Ouch! When breastfeeding hurts

If you’re experiencing pain in your breasts or nipples, then that is a sign that something isn’t quite right. Breastfeeding should not hurt when it is going well, but many mothers do experience pain, particularly in the early days. Pain always has a cause and, thankfully, there is usually something which can be done about it! This post will focus on nipple pain. Resources for deeper breast pain can be found here. Here I will discuss some of the causes of nipple pain, what can be done to help, and how to heal sore and cracked nipples.

What causes sore nipples?

There are lots of things which can cause sore nipples, and sometimes there are a mixture of causes. The cause of your sore nipples could be:

  • Ineffective attachment/shallow latch (most likley)
  • A forceful milk-ejection/let-down reflex
  • Friction from an ill-fitting or incorrectly positioned breastpump
  • Inappropriate/incorrect use of nipple shields
  • A milk bleb
  • Raynaud’s phenomenon or vasospasms
  • Hormonal changes caused by pregnancy, ovulation or menstruation
  • Irritation from increased saliva during teething
  • Contact dermatitis or other skin conditions such as psoriasis or eczema
  • Thrush (fungal or ‘yeast’ infection)
  • Bacterial infection
  • (very rarely) malignancy and/or Paget’s disease

Ineffective/shallow attachment

The most common cause of nipple pain is a shallow attachment (latch). Breastfeeding is a skill and it sometimes takes a little time for both you and your baby to get it right every time. For a good latch, we want baby to take a big mouthful of breast and for your nipple to go all the way to the back of their mouth where their soft palate is.

Feel the roof of your mouth, just behind your teeth, with your tongue. This area is hard and unyielding, so you can see how having your nipple repeatedly rubbing on this area and being pinched between the roof of your baby’s mouth and their tongue would be painful! When your nipple is here, your baby is unable to draw much milk from your breast and your nipples are likley to become sore and cracked.

This image shows a shallow latch. As you can see, this woman’s nipple is being pinched between her baby’s tongue and the hard roof of her mouth. Baby’s chin is not touching mum’s breast, and their mouth is not open very wide. In this position, breastfeeding will be painful for mum, and baby will not get much milk.
Image credit: Global Health Media

Now move your tongue right to the back of your mouth and feel how much softer the soft palate is. That’s where we want your nipple to go! Here, your baby’s tongue will not be pinching your nipple, but rather rhythmically compressing your breast, which will allow them to draw plenty of milk out and will not cause you any pain.

This image shows a good latch. Mum’s nipple is reaching baby’s soft palate and is not being pinched when baby feeds. Baby’s mouth is wide open, and their chin is pressing into mum’s breast. In this position, breastfeeding will be comfortable and baby will get plenty of milk.
Image credit: Global Health Media

What are the signs and symptoms?

Pain is subjective, so the pain you feel might be slightly different to what is described here. However, if your baby is not latching properly you will likley see one or more of the following:

  • Pain during feeds which does not disappear after the first few seconds
  • A stinging/pinching, often toe-curling pain
  • Nipples appearing misshapen or blanched white after feeds
  • Cracked or bleeding nipples
  • Engorgement, blocked ducts, and mastitis
  • Slow weight gain or excessive weight loss in baby

If you have been told that your latch looks fine but you are still experiencing any of these symptoms, seek a second opinion, preferably given by more specialist breastfeeding support such as a breastfeeding counsellor or an IBCLC. Painful breastfeeding is NOT normal and you do not need to suffer in silence. Even a good latch can be made better, and often all that is needed is a little tweak in technique! Find breastfeeding support here.

What causes a shallow latch?

A shallow latch may be caused by any of the following:

  • Holding baby in a position which doesn’t allow them to latch well
  • Engorgement
  • Baby not opening their mouth wide enough
  • Anatomical variances in your such as a tongue tie or high arched palate
  • Anatomical variances in yourself such as flat or inverted nipples
  • Having a premature baby or a baby with a naturally small mouth
  • Having comparatively large nipples for your baby’s mouth

What can help?

The most important thing to do if your baby is not latching on properly is to find support. It is possible to deal with this on your own, but seeking support from someone trained in assisting breastfeeding can make this much, much easier! How you deal with your baby’s latch largely depends on what is causing it, and having some face to face support can help you to find out what the problem is.

