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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

Click on the points below for more detail:

  • Staphylococcal infection
    • Colonisation of the nipple with Staphylococcus aureus appears to be a common occurrence in women with sore, cracked or fissured nipples. Symptoms include persistent sore nipples or non-healing cracks or fissures after resolution of any obvious cause. A yellow exudate in cracks or fissures may be evident. Women with proven Staphylococcus aureus colonisation have a much higher risk of mastitis than other breastfeeding women 1 .
    • Treatment (in addition to the measures discussed previously):
      • Clean affected nipples with warm salty water, especially if cracks and/or exudate are evident 2 .
      • Treat with ointment such as mupirocin (Bactroban) or oral antibiotics such as dicloxacillin or cephalexin. One study showed a reduction in the incidence of mastitis in women with infected nipples who were treated with oral rather than topical antibiotics 1 .
  • Thrush
    • Symptoms attributed to candida (usually Candida albicans) infection of the nipple and/or breast include persistent nipple pain (burning or stinging that last throughout and after a feed), very tender nipples, and breast pain (stabbing, shooting, like hot cords) that often radiates through the breast to the back. There may be no obvious abnormality seen on clinical examination or the skin of the nipple/areola may be red, shiny or flaky. Nipple fissures and cracks may fail to heal 3 . The infant may have oral thrush or candida nappy rash and the mother may have a history of vaginal thrush.
      • Treatment (both mother and infant need to be treated):
        • Infant – miconazole oral gel qid 4 , or nystatin oral drops, one drop in each cheek qid for a week and then daily until one week after symptoms resolve.
        • Mother – wash nipples with a solution of a cup of water and one tablespoon of white vinegar ( 5 6 ).
        • Mother – Miconozole oral gel or cream or Nystatin cream applied to nipples four to six times a day after feeds.
        • Mother – If symptoms are severe or long-standing, The Royal Women's Hospital (Melbourne) Clinical Practice Guidelines 4 recommend Nystatin tablets or capsules 500,000 units two tds for a course of 50 tables. If pain has not resolved in a week continue Nystatin and add Fluconazole 150mg on alternate days for three doses.
      Nipple candidiasis

      Nipple candidiasis.
      © B.Ingle, IBCLC


  • Herpes
    • Blisters occurring on the nipple or areola associated with significant pain may be due to Herpes simplex infection. Because of the risk to young infants if they contract Herpes infection, breastfeeding from the affected breast should be withheld until the blisters have healed, or another diagnosis is confirmed 7 . If the infant is older, or the infant transmits the infection to the mother, the risk of continued breastfeeding is less of an issue.
  • Investigations for infected nipples
    • Swabbing sore nipples and those with cracks, fissures or vesicles often enables a more definitive diagnosis and appropriate treatment of Staphyloccus or Herpes infection. Candida, however, is difficult to grow and a negative result does not preclude the diagnosis. Culture media with added iron has a higher positive culture rate 8 . Recently Candida PCR has been used to demonstrate Candida infection.

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. It is often misdiagnosed as thrush or bacterial infection.10

  • Treatment:
    • Give an explanation of the pain, and reduce stress if possible11.
    • Apply warmth to nipples and breast.
    • Correct any underlying causes.
    • Reduce smoking/caffeine.
    • Ca++ 2000mg/day and Mg 1000mg/day.
    • Nifedipine 30mg/day (9,12).
Vasospasm - blanched nipple

Vasospasm - blanched nipple.
© Goldfarb Breastfeeding Clinic

Vasospasm - perfused nipple

Vasospasm - perfused nipple.
© Goldfarb Breastfeeding Clinic


Other dermatological conditions

Click on the points below for more detail:
  • Eczema
    • Symptoms and signs of eczema of the nipple and areola (endogenous atopic eczema, irritant contact dermatitis and allergic contact dermatitis) may include an itchy, painful erythematous rash that may be associated with dry, flaky skin, or crusting vesicular eruptions 13 . The rash may be more prominent where the infant's mouth would rest during a breastfeed. It occurs more commonly on the areola and tends to spare the area around the junction of the nipple and areola. Women may have a history of eczema on other parts of the body or it may be in response to contact with allergens such as nipple creams, soaps, detergents, or with food particles in the infant's mouth following the introduction of solids.
    • Treatment:
      • Avoid aggravating factors such as nipple creams, detergents or soaps.
      • Use topical corticosteroids (ointments in preference) sparingly after breastfeeds. Potent corticosteroids may be used for a short period (no longer than seven days) if necessary 13 .
  • Paget's disease of the nipple
    • Paget's disease of the nipple is a form of ductal carcinoma-in-situ where cancer cells track under the epidermis and causes skin changes 14 . It begins as a red velvety rash on the face of the nipple but over time spreads outwards becoming ulcerated and crusting. Although non-painful to start with, itching and burning are not uncommon. Breast lumps are often not palpable. Urgent referral and biopsy is required.

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. # Barrett ME et al. (2012) Raynaud Phenomenon of the Nipple in Breastfeeding Mothers: An Underdiagnosed Cause of Nipple Pain.
  11. # Morino C et al. (2007) Raynaud's Phenomenon of the nipples: An elusive diagnosis
  12. # Lawlor-Smith L et al. (1997) Raynaud's phenomenon of the nipple: A treatable cause of breastfeeding failure
  13. # Barankin B et al. (2004) Nipple and areolar eczema in the breastfeeding woman
  14. # Bassett L et al. (1997) Diagnosis of diseases of the breast