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 milieu 1 , is common in the first seven to 10 days postpartum, often peaking between days three and five 2 3 . Antenatal nipple preparation 4 or restricting the number or length of breastfeeds in the immediate postpartum period 5 has not been shown to reduce the incidence of nipple tenderness or damage, although antenatal education has6. 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 breast 7 .

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, along with the tongue and fat pads in the masseter muscle 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. A vacuum is created as the posterior tongue and soft palate move down, holding the breast in place and drawing milk from the breast8. 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 function9.
- The mother holds the slightly flexed infant firmly and close to her body, ventral surface to ventral surface.
- A semi-reclined position of the mother with the infant prone on her chest, mouth level with the nipple, optimises normal feeding reflexes and gives stability to the infant. 10
- Support across the shoulders and lower neck also provides the stability for appropriate head and neck movement if the mother is in another position.
- The head, neck and body are aligned and the neck slightly extended.
- The infant is at breast level with the nipple opposite the infant's nose.
- When the infant's chin comes in contact with the breast, he begins to gape and the jaw and tongue fall forward to attaché to the breast.
- Infant-led attachment rather than mother-led attachment is often more effective in achieving good attachment.11
- The mother may wish to hold and shape the breast in the plane of the infant's mouth, although her fingers should not be close enough to the nipple to interfere with attachment 12 .
- 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) 12 .
What to look for when assessing positioning and attachment
- Mother is comfortable and has minimal pain or discomfort.
- The infant is close to the mother with minimal space between the two.
- The infant has a wide gape.
- 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 are rounded and do not cave in. There is no clicking noise, although audible swallowing is evident.
- The nipple should not appear pinched, compressed or deformed after a feed.

Pause a moment
However, positioning and attachment are not a visual skill. If the mother is experiencing pain, something is wrong.13.
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?
- # Duffy EP et al. (1997) Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates.
- # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
- # Geddes DT et al. (2008) Tongue movement and intra-oral vacuum in breastfeeding infants.
- # Glover R (July 14-18 2004) Lessons from Innate Feeding Abilities Transforms Breastfeed Outcomes
- # Colson S et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.
- # Glover R et al. (2013) Supporting sucking skills in breastfeeding infants
- # 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