by Dr Jenny Boyd, General Practitioner
Breastfeeding comprises a complicated and special relationship between mother and baby and many factors influence how that relationship develops. Pain in breastfeeding can have a significant impact on the breastfeeding relationship and whether a mother chooses to continue breastfeeding her child. A cross sectional self report survey carried out and published in 2015 showed that mothers who stopped breastfeeding as a result of physical issues or pain were at higher risk of postnatal depression than those who stopped for social reasons eg. embarrassment1.
There are many causes of pain in breastfeeding and a good history and assessment of feeding is essential to identifying the problem and treating it effectively.
See our page on ‘Positioning and Attachment‘ which demonstrates the role of good positioning and attachment of the infant at the breast in enabling comfortable feeding.
The Breastfeeding Network: If Breastfeeding Hurts Enables following web page links to determine the likely cause of breastfeeding related pain.
Sore nipples are common and are usually due to positioning and attachment issues. Some women find that they experience cracked nipples in the early days but with time and practice this pain gradually settles. Breastfeeding is a learned skill for both mother and baby and as both become more confident, positioning and attachment improves. Breastfeeding should not be painful and persevering and ignoring the pain can be damaging. When the baby is attached well the nipple should be resting against the soft palate at the back of their mouth. If the baby is attached poorly the nipple may be rubbing on the hard palate and can be pinched leading to pain.
The most important first step with painful, cracked nipples is to address any attachment issues and thereby removing the cause. Trying different feeding positions may help. There may be a physical reason why the baby can’t attach eg. tongue-tie and this should be checked for. A referral should be made to an appropriate skilled Breastfeeding Support colleague to improve attachment and positioning.
To manage the cracked nipples, expressing a few drops of breastmilk after a feed and applying it to the nipples can help. Applying purified lanolin (commercial ‘nipple creams’) to the nipple to allow moist wound healing may also be helpful although a recent Cochrane review suggested that none of the commonly used treatments were more effective than conservative management or the use of breastmilk2.
Milk Bleb (Milk Blister)
A milk bleb or blister is a blocked nipple pore. It occurs when a tiny bit of skin grows over a milk duct and milk backs up behind it. This then shows as a white, yellow or clear ‘dot’ on the nipple or areola which is very painful. If you compress the breast so that milk flows down towards the nipple, the blister will bulge outwards. They can remain for several days to weeks and then clear when the skin breaks away from the affected area. Underlying causes include oversupply, pressure on that area or other causes of blocked ducts. Friction due to attachment issues can also cause blisters but have a different aetiology.
Treatment for a Milk Blister:
- Apply heat to the area before nursing
- Clear the skin from the blister – this can be done by rubbing a moist flannel on the area, gently scraping with the fingernail or pulling the plug if it is protruding from the nipple. A sterile needle can be inserted at the edge of the blister to lift it.
A blocked duct can occur when one of the segments in the breast isn’t drained properly possibly due to attachment problems. This leaves a hard lump on the breast which can be tender. If the duct is not cleared this can lead to mastitis. In order to clear the blockage, mum should be advised to feed frequently from the affected breast, use warm compresses and gentle massage of the lump towards the nipple while baby is feeding. She should also be advised to avoid tight fitting clothes or bras so that the milk can flow freely.
Nipple Vasospasm (including Raynaud’s Phenomenon of the Nipple)
Vasospasm in the nipple can result in blanching of the nipple and severe throbbing pain. Causes include suboptimal positioning and attachment, and mechanical trauma (e.g. biting and compression of the nipple). Attachment and positioning should be assessed as in all cases of breast/nipple pain and the appropriate action taken to manage the suspected problem. Vasospasm is an under-recognised cause of nipple pain and may be misdiagnosed (eg. as thrush).
One possible cause of nipple vasospasm is Raynaud’s phenomenon of the nipple. Raynaud’s phenomenon affects up to 20% of women of childbearing age3. It affects mainly fingers and toes but can affect other areas of the body including nipples. Symptoms include pain in the nipple during and after a breastfeed. Raynaud’s usually affects both nipples although not necessarily at the same time. The pain is severe, debilitating and throbbing and may be precipitated by the cold. There may be a history of other circulation problems. As compared to other causes of vasospasm, Raynaud’s phenomenon causes blanching of the nipple followed by cyanosis or erythema. Pain resolves when the nipple returns to its normal colour.
The mother should be advised to avoid cold exposure, wear plenty of layers to keep warm and breastfeed in a warm environment. She should stop smoking if applicable and limit caffeine intake. Applying a warm compress immediately after feeds and moderate exercise can help.
If simple measures are not sufficient to control symptoms Nifedipine can be prescribed at a dose of 10mg immediate release three times daily or 30mg modified release once daily for 2 weeks. Usually this is sufficient to treat the symptoms but some women need ongoing treatment. See the Breastfeeding Network’s useful factsheet below for more information.
Scleroderma & Raynaud’s UK (SRUK): Identifying Raynaud’s in Breastfeeding Mothers Factsheet The Charity SRUK has medical information on Raynaud’s and Scleroderma, and links to support.
Pregnancy or menstruation can increase nipple sensitivity. Hand expressing a little before feeds or trying different feeding positions can improve symptoms.
The nipples can become irritated due contact with allergens, baby teething or a reaction to food particles once baby has started weaning. Avoid precipitants eg. soap and shampoo, nipple cream, breastfeed before solids, rinse baby’s mouth before a feed, rinse the nipple after a feed and if the nipples don’t settle treat with mild to moderate corticosteroids.
If unilateral and not responsive to treatment, consider Paget’s disease and refer urgently.
Other Conditions Causing Breast Pain
The following conditions are covered in detail on our dedicated webpages:
NICE CKS Breastfeeding Problems Revised January 2017- Includes recommendations on a variety of causes of breast and nipple pain.
La Leche League GB: Nipple Pain Divides up types of pain and highlights conditions responsible for each. Also covers causes of pain if this develops when feeding older babies.
NCT: Sore Nipples when Breastfeeding Patient information, including advice regarding the use of nipple shields.
Association of Breastfeeding Mothers: Using a Nipple Shield with a Breastfed Baby A nipple shield can be a temporary solution but not a permanent fix to an underlying problem with breastfeeding pain and should only be used with supervision from a skilled breastfeeding practitioner. This page explains in detail the reasons for using nipple shields, what to consider before using a shield, how to fit and use a shield and contains a link to an information factsheet pdf.
- Brown A, Rance J, Bennett P. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing. 2015;72(2):273-282.
- Dennis C, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews. 2014;Issue 12. Art. No.: CD007366.
- Anderson J, Held N, Wright K. Raynaud’s Phenomenon of the Nipple: A Treatable Cause of Painful Breastfeeding. Pediatrics. 2004;113(4):e360-e364.