Nipple Care
What does your nipple look like after the breastfeeding session? Is it flattened, misshapen like a new lipstick, or red and irritated? If your baby was latched well, it should look about the same coming out as it did going in: round and maybe a little elongated.
Nipple tenderness is common from the pulling and stretching during the first days, but pain or damage means something is wrong. Inspect your nipple for abrasions, bruises, scabs, or cracks.
You can use your phone camera to look at your nipple from the underside. If there is any irritation or damage, or if you have experienced nipple pain during the feeding, it’s important to treat it early to prevent nipple trauma, which can be painful and compromise breastfeeding.
Sore nipples are one of the top reasons mothers stop breastfeeding, and you and your baby deserve pain-free feeding. Prevention is always better than correction after the fact.
Want to learn more about this topic and get valuable tips on breastfeeding your baby while ensuring adequate feeding?
Dr. Christie and board-certified lactation consultant Lynnette Hafken have just released the online Fed Is Best Breastfeeding Course, where they discuss all the things that you will not hear from a breastfeeding book or class. In it they include secret tips and tricks that you normally have to pay hundreds of dollars to learn about, for the same cost of a hospital breastfeeding class. Click below to get in on the training!
Sore Nipples without Cracks or Bleeding
Approximately 80% of mothers experience nipple pain. The most common causes are problems with positioning and latch, tongue tie, infection, differences in infant palate anatomy, flat or inverted nipples, and vasospasm (contraction of the blood supply to the nipples).
Because there are so many potential causes, and because every person has their own tolerance level for discomfort or pain, no one should tell you that “if you are doing it right, breastfeeding will not hurt.” Your pain should always be taken seriously and investigated.
The first step is to minimize further nipple pain and trauma by reducing or removing the cause. The most common reasons are suboptimal breastfeeding latch and positioning. Therefore, it is important to get professional help to optimize them.
Sometimes variations in a baby’s oral anatomy can cause nipple pain and trauma; an IBCLC or CLC can help.
Begin breastfeeding on the least sore nipple first, as the latch-on is the most powerful when the baby is very hungry. It’s important to inspect your nipples after each feeding to be sure there is no damage.
Pain relievers after delivery may mask the beginning of sore nipples, which can quickly worsen if not addressed in a timely manner.
If latch and positioning are correct, friction may have led to mild skin breakdown or abrasion. Applying a nipple ointment before and after breastfeeding may lessen this friction and heal abrasions. Nipple ointments also provide a moist environment that can reduce scab formation and improve wound healing.
Hydrogel pads are soothing and provide moisture for healing as well. Warm water or saline compresses on painful or mildly abraded nipples have also been shown to reduce pain and promote circulation and wound healing. Some have recommended expressed mother’s milk to help with nipple pain and abrasions, but most studies show it does not provide equivalent outcomes to nipple ointments, warm compresses, or hydrogel pads.
Unfortunately, studies on treating sore nipples have conflicting results. No single treatment agent has been shown to be clearly superior to others, so it may require some trial and error to find the right treatment for you. If nipple pain or tissue damage continues despite these remedies, talk with your health professionals about the best course of action to prevent further damage.
Note to mobile users: The following is best viewed in landscape or horizontal mode.
| Good Latch | Poor Latch |
|---|---|
| Round and slightly elongated | Flattened, misshapen like a new lipstick |
| Skin is your normal color | Reddened and irritated or pale/blanched |
| Tenderness with initial latching | Painful during latch or feeding session |
| Healthy, intact skin | Abrasions, bruising, blisters, or cracks |
| Pain free in between feedings | Pain occurs during and after nursing |
Cracked, Scabbed, and Severely Abraded Nipples
Broken skin can put the nipple at risk for bacterial and yeast infections, so cracked nipples should be kept clean. If there are signs of infection like redness, swelling, pain or discharge, make sure to seek physician evaluation and treatment as soon as possible.
