The breastfeeding mom’s complete guide to nipple pain
When asking pregnant moms what concerns them most about breastfeeding, I always receive these two replies:
- That they won’t have enough breast milk (read our article on false alarms for low milk supply)
- That breastfeeding will be painful
And painful nipples are indeed cringe-worthy. New mothers are subjected to horror stories of tiny newborn babies basically chewing away at their mothers’ nipples like little piranhas.
The good news is that the above is not a given, and that there is a lot that you can do about this matter. Let’s take a closer look.
Is nipple pain in breastfeeding normal?
According to most breastfeeding books and experts, breastfeeding shouldn’t be painful. However, I have been working as a certified lactation consultant for many years now, and I breastfed my two babies for a collective 6,5 years. In my experience, most mothers will experience some discomfort in the beginning, and possibly again from time to time on their breastfeeding journey (for example when the little piranha starts actually showing some teeth!).
Even if breastfeeding is going well, most moms will have some tenderness around days 3-7 of breastfeeding. Pain is usually experienced in the first few seconds of feeding until baby manages a deep latch, and then it eases out for the rest of the feed. It is not severe or unbearable, baby has enough wet/dirty nappies and weight gain is within normal limits.
Breastfeeding is something that both mom and baby need to get used to. Your nipples do eventually desensitize a bit, and your baby figures out how to get the latch exactly right. At this point it usually becomes comfortable.
So perhaps we should rephrase the question.
When is nipple pain in breastfeeding not normal?
If any of the below statements fit your situation, I want to seriously urge you to consider seeing a CERTIFIED lactation consultant. Your doctor and midwife/postnatal nursing sister may be able to deal with the most common, easy-to-solve breastfeeding difficulties. But there really are latching and nipple pain causes that they have not received training in and that they are not able to successfully identify and manage.
Nipple pain in the early days of breastfeeding is concerning in the following cases:
- If your nipples are already very painful on days 1-2 of feeding (or sometimes after the very first feed). This indicates a more severe latching difficulty.
- Nipples that are cracked and bleeding – ‘normal’ nipple pain will cause some tenderness, not cracks and tears in your skin.
- Pain that is severe.
- Latching that hurts throughout the feed (as opposed to the first few seconds of the feed).
- Your nipple comes out misshapen (think lipstick shape).
- Your nipple shows a blanched area after a feed.
- Breasts that become full and engorged, yet do not feel softer and emptier after a feed.
- If your baby loses more than 10% of body weight in the first 72 hours after birth.
- Baby that is having less than 5-6 wet and/or dirty nappies in 24 hours (read more on normal stool patterns for breastfeeding babies, your number one clue as to how feeding is progressing).
- If baby is not yet back on birth weight 14 days after birth.
The most common cause – an incorrect latch
Latching refers to how your baby takes the nipple into his mouth. This is the position in which baby will start sucking. If baby is holding the nipple incorrectly, sucking will hurt.
Click here to read more on correctly latching baby onto the breast, and or factors in your baby’s mouth or on your nipples that can influence latching.
Correcting the latch is the first and most crucial step to addressing nipple pain. Most moms will benefit from the assistance of a certified lactation consultant.
First things first – should you use a nipple ointment?
Many newer guidelines on managing sore nipples suggest that instead of using an ointment, you should express some breast milk and rub this onto your nipples after feeds. Breast milk is antiseptic, free and always available.
But for years evidence supported using purified Lanolin ointment for nipple care. Studies show contradicting results. A study done in 2010 by Abou-Dakn et al showed that HPA lanolin was more effective in reducing nipple pain and promoting healing of nipple trauma.
A similar study done in 2005 by Mohammadzadeh et al found expressed breast milk to be more effective than Lanolin for treating sore nipples
This highlights that there is not one answer for all moms. In my opinion most moms find that a purified lanolin ointment does bring relief. Quality brands include Lansinoh, Medela and Ameda nipple ointments. There is no need to rinse this off before feeding. One exception to this rule would be moms that are allergic to Lanolin (found in wool products).
I personally suggest that moms avoid other nipple ointments with multiple ingredients.
