Navigating Sore Nipples & When to Seek Professional Lactation Care

Breastfeeding is an excellent way to feed your baby and provides many benefits for both the infant and the breastfeeding parent. For most parents, breastfeeding goes very smoothly. Others experience some challenges. Sore nipples are one of the most common concerns reported by new breastfeeding parents. It is helpful to consider the timing and other associated symptoms to determine the most probable cause.

Incorrect Latch

An incorrect latch most often causes sore nipples in the early days to weeks of breastfeeding. For babies to nurse effectively at the breast, how they are latched on or attached to the breast is essential. An improper latch can result in the inadequate transfer of milk from the mother to the baby and cause nipple pain for the mother.

Before latching the baby, the mother should be comfortably seated or lying, with her shoulders or arms supported. Babies can be positioned in a variety of ways. The mother holds the breast between the thumb and fingers to present the breast to the baby. When latching the baby, the mother should pull the baby in closely, touching the baby’s chin to the mother’s breast. The sensation of touching the breast will often cause the baby to open the mouth wide, allowing the baby to take enough of the breast in the mouth to latch well. The baby may also open the mouth if the nipple touches the lower lip.

A baby latched on well to the breast will have the lower jaw close to the breast, with a slight gap between the nose and the breast. There will be slightly more of the mother’s areola, the darker portion of the breast surrounding the nipple, visible above the baby’s upper lip than below the lower lip. Often called an asymmetric latch, this allows the nipple to be placed optimally in the baby’s mouth. The baby should have the nipple and as much of the areola as possible inside the baby’s mouth. This attachment allows the milk to flow well as the baby’s jaws compress the breast. A wide angle should be visible at the corner of the baby’s mouth, with the mouth wide open as if the baby were eating a sandwich. The lips should be turned slightly outward, sometimes called “fish lips.” The baby’s lips should be sealed well, all the way around the breast. If the seal of the lips to the mouth is not snug, there may be clicking sounds as the baby tries to suckle. A narrow angle at the corner of the baby’s mouth is a sign of a very shallow latch.

In the early days of breastfeeding, it is common to feel a slight tug or pulling as the baby begins to nurse. If this discomfort persists, the mother should remove or detach the baby from the breast and relatch more deeply. Detaching from the breast can be achieved by slipping a finger gently into the corner of the baby’s mouth. Allowing the baby to continue to latch with a poor latch can quickly lead to sore nipples and even cracking and bleeding of the nipples. Once this occurs, it can take days for the situation to resolve.

The best way to avoid improper latching is to have a trained professional check the baby’s latch during the first feedings and throughout the newborn hospital stay. Many hospital nurses are trained to assist new mothers with breastfeeding. If the mother needs additional assistance, an International Board Certified Lactation Consultant (IBCLC), sometimes referred to as a lactation consultant or another trained lactation supporter, can assess the baby’s position and latch, helping the mother and baby secure a better attachment. Ensuring the baby is latching well before discharge from the maternity hospital or birthing center is essential.

Changing the position in which the mother holds the baby can facilitate a better attachment to the breast. Avoiding bottle feeding in the early weeks of breastfeeding can also help. The way babies suck from a bottle is different from the way the baby suckles at the breast, with a deep attachment. It is often easier for the baby to learn to suckle at the breast before using pacifiers or feeding from a bottle. Frequent breastfeeding sessions also help to encourage a good milk supply.

While inadequate attachment is the most common cause of sore nipples, especially as breastfeeding is getting started, there are other causes.

Nipple Type

Some mothers have nipple variations that can contribute to sore nipples. If the nipples are very flat or turn inward instead of protruding outward, these types of nipples can experience nipple friction as the baby tries to latch. The obstetric provider should examine the mother’s breasts and nipples during pregnancy. The obstetrician should also take a good breastfeeding history if the mother has breastfed or attempted to breastfeed a prior child. Women with a history of breastfeeding challenges may need additional support.

When the areola is compressed or gently squeezed an inch or so behind the nipple, the nipple should point outward. If the nipple does not point out, this does not mean that breastfeeding necessarily will be a problem. These situations need to be monitored closely after the baby is born to assess the latch and the ability of the baby to remove milk from the breast.

If the mother experiences pain when trying to feed and the nipples do not protrude outward, some devices may help. The mother can apply a nipple shield. Nipple shields are thin silicone devices placed over the nipple and areola to give the baby a better attachment. A nipple shield may allow more milk to be removed from the breast when the baby feeds. Nipple shields are recommended only for short-term use.

If the mother has an inverted nipple that points deeply inward and does not turn outward when the areola is compressed, it can be difficult to latch the baby well. There are also devices, sometimes called nipple everters, available commercially that can be used to try to draw the nipple outward before latching the baby. Some mothers are successful in using an electric breast pump to draw the nipple outward. The most severe cases of inverted nipples may require surgical correction.

Mothers who have an inverted nipple on one breast and a nipple that everts on the other breast can breastfeed successfully using only the breast with the everted nipple. Over time, the breast with the inverted nipple will stop producing milk if that milk is not removed from that breast either by the baby’s suckling or by using a breast pump. The mother may experience some difference in the size of the breasts while breastfeeding, but this is a temporary issue. Most women have breasts that are slightly different in size anyway.