Warm water soaks four times a day can help soften crusty scabs and improve blood flow and wound healing. Do not forcibly remove any scabs that have formed as they are there to protect the healing skin underneath; doing so will only prolong the healing process. If they come off during feeding, it will not harm your baby.
Once a day you may cleanse your damaged nipples with a very mild non -antibacterial cleanser; make sure they are rinsed thoroughly. Keeping a nipple wound clean reduces bacteria and lowers the risk of infection. Remember that healthy non-damaged nipples do not require cleansing.
Nipple fissures, which are deeper wounds, may benefit from lanolin nipple ointment or nipple shields. Lanolin provides a permeable, moist barrier that promotes wound healing. If a fissure develops, apply a thin coat of ointment to the nipple, which does not have to be removed before nursing.
Lanolin is made from sheep’s wool so do not use it if you have a wool allergy. Lanolin can reduce friction, while nipple shields can protect fragile healing skin during breastfeeding sessions.
A prescription topical or oral antibacterial and/or antifungal medication from your doctor may be necessary if infection is evident. Sometimes, thrush (a yeast infection that looks like white dots in your baby’s mouth) can cause a painful overgrowth of yeast on the nipple; this can require treatment of both mother and baby.
A pediatrician can also evaluate for tongue tie, a condition where a piece of tissue called the frenulum keeps the tongue from moving appropriately, leading to poor latch, nipple pain and trauma; this can be referred for correction.
While these remedies can often correct the problem, sometimes temporary cessation of direct nursing is needed to allow for adequate wound healing. Manual expression and/or breast pumping can be done temporarily.
Unfortunately, breast pumping can sometimes perpetuate nipple trauma, so you will have to experiment with different pump settings and flange sizes to reduce further skin trauma. While hydrogels can be beneficial for sore or irritated nipples, we do not recommend them for fissured nipples; in our experience, they can increase the risk of infection, though the research on this is unclear. Nipple fissures often require ongoing monitoring and treatment by your doctor.
In some cases, the reason for the nipple soreness cannot be identified. While nipple pain is often a sign of incorrect latch, sometimes, even with optimization of latch and position, it will continue to hurt. Regardless of what happens or why, for most women, the pain should go away after a few weeks, and you can begin to relax and enjoy breastfeeding.
| Nipple Pain Without Skin Breakdown | Nipple Abrasions, Fissures, Infections |
|---|---|
| Correction of latch and position | Warm water soaks 4 times a day |
| Breastfeed on least sore nipple first | Clean with mild non-antibacterial soap and water once daily |
| Lanolin nipple ointment for pain | Lanolin nipple ointment during and in between feedings |
| Hydrogel pads | Antibacterial/antifungal ointment or medications for infections |
| Warm water compresses | Antifungal treatment of baby for oral thrush |
| Diagnosis and treatment of oral anomalies (e.g., tongue tie) | Diagnosis and treatment for oral anomalies |
| Nipple shields for nursing sessions if pain is uncorrectable | Temporary cessation of direct nursing; bottle feeding of pumped milk |
| Nipple shields |
Nipple Variations
Nipple shields are primarily used for flat or inverted nipples that can impair optimal latch, but they can also be used for nipple pain that has not responded to adjustments in the baby’s latch. You may consider using a nipple shield if your baby is unable to latch effectively or if it causes you pain.
Nipple shields often get a bad rap in some circles, due to a belief that they can reduce milk transfer and mother–baby skin contact, thus potentially reducing milk production. However, a recent comprehensive review shows they are quite helpful when needed, and mothers who use them often credit them with saving their ability to breastfeed long term.
Concerns about milk transfer are primarily associated with older, thicker shields that are no longer sold, and there is no evidence that reduced nipple skin contact has a deleterious effect. They are also used for babies with dysfunctional sucking patterns, different oral anatomy (such as high palates), or tongue ties (until a revision is performed).
