When it hurts to breastfeed Part 2
Breast or nipple pain in a breastfeeding mother is never normal nor should it be dismissed as insignificant or not worth looking into. Breast and nipple pain have a cause – most frequently related to the way the baby latches on to the breast – it should be investigated and treated appropriately.
For the article on sore nipples: nipple pain
Many physicians will consider any pain in the breast(s) of a breastfeeding mother to be mastitis. It is simply not true that pain in the breast means “mastitis”. There are several causes for sore breasts and treatment with antibiotics will not improve most of them.
What causes pain in the breast(s)?
Referred pain or radiating pain
A common cause of pain in the breast is what is generally called referred pain or also radiating pain. Referred pain describes a pain whose origin is elsewhere than where it is felt – in the case of a breastfeeding mother, the source of breast pain originates from pain in the nipple. How this happens is the same as for a person having angina (pain in the chest due to diminished blood flow to the heart) to feel pain not only in the area of the heart, but also in the arm and even down to the hand, though obviously the pain in the arm is not due to something wrong in the arm. In fact, it is possible that such pain is felt only in the arm and hand.
Another example of referred pain is seen in pregnant women who often have reflux of stomach acid into the esophagus, but they may feel pain only in the neck.
Thus pain from the nipple may be felt in the breast and sometimes only in the breast once the nipple pain has diminished during the feeding or once the baby has come off the breast. This could be an example of referred pain or radiating pain. But it is not the only cause.
Vasospasm, often called Reynaud’s phenomenon, can be another cause of referred pain and can usually be felt in the nipple once the baby has come off the breast and the temperature of the nipple decreases; after the baby is off the breast, the nipple turns white from decreased blood flow to the nipple and subsequently back to its original colour once the blood vessels dilate again. It is usually secondary to nipple trauma. Mothers who have Reynaud’s phenomenon when not pregnant or breastfeeding, do not seem to have a higher incidence of vasospasm of the nipple. The cause of vasospasm needs to be investigated and dealt with, which most often involves correcting the latch, and checking the baby for a possible tongue tie, a tongue tie being a cause of a less than ideal latch. The use of the “all-purpose nipple ointment” can help considerably until more definitive corrective measures are instituted. Watch our video of what a vasospasm looks like.
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.
Milk Blisters can also cause pain that radiates into the breast and the white bleb on the nipple can go unnoticed or be ignored.
Sore breasts within days of birth
I do not accept that painful engorgement on the third or fourth day after birth is “normal” and even a good thing because “it means you are making lots of milk”. I don’t believe this. I think that painful engorgement, anything more than fullness of the breast, is not normal and should not be considered normal or good. Sometimes the swelling of the breasts is so severe and so painful than mothers will decide not to breastfeed. And that is unfortunate because the problem is both preventable and treatable if it does occur.
Why do mothers have such severe engorgement? Basically, because the baby was not breastfeeding well during the first few days. Prevention of such painful engorgement depends on getting the baby to latch on well as soon as possible after birth. This approach starts with the breast crawl, allowing the baby to “climb” up to the breast while skin to skin with the mother immediately after birth. A baby not too affected by the drugs given to the mother during labour and birth and placed naked on the mother’s chest will spontaneously crawl to the breast and latch on without help if given enough time. This is important as a start to breastfeeding and would help prevent a lot of breastfeeding problems in the first few days and after.
Breast and nipple pain in the first days after birth
Mothers, especially first time mothers, but not only first time mothers, need good information and support in the first few days to make sure the baby is latched on well. And mothers need help especially when they say their nipples hurt. Hospital staff must not accept that it is “normal” for breastfeeding to hurt and pain should not be ignored even on day 1.
When mothers complain about pain, the baby should not be removed from the breast and re-latched over and over again. Einstein apparently denied ever saying that “Madness is doing the same thing over and over and expecting a different result”. But from the point of view of latching on, it’s something worth remembering. Re-latching, removing the baby from the breast and re-latching yet again results in the mother’s experiencing several painful latches instead of just one.
Often the baby’s latch can be improved by putting some downward pressure on the baby’s chin to open the mouth wider and/or shifting the baby so he is on the breast more asymmetrically which can be done without taking the baby off the breast (see the first video below). This is achieved by the mother’s pushing the baby’s bottom (bum, butt) into her chest. The baby’s latch becomes more asymmetric.
The baby can also be brought closer to the breast so that the latch is not “shallow”. Increasing the flow of milk to the baby can go a long way in improving breast and nipple pain because increased milk flow contributes to improving the latch. And breast compression can help as well by increasing the flow of milk to the baby. A good latch improves milk flow to the baby; but a good milk flow also improves the latch (a “virtuous” circle). See the second video below.