Go back to basics. There is no right or wrong way to hold your baby while breastfeeding, but it can help to experiment with different positions to help you find one which is comfortable for you and allows your baby to latch on correctly and stay latched on. Here are some common positions mothers adopt whilst breastfeeding. Have a read through this article to learn about the basics of attachment, and watch the following videos to help you learn how to achieve a deep latch with your baby:

UNICEF positioning and attachment videoh

Global Health Media attaching your baby at the breast video

If your baby is not opening their mouth wide enough, try the ‘flipple technique‘. This aims to exaggerate your baby’s latch by using your hand to tilt your nipple up towards baby’s nose, encouraging them to take as much of your areola as possible into their mouth, and then flipping your nipple into their mouth. There are lots of videos on YouTube explaining how this is done, but the most useful ones I have seen are this explanation by IBCLC Lucy Ruddle, and this one by The Milk Meg.

If your breasts are engorged with milk, try massaging them before feeds and hand expressing a little to soften your breasts slightly. Don’t worry, expressing a small amount will not cause your supply to increase. In the first few days following birth, it is common for breasts to become oedematous (swollen with fluid from increased vascular circulation) . If this is causing your engorgement, you might find reverse pressure softening helpful.

Around 10% of babies have a short or tight membrane underneath their tongue known as a ‘tongue tie’. However, tongue tie doesn’t always cause feeding issues. Many babies with tongue tie manage to feed effectively without any treatment. If your baby’s tongue tie is restricting their tongue movement, it can be divided in a quick and painless procedure called frenotomy (or frenulotomy). A tongue tie can not be diagnosed just by looking. If you think your baby may have a tongue tie, they will need to be assessed by someone trained in assessing tongue function. Have a look at the Association of Tongue Tie Practitioners website here to learn more.

If your nipples are flat or inverted, it is still possible for you to breastfeed your baby. Babies don’t ‘nipple-feed’, they ‘breastfeed’, so as long as they can get a good mouthful of breast then they should be able to breastfeed without any issues. Click here for some tips on getting a good latch with flat or inverted nipples.

Healing sore and cracked nipples

As I explained in the beginning of this article, sore and cracked nipples can have many causes. The following will help if your sore nipples are caused by an issue with your baby’s attachment, which is the cause of most sore nipples. However, it is essential to keep working on developing good attachment whilst you heal your nipples, otherwise the damage and pain will continue.

Sore nipples with no broken or blistered skin

If your nipples are feeling very sore it can be tempting to slather them with nipple cream. However, there is no evidence that this will help unless they are cracked and bleeding, and applying creams can make your nipples smell and taste slightly different and can make them slippery which may make your latch issues worse.

Research shows that the most effective treatment for sore nipples is breastmilk. Breastmilk is full of anti-infective, anti-inflamatory, and pain-relieving properties that can protect your nipples and promote healing. Expressing a little breastmilk onto your nipples and allowing it to air dry often helps. Try to go braless as much as possible expose your nipples to air. If you are using breastpads, change them frequently– do not allow them to feel damp. Breastpads which have a plastic backing can increase the risk of soreness and infection, so go for breastpads without a plastic backing if you can.

Unless you have a medical reason not to, it is safe to take Paracetamol and Ibuprofen while breastfeeding if you need to. Have a read through the Breastfeeding Network’s fact sheet on pain killers and never exceed the stated dose.

Cracked or bleeding nipples

Some cracks are very fine and hard to see so you might just notice a bit of bleeding, but you might see a crack in the skin on your nipple or where your nipple joins your areola. Breastfeeding with a cracked nipple can be very painful and cracked nipples may bleed during breastfeeds. You might see blood in your milk if you express, but don’t worry, this is not harmful to your baby.

When your nipples are cracked and bleeding, it is important to keep them clean to avoid infection. After feeds, wash your hands with soap and water and then gently clean your nipples with a saline solution (made by dissolving 1/2 tsp of salt in a full cup of water) and pat dry with a paper towel. Avoid using perfumed soaps, as this may increase your risk of developing thrush (fungal infection).

