We often hear of breastfeeding moms complaining of sore, cracked, painful, damaged nipples. Unfortunately, it tends to be one of the most common symptoms that women experience when they first begin breastfeeding their baby. It is also what I see most often in clinical practice in the early days of breastfeeding and one of the many reasons why women seek help.
If sore nipples are so common then is it a normal part of breastfeeding?
The answer is No. In the initial days, women may experience some nipple discomfort as the nipple is stretching but this should never be described as pain. If your nipples are sore making breastfeeding painful, then this is not normal and the cause of the pain should be addressed as soon as possible.
WHAT ARE THE CAUSES OF SORE PAINFUL NIPPLES IN THE EARLY DAYS OF BREASTFEEDING?
Baby is not properly positioned at the breast
Remember the importance of skin-to skin contact! Especially in the beginning. A mother and a baby who are in skin-to-skin contact immediately after birth for ~ 1-2 hours will often result in the baby latching all by themselves with a ‘good latch’. A common mistake that mothers and many health professionals make in the early days is that we often try to ‘put the baby on the breast’ and in doing so we interfere with their natural ability to do this properly all by themselves. The key to achieving a good latch is to first provide them with the best positioning to enable baby to self-latch. If difficulties continue to persist, we can help guide them to improve the latch.
For more information on good positioning, read my previous blog here.
Baby is not properly latched onto the breast
Difficulties latching your baby is very common for mothers in the beginning of breastfeeding. So if you’re having trouble … you are not alone. As mentioned, the first step to a good latch, is proper positioning. If the baby is positioned properly, you are helping him/her to achieve a better latch.
A good latch will help prevent sore, painful nipples and helps the baby to be better able to control the flow of milk which prevents the baby from becoming ‘gassy’.
A poor latch will likely lead to sore, painful nipples, frequent feeding sessions, poor weight gain and a colicky baby.
For more information on how to improve your baby’s latch, read my previous blog here.
Baby is not suckling properly
Like most of us, babies learn by doing and by practicing. Babies learn to properly suck by being latched on well to the breast and by getting a good flow of milk. If babies are not suckling properly, my first thought would be that the baby’s latch has to be improved.
Some factors may interfere with the baby’s ability to properly learn how to suckle, as in the early use of artificial nipples. Artificial nipples (ie. bottle, pacifier) involve a different mechanism of sucking. If the introduction of these devices are done before breastfeeding is well established (~ 4-6 weeks) it may interfere with the baby’s ability to properly learn to suckle at the breast.
Some babies, for some reason or another, just take a little longer than others to develop an effective suck.
Every baby that seems to be having difficulties achieving a proper latch or effective suckling should be examined for the presence of a tongue tie. These are seen quite commonly in newborn babies and the treatment is very simple and effective making the world of a difference in their ability to breastfeed.
OTHER POTENTIAL CAUSES FOR SORE, PAINFUL NIPPLES
Fungal Infections can affect the nipple making them sore and painful. They affect many women and are caused by the fungus, Candida albicans.
Vasospasms (AKA Raynaud’s Phenomenom)
Vasospasms of the nipple can also be a cause for sore painful nipples. During a vasospasm, the blood vessels of the nipple become irritated. Once the baby comes off the breast, the nipple turns white as the blood vessels spasm (for a few minutes) and will then return to a normal color as the blood vessels relax once again (few seconds to a few minutes). The cycle then repeats itself. Vasospasms are almost always a result of a poor latch but they can also be caused by a fungal infection.
IS THERE A DIFFERENCE BETWEEN SORE PAINFUL NIPPLES CAUSED BY A POOR LATCH/INEFFECTIVE SUCKLING, A FUNGAL INFECTION AND VASOSPASMS?
Yes, Often. But Not Always.
When does the pain happen?
Sore, painful nipples caused by poor latching and effective sucking usually hurts the most when the baby first latches on and will often fade away as the breastfeeding session continues. But, if the damage is severe enough it could last the entire feeding session
Sore painful nipples from a fungal infection usually lasts the entire feeding session and may even continue after the feed is done
Sore painful nipples from vasospasms usually begin after the feeding session is done
How is the pain described?
Sore, painful nipples caused by a poor latch is often described as ‘knife-like’
Sore, painful nipples caused by a fungal infection is often (not always) described as ‘burning’
Vasospasms are described as ‘burning’ as the blood vessels spasm (nipples turn white) and ‘throbbing’ as they relax (nipples return to normal color)
- If nipple pain begins after a time when breastfeeding had been painless, it more likely would be due to a fungal infection
- Cracks in nipple are often a sign of a fungal infection
It’s important to get the help you need!
Sore painful nipples, regardless of the cause (s), will often lead to the baby receiving less milk resulting in poor weight gain. It will also cause the breast to not properly and completely drain, leading to a low milk supply. All of which, will hinder the breastfeeding relationship.
If you have sore painful nipples, this is not considered ‘normal’ (although common). You are not alone and you may need help improving your latch and/or treating the cause whether it be a fungal infection, vasospasm or a tongue tie.
GENERAL TREATMENT RECOMMENDATIONS FOR SORE PAINFUL NIPPLES
The very best way to treat sore painful nipples is in PREVENTION!