Video 2: It is possible to improve the latch without taking the
baby off the breast. By having the mother push the baby’s bottom
(bum, butt) with her arm into her chest, the baby gets a more
asymmetric latch. If you watch carefully, you can see the baby
also starts to have better drinking with a longer pause in the chin.
Video 3: This video shows a baby who is barely latched on. He sucks but gets almost no milk.
However, when the milk starts to flow, the baby’s latch improves to the point that we can call
it a good latch.
If the pain is intolerable, pain medication such as ibuprofen can be used to help the mother continue breastfeeding while resolving and treating the cause of the pain.
Swaddling the baby, not looking for early cues that the baby is ready to feed
In many hospitals, and perhaps even with babies born at home, babies are often swaddled so that they don’t wake up as frequently as they normally would if they were not swaddled. Swaddling has been shown to be harmful, it is the opposite of what babies need – which is skin to skin contact. Many studies, here are just a few, over the years have documented the value of skin to skin contact for premature babies, and full term well and sick babies. Swaddled babies are, in fact, babies that are separated from their mothers by layers of cloth and are thus unaware of the regulation and signals provided by the mother’s body. Swaddled babies sleep longer than is physiological, they spend much more energy trying to regulate their temperatures, they take longer to make their readiness to feed noticed, and unnoticed feeding cues may result in the babies not feeding as often as they would want or what is good for establishing breastfeeding. The same goes for use of the pacifier which causes the baby’s feeding to be delayed and his feeding cues go unnoticed.
This video shows a baby who is 24 hours old. The mother felt the baby was just fed and wasn’t hungry. But the baby was heavily swaddled and thus was asleep. Once the swaddling was removed, he cried and was obviously hungry. He went to the breast and drank well.
Video 4: This baby was so heavily swaddled that he did not
show signs of wanting to feed. The mother was convinced that
he had breastfed very well. But when he was undressed, he
showed he was not happy, that he wanted to feed more and
he readily went to the breast and breastfed very well. Though
the latch could be better, he is drinking very well, as can be
seen by the long pauses in his chin.
The consequences of the baby not feeding as frequently or as well as he would need, may result in painful engorgement on the third or fourth day when the milk production increases. And, in yet another vicious circle, engorgement may make it difficult for the baby to latch on well.
How to prevent painful engorgement?
- Ask the anaesthetist to avoid large amounts of intravenous fluids unless absolutely necessary. The large fluid volumes the mothers receive routinely are hardly ever necessary and could be reduced significantly or avoided entirely.
- Have the baby skin to skin on the mother’s chest immediately after birth and allow the baby time to crawl to the breast and latch on without help.
- Get the best latch possible as soon as possible after the birth.
- Help the baby get more milk from the breast using breast compression.
- Avoid bottles. If the baby truly needs supplements, which should be a rare situation, a lactation aid at the breast is a better way than to give bottles. And finger feeding to supplement is not a good method as it can be slow and arduous, and the baby is not on the breast. In fact, any supplementation off the breast should be avoided.
- A nipple shield is not the answer to breastfeeding problems, including sore nipples and baby not latching on and only leads to poor drainage of the breast. And thus, not a way to prevent or treat engorgement.
- If the mother and baby are leaving hospital within 24 hours as is now common, the parents need to know how to get good hands on help quickly. But if they need good hands on help quickly on leaving the hospital, maybe they needed good hands on help while still in hospital. And if good hands on help is available in hospital, discharge should be delayed.
Blebs or blisters/blocked ducts/mastitis and on occasion, abscess
These problems almost always occur when the mother has a very good or even an abundant milk supply but the baby does not have a good latch. And why does the baby not latch on well?
2. Use of artificial nipples such as bottles and nipple shields and pacifiers.
3. The baby has a tongue tie. Some tongue ties are obvious, but many tongue ties are more subtle and require an evaluation that goes farther than just looking but includes feeling under the baby’s tongue as well and knowing what to feel for, especially upward mobility of the tongue. Unfortunately, few health professionals, including lactation consultants, know how to evaluate whether or not the baby has a tongue tie.
Denial of tongue tie even being a possibility in breastfeeding problems has become a new battleground of breastfeeding. In some hospitals, pediatricians have taken the unbelievable step of forbidding nurses and lactation consultants, on pain of dismissal, of even mentioning to the parents that the baby may have a tongue tie. Oh, Galileo, who would have imagined that “scientists” in the 21st century would have such closed minds!
4. The mother has had a decrease in her milk supply. On the other hand, blebs or blisters/blocked ducts/mastitis may also occur because milk supply has decreased. Recurrent blocked ducts may actually result in milk supply decreasing. Late onset decreased milk supply is not uncommon in the population of mothers experiencing breastfeeding problems and results the baby slipping down on the nipple and pulling at the breast. The baby may pull off the breast when milk flow slows resulting in a breast that is not well drained. In fact, the mother may feel her milk supply is still good, even “overabundant” because the breasts are frequently “full” even painfully so after a feeding is over. Watch these videos for really good drinking, nibbling only, “Borderline” drinking showing babies drinking well at the breast, or not. Watch the videos, read the texts and then watch the videos again.
