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5.4 Further causes of nipple pain

Key Points - Case Study E

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?

Topic 5.1: Sore nipples
Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.

What other conditions may contribute to nipple damage occurring in the first week postpartum?

Topic 5.2: Factors causing nipple damage
Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.

After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?

Topic 5.3: General treatment for sore nipples
The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.

Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?

Topic 5.4: Further causes of nipple pain
Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.

Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?

Infection

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Vasospasm

Women with nipple vasospasm present with nipple and breast pain, often throbbing, sharp or burning, that begins towards the end of the feed, after the feed or independent of the feed. Vasospasm is similar to Raynaud's phenomenon and is associated with bi- or tri-colour change of the nipple. Blanching of the face of the nipple when pain occurs is usually the most obvious clinical sign. Vasospasm does not cause nipple tenderness at other times. Vasospasm is more common in women with a history of Raynaud's phenomenon; in colder weather; in association with other nipple conditions such as trauma or infection; or with medications (theophylline, diflucan) and other drugs (nicotine and caffeine)9.

Vasospasm - white

Vasospasm - blanched nipple.
© Goldfarb Breastfeeding Clinic

Vasospasm - red

Vasospasm - perfused nipple.
© Goldfarb Breastfeeding Clinic


Other dermatological conditions

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Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Livingstone V et al. (1999) The treatment of staphylococcus aureus infected sore nipples: a randomized comparative study
  2. # Wilson-Clay B et al. (2002) The Breastfeeding Atlas
  3. # Amir LH et al. (2002) Candidiasis and breastfeeding Lactation Consultant Series 2
  4. # Royal Women's Hospital (Melbourne) (2006) Thrush in lactation
  5. # Heinig M et al. (1999) Mammary candidosis in lactating women
  6. # Hoover K (2001) The link between infants' oral thrush and nipple and breast pain in lactating women
  7. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  8. # Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women
  9. # Anderson JE et al. (April 2004) Raynaud's phenomenon of the nipple: a treatable cause of painful breastfeeding
  10. # Morino C et al. (2007) Raynaud's Phenomenon of the nipples: An elusive diagnosis
  11. # Lawlor-Smith L et al. (1997) Raynaud's phenomenon of the nipple: A treatable cause of breastfeeding failure
  12. # Barankin B et al. (2004) Nipple and areolar eczema in the breastfeeding woman
  13. # Bassett L et al. (1997) Diagnosis of diseases of the breast