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 get better spontaneously over the 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, received the retort “You are just lucky.”
The approach that breastfeeding is supposed to hurt is an excuse for not doing anything to help the mothers. But something needs to be done. Sore nipples can be agonizingly painful. Unfortunately, too many health providers don’t know what to do, how to help and assume that “It can’t be so bad if you are continuing to breastfeed.”
I don’t accept that pain is a normal part of breastfeeding; painful breastfeeding seems to be unique to humans in the mammalian world. 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, but if the mother has sore nipples, the latch definitely is not as good as it could be.
- 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.
- Using artificial nipples such as bottles, pacifiers and nipple shields.
- The baby has a tongue tie.
- Decreased milk supply, (which does not mean “not enough milk” but rather a decreasein milk supply relative to what the baby was used to) can lead to even more decrease in the milk supply. Late onset decreased milk supply This is due to the fact that when milk flow decreases, babies can slip down from the breast to the nipple and many babies will pull the nipple.
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 are at risk of developing infection with Candida.
In the case of a breastfeeding mother, if Candida is there, 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 should. 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 still, make sure the baby’s latch is good and not causing continuing damage to the nipple.
The APNO contains, usually, three ingredients, one that kills bacteria, one that kills Candida, and one that decreases inflammation. This essentially treats many, if not, frequent causes of nipple pain. Sometimes we will prescribe an APNO with an extra ingredient, ibuprofen powder, but we require this only rarely.
- Mupirocin ointment 2% (an antibiotic): 15 grams
- Betamethasone ointment 0.1% (a corticosteroid): 15 grams
- 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, which are less effective. Or adds miconazole or clotrimazole cream instead of using the miconazole powder.
2. In the Britain and several other countries, miconazole powder is difficult to find, as 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 stopgap 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 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 seem the most common in our experience. Treatment for these problems is the same as it would be in other parts of the body.
When the mother’s nipples contain cracks or craters
Unfortunately, too often we see mothers only 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) does not get resolved. 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 will likely 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 and thus might consequently contribute to sore nipples again.
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 latched on. Thus, the baby’s latch after being on a nipple 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 does not work easily for most mothers.
Having difficulty with breastfeeding? Make an appointment with our clinic
Copyright: Jack Newman, MD, FRCPC, 2017