Sore and damaged nipples
by Cordelia Uys, NCT Breastfeeding Counsellor
Terracotta sculpture circa 1873. Peasant woman nursing a baby, by Aimé-Jules Dalou, Victoria and Albert Museum
In this article we look at why breastfeeding mothers might get sore and damaged nipples and we discuss what can be done to achieve totally comfortable breastfeeding.
Pain means something is wrong
Many people believe that having sore nipples is an inevitable part of breastfeeding. But in fact, pain when breastfeeding, just as in any other circumstance, means that something is wrong.
Tiny exception: initial latching pain
The only exception to the above statement is that in the first couple of weeks of a baby’s life, when a mother first latches her baby, the relaxing of her nipple tissue can cause a few seconds of pain. If that pain lasts longer than a few seconds, or if the initial latching pain lasts for more than two weeks, please seek help.
Damage is never okay, please seek qualified help immediately if your nipples are cracked, scabbed or damaged in any way.
Causes of pain and damage
Why do many women experience pain and damage when breastfeeding? To understand, please put your thumb nail-side down in your mouth to the first knuckle and suck on it: can you feel your hard palate? Now, without making yourself gag, please put your thumb as far back in your mouth as it will go. Can you feel the junction between your hard and soft palate? That’s how far back in your baby’s mouth your nipple needs to go in order for breastfeeding to be pain-free and for your baby to be able to get good quantities of milk.
Pain and damage happen when a mother’s nipples are not correctly positioned in her baby’s mouth, and her nipples therefore gets squeezed up against the baby’s hard palate by their tongue. This can happen for a number of reasons:
Positioning
Babies need to be positioned in a way that allows them to take a deep mouthful of breast. Whatever position a mother is using, her baby needs to be totally facing her, with the whole of the front of the baby’s body fully touching hers. The baby’s ears, shoulders and hip need to be in a straight line, and the baby’s head needs to be tilted back, so their chin juts into the breast.
Attachment/latching
As well as the baby needing to be well-positioned, they need to take a deep mouthful of breast. In the baby-led position, in which the baby lies on top of their mother’s body (also known as the laid-back position, or Biological Nurturing), the baby will automatically get a big mouthful of breast once they start sucking, thanks to gravity. But in the more traditional positions (cross cradle, cradle, rugby and side-lying) mothers need to learn how to achieve an asymmetric latch in order for the baby to take a big enough mouthful of breast, as gravity and the baby’s reflexes make achieving a deep latch harder. In addition, instead of bringing their baby up and over the breast in order to latch him or her, women often try to put their breast in the baby’s mouth, resulting in a shallow latch.
Tongue-tie
If a baby has a tight lingual frenulum, they can struggle to fully extend their tongue while feeding, meaning that the mother’s nipple repeatedly gets squeezed against the baby’s hard palate.
Tightness in the baby’s body
Sometimes babies have a tight jaw (this is common with tongue-tied babies), or stiffness in their neck or some other part of their body due to their position in utero, or due to being delivered with the use of forceps or ventouse. This tightness can make it harder for a baby to tilt their head back and open their mouth nice and wide.
Nipple thrush
Very occasionally, women can develop thrush in their nipples, although this is rare. It’s very common for vasospasm to be mistaken for nipple thrush. Genuine nipple thrush is absolute agony; it feels like having shards of glass inside one’s nipples. Mothers will experience excruciating pain during a feed and for up to an hour afterwards. Because it spreads so fast, thrush will always be in both breasts. Anything touching a mother’s nipples will be unbearable. If thrush is suspected, it’s best practice for your GP to swab your nipples.
Conditions that can happen when nipples are compressed
Vasospasm
When a mother’s nipples are repeatedly compressed, they become traumatised. The blood vessels inside the nipples contract, meaning that the mother doesn’t just experience pain during a feed, but also afterwards, once the blood starts to flow back into her nipples. After a feed, women with vasospasm often notice their nipples turning white, then red and/or blue. The pain is sharp and burning or throbbing. Some women experience nipple vasospasm when they’re exposed to the cold – this is known as Raynauld’s phenomenon and can happen in fingers and toes too.
Blebs (milk blisters)
A bleb is one, or more, blockages right at the tip of a mother’s nipple, where the milk duct orifices are. A bleb looks like a white dot, similar to a pimple.
What to do if you have sore and/or damaged nipples
Get support with attachment and positioning
The first thing to do if you are experiencing pain and damage is to get help with attachment and positioning from a breastfeeding counsellor or an IBCLC Lactation Consultant. Often a tiny adjustment is all it takes to go from agony to complete comfort.
