Sore nipples

Nipple pain or tenderness is one of the most common issues cited by mums in the first few days of breastfeeding. Nipple pain that extends beyond this period should not be considered normal and warrants further attention. If left untreated, sore nipples can lead to other breast problems such as engorgement, mastitis or early cessation of breastfeeding. Nipple pain or sore nipples may occur with or without infection.

Some causes of nipple pain include:

  • poor positioning and attachment
  • high baby vacuums
  • failing to release suction before removing the baby from the breast
  • climate variables
  • skin sensitivity

Signs of sore nipples

Symptoms of sore nipples may include temporary pain as a result of suction (vacuum) injury in the first few days post-partum. Nipple pain that extends beyond this may include signs of fissures, skin abrasions, cracked nipples, scab formation, or pale or dark blotches on the nipple. Signs of inflammation in the nipple or areola may be present as well. They include pain, particularly during latch, redness, oedema and higher temperatures than normal.

If a bacterial infection is present, a yellowish discharge and a reddened nipple may also be observed.

Evaluation of nipple pain

Consultation with a lactation professional is recommended. A feeding history, examination of the mum's breast and nipples and the baby's mouth, along with observation of a breastfeed, is recommended.

Management

In conjunction with advice from a lactation professional, evidence-based strategies that may be implemented, depending on the issue, may include:

  • Help with positioning and attachment, trying different feeding positions to help reduce pain
  • Feeding with the unaffected side first (unless a blockage or mastitis is present)
  • Washing hands before handling breasts to minimise bacteria, and changing nursing pads, if used, at each feeding session
  • Gently breaking the suction on the nipple with a clean finger to detach the baby, rather than pulling the baby from the breast
  • Avoiding topical applications – they are not needed if the skin is intact

If nipples are damaged or cracked

  • washing them more frequently
  • considering a warm and wet compress before breastfeeding to soften/soak the scab
  • based on the principles of moist wound healing, applying purified lanolin, which may help the nipples heal. This does not need to be washed off prior to feeding. If any irritation or discomfort occurs, its use should be discontinued
  • Ensuring breast shields are positioned correctly and are the right size, if pumping
  • Avoiding tight clothing, such as underwired bras, to minimise pressure on the breast
  • Cooling breast and nipples with cool packs after a feed to help relieve pain and inflammation
  • Taking pain relief – an anti-inflammatory agent such as Ibuprofen is considered safe during breastfeeding and may help relieve pain prior to feeding
  • Expressing temporarily for 24 hours if breastfeeding is too painful, with the gradual reintroduction of breastfeeding as the pain subsides
  • Using nipple shields as a method of reducing pain
  • If nipple tenderness remains or the nipples are slow to heal, they may need to be swabbed and cultured to check if an infection is present
  • If nipples are infected, extra hygiene measures are necessary. This includes carefully cleaning the nipples using water and a pH-neutral soap or sterile saline solution
Study abstracts
Nipple pain during breastfeeding with or without visible trauma

Nipple pain is a major cause of early weaning. The causes of nipple pain are diverse, and most treatments involve experience-based assessment. There is little ...

McClellan HL, Hepworth AR, Garbin CP, Rowan MK, Deacon J, Hartmann PE, Geddes DT (2012)

J Hum Lact. 28(4):511-21
Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain

Nipple pain and insufficient milk supply are major causes of early weaning. We have found that persistent nipple pain was associated with strong infant sucking ...

McClellan HL, Hepworth AR, Kent JC, Garbin CP, Williams TM, Hartmann PE, Geddes DT (2012)

Breastfeed Med. 7:275-81
References

Amir, L.H. ABM Clinical Protocol #4: Mastitis, Revised March 2014. Breastfeed Med 9, 239-243 (2014).

Jacobs, A. et al. S3-Guidelines for the Treatment of Inflammatory Breast Disease during the Lactation Period: AWMF Guidelines, Registry No. 015/071 (short version) AWMF Leitlinien-Register Nr. 015/071 (Kurzfassung). Geburtshilfe Frauenheilkd. 73, 1202-1208 (2013).

American Academy of Pediatrics and The American College of Obstetricians and Gynecologists. Breastfeeding handbook for physicians 2006).

Lawrence, R.A. & Lawrence, R.M. Breastfeeding: a guide for the medical profession (Elsevier Mosby, Maryland Heights, MO, 2011).

McClellan, H.L. et al. Infants of mothers with persistent nipple pain exert strong sucking vacuums. Paediatica 97, 1205-1209 (2008).

McClellan, H.L. et al. Breastfeeding frequency, milk volume, and duration in mother-infant dyads with persistent nipple pain. Breastfeed Med 7, 275-281 (2012).

McClellan, H.L. et al. Nipple pain during breastfeeding with or without visible trauma. J Hum Lact 28, 511-521 (2012).

Hale, T.W.,& Rowe H.E.,. Medications and mothers' Milk 2014 (Hale Publishing, Plano, 2014).