Okay, that’s how we prevent blocked ducts and mastitis and breast abscess, but how do I deal with these problems if I have them right now?
It seems to me that a blocked duct and mastitis are essentially the same condition, really different degrees in the severity of the same condition. The same process seems to be happening in both, but on a different scale. The mother has an abundant milk supply, but the baby is not latched on as well as he could be. Consequently, there is a part of the breast from which breastmilk is not draining as well as it should be. The milk being collected in a particular area of the breast results in swelling and the surrounding tissue being under pressure which results in inflammation of differing severity.
In any case, blocked ducts and mastitis often will get better without antibiotics. The mother should continue breastfeeding on the side affected, though sometimes the baby will not latch on, because of the swelling and the difficulty to latch on. The mother should get help with latching the baby on.
Sometimes the mother will have such pain that she cannot bear to put the baby on the breast. In such a case, pain medication such as ibuprofen or other non-steroidal anti-inflammatory drugs, can be used to help the mother continue breastfeeding. Helping the baby continue breastfeeding will ultimately contribute to the mother’s symptoms resolving sooner. Improving the latch is a way to prevent recurring blocked ducts or mastitis.
As much rest and sleep as possible is very helpful in this situation though new mothers often do not get as much rest as they would like.
Often mothers with blocked ducts or mastitis have sore nipples at the same time and the sore nipples should be addressed as well.
What about antibiotics?
Even when the mother clearly has mastitis, with a painful lump in the breast, with redness of part of the breast, and the mother has fever, I will recommend caution with the antibiotics, partly because they are often not necessary and too often mothers are told that they must interrupt breastfeeding if they take antibiotics. Not true. I know of no antibiotic that requires a mother to interrupt breastfeeding.
If the mother has the symptoms of mastitis for less than 24 hours, I will give her a prescription for antibiotics, but ask her to wait before starting to take them. If the symptoms are obviously worsening over the next 12 or so hours, she should start the antibiotics. If the symptoms are improving or stable, I will ask her to wait another 12 hours and see. Often the mother will get better without antibiotics. If there is doubt about the situation, she should start the antibiotics.
If the mother has already had symptoms for 24 or more hours without the symptoms improving, she should start the antibiotics.
There is nothing that is magical about these times, only a guideline and each mother needs to be treated (or not), according to her own individual situation.
Antibiotics for mastitis should be chosen based on the fact that mastitis is almost always caused by Staphylococcus aureus, which is resistant almost always to antibiotics such as amoxicillin, penicillin and erythromycin. If a mother’s mastitis improves on amoxicillin, chances are she would have improved just as quickly without amoxicillin.
When mastitis is not getting any better at all within 24 hours of starting antibiotics, the mother may have Methicillin Resistant Staphylococcus Aureus (MRSA) and a drug which works for MRSA should be started instead of the one she is on. Cotrimoxazole, which is a combination of two very different antibiotics, Trimethoprim/sulfamethoxazole (TMP/SMX), and thus, more likely to be effective against Staphylococcus aureus.
How quickly should the mastitis improve? Usually mastitis starts to get better over 24 to 48 hours, whether the mother is on antibiotics or not. Pain and fever are decreasing, and within 2 to 3 days the mother is starting to feel better. The lump in the breast may take a week or a little more to resolve completely, but by day 3 or 4 should be getting progressively smaller and less tender.
Mastitis that does not follow the improvement as above or seems to improve but not completely could be an abscess. If an abscess is present, on examination, one can usually tell that there is fluid in the lump, and that fluid, in the context of a mastitis not improving, is likely to be pus and the mother has an abscess. However, a blocked duct sometimes, I believe, then turns into a galactocoele, also called a milk cyst.
Surgeons like to operate, it’s “their thing”. But operating on a lactating breast is fraught with difficulties and possible complications. There is a better way than making incisions in the breast. Intervention radiologists have a better cure. Read more about a better solution of how to treat breast abscess.
Breast lumps that are not any of the above
There are many types of lumps in the breast that do not fit the clinical picture of any of the above problems. Breast cancer usually is not painful in the early stages. The issue for the breastfeeding mother and her doctor is how to deal with a lump that may require further investigation. It is best to avoid surgery on the lactating breast if it is at all practical and possible. Usually, it is possible.
Needing help with breastfeeding? Make an appointment with our clinic.
Copyright: Jack Newman, MD, FRCPC, 2017, 2018