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8.2 Nipple Pain

Nipple pain is a common early postpartum concern. 1

It causes mothers

Nipple pain can be caused by several factors:

Transient nipple pain is common during the first week postpartum, peaking at day 3 and decreasing by day 7. 9 There is no damage evident and the pain disappears within a short time of commencing the feed (ie, about 30 seconds).

Management basics

There is nothing to be achieved by treating sore or damaged nipples if you don't simultaneously treat the cause.
  1. Identify the cause of the pain or damage.
  2. Treat or manage the cause.
  3. Initiate supportive management strategies to aid healing.

Supportive strategies

When the cause of the damage is treated the nipple will heal quickly even while the mother continues to breastfeed from the affected breast. After identifying the cause and initiating the appropriate action plan, the mother will also benefit from other supportive measures.

Topical applications

Many topical applications have been tried and studied (or not studied!) with often conflicting outcomes. What this essentially means is that no single evidence-based intervention can be recommended for all mothers. In the absence of an evidence-based practices that will provide pain relief, speed healing and prevent premature weaning the goal is to 'first, do no harm' .

The most common topical applications include:

  • Expressed breastmilk (EBM). Breastmilk contains:
    • anti-infective agents that reduce the risk of a superimposed infection,
    • epidermal growth factor that aids healing,
    • as well as the hindmilk being high in fat to soothe the nipple.
      Applied after and between breastfeeds to keep the wound moist, it is a simple, no-risk, no-cost and very successful intervention.

  • Warm water compresses. A meta-analysis 10recommended the application of warm water compresses to relieve pain, and breastmilk to hasten healing of cracked nipples. Again, simple, no-risk, no-cost and often effective.

  • Pharmaceutical grade lanolin. Mothers often report an immediately soothing effect from this treatment. Some studies found faster healing of nipple trauma and nipple pain reduction when compared to EBM 11 while others 12 find no difference between the two.
    Contamination of the lanolin within the container risks causing or prolonging the nipple problem.

  • Hydrogel dressings. There have been no reviews of the effectiveness or safety of this intervention for nipple wound treatment in recent years. Older studies 13 14 noted an increased incidence of infections in the groups using this wound dressing, with one study discontinued early because of this outcome. Recommend with caution, stressing the importance of hygiene.
    Generally considered unsuitable for use in the presence of nipple infection.

Wound management

The damage on a nipple is a wound. However, unlike a wound on other parts of the body, a nipple wound has unique characteristics:
  • a large volume of a bodily secretion (ie breastmilk) must be allowed to flow past it frequently
  • an infant must latch over the top of it frequently

Moist wound healing management that involves occluding the wound for days at a time while the wound exudates perform healing and antiinfective functions, can not be applied.
However, scab formation or a covering that sticks to the wound causing damage on removal is to be avoided.

What about resting the nipple?

Severely damaged nipples may need to be rested for 24 hours or longer due to the severe pain caused to the mother. During this time regular expressing of breastmilk will be required.

We live in a time of technology and gadgets. A breast pump (electric or manual) is often the only option considered for milk removal. Just as infants who exert a stronger baseline peak and pause vacuum will cause more pain for their mothers compared to infants with vacuum within normal range15 so too the vacuum of breast pumps has been associated with increased nipple pain and damage.16 If a pump is to be used careful instruction to mothers about the correct use will prevent a bad situation becoming worse.

Hand expressing breastmilk is frequently the better option for many mothers.

Group Activity

Review the management of nipple pain and damage in your unit's Breastfeeding Policy. Is it up-to-date and focussed on 1. identifying the cause, 2. treating the cause and 3. supportive management?

If not, you may like to form a small committee to review the contemporary literature and draft a new section for consideration by the relevant parties.

Identification and Management of Specific Causes

Technique factors

Historically, an intervention to try to prevent nipple damage was to limit the number of feeds and length of time on the breast. A Cochrane Review 17 concluded that this practice was associated with an increased incidence of sore nipples, engorgement and the need to give additional (formula) feeds, and is therefore not recommended.

One study noted that 94% of women with breastfeeding problems had babies who had a "superficial, nipple-sucking" technique. 18

Many authors implicate a poorly latched baby as being the major culprit of nipple damage. 19 20 21

It has also been noted that there is a correlation between the early use of bottles and/or pacifiers and a disorganized suck and nipple damage. 18 22

From this body of work it is clear that the most common cause of nipple pain and nipple damage is preventable by:

  • achieving correct positioning and latching techniques, and
  • avoiding artificial nipples (teats/pacifiers/dummies) during the learning period.

Back to basics

Poor latch (whether from maternal technique or infant ability) may exist in the presence of other risk factors for nipple pain/damage.
In assisting the mother, go back to basic principles of position and latch FIRST to obtain a clearer picture of the other factors.

