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5.1 Sore nipples

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.

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

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

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.

What to look for when assessing positioning and attachment

Pause a moment

Visual assessment of positioning and attachment is only one aspect. If the mother is experiencing pain, something is wrong.9.

Notes

  1. # Robinson JE et al. (1977) Changes in breast sensitivity at puberty, during the menstrual cycle, and at parturition
  2. # Hewat RJ et al. (1987) A comparison of the effectiveness of two methods of nipple care
  3. # Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation
  4. # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
  5. # de Carvalho M et al. (1984) Does the duration and frequency of early breastfeeding affect nipple pain?
  6. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
  7. # Glover R (July 14-18 2004) Lessons from Innate Feeding Abilities Transforms Breastfeed Outcomes
  8. # Neifert MR (2004) Breastmilk transfer: Positioning, latch-on, and screening for problems in milk transfer
  9. # Renfrew MJ (1989) Positioning the baby at the breast: More than a visual skill