  • an infant must latch over the top of it frequently

Because of this, moist wound healing management that involves occluding the wound for days at a time, permitting the wound exudates to perform healing and antiinfective functions, can not be applied. However, scab formation or a covering that sticks to the wound, causing damage on removal, is to be avoided.

Many topical applications have been tried and studied (or not studied!) with often conflicting outcomes. What this essentially means is that no single evidence-based intervention can be recommended for all mothers. In the absence of an evidence-based practice the goal is to 'first, do no harm' in an attempt to provide pain relief, speed healing and prevent premature weaning.

The most common topical applications include:

  • Expressed breastmilk (EBM). Breastmilk contains anti-infective agents that reduce the risk of a superimposed infection, epidermal growth factor that aids healing, as well as the hindmilk being high in fat to soothe the nipple. Applied after and between breastfeeds to keep the wound moist, it is a simple, no-risk, no-cost and often very successful intervention.

  • Warm water compresses. A meta-analysis 30 on the available research to 2009 recommended the application of warm water compresses to relieve pain , and breastmilk to hasten healing of cracked nipples. Again, simple, no-risk, no-cost and often effective.

  • Pharmaceutical grade lanolin. Mothers often report an immediately soothing effect from this treatment. Some studies found faster healing of nipple trauma and nipple pain reduction when compared to EBM 31 while others 32 find no difference between the two. Care should be taken to avoid contamination of the lanolin within the container from infected fingers or implements going from breast to container.

  • Hydrogel dressings. There have been no reviews of the effectiveness or safety of this intervention for nipple wound treatment in recent years. Older studies 33 34 noted an increased incidence of infections in the groups using this wound dressing, with one study discontinued early because of this outcome. Recommend with caution, stressing the importance of hygiene. Generally considered unsuitable for use in the presence of nipple infection.

Of note is this conclusion to one study: 35
“ No one topical agent showed superior results in the relief of nipple discomfort. The most important factor in decreasing the incidence of nipple pain is the provision of education in relation to proper breastfeeding technique and latch-on as well as anticipatory guidance regarding the high incidence of early postpartum nipple pain. ”

What about resting the nipple?

Severely damaged nipples may need to be rested for 24 hours or longer for initial healing to occur. During this time regular expressing of breastmilk will be required.

We live in a time of technology and gadgets. A breast pump (electric or manual) is often the only option considered for milk removal. Just as infants who exert a stronger baseline peak and pause vacuum will cause more pain for their mothers compared to infants with vacuum within normal range36 so too the vacuum of breast pumps has been associated with increased nipple pain and damage.37 If a pump is to be used careful instruction to mothers about the correct use will prevent a bad situation becoming worse.

Hand expressing breastmilk may be a better option for many mothers.

Group Activity

Review your unit's Breastfeeding Policy for the management of nipple damage. Is it up-to-date and evidence-based? Is this the procedure all your colleagues follow?

What should I remember?

  • Nipple pain threatens breastfeeding continuation and is therefore a SERIOUS PROBLEM requiring prompt and effective management.
  • The many causes of nipple pain.
  • The most important basic principle to address nipple pain.
  • How to assist mothers with non-protractile nipples.
  • Identification of ankyloglossia and impact on breastfeeding dyad.
  • How to recognise nipple infections such as candidiasis and Staph aureus.
  • Treatment choices for nipple candidiasis and Staph aureus.
  • Supportive management for damaged nipples.

Self-test quiz

Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

Notes

  1. # Amir LH et al. (1996) Candida albicans: is it associated with nipple pain in lactating women?
  2. # Schwartz K et al. (2002) Factors associated with weaning in the first 3 months postpartum.
  3. # Lewallen LP et al. (2006) Breastfeeding support and early cessation.
  4. # Amir LH et al. (2005) Why do women stop breastfeeding? A closer look at not enough milk among Israeli women in the Negev Region.
  5. # Morland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review.
  6. # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
  7. # Righard L (1998) Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles?
  8. # Gunther M (1945) Sore Nipples: Causes and Prevention
  9. # Prachniak GK (2002) Common breastfeeding problems
  10. # Wight NE (2001) Management of common breastfeeding issues
  11. # Centuori S et al. (1999) Nipple care, sore nipples, and breastfeeding: a randomized trial
  12. # Woolridge MW et al. (1980) Effect of a traditional and of a new nipple shield on sucking patterns and milk flow.
  13. # Jackson DA et al. (1987) The automatic sampling shield: a device for sampling suckled breast milk.
  14. # Auerbach KG (1990) The effect of nipple shields on maternal milk volume.
  15. # Pincombe J et al. (2008) Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.
  16. # Meier PP et al. (2000) Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding.
  17. # Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad
  18. # Griffiths DM (2004) Do Tongue Ties Affect Breastfeeding?
  19. # Geddes DT et al. (2008) Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound.
  20. # Cotch MF et al. (1998) Epidemiology and outcomes associated with moderate to heavy Candida colonization during pregnancy
  21. # Comina E et al. (2006) Pacifiers: a microbial reservoir
  22. # da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.
  23. # Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women
  24. # Andrews JI et al. (2007) The yeast connection: is Candida linked to breastfeeding associated pain?
  25. # Ogbolu DO et al. (2007) In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.
  26. # Hoppe JE et al. (1996) Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group
  27. # Newman J et al. (2005) Dr Jack Newman's Guide to Breastfeeding (The Ultimate Breastfeeding Book of Answers)
  28. # Livingstone V et al. (1999) The treatment of staphylococcus aureus infected sore nipples: a randomized comparative study
  29. # Amir LH et al. (2004) A failed RCT to determine if antibiotics prevent mastitis: Cracked nipples colonized with Staphylococcus aureus: A randomized treatment trial
  30. # Johanna Briggs Institute et al. (2009) The management of nipple pain and/or trauma associated with breastfeeding.
  31. # Abou-Dakn M et al. (2011) Positive effect of HPA lanolin versus expressed breastmilk on painful and damaged nipples during lactation.
  32. # Vieira F et al. (2013) A systematic review of the interventions for nipple trauma in breastfeeding mothers.
  33. # Ziemer MM et al. (1995) Evaluation of a dressing to reduce nipple pain and improve nipple skin condition in breast-feeding women.
  34. # Brent N et al. (1998) Sore nipples in breast-feeding women: a clinical trial of wound dressings vs conventional care.
  35. # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
  36. # McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums
  37. # Clemons SN et al. (2010) Breastfeeding womens experience of expressing: a descriptive study.