Sore Nipples
INTRODUCTION
The best treatment of sore nipples is, as with all breastfeeding problems, prevention. The best prevention is getting the baby to latch on well from the first day. Mother and baby skin to skin contact immediately after birth for at least the first hour or two will frequently result in a baby latching on all by himself with a good latch. See the information sheets Breastfeeding—Starting Out Right and The Importance of Skin to Skin Contact.
Early onset nipple pain is almost always due to the baby not latching on well. It has been frequently said that another cause is that the baby is not sucking properly, but that is essentially the same thing as the baby not latched on well. Babies learn to “suck properly” by receiving a good flow of milk from the breast when they are latched on well. And they receive a good flow of milk by latching on well. (They learn by doing). Thus, “suck” problems are also usually caused by a latch that is not as good as it could be.
Fungal infections of the nipple (due to Candida albicans) may also cause sore nipples. But Candida albicans does not grow on normal skin, only on damaged skin. Nipple soreness and damage to the skin, even if the skin of the nipple and areola looks normal usually has at least microscopic damage.
Vasospasm (due to irritability of the blood vessels in the nipple may also cause sore nipples (see the information sheet Vasospasm).
Though the character of the pain is not usually useful in making a diagnosis of the pain ,the pain due to a poor latch hurts most as the baby latches on and usually improves as the baby breastfeeds and the flow of milk increases. However, if damage is severe, the soreness of a poor latch may go on throughout the feeding.
The pain from the Candida infection often goes on throughout the feed and may continue even after the feed is over. Women often describe knifelike pain from a poor latch. The pain of the Candidal infection is often, but not always, described as. A new onset of nipple pain when feedings had previously been painless is a tip off that the pain may be due to a Candida infection, but we now believe that most late onset nipple pain is due to late onset decreasing milk supply and flow.
Dermatologic conditions may also cause late onset nipple pain. Psoriasis and atopic dermatitis as well as the virus herpes simplex, for example, may occur on the nipples. Treatment of the underlying condition will treat the nipple pain. Please note that most medications used for treatment of these conditions does not require the mother to interrupt or stop breastfeeding.
PROPER POSITIONING AND LATCHING
(See the blogs What is a good latch, tongue tie and latch quiz)
It is not uncommon for women to experience difficulty positioning and latching the baby on. In the first few days after birth, difficulty with latching the baby on is often due to the fact the new mother has received a lot of intravenous fluids and thus swelling of the areola and breast make it difficult for the baby to get a good latch or even to have difficulty latching on at all.
In this photo, it is obvious the
mother’s breast is swollen with fluid.
The sore on her nipple is due to a poor
latch due to the swelling.
If the mother positions the baby well, she facilitates the baby’s getting a good latch and a good latch not only decreases the risk of the mother becoming sore, but also reduces the baby’s chances of becoming “gassy”. In truth, babies are rarely bothered by “gas”. If they are crying, it almost always means they want more milk.
If the baby does not latch on or does not latch on well enough to receive milk from the breast, alternative methods of feeding should be used, but not a bottle. Cup feeding or spoon feeding of a newborn baby is quite possible and generally easy. Indeed, premature babies can be cup fed. The photo below is of a baby less than a day old drinking from a cup.
POSITIONING—FOR THE PURPOSES OF EXPLANATION, LET US ASSUME THAT YOU ARE FEEDING ON THE LEFT BREAST
Good positioning facilitates a good latch. A lot of what follows under latching comes automatically if the baby is well positioned in the first place.
At first, it may be easiest for many mothers to use the cross cradle hold to position your baby for latching on.
See this video of latching on with a cross cradle hold. The same baby on the other side, but who does most of the latching on himself.
To feed your baby on the right breast, hold your baby with your left arm, pushing in the baby’s bottom with the side of your forearm so that your hand turns palm upwards (towards the ceiling). This will help you support his body more easily as the baby’s weight is on your forearm rather than your wrist or hand.
Your hand will be palm up under the baby’s face (not shoulder or under his neck). The web between your thumb and index finger should be behind the nape of his neck (not behind his head). The baby will be almost horizontal across your body, with his head slight tilted backward, and should be turned so that his chest, belly and thighs are against you with a slight tilt upwards so the baby can look at you. Hold the breast with your right hand, with the thumb on top and the other fingers underneath, fairly far back from the nipple and areola.