Tips for managing sore nipples during breastfeeding
- Feed with care
Try to experiment with different positions to find the one most comfortable for you. Take great care to latch baby as deeply as possible (see our article on positioning and latching). If you can feel that baby is not latched on well, remove her from the breast by putting your pinky finger in her mouth and gently breaking the suction. It is better to relatch a few times and get it right, than to feed with an incorrect latch.
- Preventing infection
A cracked nipple is a wound like any other and has the potential for getting infected by a bacteria or a fungus. Wash your hands before touching your breasts, and change breast pads and underwear regularly. If you have obvious signs of infection like a fever or pus draining from the area you should contact your healthcare provider.
- Salt water rinses
This is part of preventing infection and encouraging healing. Make a mild salt-water solution by adding one teaspoon of salt in 250ml of luke-warm water. Rinse your breasts after feeds. You can also soak your nipples for 2-3 minutes. Rinse with clean water and gently pat dry before applying any ointment or dressing.
- Coconut oil
You can also use Virgin Coconut Oil on your nipples after feedings. A study by Alikamali et al found this to be a good option for treating especially nipple fissures. Coconut oil has anti-fungal properties and can help to treat and prevent nipple thrush infections. Moms can also variate this with Lanolin ointment and feel for themselves which works best for them.
- Hydrogel breast pads
For cracked and bleeding nipples hydrogel pads is an option. Though more costly, most mothers experience relief. Click here for more information on where to find this and on how to use (and not to use).
- Silver nipple caps
The healing properties of silver have been proven over millenniums to have anti-inflammatory, antimicrobial, anti-fungal and antibacterial properties. Silver nipple caps have been used for many years in countries like Italy to help treat nipple pain in breastfeeding. They can help to repair and heal cracked nipples and alleviate pain throughout your breastfeeding journey. These haven’t been available in South Africa until fairly recently. We stock Silver Mama’s nipple caps, and although this is a strange concept, the feedback from mothers on this product is excellent. It is a more expensive option though.
- Breast shells
Moms often find that clothing and breast pads further hurt sore nipples. Breast shells fit over the breast and give the nipple time to heal without anything touching it. I have seen moms for sore nipples where the shell is the item that makes the biggest difference of all. It is an extra expense though, considering that it is a product that will be used for a short period of time only. Be sure to wash and sterilise it thoroughly between use. You should also be careful to not wear the shells with a tight bra or top, as this can put excessive pressure on the breast and can lead to engorgement and blocked ducts. We stock Youha’s Breast shells, and you can read more about the product here.
- Resting your nipples
If pain is severe a mom may choose to not feed from that side for a few feeds, just to give the nipple a chance to heal. If you do this you need to express (either by hand or with a pump) to empty that breast and maintain supply. You can feed your baby this expressed milk with a cup or syringe. Note that this should only be a short-term solution.
- APNO ointment
APNO stands for All Purpose Nipple Ointment, and consists of a mixture of an anti-bacterial, antifungal and cortisone ointment. Not many doctors or pharmacists are familiar with this mix, for which you may need a prescription. Miconazole powder (one of the ingredients) is also not always available in South Africa and a pharmacist may have to use alternative options. APNO should be considered if a mom has tried everything else with no success, as sometimes this is due to an infection. You can show your doctor this link to explain what medication is needed.
- Pain relief
You can use oral paracetamol or ibuprofen for pain relief, though this will be limitedc
I put this one last because there is no evidence to prove that it works and many professionals don’t recommend unprotected sun exposure due to the risk of skin cancer. But a few minutes of airing your nipple and exposing them to sunlight early morning or late afternoon for a few days in a row is unlikely to cause damage to the skin. The environment inside a breast pad and bra is warm, moist and dark. This makes it an ideal place for organisms to grow in. Some fresh air and sunshine may can help.
Other causes of nipple pain
Nipple thrush is a BIG and controversial topic. As mentioned above, the environment inside a breast pad is dark, warm and moist – the circumstances where Candida flourishes. Nipple thrush can occur if nipples are damaged and sore for an extended period of time. If pain occurs suddenly after a period of comfortable feeding thrush should also be considered.
