Nipple pain - Breastfeeding.ie

Breastfeeding
Information for GPs and Pharmacists
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Nipple pain
05
Nipple pain is a common early postpartum concern and a frequent reason for
mothers to stop breastfeeding prematurely. Transient soreness occurs during the first
week postpartum, particularly at the start of a feed. Soreness that extends beyond the
first week is considered abnormal and has a variety of contributory factors.
The most common causes of nipple pain
• Incorrect positioning and attachment of the baby
to the breast
• Disorganised or dysfunctional suckling
• Incorrect use of breast pump
• Bacterial infection of nipple
• Candidiasis of nipple/breast
• Tongue tie (ankyloglossia)
• Vasospasm of nipple
Positioning and attachment
Effective attachment of the baby to the breast is
necessary to:
• prevent nipple damage and pain,
• facilitate removal of milk from the breast,
• maintain an adequate milk supply. (2)
The four principles of correct positioning
1. Baby is held close to the mother and facing her
breast.
2. Baby’s head and body are in alignment allowing
the baby freedom to tilt his head backwards.
3. Baby is held with his nose or top lip at the level
of the nipple – this allows the baby to open
his mouth wide and grasp a good mouthful of
breast.
4. Ensure the mother has good back and arm support to sustain the position. (3)
Signs of effective positioning and attachment
• Baby’s chin is in contact with the breast, leaving
his nose free to breathe.
• Baby’s mouth is open wide.
• His bottom lip is curled outwards.
• His cheeks are full and rounded.
Nipple pain
• If any of the areola is visible it is mainly under the
bottom lip.
• The baby sucks and swallows in rhythmic pattern.
• The process is not painful for the mother. (3)
Putting baby to the breast
• Ensure mother is in a comfortable position with
good back support.
• Support breast with one hand.
• Bring baby to breast.
• Tickle lower lip with nipple.
• Baby should open mouth wide.
• Aim nipple at roof of mouth and allow him to
draw it into his mouth. (3)
Breaking suction
• Gently insert finger into baby’s mouth beside
nipple and allow baby to open mouth widely
before removing nipple. (3)
Note: see www.llli.org for illustrations of good positioning and latch-on technique.
Non-prescription topical treatments for sore nipples
Various topical treatments are recommended for
prevention and treatment of sore nipples.
• Air drying of nipples
• Application of breastmilk to nipple after feeding
• Lanolin (Lansinoh)
• Hydrogel dressings
Studies have not shown any one treatment to be
effective. No treatment has been shown to have
harmful effects. Advising a mother to use a topical
preparation may have a placebo effect. (4)
© Health Service Executive 2008
Breastfeeding
Information for GPs and Pharmacists
Candidiasis
Predisposing factors include:
• A history of antibiotics in pregnancy,
• Mother has vaginal candidiasis,
• Baby has oral candidiasis,
• Deep breast pain suggests ductal candidiasis.
Characteristics of pain
• Usually starts after a period of painfree breastfeeding and after breastfeeding is established,
• lasts for the duration of the feed and continues
between feeds,
• shooting pain which radiates to axilla.
Note
It is important to distinguish between pain caused by
candidiasis and pain caused by poor positioning and
attachment or mastitis.
Treatments include:
• Nystatin cream/ointment (Mycostatin)
• Miconazole cream (Daktarin)
• Clotrimazole cream (Canesten)
• Oral Fluconazole for mother, especially if ductal
candidiasis is suspected
• Nystatin oral suspension or Miconazole oral gel
for the baby. (Manufacturers of Miconazole gel
do not recommend its use before four months of
age because of the risk of choking.)
General advice for the mother
• Apply creams or ointments after each feed and
wipe off any excess before offering the baby the
breast.
• Avoid plastic backed breast pads.
Ankyloglossia (tongue-tie) (7)
What is tongue tie?
The frenulum is unusually thick, tight or short. This
prevents the baby from extending the tongue over
the lower lip and gum ridge and leads to feeding
problems.