The most important factor in decreasing the incidence of nipple pain is the provision of education in relation to proper breastfeeding technique and latch-on ...23

Quality assurance activity

Would you and a small group of colleagues be able to organize an audit of all cases of nipple damage at discharge from your maternity unit over a one-month period?
It may be as simple as just an incident report, though trying to determine a cause for each would be useful. You may like to discuss with your colleagues the significance of this data once collected. Together you could work on ways to reduce the incidence before surveying again.

General tips:

  • Skin-to-skin contact and the biological nurturing position are your first line of assistance whenever latching difficulties are evident.
  • Gentle touch or massage, or a cold cloth over the nipple will stimulate the nipple erectile tissue.
  • Compress the breast to hold the shape - the compression points on the breast coincide with where the baby's bottom and top jaws will be. Maintain this hold for a minute or two until sucking well established.
  • The best time for the baby to learn to breastfeed from his mother's breasts is prior to secretory activation (lactogenesis II) while her breasts are still soft. Avoid artificial teats (bottle nipples or nipple shields) until baby has this opportunity.

Workbook Activity 8.3

Complete Activity 8.3 in your workbook.

Inverted or non-protractile nipples

Non-protractile or inverted nipples are difficult to draw out. Attempt to shape the breast well and hold that shape until infant is well established on the breast.

Some devices may assist:
Syringe on right modified for mother to gently draw out non-protractile or inverted nipple.

Syringe on right modified for mother to gently draw out non-protractile or inverted nipple.
Photograph © Health e-Learning

Devices to evert the nipple immediately prior to latching can be successful. For example

  • a modified syringe, 24 25 or commercial nipple everting devices
  • using a hand pump immediately before latching.

These techniques are not always necessary though as many babies latch well to the breast regardless of nipple protractility.

Remember it is breastfeeding, not nipple feeding.


Infant well-latched to nipple shield.

Infant well-latched to nipple shield.
© B. Wilson-Clay IBCLC

Sometimes a nipple shield may be helpful. 26

However, thin silicone nipple shields are associated with 27 a decrease in milk transfer, loss of maternal self-confidence, 28 and premature weaning 29 30

Milk transfer via a shield before secretory activation will be negligible and therefore shields should not be started until mother has established a good milk supply. Introduction during the first postpartum week gives mothers a false sense of breastfeeding success and is more likely to lead to poor milk transfer, sore nipples and loss of milk supply. 27

Note: Once a nipple shield has been introduced, observe for a good deep latch and nutritive sucking pattern. Follow-up assessment of infant condition and maternal milk supply is very important with the aim to weaning off the shield when the initial problem has resolved.


Ankyloglossia (tongue tie)

Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.

Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.
© Dr E. Jain

A short or tight lingual frenulum (the membranous attachment between the inferior aspect of the tongue and the floor of the mouth) may prevent the baby from extending the tongue over the bottom gum line or elevating the tongue (both essential actions for breastfeeding).

This can result in:

  • breastfeeding difficulties
  • nipple pain and trauma
  • ineffective feeding
  • poor infant weight gain
  • down-regulation of milk supply


Treatment

Mild or even moderate tongue-tie may have minimal effect on breastfeeding. However, when tongue-tie is noted it must always be considered when a breastfeeding problem develops.

Frenotomy
- is a simple surgical procedure to release the restriction and provide greater movement.

The following outcomes of frenotomy have been achieved:
  • Where poor latch was their major complaint, 100% of women found latch was improved. 31
  • Of those presenting with nipple pain, mean pain score reduced from 6.9 to 1.2 immediately after the procedure. 31
  • A significant decrease in nipple pain score reported after frenotomy compared to after sham procedure. 32
  • Ultrasound post-frenotomy demonstrated less nipple compression by the tongue and was associated with "better attachment, increased milk transfer and less maternal pain". 33
  • Normal milk volume transfer possible by direct breastfeeding.34

When tongue-tie is noted ...

and in the presence of breastfeeding difficulties
  • refer the mother and her infant to a health professional who has experience assessing tongue ties and performing frenotomy.
Unfortunately, despite obvious breastfeeding difficulties affecting both mother and baby, some health professionals refuse to treat ankyloglossia.

Fungal overgrowth (candidiasis, thrush, yeast)

Amongst women who report breastfeeding-associated pain, Candida albicans is the most commonly cultured organism. 35 36

C. albicans is a fungus (a form of yeast), which exists normally on the mucous membranes of the gut and vagina and usually presents no problems to a healthy individual. Factors that cause an imbalance of the normal flora of the body often result in candidiasis - the condition caused by an overgrowth and change in form of the fungus as it infects the host tissue.