Check for a tongue-tie
If the pain doesn’t resolve with good positioning and attachment, it’s worth checking the baby for a tongue-tie. 10% to 11% of babies are tongue-tied, and it’s the most common cause of breastfeeding difficulties. If your baby has a tongue-tie, a tongue-tie practitioner can release it using sterile, one usage scissors. It’s a very quick and straightforward procedure.
Consider seeing a cranial osteopath or chiropractor who specialises in treating babies
There is evidence that cranial osteopathy or chiropractic treatment, alongside good breastfeeding support, can improve breastfeeding outcomes.
Please note that nipple creams or ointments will not prevent pain or damage
In fact, some women are allergic to lanolin and get pain and damage from the most popular brand of nipple cream.
Treating nipples which are red, scabbed or cracked
The best way to heal damaged nipples is with moist-wound healing. If damage is mild, the antibacterial, pain-killing properties in breastmilk might be all that is needed. Many women find Vaseline, or a lanolin-based ointment, good for moist-wound healing; a pea-sized amount applied to the damaged-area is sufficient. Smearing the whole areola with ointment should be avoided as it will become slippery, making latching harder. In addition, there are little glands on the areola called Montgomery’s tubercles, which produce a sweet-smelling, antibacterial oil, which will be masked if too much ointment is applied.
If there is substantial damage, some kind of gauze or pad that holds the ointment in place will be helpful. All of these products tend to work well:
Jelonet gauze: https://www.cordeliauys.co.uk/moistwoundhealing
Multimam compresses
Novogel Pads (a prescription might be needed)
If there is an infection in your nipples, for example if there is oozing or pus visible, your GP can prescribe an antibiotic cream. Sometimes oral antibiotics might be necessary.
Once the initial cause of the nipple damage has been resolved, it’s remarkable how quickly nipples heal. If your nipples don’t start to heal within a few days, it’s worth asking your GP to do a swab in case there is a Staph Aureus infection.
Treating vasospasm
The first step is to treat whatever has caused the vasospasm, which can mean working on attachment and position, and, if there is a tongue tie, having it released.
Applying dry heat immediately the baby comes off the breast and avoiding exposing your breasts to cold are recommended, as is massaging some warm oil into your nipples after feeds. Taking ibuprofen can be helpful too.
Caffeine, nicotine, decongestant cold remedies, the contraceptive pill and fluconazole can all worsen symptoms.
Some mothers find it helps to take the following dietary supplements:
Calcium and magnesium
High doses of vitamin B complex
Fatty acids and fish oil supplements
Ginger (2000mg-4000mg daily)
Please consult your health professionals for doses specific to your case.
If none of the above works, your GP might consider prescribing low dose oral nifedipine, which is a vasodilator.
How to treat a bleb (milk blister)
You will find detailed information on treating a bleb here: https://www.cordeliauys.co.uk/treating-a-nipple-bleb
Treating nipple thrush
If you have a confirmed diagnosis of nipple thrush, both you and your baby need to be treated, otherwise you will re-infect each other. The baby needs to be treated with miconazole oral gel (not nystatin which doesn’t work for babies) four times a day, carefully applied all around the inside of the baby’s mouth with a clean finger. Mothers need to apply miconazole cream to their nipples after every feed. Please see the Breastfeeding Network (BfN) leaflet for detailed information.
Pain-free breastfeeding is achievable
Unpleasant as the above conditions can be, it’s important to point out that with good information and support, it is absolutely possible to resolve whatever is causing a mother nipple pain and damage, and for her to be able to go on to have a successful and completely comfortable breastfeeding journey
Links:
Nipple pain: https://gpifn.org.uk/pain-when-breastfeeding/
If breastfeeding hurts:
https://www.breastfeedingnetwork.org.uk/if-breastfeeding-hurts-05-may-2015/
Osteopathy and breastfeeding: https://pubmed.ncbi.nlm.nih.gov/28027445/
https://www.cordeliauys.co.uk/cranialosteopathyandbreastfeeding
Tongue-tie: https://www.nhs.uk/conditions/tongue-tie/
https://www.cordeliauys.co.uk/what-is-tonguetie
Moist wound healing: https://www.cordeliauys.co.uk/moistwoundhealing
Vasospasm: https://www.breastfeedingnetwork.org.uk/raynauds/
Lecithin dosage: https://kellymom.com/nutrition/vitamins/lecithin/