Diagnosis: diagnosis should rest on observation and
analysis of feeding difficulties, rather than static appearance of the tongue.
Incidence: possibly 3-4% of neonates but true incidence unknown.
Symptoms attributed to tongue tie
• Nipple pain and trauma
• Attachment difficulties
• Frequent feeding
• Inco-ordinate sucking
• Premature termination of breastfeeding
• Poor weight gain
• Hypernatraemic dehydration
Treatment
Feeding difficulties caused by tongue tie may improve without surgical intervention.
Nipple pain
© Health Service Executive 2008
Breastfeeding
Information for GPs and Pharmacists
A mother can be taught to use different feeding
positions to maximise attachment which encourages
the frenulum to stretch. Failure to thrive or persitent
nipple pain may require further intervention such as:
• Timely frenulotomy and breastfeeding counselling.
• Frenulotomy is a low risk procedure when carried
out by a trained professional
Bacterial infection (8)
The commonest organism causing infection of the
nipple is Staph Aureus.
Diagnosis
• Nipple abrasions which are slow to heal despite
improved breastfeeding technique
• Crusted nipples which ooze a yellow fluid.
Treatment: Mupirocin ointment (Bactroban) is a safe
and effective treatment. It should be applied four
times daily.
Vasospasm of the nipple (9, 10)
Diagnosis
• Suspect if severe episodic breast and nipple pain.
• May be accompanied by pallor of the nipple.
• Mother may have a history of similar pain in pregnancy or when exposed to cold conditions.
• Mother may describe tri-phasic colour changes in
the nipple.
• May be confused with fungal infection.
Treatment
• Nifedipine 30-60mgs daily in a sustained release
preparation is a safe, effective treatment. (7, 9, 10)
Nipple pain
Summary: management of sore nipples
• Take history of onset, duration and type of pain.
• Inspect nipple for trauma, erythema, dryness, crusting or oozing.
• Address positioning and latch-on problems.
• Consider referral to lactation consultant if latch-on
problems persist.
• Enquire as to predisposing factors for candidiasis.
• Inspect baby for anatomical oral variations that may
contribute to pain.
• If open wound or discharge visible send swab for
culture and sensitivity.
• Consider empirical treatment with topical antibiotic
and/or antifungal cream/ointment.
• If accompanied by deep breast pain consider oral
treatment for candidiasis.
• Consider vasospasm of nipple if severe, episodic
nipple pain accompanied by colour changes.
References
1. Gail K. Prachniak. Common Breastfeeding problems. Obstetrics and Gynaecology Clinincs of North
America. 29. No. 1. March 2002.
2. Woolridge MW. Breastfeeding: physiology into
practice. In: Davis DP (ed). Nutrition in Child Health.
London: Royal College of Physicians, 1995.
3. UNICEF Teaching breastfeeding skills. DVD. Available from HPA for Northern Ireland. [email protected]
4. Morland-Schultz K. et al. Journal of Obst., Gynae.,
and Neonatal Nursing. 34(4):428-37, 2005. Jul-Aug
5. Merewood A, Philipp B. Breastfeeding: conditions
and diseases. A reference guide. Amarillo, TX: Pharmasoft Publishing, 2001.
6. Hale T. Medications and mothers milk (Eleventh
edition). Amarillo, TX: Pharmasoft Publishing, 2004
7. Hall D et al. Tongue tie. Arch Dis Child
2005;90:1211-1215
8. Porter J et al. Treating Sore, possibly infected
nipples. J Hum Lact. 20(2), 2004
9. Anderson JE et al. Raynauds Phenomenon of the
nipple: a treatable cause of painful breastfeeding.
(Case reports Journal Article) Paediatrics. 113(4) e3604; 2004 Apr.
10. Page SM et al. Vasospasm of the nipple presenting as painful lactation. (Case Reports Journal Article)
Obstetrics and Gynaecology. 108 (3 pts) 806-8 2006
Sept.
© Health Service Executive 2008