And … the best prevention is to make sure that the baby is properly latched onto the breast from day one. I often recommend to my friends, family and my patients that they have someone come to their home and/or have a planned appointment in the first week their baby is born with either a breastfeeding support person or a lactation consultant to simply observe and ensure that you are getting the best latch possible.
- Get your baby to open their mouth wide, you want a deep latch
- Don’t let baby latch onto the nipple but rather make sure that as much of the areola (brown part of the breast) gets into the mouth as possible
- A baby properly latched on will be covering more areola with lower lip than with upper lip
- If your baby is already latched on and your nipple is hurting, use your index finger to pull the bay’s chin down. This will help bring more of the breast into his/her mouth, deepening the latch and decreasing pain.
- Do not take baby on and off several times to get perfect latch. This will only result in more pain for you, more damage to your nipple and a frustrated, hungry baby.
- Practice makes perfect. You’ll have another chance at improving the latch when you feed on the next breast or at the next feeding
What else can I do to treat my sore painful nipples and help them heal?
- You can gently warm your nipples after a feed for a few seconds/minutes by using a hair dryer on a low setting, hot wash cloth or a hot water bottle. This is especially helpful with vasospasms. In the case of vasospasm however you will want to apply dry heat rather than wet heat as the moisture may further damage nipples.
- Expose your nipples to air as much as possible (except in the case of vasospasms)
- With vasospasms you will want to cover your nipples immediately after the feed to reduce pain
- When exposing your nipples to air is not possible, use dome-shaped breast shells to protect your nipples from rubbing against your clothes (DO NOT USE NIPPLE SHIELDS)
- Avoid using breast pads as these will trap moisture which could lead to increased nipple pain, fungal growth and they may stick to your damaged nipples causing more pain when removing them. If leaking milk is an issue for you, wear the breast pads over the breast shells mentioned in the previous point
- You do not need to wash your nipples frequently. Regular daily bathing is sufficient.
- If your baby is gaining weight well and thriving, then there is no reason why your baby must be fed on both breasts at each feeding. Try feeding on only one side at a time allowing your nipples the time to heal. This being said, not all women can feed on only one breast per feeding.
- NEVER USE NIPPLE SHIELDS! We never recommend the use of nipple shields. These may seem to temporarily help some women but more often than not they cause more problems. They often cause more damage to the nipples and they greatly reduce milk supply leading to increased gas and fussiness and poor weight gain. Once baby gets used to them, it may be impossible to ever get them to latch onto the breast again, often leading to early weaning.
- TOPICAL OINTMENTS are great to use to help speed the recovery of your damaged nipples as long as you are concurrently addressing the cause of your pain
- For mild/moderate nipple pain, you can purchase some great products at your local health store. Some of my favorite products are Mama’s Nipple Butter by Earth Mama Angel Baby, Nipple Cream by Matter Company, Soothing Nipple Balm by Mini Organics, Mother Nurture Nipple Butter by All Things Jill, Organic Nipple Balm by The Honest Company
- For moderate/severe nipple pain, I recommend that you request a prescription from your Midwife, OBGYN, Pediatrician or Family Doctor for the All Purpose Nipple Ointment (APNO) developed by Dr. Jack Newman.
I’ve heard of the APNO ointment but what is it and how do I use it?
The APNO ointment is considered ‘all-purpose’ because it combines various treatments all in one so that it can address multiple causes of sore painful nipples.
So, what are the ingredients?
Mupirocin 2% Ointment
- An antibiotic effective against many bacteria especially staphylococcus aureus which is found commonly in abrasions or cracks in the nipple
Is it safe for my baby? Most of it gets stuck to the skin/nipple so very little is ingested by the baby. If any ingestion does happen, this medication is metabolized very quickly by the body, making it safe in the case some does get swallowed.
Betamethasone 0.1% Ointment
- A corticosteroid that works by decreasing inflammation
- The redness of the nipples and areola is a sign of inflammation which leads to a lot of the pain associated with sore painful nipples
Is it safe for my baby? Most of it is absorbed immediately by the skin of mom, so baby ingests very little.
Miconazole powder 2%
- An antifungal agent particularly effective against Candida albicans
How do I use the APNO ointment? There seems to often be some confusion around how to apply the ointment, so I want to offer clarification.
- Apply it sparingly after each feed. Sparingly means a small amount, just enough to make the nipples and areola ‘glossy-looking’
- Do NOT wash it off or wipe it off before the next feed even if baby wants to feed earlier than expected
How long do I use the APNO Ointment? This is another question that I frequently get from breastfeeding moms.
- This ointment is very fast acting and you should have some relief very soon after beginning to apply it
- You will want to continue to use it until the pain subsides and the cause of the nipple pain has been fully and successfully addressed
- You can technically use this for more than 2-3 weeks BUT if you are needing it beyond this time I would be questioning if the cause (s) of the pain have been properly identified and are being treated
- Again, if you are still feeling pain during this time, you will want to reach out for help in addressing the cause
Preventing sore painful nipples is #1 and this is done by
achieving the best latch possible!