5.1 Sore nipples
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![]() Key Points - Case Study EAnna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
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Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
Nipple tenderness, related to changes in the hormonal milieu1, is common in the first seven to 10 days postpartum, often peaking between days three and five (2,3). Antenatal nipple preparation4 or restricting the number or length of breastfeeds in the immediate postpartum period5 has not been shown to reduce the incidence of nipple tenderness or damage. Nipple cracks, grazes or significant pain indicate the occurrence of nipple trauma, usually associated with sub-optimal positioning and attachment of the infant at the breast6.

Poorly positioned and latched baby.
© WHO
What is good attachment?
When an infant attaches well to the breast, his tongue is down and forward over the lower gum, his mouth is open wide so that the breast fills the oral cavity and the tip of the nipple reaches towards the junction of the hard and soft palate. In this position, there is little friction or trauma to the nipple. The nipple lying along the tongue and at the back of the hard palate is thought to elicit the sucking reflex. It is important to note that the infant breastfeeds not nipple feeds.

Well positioned and latched baby.
© D.Fisher, IBCLC
To facilitate optimal attachment to the breast, the infant has to receive appropriate sensory input and positional stability to enable his or her innate reflexes to function7.
- The mother holds the slightly flexed infant firmly and close to her body, ventral surface to ventral surface.
- Support across the shoulders and lower neck provides the stability for appropriate head and neck movement.
- The head, neck and body are aligned.
- The infant is at breast level with the nipple opposite the infant's nose.
- The mother often holds and shapes the breast in the plane of the infant's mouth, although her fingers should not be close enough to the nipple to interfere with attachment8.
- As the infant opens his/her mouth wide, either instinctively or in response to contact with the breast/nipple, the mother brings the infant closer to the breast – chin first so that he/she takes more breast from the underside side of the breast than the upper side (asymmetric latch)8.
What to look for when assessing positioning and attachment
- Mother is comfortable and has minimal pain or discomfort.
- The infant faces the mothers body and is held firmly.
- The head, neck and body are aligned.
- The chin is pressed into the breast, the nose is clear and the neck slightly extended.
- Upper and lower lips are flanged and wide.
- More areola is evident above the upper lip than below the lower lip.
- The tip of the tongue is over the lower lip and may be seen. However, the infant is usually too close to the breast for this to be routinely observed.
- After the first few minutes, the infant takes deep rhythmic sucks with wide excursion of the mandible. The cheeks do not cave in and there is no clicking noise, although audible swallowing is evident.
- The nipple should not appear pinched or deformed after a feed.
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![]() Pause a momentVisual assessment of positioning and attachment is only one aspect. If the mother is experiencing pain, something is wrong.9. |
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Notes
- # Robinson JE et al. (1977) Changes in breast sensitivity at puberty, during the menstrual cycle, and at parturition
- # Hewat RJ et al. (1987) A comparison of the effectiveness of two methods of nipple care
- # Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation
- # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
- # de Carvalho M et al. (1984) Does the duration and frequency of early breastfeeding affect nipple pain?
- # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
- # Glover R (July 14-18 2004) Lessons from Innate Feeding Abilities Transforms Breastfeed Outcomes
- # Neifert MR (2004) Breastmilk transfer: Positioning, latch-on, and screening for problems in milk transfer
- # Renfrew MJ (1989) Positioning the baby at the breast: More than a visual skill