When it hurts to breastfeed Part 1

Sore nipples are the problem we see most commonly in our clinic, neck and neck with the “baby not getting enough from the breast”, though, of course, unfortunately, the two problems often co-exist.

Sore nipples can almost always be prevented or if they do occur, they can be much more easily treated when the baby is a few days old than when the baby is a few weeks old or even older.

Unfortunately, too many health providers seem to believe that it is normal for breastfeeding to hurt.  I strongly disagree with this. Pain tells us something is wrong.  But as a result of this belief that breastfeeding “normally” hurts, mothers are told, in various ways, “Just bear with it, it will get better”.  Okay, sometimes sore nipples do get better spontaneously over the first few weeks, but why should mothers suffer for weeks, when effective treatment is available?  As one of our patients was told by a postpartum nurse “You wanted to breastfeed?  So just suck it up.”  On the other hand, one lactation consultant who mentioned to a nurse that she had no pain with her own two day old baby, received the retort “You are just lucky.”

The notion that breastfeeding is supposed to hurt, that it is normal for breastfeeding to hurt, is an excuse for not doing anything to help a mother in pain.  But something needs to be done.  Sore nipples can be agonizingly painful. Unfortunately, too many health providers don’t know what to do, don’t know how to help and too often blithely state or think: “It can’t be so bad if you are continuing to breastfeed.”

 

 

 

 

 

 

 

 

 

 

 

 

The latch, the latch, the latch!

I don’t accept that pain is a normal part of breastfeeding; painful breastfeeding seems to be unique to humans in the mammalian world.  There seems to be an idea that, well, if labour hurts, then it’s natural that breastfeeding hurts.  This is nonsense and fuzzy thinking. The end of the pain of labour, accompanied by the birth of the baby is double joy. Painful breastfeeding is in no way joyful and serves no purpose.  Furthermore, we can help mothers have pain free breastfeeding.

But if breastfeeding hurts, what is the cause?  Almost always, the problem is the way the baby latches on. And just as a latch can be a cause of the baby not getting as much milk from the breast as he could, so can the way a baby latches on can cause the mother sore nipples. Yes, admittedly, even with a terrible latch, a mother may not have sore nipples and if she has an abundant milk supply, things can be fine, for a while.  But if the mother has sore nipples, the latch definitely is not as good as it could be.

And why is the latch not as good as it could be?

Because of:

1. How the baby is positioned and latched on. Babies often have difficulty latching on well in the first days after birth because of the swelling of the mother’s nipples and areolas from the intravenous fluids the mother receives during labour, birth and after.
2. Using artificial nipples such as bottles, pacifiers and nipple shields.
3. The baby having a tongue tie.
4. Late onset decreased milk supply is fairly common in mothers attending our clinic, and can cause late onset sore nipples.  Why? When the milk flow slows, the baby tends to slip down on the nipple and/or pulls at the breast. Watch this video and how the baby pulls the nipple when the flow slows.

Infection of the nipples with Candida albicans (“thrush”, “yeast”)

It is vital that all health professionals understand that Candida does not grow on normal skin.  I admit that though I knew this many years ago, even as a medical student, I didn’t understand the connection and the importance of this fact to the problem of the mother having sore nipples. Thus, even if the mother has Candida growing on her nipples and/or there is a good reason to believe the mother’s nipples are infected by Candida, Candida is a secondary problem. Candida is widely known in medicine as being “opportunistic”, taking advantage of “weakness” in the immune system, so that people with cancer or AIDS, for example, are at risk of developing infection with Candida.

In the case of a breastfeeding mother, if Candida is causing infection of the nipples, and especially, if it is difficult to treat, or keeps returning after adequate treatment, there is an underlying problem.  And that underlying problem is almost always damage to the nipple caused, almost always, by the baby’s not latching on as well as he could.  Once damage occurs, Candida takes the opportunity to grow there. And, to repeat, the damage is almost always due to a less than ideal latch.  I repeat this because the emails I receive from breastfeeding mothers shows that the mothers/health providers are fixated on the Candida and not the underlying problem.