Factors often associated with nipple candidiasis are:

  • presence of vaginal candidiasis - up to 25% of women are affected by end of pregnancy 37
  • use of antibiotics 7
  • break in skin integrity of nipple36
  • infant who has oral candidiasis (acquired during birthing or being introduced on fingers, etc)
  • infant use of pacifiers/dummies 38 39 - may also contribute to persistence of infant oral infection
  • use of bottles - 23% of lactating women who used bottles tested positive for Candida and 20% had nipple candidiasis. A risk factor for colonization of the mother was bottle use in the first 2 weeks postpartum. Of these women 57% had weaned by 9 weeks postpartum, compared to 31% who were negative for Candida. 40

Presentation and Diagnosis

Notice the shiny red areas around the nipple.

Notice the shiny red areas around the nipple.
© Goldfarb Breastfeeding Clinic

Nipple candidiasis commonly presents with the following signs and symptoms

  • acute breast/nipple pain after a period of pain-free feeding
  • deep shooting, burning, or stabbing pain in the breast
  • burning nipple pain, during and for some time after a breastfeed
  • nipple and/or areola may be red, shiny or flakey; though may show no changes
  • Candida may be obvious in the baby's mouth
  • history that includes a risk factor, eg. recent antibiotics, bottle use, etc.
  • observation of a breastfeed to eliminate other causes

Workbook Activity 8.4

Complete Activity 8.4 in your workbook.

Management

Candida branches and multiplies rapidly and exists in many different stages at the same time. Management is aimed at eradicating the pathogen and preventing re-infection. The mother's doctor will confirm the diagnosis and may prescribe a pharmaceutical antifungal agent.

Antifungal agents that have been found to be effective in treating Candida albicans include:

  • Effective home remedies:
    • Gentian violet aqueous 0.5% - painted on the nipples. This purple dye kills Candida on contact.41 42 (not readily available in some countries)
    • honey in a >80% concentration 43
    • Pure coconut oil - rubbed into nipples and ingested for candida in other sites. 100% effective against candida albicans in vitro 44
  • Miconazole - cream applied sparingly to nipples; also oral gel for infant. Effective in 99% of cases.45
  • Fluconazole - systemic agent, usually administered orally. 46
  • Nystatin. Not usually the drug of first choice. Resistance has developed to this drug, only being effective in 54% of cases. 45

Educate the mother about the following supportive strategies that will enhance the antifungal treatment and prevent re-infection.

  • Meticulous attention to hygiene.
    • wash hands in warm, running soapy water before and after breastfeeding and any time when potentially infected areas have been touched, drying hands on a paper towel.
    • discard reusable gel breast pads if they were being used and don't recommence until infection is cured, and preferably not at all.
    • wash bras and cloth nursing pads daily and dry in direct sunlight if possible.
    • boil pacifiers or artificial teats/nipples daily and replaced frequently.
    • wash and thoroughly dry all toys, etc the baby puts in his mouth.
  • Rinse the nipples in a bicarbonate of soda solution to create an alkaline skin environment. Nipples may respond differently to traditional vaginal thrush soothing treatments.
  • Consider and treat all possible sources of recurring infection
    • trim the baby's finger nails to prevent Candida being harbored under the nail and transferred to the mouth.
    • the moist fold under the breasts of large breasted women
    • other children, maternal vaginal infection, sexual partner, a pet
  • Some women have reported faster resolution of symptoms when they eliminate simple sugars and yeasts from their diet and consume pure coconut oil, acidophillus and/or bacillo bifidus either in yoghurt form or in a commercially prepared capsule.
Treatment of the infant
The infant may be a source of a re-infection cycle. Simultaneous treatment of infant with an appropriate infant preparation such as miconazole gel is standard care.

Workbook Activity 8.5

Complete Activity 8.5 in your workbook.

Bacterial infections

Whenever nipple skin integrity is broken the risk of colonization with bacterial and fungal pathogens is significantly increased.
Staphylococcus aureus is the most common causative organism of bacterial infections on the nipple, 36 though streptococcus may also be implicated. Mastitis is often associated with S. aureus-infected nipple damage

Diagnosis is usually made following careful history taking:

  • pain described as stinging,
  • observation of nipple damage,
  • presence of an exudate that could be yellow to red and crusting,
  • a delay in wound healing


© Goldfarb Breastfeeding Clinic

Management:
  • Treat the original cause of the break in nipple skin integrity.
  • Gently clean the nipple wound in a saline solution.
  • Apply antibiotic ointment as ordered by the doctor. A compound many find useful is a combination of a mild topical steroid, an antibiotic and an antifungal agent. 47

What should I remember?