Babies born before 38 weeks may benefit from using a nipple shield as well. Mothers typically use nipple shields for a few weeks to months, but they can be used as long as necessary.
It is important to have weekly infant weight monitoring and professional lactation follow-up when using this tool; a weighted feed can ensure your baby is transferring sufficient milk. Sometimes, temporary pumping after nursing is necessary to completely empty the breast if your baby is not transferring effectively.
It is important that difficulties with latch due to nipple variations, nipple pain, or infant oral anatomy are diagnosed as early as possible. If nipple pain or a problem with latch can be corrected with a nipple shield, it is better to get the baby latched by any means necessary to optimize milk intake and breast stimulation while preserving nipple integrity.
Ask to see an IBCLC while at the hospital to help you with your latch, as they have a wealth of knowledge about latching and positioning. If an LC is not available, your nurse may be able to help you.
Expert Tip: Taking Video of Latch Consultation
Have your partner or support person take a video of the positioning and latching process during your lactation consultation so you can refer to it at any time.
Want to learn more about this topic and get valuable tips on breastfeeding your baby while ensuring adequate feeding?
Dr. Christie and board-certified lactation consultant Lynnette Hafken have just released the online Fed Is Best Breastfeeding Course, where they discuss all the things that you will not hear from a breastfeeding book or class. In it they include secret tips and tricks that you normally have to pay hundreds of dollars to learn about, for the same cost of a hospital breastfeeding class. Click below to get in on the training!
To learn more about this topic, read the Fed Is Best book available on paperback, e-book, and audiobook.
References
- Niazi et al., “A Systematic Review on Prevention and Treatment of Nipple Pain and Fissure: Are They Curable?,” 21, no. 3 (September 2018): 139–50, https://doi.org/10.3831/KPI.2018.21.017.
- Kent et al., “Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments,” International Journal of Environmental Research and Public Health 12, no. 10 (September 29, 2015): 12247–63, https://doi.org/10.3390/ijerph121012247.
- Junker et al., “Clinical Impact Upon Wound Healing and Inflammation in Moist, Wet, and Dry Environments,” Advances in Wound Care 2, no. 7 (September 2013): 348–56, https://doi.org/10.1089/wound.2012.0412.
- Walker, M. “Are There Any Cures for Sore Nipples?,” Clinical Lactation 4, no. 3 (August 2013): 106–15, https://doi.org/10.1891/2158-0782.4.3.106.
- Morland-Schultz K, Hill PD. Prevention of and therapies for nipple pain: a systematic review. J Obstet Gynecol Neonatal Nurs. 2005 Jul–Aug; 34(4):428–37, https://doi.org/10.1177/0884217505276056.
- Marsha Walker, “Are There Any Cures for Sore Nipples?,” Clinical Lactation 4, no. 3 (August 2013): 106–15, https://doi.org/10.1891/2158-0782.4.3.106.
- M. Abou-Dakn et al., “Positive Effect of HPA Lanolin versus Expressed Breastmilk on Painful and Damaged Nipples during Lactation,” Skin Pharmacology and Physiology 24, no. 1 (2011): 27–35, https://doi.org/10.1159/000318228.
- Brent N, Rudy SJ, Redd B, Rudy TE, Roth LA. Sore nipples in breast-feeding women: a clinical trial of wound dressings vs conventional care. Arch Pediatr Adolesc Med. 1998;152(11):1077–1082. doi:10.1001/archpedi.152.11.1077
- Dodd, Victoria et al. Comparing the Use of Hydrogel Dressings to Lanolin Ointment With Lactating Mothers. Journal of Obstetric, Gynecologic & Neonatal Nursing, Volume 32, Issue 4, 486–494, https://doi.org/10.1177/0884217503255098.
- Chow, Selina, et al., “The use of nipple shields: a review.” Frontiers in Public Health 01 (November 2016). https://doi.org/10.3389/fpubh.2015.00236