There is no reason that Candida of the nipples could not be easily treated with our “all-purpose nipple ointment” (APNO).  So, if it is not easily treated, look for the underlying, real cause of sore nipples.  And the health provider should make sure the baby’s latch is good and not causing continuing damage to the nipple.

The “all-purpose nipple ointment” (APNO)

The APNO contains, usually, three ingredients, one that kills bacteria, one that kills Candida, and one that decreases inflammation.  This combination essentially treats many, if not all, causes of nipple pain.  Sometimes we will prescribe an APNO with an extra ingredient, ibuprofen powder, but we require this only rarely.  Only rarely, because in our clinic we help the babies achieve a good latch as well as prescribe the ointment for the mother.

Here is the recipe and the way I write a prescription:

1. Mupirocin ointment 2% (an antibiotic): 15 grams
2. Betamethasone ointment 0.1% (a corticosteroid): 15 grams
3. To which is added miconazole powder to a concentration of 2% miconazole

Total: 30 grams combined.

Apply sparingly after each feeding. Do not wash or wipe off.

There are a few issues with the APNO

1. Some health providers make up their own ointment or cream and call it APNO. That’s fine, the terms “all-purpose nipple ointment” and APNO are not under copywrite. But often the changes that are made in the “APNO” don’t make sense and decrease its effectiveness. I have used this recipe for APNO for at least 25 years and its effectiveness is proven for me.  But, for example, the health provider prescribes creams instead of ointments, and I believe that creams are less effective.  Or adds miconazole or clotrimazole cream instead of using the miconazole powder.  If the APNO looks and feels like Vaseline, it might be the correct recipe.  If it looks “creamy white” it is almost surely not our APNO.

2. In the United Kingdom and several other countries, miconazole powder is difficult to find, and most pharmacies don’t carry it. In that case, rather than substitute something, it is better just to use the first two ingredients, mupirocin and betamethasone. The mupirocin kills bacteria which inhabit the areas of nipple damage, which may be microscopic and impossible to see with the naked eye, and the betamethasone treats the inflammation which is a large part of the pain the mother feels.

3. Mothers are commonly told to stop using the APNO after a week or two because, it seems, everyone is afraid the mother will get thinning of the skin of the nipples and areolas. We have never seen this happen in our clinic patients, but maybe that is due to our not using the APNO as the definite treatment. It is a stop gap treatment only. The answer to sore nipples is to improve the way the baby latches on. So, the mother uses the APNO until she doesn’t need it, which is usually less than 1 or 2 weeks if we see the mother early and can help the mother latch the baby on well.

4. Many pharmacists, especially in hospital practice, get all in a rage because they feel that mupirocin should not be used. They argue that it is one of the few antibiotics still effective against methicillin resistant Staphylococcus aureus (MRSA), and we should not use it too much for fear that MRSA will become resistant to this drug as well. Well, bacterial overgrowth and infection of the nipples is often due to Staphylococcus aureus.  So, we need a good antibacterial agent in the APNO.

This speaks volumes about how breastfeeding and breastfeeding mothers are seen in our society.  Mothers’ pain is not seen as a real problem.  Breastfeeding is nice but not necessary, so if the mother stops breastfeeding because of pain, well, that’s not a great loss.  Here we have a treatment, the APNO, that can decrease severe pain.  But we cannot use it for a “trivial” problem like sore nipples.  It makes me angry.

5. Many mothers are told to use the ointment only once or twice a day, or to wash or wipe it off before the baby goes back to the breast. No, I don’t agree. Washing the nipples can cause them to dry out and make the pain worse. Wiping the ointment off is of no use. Our approach, as above? Apply sparingly after each feeding. Do not wash or wipe off.

6. It is necessary to say that I do not make a cent on the “all-purpose nipple ointment”. I recommend it, not because I make money on it, which I don’t, but rather, because it works, and it often helps the mother manage until the baby’s latch improves.

Other causes of sore nipples

1. Some dermatological problems can affect the nipples.  These include eczema (atopic dermatitis) and psoriasis which seem the most common in our experience.  Treatment for these problems is the same as it would be in other parts of the body.