Nipple thrush typically caused burning pain, itching of the nipples and shooting pains into the breast. You may also see thrush in baby’s mouth, or a fungal nappy rash.
Both mom and baby must be treated for thrush. Dr Jack Newman is a Canadian paediatrician specialising in breastfeeding, and many of his protocols are accepted worldwide as the standard of care. Read his protocol for managing thrush here; you can show this to your doctor to ensure that you receive the correct treatment.
Raynaud’s phenomenon is best known for causing a constriction of blood vessels that goes to the hands and feet. The fingers and toes turn white and experience pain when they are cold. This is also known as winter’s hands and feet. Less commonly, the blood vessels in the nipples are affected, causing pain during, immediately after, or between breastfeeds.
If nipple pain is due to Raynaud’s phenomenon mom will see her nipples turning white during a feed, and then becoming blue/purple before turning dark red. This causes severe pain.
For many mothers with Raynaud’s phenomenon applying heat after a feed will sort out the discomfort. If this doesn’t help your doctor can subscribe a calcium-channel blocker like Nifedipine for a few weeks.
This is once again a treatment that many doctors may not be familiar with, and your lactation consultant may provide a referral or put you in touch with a practitioner informed about and focused on breastfeeding.
Mammary Constriction Syndrome
Mammary Constriction Syndrome is a fairly new explanation of nipple and breast pain, one that we are still learning about. In short, due to tension in a mother’s breast and shoulders, the pectoral muscles can suppress the blood vessels supplying the breast tissue and nipples, causing reduced blood flow to those areas. This is accompanied by deep stabbing or shooting pains in the breasts. Tension can be caused from sitting in an incorrect position (remember, baby-to-boob), and from anticipating a painful latch.
Treatment involves massaging the muscles in the breast and chest area before feeding, and supporting your back during feedings (instead of hunching forward). IBCLC Philippa Pearson-Glaze provides more information on this phenomenon on www.breastfeeding.support
A nipple bleb
A nipple bleb or milk blister is caused by a blocked nipple pore. This can happen when a pore is blocked by either dried milk or (more often) by some skin that overgrows the opening and block milk coming out. A milk blister looks like a painful white/yellow dot on the nipple that bulges outwards when you squeeze the nipple.
A milk blister can take some days or even longer to resolve and then to heal. You can try applying olive oil to cotton wool and leaving it inside your breast pad to soak for 2-3 hours. Try to gentle rub away the piece of skin. Soaking in salt water may also help. In severe cases a doctor may assist you with opening the blister with a sterile needle. You can read more on milk blisters in this fantastic article by IBCLC Kelly Bonyata.
Eczema and dermatitis
Sometimes a mother may have a skin reaction to breast pads or a nipple ointment that she used. A lanolin allergy will also cause this. You may also find that the skin around the nipple area is affected, and that there may be some itching or scabbing. Try to eliminate the cause by stopping all ointments and only applying breast milk, and by changing the brand of breast pads that you use (or by switching to cloth breast pads). A cortisone ointment may help.
Very rarely nipple pain can be caused by a viral infection such as Herpes Simplex (fever blisters). If you see sores/blisters appearing on your nipple that does not seem linked to any of the other causes discussed here, especially if you were in contact with someone who has a fever blister you should consult your doctor. If this is the case you would need to express and discard the milk from that breast until it is fully healed. This is a serious step though, so be sure to get a proper diagnosis.
A last word
I completely realize that sore nipples make the breastfeeding experience in the early days very unpleasant. I want to encourage moms to persevere though, as in most cases this will pass and you will get to the point where breastfeeding becomes comfortable, convenient and enjoyable. Above all, see help sooner rather than later. You can email email@example.com for assistance in finding a lactation consultant in your area.
Alikamali et al, Comparing the Efficacy of Breast Milk and Coconut Oil on Nipple Fissure and Breast Pain Intensity in Primiparous Mothers: A Single-Blind Clinical Trial, Breastfeed Medicine, 2023 Jan;18(1):30-36