  • Nipple pain threatens breastfeeding continuation and is therefore a SERIOUS PROBLEM requiring prompt and effective management.
  • The many causes of nipple pain, but especially the MOST COMMON cause.
  • Supportive management strategies for damaged nipples.
  • How to assist mothers with non-protractile nipples.
  • Identification of ankyloglossia and impact on breastfeeding dyad.
  • How to recognise nipple infections such as candidiasis and Staph aureus.
  • Treatment choices for nipple candidiasis and Staph aureus.

Self-test quiz

Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

Notes

  1. # Buck ML et al. (2014) Nipple pain, damage, and vasospasm in the first 8 weeks postpartum.
  2. # Schwartz K et al. (2002) Factors associated with weaning in the first 3 months postpartum.
  3. # Lewallen LP et al. (2006) Breastfeeding support and early cessation.
  4. # Amir LH et al. (2005) Why do women stop breastfeeding? A closer look at not enough milk among Israeli women in the Negev Region.
  5. # Indraccolo U et al. (2012) Pain and breastfeeding: a prospective observational study.
  6. # McClellan HL et al. (2012) Nipple pain during breastfeeding with or without visible trauma.
  7. # Amir LH et al. (1996) Candida albicans: is it associated with nipple pain in lactating women?
  8. # Annagur A et al. (2013) Is maternal depressive symptomatology effective on success of exclusive breastfeeding during postpartum 6 weeks?
  9. # Morland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review.
  10. # Johanna Briggs Institute et al. (2009) The management of nipple pain and/or trauma associated with breastfeeding.
  11. # Abou-Dakn M et al. (2011) Positive effect of HPA lanolin versus expressed breastmilk on painful and damaged nipples during lactation.
  12. # Vieira F et al. (2013) A systematic review of the interventions for nipple trauma in breastfeeding mothers.
  13. # Ziemer MM et al. (1995) Evaluation of a dressing to reduce nipple pain and improve nipple skin condition in breast-feeding women.
  14. # Brent N et al. (1998) Sore nipples in breast-feeding women: a clinical trial of wound dressings vs conventional care.
  15. # McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums
  16. # Clemons SN et al. (2010) Breastfeeding womens experience of expressing: a descriptive study.
  17. # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
  18. # Righard L (1998) Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles?
  19. # Gunther M (1945) Sore Nipples: Causes and Prevention
  20. # Prachniak GK (2002) Common breastfeeding problems
  21. # Wight NE (2001) Management of common breastfeeding issues
  22. # Centuori S et al. (1999) Nipple care, sore nipples, and breastfeeding: a randomized trial
  23. # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
  24. # Kesaree N et al. (1993) Treatment of inverted nipples using a disposable syringe
  25. # Patel Y (2008) Inverted nipples: correction using a simple disposable syringe.
  26. # Hanna S et al. (2013) A description of breast-feeding outcomes among U.S. mothers using nipple shields.
  27. # McKechnie AC et al. (2010) Nipple shields: a review of the literature.
  28. # Keemer F (2013) Breastfeeding self-efficacy of women using second-line strategies for healthy term infants in the first week postpartum: an Australian observational study.
  29. # Rius JM et al. (2014) [Factors associated with early weaning in a Spanish region].
  30. # Pincombe J et al. (2008) Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.
  31. # Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad
  32. # Griffiths DM (2004) Do Tongue Ties Affect Breastfeeding?
  33. # Geddes DT et al. (2008) Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound.
  34. # Garbin CP et al. (2013) Evidence of improved milk intake after frenotomy: a case report.
  35. # Andrews JI et al. (2007) The yeast connection: is Candida linked to breastfeeding associated pain?
  36. # Amir LH et al. (2013) Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia.
  37. # Cotch MF et al. (1998) Epidemiology and outcomes associated with moderate to heavy Candida colonization during pregnancy
  38. # Comina E et al. (2006) Pacifiers: a microbial reservoir
  39. # da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.
  40. # Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women
  41. # Wright SC et al. (2009) Treatment of oral thrush in HIV/AIDS patients with lemon juice and lemon grass (Cymbopogon citratus) and gentian violet.
  42. # Gomes-de-Elvas AR, (2012) In vitro assessment of gentian violet anti- candida activity.
  43. # Banaeian-Borujeni S, (2013) Comparison of the effect of honey and miconazole against Candida albicans in vitro.
  44. # Ogbolu DO et al. (2007) In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.
  45. # Hoppe JE et al. (1996) Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group
  46. # Moorhead AM et al. (2011) A prospective study of fluconazole treatment for breast and nipple thrush.
  47. # Newman J et al. (2005) Dr Jack Newman's Guide to Breastfeeding (The Ultimate Breastfeeding Book of Answers)