2. Vasospasm, also can cause severe nipple and breast pain.  It is often also called Reynaud’s phenomenon. Vasospasm typically occurs after the baby comes off the breast and the temperature of the nipple falls from the warmth inside the baby’s mouth to the cooler outside air.  The nipple typically turns white from blood not reaching the end of the nipple and the mother often complains of a burning pain in the nipple.  Sometimes this pain may radiate into the breast, so the mother may believe something is wrong in the breast itself.  This is also called referred pain.  When the blood returns to the nipple, the mother may then feel a pulsating pain.  Vasospasm is usually secondary to some other cause of pain in the nipples (the pain of a less than adequate latch), but sometimes may occur without any pain during latching on or during the feeding.  Thus, in general, improving the latch and using the APNO will result in the vasospasm improving, though it may take a week or two to disappear completely even after the mother has no pain with latching on or during the feeding.  If the pain of vasospasm is severe, we will usually treat with oral nifedipine, slow release, 30 mg once a day.  Watch this video.

Video 1: The baby has just come off the breast. The mother’s nipple which was initially pink, turned white before our eyes. This blanching of the nipple was due constriction of the vessels to the nipple, causing the mother pain, a burning pain. As time went on, the nipple returned  to pink during which time the mother had a throbbing type of pain. Not all vasospasm hurts in exactly this way. For example the pain on returning of blood to the nipple may not be throbbing  and may even be absent.

3. A similar but somewhat different condition is called mammary constriction syndrome.

When the mother’s nipples contain cracks or craters

Unfortunately, too often we see mothers only once the problems have gone very far, when the nipples have dramatic, wide-open cracks or craters.

In such cases, we have been trying and working with many treatments, most of which have been disappointing.  In the last couple of years, we have found Medi-Honey (trademark) wound gel to be most helpful, but not in all cases either. The mother applies it inside the crack or crater and then applies the “all-purpose nipple ointment” over it and the rest of the areola.

Some common solutions that should not be used:

 1. Taking the baby off the breast “to rest the nipple(s)”

The most important treatment for sore nipples is, of course, prevention, helping the baby get the best latch possible, which also helps the baby get more milk.

But if the mother has sore nipples, the approach is not to take the baby off the breast.  The first step is to help the baby latch on well and if necessary, use the “all-purpose nipple ointment”.  This approach works, so why are so many mothers not offered it?

Unfortunately, many of our clinic patients have been told to take the baby off the breast “to rest the nipples” on day 2 or 3 after birth.  I ask myself: has everything really been tried to help this mother and baby before she was told to take the baby off the breast?  It seems very unlikely.

There are many things to keep in mind as reasons for not taking the baby off the breast:

If the baby is taken off the breast, the real cause of the sore nipples (the latch) has not been dealt with.  In fact, the baby while off the breast learns how to “latch” onto something quite different from the breast and when (and IF – a big “if”) goes back to the breast, the baby’s latch could easily be even worse than it was initially.

A baby being fed away from the breast may mean the baby may not go back to the breast. As well, the baby being off the breast will likely decrease the mother’s milk supply even if she expresses her milk diligently and the decrease in milk flow might consequently contribute to sore nipples again.

2. Nipple shields to “treat” sore nipples

I believe that using a nipple shield to treat sore nipples is even worse. A nipple shield is very likely to result in a significant decrease in milk supply.  And when the milk supply decreases, it becomes even more difficult to treat sore nipples. Additionally, a baby on a nipple shield is not truly latched on.  A baby on a nipple shield has, essentially, been take off the breast. Thus, the baby’s latch after being on a nipple shield and then being put back to the breast will be far from the ideal and may result in sore nipples again.  Getting the baby to take a ‘bare’ breast without a nipple shield after using the nipple shield for several days does not work easily for most mothers.

Having difficulty with breastfeeding? Make an appointment with our clinic

Copyright: Jack Newman, MD, FRCPC, Andrea Polokova 2017, 2018, 2020