The baby should be approaching the breast with the head just slightly tilted backwards. The nipple then automatically points to the roof of the baby’s mouth.
LATCHING
- Now, get the baby to open up his/her mouth wide. The way to do this is to run your nipple, still pointing to the baby’s upper lip, along the baby’s upper lip (not lower), lightly, just a light tickle, from one corner of the mouth to the other. Or you can run the baby along your nipple, something some mothers find easier. Wait for the baby to open up as if yawning. As you bring the baby toward the breast, only his chin should touch your breast. Do not scoop him around so that the nipple points to the middle of his mouth. Instead the nipple should still be pointing to the roof of the baby’s mouth.
- When the baby opens up his mouth, use the arm that is holding him to bring him straight (not scooped around) onto the breast so that your nipple remains pointing to the roof of the baby’s mouth. Don’t worry about the baby’s breathing. If he is properly positioned and latched on, he will breathe without any problem since his nose will be away from the breast. If he cannot breathe, he will pull away from the breast. If he cannot breathe, he is not latched properly. Don’t be afraid to bring the baby onto the breast with a quick movement.
In the this photos, the latch on the left is
less asymmetric than the one on the right.
Photo 2 is the asymmetric latch and is better
because the baby will get more milk and
the mother should not have pain.
- If the nipple still hurts, use your index finger to pull down on the baby’s chin; this will bring more of your breast into the baby’s mouth. You may have to do this for the duration of the feed, but not usually because the baby should receive more milk and thus keep his/her mouth wider.
- Do not take the baby on and off the breast several times to get the perfect latch. If the baby goes on and off the breast 5 times and it hurts, you may have 5 times more pain, and worse, possibly even 5 times more damage, and the baby and you will both be frustrated.Adjust the latch when putting him to the other breast, or at the next feeding.
- The same principles apply whether you are sitting or lying down with the baby or using the football or cradle hold. Get the baby to open wide; don’t let the baby latch onto the nipple, but get as much of the areola (brown part of breast) into the mouth as possible (not necessarily the whole areola).
Note:
There is no “normal” length of feeding time, so do not time the feedings. If you have questions, call the clinic.
A baby properly latched on will be covering more of the areola with his lower lip than with the upper lip.
See the video clips on our website
IMPROVING THE BABY’S SUCK
The baby learns to suck properly by breastfeeding and by milk flowing into his/her mouth. The baby’s suck may be made ineffective or not appropriate for breastfeeding by the early use of artificial nipples or from poor latching on from the beginning. Some babies just seem to take their time developing an effective suckle. Suck training and/or finger feeding (See the information sheet Finger and Cup Feeding) may help, but note, taking the baby off the breast to finger feed instead is not a good idea and should be done as a last resort only.
Finger feeding really should be used to prepare a baby who is not latching on to latch on. See this video. What do you see in this video? The baby is 2 months old. He was born 8 weeks prematurely and as usual in most premature units, breastfeeding (as opposed to breastmilk feeding) was not prioritized. The baby had never in his life latched on to the breast.
The video begins with the baby being finger fed to calm him and to getting him sucking well, receiving milk. The finger feeding is to get him to feed with the tongue down. He is then attempted on the right breast. He does not latch on. Why? Because the milk flow is slow; he had already latched on and fed on that breast, so there is less milk flow and he does not like that. He is then tried on the left breast, and he latched on with only a little trouble, but he did latch on and drink. Babies like fast flow.
VASOSPASM: “MY NIPPLE TURNS WHITE AFTER THE BABY COMES OFF THE BREAST”
The pain associated with this blanching of the nipple is frequently described by mothers as “burning”, but generally begins only after the baby has been taken off the breast, presumably because the air is cooler outside the baby’s mouth (interestingly, we see more mothers with vasospasm in summer than in winter, probably because of air conditioning cooling the air.