Next, apply a THIN layer of pure lanolin or soft white paraffin (vaseline). This helps the skin to retain its natural internal moisture, without making the skin wet, which prevents the formation of a scab. When a scab forms, it can then be pulled off during feeds causing further damage, so it’s something we aim to avoid where possible! This is known as moist wound healing and can reduce healing time by 50%. It also prevents the nerve endings from repeatedly drying out then becoming re-hydrated at feeds, which can significantly reduce your pain.

Between feeds, as above, go without a bra if possible and keep your nipples exposed to air as much as you can. When wearing breastpads, change them frequently.

If you’re finding it too painful to breastfeed, it’s really important to express regularly to protect your supply and reduce your chance of developing blocked ducts and mastitis. You might find it more comfortable to hand express rather than using a pump. Click here to learn more about expressing and storing milk.

If you develop any symptoms of a fungal or bacterial infection (listed below), speak to your Dr as soon as possible.

Other causes of sore nipples

Thrush (fungal or ‘yeast’ infection)

Thrush can sometimes be difficult to identify and is often wrongly diagnosed. If you suspect thrush, it is recommended that your Dr confirms this with a swab test before prescribing treatment, to reduce your exposure to unnecessary treatment.

If you have thrush, you will probably experience an intense burning or shooting pain in BOTH nipples, which may or may not radiate deeper within your breast. The pain tends to become worse immediately after a feed and can remain intense for up to an hour after each feed. The skin on your nipples may look normal, or it may be shiny or flaky. If you are white or fair skinned, your nipples may be redder than usual. If you are a woman of colour, you may notice some loss of colour in your areola.

Nipple thrush is almost always present in both nipples and in your baby’s mouth. If your baby has oral thrush you may notice white patches on their tongue, lips, gums or the inside of their cheeks. The fungus which causes thrush (candida albicans) can survive the digestive tract, so some babies will also develop a distinctive nappy rash which is bright red and formed of small bumps or pustules and does not improve with normal treatment.

If you or your baby have symptoms of thrush, visit your GP. Treatment usually consists of a course of miconazole oral gel or nystatin oral suspension for your baby and miconazole cream for your nipples (and their bottom if needs be). It is very important that both you and your baby are treated at the same time, or you will just repeatedly pass the infection back and forth.

During a bout of thrush it is usually recomended to use disposable breastpads which do not have a plastic backing if possible, to wash your bras and your baby’s clothes at a high temperature, and to use a separate towel for each member of the family.

More information on thrush can be found here.

Bacterial infection

A bacterial infection is usually caused by bacteria entering broken skin in your nipple. Symptoms are often confused for thrush, but thrush treatment will not be effective.

Symptoms include intense pain in your nipples coupled by signs of inflammation such as red, tight skin. There may also be swelling or a discharge of puss. You may also develop systematic symptoms such as a fever and malaise. If you notice any of these symptoms, see your GP as soon as you can.

Forceful milk-ejection/let-down reflex

When your baby suckles at your breast, your brain releases oxytocin which causes the little sacs of milk inside your breasts to contract, pushing milk down your ducts and out through your nipple (see ‘How Your Breasts Work for more info). This is known as your milk ejection reflex, or let down reflex. Sometimes, this reflex can be quite forceful which may cause you to feel a stinging or tightening pain in your nipples and breasts. The pain lasts for less than a minute and is coupled with a rapid increase in milk flow. Your baby may cough and splutter and pull themselves off your breast, sending your milk flying accross the room and all over their face! Pain from a forceful let down usually improves as your baby gets older. It may help to feed your baby more frequently, and to recline while feeding so that gravity helps to reduce the force at which your milk comes out.

Milk Blebs

A milk bleb is a blocked nipple pore and appears as a small white spot on the nipple. They are usually painful, and often more so during feeds. They occur when a tiny bit of skin grows over an opening in your nipple, and milk builds up behind it causing a blockage.

To treat a milk bleb, apply moist heat such as a flannel or disposable nappy soaked in ho water, remove the skin covering the duct using either a sterile needle or a freshly cleaned flannel, then express or feed your baby. See here for a more detailed explanation.

