Introduction
The best treatment of sore nipples is prevention.
The best prevention is getting the baby to latch on
properly from the first day.
Sore nipples are usually due to one or both of two
causes. Either
the baby is not positioned and latched properly, or the baby is
not suckling properly, or both.
However, babies learn to suck properly by getting
milk from the breast when they are latched on well.
(They learn by doing).
Thus, “suck” problems are often caused by poor
latching on. Fungal
infection (due to Candida
albicans) may also cause sore nipples.
The soreness caused by poor latching and ineffective
suckling hurts most as you latch the baby on and usually
improves as the baby nurses. The pain from the fungal infection
goes on throughout the feed and may continue even after the feed
is over. Women
describe knifelike pain from the first two causes.
The pain of the fungal infection is often described as
burning, but may not have this character.
A new onset of
nipple pain when feedings had previously been painless is a tip
off that the pain may be due to a yeast infection, but the pain
may be superimposed on pain due to other causes.
Cracks may be
due to a yeast infection. Dermatologic
conditions may also cause late onset nipple pain.
There are several other causes of sore nipples.
Proper
positioning and latching (see
also the handout A: When
Latching)
It is not uncommon for women to experience difficulty
positioning and latching the baby on.
Proper positioning facilitates a good latch and good
latching reduces the baby's chances of becoming
"gassy", and also allows the baby to control the flow
of milk. Thus, poor latching may also result in the baby not gaining
adequately, or feeding frequently, or being colicky (handout #2 "Colic
in the Breastfed Baby).
See also videos
that show how to latch a baby on, how to know a baby is getting
milk and how to use compression.
Positioning—For
the purposes of explanation, let us assume that you are feeding
on the left breast.
Good
positioning facilitates a good latch.
A lot of what follows under latching comes automatically
if the baby is well positioned in the first place.
At
first, it may be easiest to use the cross
cradle hold to position your baby for latching on.
Hold the baby in your right arm, pushing in the baby’s
bottom with the side of your forearm so that your hand
turns palm upwards. This
will help you support his body more easily, and also bring the
baby in from the correct direction so that he gets a good latch. Your hand will be palm up under the baby’s face (not
shoulder or under his neck).
The web between your thumb and index finger should be behind
the nape of his neck (not behind his head). The baby will be almost horizontal across your body, with his
head slight tilted backward, and should be turned so that his
chest, belly and thighs are against you with
a slight tilt so the baby can look at you.
Hold the breast with your left hand, with the thumb on
top and the other fingers underneath, fairly far back from the
nipple and areola.
The
baby should be approaching the breast with the head
just slightly tilted backwards.
The nipple then automatically points to the roof of the
baby's mouth. (See
handout When Latching and the videos
)
Latching
1.
Now, get the baby to open up his mouth wide.
The way to do this is to run your nipple, still
pointing to the roof of the baby's mouth, along the baby's upper
lip (not lower), lightly,
from one corner of the mouth to the other.
Or you can run the baby along your nipple, something some
mothers find easier. Wait for the baby to open
up as if yawning. As
you bring the baby toward the breast, his chin
should touch your breast first.
Do not scoop him around so that the nipple points to the
middle of his mouth, but rather to the roof of his mouth.
2.
When the baby opens up his mouth, use the arm that is holding
him to bring him straight onto the breast.
Don't worry about the baby's breathing.
If he is properly positioned and latched on, he will
breathe without any problem.
If he cannot breathe, he will pull away from the breast. Don't be afraid to be vigorous.
3.
If the nipple still hurts, use your index finger to pull down on
the baby's chin in order to bring the lower lip out.
You may have to do this for the duration of the feed, but
this is usually not necessary.
The
pain will usually subside.
Do not take the baby on and off the breast several times
to get the perfect latch. If
the baby goes on and off the breast 5 times and it hurts, you
will have 5 times more pain, and worse, 5 times more damage.
Fix the latch when putting him to the other breast, or at
the next feeding.
4.
The same principles apply whether you are sitting or lying down
with the baby or using the football hold.
Get the baby to open wide; don't let the baby latch onto
the nipple, but get as much of the areola (brown part of breast)
into the mouth as possible (not necessarily the whole areola).
5.
There is no "normal" length of feeding time.
If you have questions, call the clinic.
6.
A baby properly latched
on will be covering more of the areola with his lower lip than
with the upper lip.
Improving
the baby's suckle
The baby learns to suckle properly by nursing and by
getting milk into his mouth.