The pain of vasospasm may last several minutes or more, after which the nipple returns to its normal colour, but then a new sort of pain develops which is usually described by mothers as “throbbing”. The throbbing part of the pain may last for seconds or minutes and then the nipple may turn white again and the process repeats itself. See this video. The cause would seem to be a spasm of the blood vessels (often called “vasospasm” or Raynaud’s Phenomenon) in the nipple (when the nipple is white), followed by relaxation of these blood vessels (when the nipple returns to its normal colour). Vasospasm may occur with no pain in the nipples during latching on or during the feeding, although usually both occur together.
How to treat vasospasm
1. Pay careful attention to getting the baby to latch onto the breast as best possible. This type of pain is usually associated with and probably caused by whatever is causing your pain with latching on and during the feeding. The best treatment for this vasospasm is the treatment of the other causes of nipple pain. If the main cause of the nipple pain is fixed, the vasospasm also usually disappears.
2. Heat (hot washcloth, hot water bottle, hair dryer) applied to the nipple immediately after breastfeeding may prevent or decrease the reaction. Dry heat is usually better than wet heat, because wet heat may cause further damage to the nipples and when the liquid evaporates, the nipples will cool.
3. Vitamin B6 multi complex can also be used, as can magnesium with calcium. On occasion, we have had to use an oral medication (nifedipine, 30 mg slow release version once a day, occasionally increased to twice a day) to prevent this type of reaction. For more on these treatments see the information sheet Vasospasm).
4. Do not take the baby on and off the breast several times to get the perfect latch. If the baby goes on and off the breast 5 times and it hurts, you may have 5 times more pain, and worse, possibly even 5 times more damage, and the baby and you will both be frustrated.Adjust the latch when putting him to the other breast, or at the next feeding.
GENERAL MEASURES FOR NIPPLE SORENESS
1. Nipples can be warmed for short periods of time after each feeding, using a hair dryer on low setting.
2. Nipples should be exposed to air as much as possible, except when there is vasospasm.
3. When it is not possible to expose nipples to air, plastic dome-shaped breast shells (not nipple shields which are not a good treatment for sore nipples or any breastfeeding problem for that matter) can be worn to protect your nipples from rubbing by your clothing (use the largest hole available so your nipple is not rubbing against the plastic). Breastfeeding pads keep moisture against the nipple and may cause damage that way. They also tend to stick to damaged nipples. If you leak a lot you can wear the pad over the breast shell.
4. Ointments can sometimes be helpful. If using our ointment, use just a very small amount after breastfeeding and do not wash it off. We use an “all purpose nipple ointment” (APNO) that we find very useful. Note, once any ointment or cream is applied to the nipples they are no longer air drying.
5. Do not wash your nipples frequently. Daily bathing is more than enough.
6. If your baby is gaining weight well, there is no good reason the baby must be fed on both breasts at each feeding. It may save you pain, and speed healing if you feed your baby on only one breast each feed, but be careful, not all mothers can feed a baby on only one breast at every feeding or even at all. It will help to compress the breast (see the information sheet Breast Compression), once the baby is no longer swallowing on his own in order to continue his getting milk. You may be able to manage this some feedings, but not others. In very difficult situations, a lactation aid (see the information sheet Lactation Aid) can be used to supplement (preferably expressed milk), so that the baby will finish the feeding on the first side.Taking the baby off the breast is a last resort.
If you are unable to put the baby to the breast because of pain, in spite of trying all the above measures, it may still be possible to continue breastfeeding after a temporary (3-5 days) cessation to allow the nipples to heal. During this time, it would be better that the baby not be fed with a rubber nipple. Of course it is also best for you and the baby if the baby is fed your expressed milk. Feed the baby with a cup or use the technique called “finger feeding” (see the information sheet Finger an Cup Feeding). Once again, it should be emphasized that this is a last resort and taking a baby off the breast should not be taken lightly. Furthermore, it often doesn’t work.
We do not recommend nipple shields because, although they sometimes help temporarily, they often do not. In fact, they may often increase the degree of trauma to the nipples. They may also cut down the milk supply dramatically, and the baby may become fussy and/or not gain weight well. Once the baby is used to them, it may be impossible to get the baby back onto the breast. Use as a last resort only but get help first.
The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.
This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!
©IBC, updated July 2009, 2021
Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).