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5.2 Factors causing nipple damage

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.

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

Nipple damage

Nipple damage caused by poor latch.
© S.Cox IBCLC

Engorgement

As the breasts become full with the onset of copious milk production (usually day three or four), they tend to loose their elasticity, the nipples become flatter and some infants have difficulty attaching properly to the breast. This is a common time for nipple damage to occur. Relieving breast fullness before commencing a feed by expressing a small amount of milk usually allows the infant to attach well and prevents or relieves further nipple trauma (see Case C).

Anatomical variations of mother

There are many variations in the size and shape of mothers' nipples and breasts, with most not interfering with breastfeeding. As long as the infant can draw sufficient breast into his/her mouth to form a teat so that the nipple area is near the junction of the hard and soft palate, breastfeeding can proceed normally. When the infant attaches but is unable to draw the nipple/breast far enough into his/her mouth, the nipple may become sore and cracked/traumatised.

Concern is often expressed regarding the ability to breastfeed, with flat or inverted nipples that were described in Case A. No specific treatment has been shown to "improve" nipple protractility antenatally (1,2), although flat nipples often become more elastic and flexible during pregnancy.

Infants find it easiest to attach to breasts with flat or inverted nipples when their reflexes are at their peak and the breasts are soft, usually within the first hour of birth. Being very careful about correct positioning and attachment from the first feed is important. Firm nipple substitutes such as bottle teats and dummies are a different shape and texture to the breast, and their use before the infant has had an opportunity to attach and breastfeed independently often leads to ongoing attachment difficulties. Devices, including breast pumps, the Avent Niplette™3 and modified disposable syringes4, can help draw out the nipple prior to a breastfeed. Some women also use these devices antenatally. Nipple shields may also provide protection to the nipple and a firm surface for the infant to attach to if he/she cannot attach unaided5.

A Modified Syringe

A Modified Syringe.
© Health e-Learning

Using a nipple shield

Using a nipple shield.
© Breastfeeding Atlas


Anatomical variations of the infant

Tongue-tie (ankyloglossia) and a high arched palate (genetic) or other palatal abnormalities from intubation (particularly in premature infants) can cause sore and traumatised nipples.

Ankyloglossia

Ankyloglossia.
© B.Ingle, IBCLC

Between 3.2 and 4.6 percent of infants are born with a tongue-tie (6,7). Tongue movement, such as the ability to protrude the tongue over the lower gum, cup a finger or the breast8 or to generate a normally shaped peristaltic wave may be limited when the sub-lingual frenulum extends further towards the tip of the tongue than normal. The degree to which breastfeeding is affected will depend on the movement restriction, the shape of the infant's mouth and the elasticity and shape of the mother's breast and nipple. In some situations (but not all), ankyloglossia results in ongoing severe nipple trauma that is not improved with corrections to positioning and attachment, and poor breast drainage9. Frenotomy (division of the tongue-tie) provides almost instantaneous pain relief, no further nipple trauma and improved attachment of the infant (7,8). The Hazelbaker Assessment Tool for Lingual Frenulum Function is an objective method of assessing the impact of a tongue tie on breastfeeding effectiveness and can be useful in deciding whether a frenotomy is necessary10.

Neurological issues with the infant

Neurological problems resulting in uncoordinated tongue movements, tonic bites or other abnormalities that preclude good attachment may present initially with sore/cracked nipples. Infants with these conditions require appropriate assessment and specialised assistance outside the scope of this resource11.

Inappropriate use of lactation aids

If the base of a nipple shield or the flange of a breast pump is too small for the nipple, pressure and friction can occur during use, exacerbating any nipple trauma already present. Different sized shields and pump flanges are available if needed. Pump pressure set too high can also prolong nipple pain.

High intra-oral pressure

Recent research indicates that the infants of some mothers who suffer from ongoing sore nipples without apparent cause generate much higher intraoral pressures than other infants12. Other researchers have identified different sucking behaviours amongst infants that may have an effect on their mothers' nipples13. Further research in this area will help elucidate further causes and treatments for nipple pain and trauma.

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. # Alexander JM et al. (1992) Randomised controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples.
  2. # McCandlish R et al. (1995) MAIN Trial Collaborative Group. Antenatal treatments for flat or inverted nipples: the MAIN Trial results
  3. # McGeorge DD (1994) The "Niplette": an instrument for the non-surgical correction of inverted nipples
  4. # Arsenault G (1997) Using a disposable syringe to treat inverted nipples
  5. # Wilson-Clay B (1996) Clinical use of silicone nipple shields
  6. # Messner AH et al. (2000) Ankyloglossia: incidence and associated feeding difficulties
  7. # Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad
  8. # Srinivasan A et al. (2006) Ankyloglossia in breastfeeding infants: The effect of frenotomy on maternal nipple pain and latch
  9. # Lalalea ML et al. (2003) Ankyloglossia: does it matter?
  10. # Amir LH et al. (2006) Reliability of the hazelbaker assessment tool for lingual frenulum function
  11. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  12. # McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums
  13. # Mizuno K et al. (2004) Sucking behavior at breast during the early newborn period affects later breast-feeding rate and duration of breast-feeding