A milk bleb
Image credit: More Than Milk

Incorrect use of breast pumps and nipple shields

If you use a breast pump to express milk, it is important to make sure that you are using the correct sized flange and that you are using your pump correctly to avoid friction to your nipples, which may cause cracks or blisters. Click here to learn more about expressing and storing breastmik.

A nipple shield is a flexible silicone or rubber shield worn over your nipple during feeds. They are not a cure for a shallow latch and can often cause more problems than they solve, but they can be useful as a short-term measure whilst you seek support and work on improving your baby’s latch, particularly for babies awaiting a tongue-tie division or for mums with inverted nipples or extensive nipple trauma. Nipple shields may offer your nipples some protection from damage and give your baby more to latch on to. However, it’s important to know that nipple shields are linked to low supply. When using a nipple shield, your baby may not be stimulating your nipples in the same way they would without a shield. If the nipple shield is preventing your baby from getting enough milk and reducing the nipple stimulation you receive, this can reduce your supply and could increase your risk of developing blocked ducts and mastitis. When they are used incorrectly, they can cause further nipple damage. It is therefore helpful for you to have regular face-to-face breastfeeding support if this is possible. If you use nipple shields, it is important to learn how to tell if your baby is getting enough milk and to protect your supply by expressing regularly if they’re not. There are many different types of nipple shields available. Some are made from rubber, while others are made from silicone. Rubber nipple shields tend to have a greater effect on milk transfer, so silicone shields are preferable. Some nipple shields have a cut out which allows your baby to have more skin-to-skin contact during feeds. If you think you need to use nipple shields, speak to someone trained in breastfeeding support first. Here are some ways you can find support.

Nipple shields
Image credit: Kelly Bonyata IBCLC

Contact dermatitis or other skin conditions

Sore nipples can sometimes be caused by a skin reaction to something which is coming into contact with your breasts, such as:

  • Nipple creams containing lanolin, chamomile, beeswax or vitamins A and E
  • Bath/shower products, perfumes and laundry detergent
  • Breast pads
  • Oral medications taken by your baby before feeds
  • Solid foods/other fluids consumed by your baby before feeds

Other skin conditions, such as exzema or psoriasis, can also affect your nipples. Contact your Dr for treatment if you are experiencing any skin conditions.

Raynaud’s phenomenon

Raynaud’s phenomen causes vasospasms (restriction of blood vessels under the skin) in certain parts of the body, particularly in response to cold. Raynaud’s usually affects the fingers and toes, causing them to turn purple/white and become painful or numb. When Raynaud’s affects the nipples, it can make breastfeeding very painful. Nipples will blanch white/purple and become intensely painful during feeds, and will stay sore and blanched for some time after feeds.

Raynaud’s is uncommon. Blanching of the nipples is more often caused by baby having a shallow latch and pinching the nipple between their tongue and the hard roof of their mouth. With Raynaud’s, the blanching will usually occur at other times in addition to feeds, such as when you are out in the cold or your nipples become wet in the shower or damp from leaking milk. Also, unlike a shallow attachment, raynaud’s will not cause your nipples to change shape after feeds. Information on how to manage raynaud’s whilst breastfeeding can be found here.

References

Berens P, et al. ABM Clinical Protocol #26: Persistent Pain with Breastfeeding. Association of Breastfeeding Medicine. 2016 Mar;11(2):46-53. doi: 10.1089/bfm.2016.29002.pjb. Epub 2016 Feb 16

NICE guidelines: Breastfeeding problems, May 2017

Dennis  CL, Jackson  K, Watson  J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007366. DOI: 10.1002/14651858.CD007366.pub2.

Phyll Bunchanan, Anabel Hands and Wendy Jones, Assessing the Evidence: Cracked Nipples and Moist Wound Healing, The Breastfeeding Network, 2002

Raynaud’s Phenomenon in breastfeeding mothers, Wendy Jones and the Breastfeeding Network January 2015

Cancer research UK: Paget’s disease of the nipple

Resources

Find breastfeeding support

Boobie Babies on Facebook

Breastfeeding Guidance and Support UK


The information on this page should not be used in place of medical advice. Information found online should always be discussed with your own IBCLC, Dr or Midwife to ensure it is appropriate for you and your baby’s situation. Contact your Dr, Midwife or Health Visitor with any concerns about your own or your baby’s health and welfare.

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