1. Breastfeeding
Information for GPs and Pharmacists
FACTSHEET
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 • If any of the areola is visible it is mainly under the
• Incorrect positioning and attachment of the baby bottom lip.
to the breast • The baby sucks and swallows in rhythmic pattern.
• Disorganised or dysfunctional suckling • The process is not painful for the mother. (3)
• Incorrect use of breast pump
• Bacterial infection of nipple Putting baby to the breast
• Candidiasis of nipple/breast • Ensure mother is in a comfortable position with
• Tongue tie (ankyloglossia) good back support.
• Vasospasm of nipple • Support breast with one hand.
• Bring baby to breast.
Positioning and attachment • Tickle lower lip with nipple.
Effective attachment of the baby to the breast is • Baby should open mouth wide.
necessary to: • Aim nipple at roof of mouth and allow him to
• prevent nipple damage and pain, draw it into his mouth. (3)
• facilitate removal of milk from the breast,
• maintain an adequate milk supply. (2) Breaking suction
• Gently insert finger into baby’s mouth beside
The four principles of correct positioning nipple and allow baby to open mouth widely
1. Baby is held close to the mother and facing her before removing nipple. (3)
breast.
2. Baby’s head and body are in alignment allowing Note: see www.llli.org for illustrations of good posi-
the baby freedom to tilt his head backwards. tioning and latch-on technique.
3. Baby is held with his nose or top lip at the level
of the nipple – this allows the baby to open Non-prescription topical treatments for sore nipples
his mouth wide and grasp a good mouthful of Various topical treatments are recommended for
breast. prevention and treatment of sore nipples.
4. Ensure the mother has good back and arm sup- • Air drying of nipples
port to sustain the position. (3) • Application of breastmilk to nipple after feeding
• Lanolin (Lansinoh)
• Hydrogel dressings
Signs of effective positioning and attachment
• Baby’s chin is in contact with the breast, leaving Studies have not shown any one treatment to be
his nose free to breathe. effective. No treatment has been shown to have
• Baby’s mouth is open wide. harmful effects. Advising a mother to use a topical
• His bottom lip is curled outwards. preparation may have a placebo effect. (4)
• His cheeks are full and rounded.
Nipple pain © Health Service Executive 2008

2. Breastfeeding
Information for GPs and Pharmacists
Candidiasis
Predisposing factors include: Ductal candidiasis
• A history of antibiotics in pregnancy, • Suspect if deep shooting breast pain radiating to
• Mother has vaginal candidiasis, axilla.
• Baby has oral candidiasis, • Clinical examination may be normal.
• Deep breast pain suggests ductal candidiasis. • Symptoms can be slow to resolve.
• Treat with Fluconazole 200-400mgs stat followed
Characteristics of pain by 100-200mgs daily depending on severity of
• Usually starts after a period of painfree breast- symptoms.
feeding and after breastfeeding is established, • Minimum of 2-3 weeks is needed to clear infec-
• lasts for the duration of the feed and continues tion.
between feeds, • For recurrent ductal candidiasis, Fluconazole
• shooting pain which radiates to axilla. 150mgs once weekly can be used prophylacti-
cally. (6)
Note
It is important to distinguish between pain caused by General advice for the mother
candidiasis and pain caused by poor positioning and • Apply creams or ointments after each feed and
attachment or mastitis. 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 ap-
pearance of the tongue.
Incidence: possibly 3-4% of neonates but true inci-
dence unknown.
Symptoms attributed to tongue tie
• Nipple pain and trauma
Treatments include: • Attachment difficulties
• Nystatin cream/ointment (Mycostatin) • Frequent feeding
• Miconazole cream (Daktarin) • Inco-ordinate sucking
• Clotrimazole cream (Canesten) • Premature termination of breastfeeding
• Oral Fluconazole for mother, especially if ductal • Poor weight gain
candidiasis is suspected • Hypernatraemic dehydration
• Nystatin oral suspension or Miconazole oral gel
for the baby. (Manufacturers of Miconazole gel Treatment
do not recommend its use before four months of Feeding difficulties caused by tongue tie may im-
age because of the risk of choking.) prove without surgical intervention.
Nipple pain © Health Service Executive 2008

3. Breastfeeding
Information for GPs and Pharmacists
A mother can be taught to use different feeding Summary: management of sore nipples
positions to maximise attachment which encourages • Take history of onset, duration and type of pain.
the frenulum to stretch. Failure to thrive or persitent • Inspect nipple for trauma, erythema, dryness, crust-
nipple pain may require further intervention such as: ing or oozing.
• Timely frenulotomy and breastfeeding counsel- • Address positioning and latch-on problems.
ling. • Consider referral to lactation consultant if latch-on
• Frenulotomy is a low risk procedure when carried problems persist.
out by a trained professional • 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 prob-
Bacterial infection (8) lems. Obstetrics and Gynaecology Clinincs of North
The commonest organism causing infection of the America. 29. No. 1. March 2002.
nipple is Staph Aureus. 2. Woolridge MW. Breastfeeding: physiology into
practice. In: Davis DP (ed). Nutrition in Child Health.
Diagnosis London: Royal College of Physicians, 1995.
• Nipple abrasions which are slow to heal despite 3. UNICEF Teaching breastfeeding skills. DVD. Avail-
improved breastfeeding technique able from HPA for Northern Ireland. info@hpani.org.uk
• Crusted nipples which ooze a yellow fluid. 4. Morland-Schultz K. et al. Journal of Obst., Gynae.,
and Neonatal Nursing. 34(4):428-37, 2005. Jul-Aug
Treatment: Mupirocin ointment (Bactroban) is a safe 5. Merewood A, Philipp B. Breastfeeding: conditions
and effective treatment. It should be applied four and diseases. A reference guide. Amarillo, TX: Phar-
times daily. masoft Publishing, 2001.
6. Hale T. Medications and mothers milk (Eleventh
Vasospasm of the nipple (9, 10) edition). Amarillo, TX: Pharmasoft Publishing, 2004
Diagnosis 7. Hall D et al. Tongue tie. Arch Dis Child
• Suspect if severe episodic breast and nipple pain. 2005;90:1211-1215
• May be accompanied by pallor of the nipple. 8. Porter J et al. Treating Sore, possibly infected
• Mother may have a history of similar pain in preg- nipples. J Hum Lact. 20(2), 2004
nancy or when exposed to cold conditions. 9. Anderson JE et al. Raynauds Phenomenon of the
• Mother may describe tri-phasic colour changes in nipple: a treatable cause of painful breastfeeding.
the nipple. (Case reports Journal Article) Paediatrics. 113(4) e360-
• May be confused with fungal infection. 4; 2004 Apr.
10. Page SM et al. Vasospasm of the nipple present-
Treatment ing as painful lactation. (Case Reports Journal Article)
• Nifedipine 30-60mgs daily in a sustained release Obstetrics and Gynaecology. 108 (3 pts) 806-8 2006
preparation is a safe, effective treatment. (7, 9, 10) Sept.
Nipple pain © Health Service Executive 2008