The baby's suckle may be made ineffective or not
appropriate for breastfeeding by the early use of artificial
nipples or from poor latching on from the beginning.
Some babies just seem to take their time developing an
effective suckle. Suck
training and/or finger feeding (handout #8 Finger
Feeding) may help, but note, taking the baby off the breast
to finger feed instead is not a good idea and should be done as
a last resort only.
"My
nipple turns white after the baby comes off the breast"
The pain associated with this blanching of the nipple is
frequently described by mothers as "burning", but
generally begins only after the feeding is over.
It may last several minutes or more, after which the
nipple returns to its normal colour, but then a new pain
develops which is usually described by mothers as
"throbbing". The
throbbing part of the pain may last for seconds or minutes and
may even blanch again. The
cause would seem to be a spasm of the blood vessels (often
called “vasospasm” or Raynaud’s Phenomenon) in the nipple
(when the nipple is white), followed by relaxation of these
blood vessels (when the nipple returns to its normal colour).
Sometimes this pain continues even after the nipple pain
during the feeding no longer is a problem, so that the mother
has pain only after the feeding, but not during it. What can be
done?
1.
Pay careful attention to getting the baby to latch onto the
breast properly. This
type of pain is almost always associated with and probably
caused by whatever is causing your pain during the feeding.
The best treatment for this vasospasm is the treatment of
the other causes of nipple pain.
If the main cause of the nipple pain is fixed, the
vasospasm also disappears.
2.
Heat (hot washcloth, hot water bottle, hair dryer) applied to
the nipple immediately after nursing may prevent or decrease the
reaction. Dry heat
is usually better than wet heat, because wet heat may cause
further damage to the nipples.
3.
On occasion, we have had to use an oral medication (nifedipine)
to prevent this type of reaction. Vitamin B6 can also be used
(see handout #3b Treatments
for Sore Nipples and Sore Breasts)
General
measures
l.
Nipples can be warmed for short periods of time after each
feeding, using a hair dryer on low setting.
2.
Nipples should be exposed to air as much as possible.
3.
When it is not possible to expose nipples to air, plastic
dome-shaped breast shells (not
nipple shields) can be worn to protect your nipples from rubbing
by your clothing. Nursing
pads keep moisture against the nipple and may cause damage that
way. They also tend
to stick to damaged nipples. If you leak a lot you can wear the
pad over the breast shell.
4.
Ointments can sometimes be helpful.
If you do use an ointment, use just a very small amount after nursing and do not
wash it off. (see handout #3bTreatments
for Sore Nipples and Sore Breasts.)
5.
Do not wash your nipples frequently.
Daily bathing is more than enough.
6.
If your baby is gaining weight well, there is no good reason the
baby must be fed on
both breasts at each feeding.
It may save you pain, and speed healing if you feed your
baby on only one breast each feed.
It will help to compress the breast (handout #15 Breast
Compression), once the baby is no longer swallowing on his
own in order to continue his getting milk.
You may be able to manage this some feedings, but not
others. In very
difficult situations, a lactation aid (handout #5 Using a
Lactation Aid) can be used to supplement (preferably
expressed milk), so that the baby will
finish the feeding on the first side.
If you are unable to put the baby to the breast because
of pain, in spite of trying all the above measures, it may still
be possible to continue breastfeeding after a temporary (3-5
days) cessation to allow the nipples to heal.
During this time, it would be better that the baby not be fed with a rubber nipple.
Of course it is also best for you and the baby if the
baby is fed your expressed milk.
Use the technique called "finger feeding" (handout #8 Finger Feeding) or cup feeding.
This is a last resort and taking a baby off the breast
should not be taken lightly.
Furthermore, it often doesn’t work.
Nipples shields are not recommended for sore nipples,
because, although they may help temporarily, they usually do not, or they seem to
help only. They may
also cut down the milk supply dramatically, and the baby may
become fussy and not gain weight well.
Once the baby is used to them, it may be impossible to
get the baby back onto the breast. In fact, many women
who have tried nipple shields find that they do not help with
soreness. Use as a
last resort only, but get
help first.
Questions?
(416)
813-5757 (option 3) or
drjacknewman@sympatico.ca or
my book Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate
Breastfeeding Book of Answers in
the USA)
Handout
#3a. Sore Nipples.
Revised January 2005
Written by Jack Newman, MD, FRCPC. © 2005
This
handout may be copied and distributed without further
permission,
on the condition that it
is not used in any context in which the WHO code on the
marketing of breastmilk substitutes is violated.
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