Mothers who need to use nipple shields, nipple everting devices, or other specialized technology should be carefully assessed by an IBCLC. The lactation consultant will ensure that the mother is able to feed without discomfort and the baby is removing enough milk to grow appropriately. The lactation consultant can coordinate care with the baby’s provider.

Infection

If the mother has been breastfeeding without any nipple soreness and then develops pain after breastfeeding has been well established, this could be due to an infection of the nipple. Infection may be associated with redness, swelling, itchiness, or flakiness of the nipple in a nipple that previously appeared normal. Infections such as Staphylococcus aureus, sometimes called Staph, or candida, a yeast or fungal infection, could be involved. There is some controversy regarding whether candida typically causes infection of the breast. It might be more likely if the baby has been diagnosed with a yeast or candida mouth infection. Candida is often associated with white patches on the inside of the baby’s cheeks. There may be some redness surrounding the white patches. If an infection is suspected, the mother and baby should seen by a medical provider for a definite diagnosis and treatment.

Eczema

Mothers with underlying skin conditions such as atopic dermatitis, also called eczema, may experience an exacerbation of it on the nipple or breast. Some mothers with psoriasis may also develop psoriasis on the breast. Treatment with ointments or creams applied to the skin between feedings can assist with these skin problems. Consult with your provider to ensure that these treatments are compatible with breastfeeding. Any treatment applied to the skin should be wiped off before the baby’s next feeding.

Raynaud’s

There is a condition called Raynaud’s that can cause nipple pain. Raynaud’s syndrome, or disease, occurs when the small blood vessels in the extremities, often the hands, clamp down (a response called vasospasm) and cause a decrease in blood flow. The decreased blood flow can result in blanching, or whiteness, of the area. It is normal for these small vessels to constrict when it is very cold. The nipple is like an extremity, such as the hand.

When this constriction is exaggerated, vasospasm can cause extreme pain. When the nipple is uncovered and becomes cold, the constriction of the small vessels may occur. It may also happen at the end of the feeding after the baby has detached from the breast. The nipple, which has been warmer while in the baby’s mouth during the feeding, is exposed to the cooler temperature of the environment, causing the small vessels to constrict abnormally and become very painful. The nipple can appear pale, very white, or occasionally red. It can also change between these colors. The mother often feels a cold sensation and pain. When the vessels enlarge again, the blood flow returns. The pain should lessen and finally resolve.

Raynaud’s syndrome occurs more commonly in younger females, especially those less than 30. There may be a history of other family members with this condition. It typically does not cause any long-term damage. Raynaud’s can be associated with other autoimmune conditions. When it occurs on the hands, it can result from jobs or hobbies that involve repetitive hand movements. Raynaud’s may also occur in individuals who take certain medications for high blood pressure. Raynaud’s can occur during breastfeeding with someone who has been previously diagnosed with this condition. It can also appear for the first time while breastfeeding.

In cases of Raynaud’s, the mother should keep the nipples covered whenever possible. Using a breast pad and avoiding exposure to the air may help to prevent vasospasm. Breastfeeding women are often advised to air dry the nipples after feeding before covering the breast. This is NOT helpful in the case of Raynaud’s. Applying heat to the breast with breast warmers or heat packs can benefit the mother experiencing Raynaud’s. It is essential to avoid extreme heat, which can damage the skin. A cloth should cover the heat source to prevent direct exposure to the skin. Immediately after feeding, applying purified lanolin cream, warmed by holding in the hand, can be helpful. When the mother is experiencing vasospasm, the baby should not be attached.

A medical provider should be consulted if Raynaud’s is suspected. The provider may prescribe specific medications. Medication should be considered if the mother is a candidate and the pain is so severe that the mother is considering stopping breastfeeding. Herbal remedies have been tried but have not been shown to be effective.

Treatment

Like many medical conditions, prevention of sore nipples is the best approach. Ensuring a good latch from the first feeding is helpful. Once sore nipples develop, assessing the baby’s latch is particularly important. The pain can cause mothers to interrupt or stop breastfeeding entirely. A poor latch can also interfere with adequate milk flow, resulting in inadequate weight gain in the baby if uncorrected.

Applying a small amount of breast milk to the nipple may help to heal and soothe sore nipples. Many mothers find that purified lanolin, available in cream or ointment, is soothing to sore nipples, especially if there is dryness, cracking, or itching. The nipples should be dried after feeding before the lanolin is applied. Lanolin is derived from sheep’s wool, so a small number of individuals could be allergic to the product, resulting in redness, itching, or swelling. If the nipple is getting worse after applying lanolin, the lanolin should be stopped.

A trained professional, either a medical provider or an IBCLC, should evaluate mothers when simple measures do not improve sore nipples to ensure breastfeeding success.

ABOUT THE AUTHOR
Joan Younger Meek, MD, FAAP, FABM, IBCLC, RD, is a pediatrician with lactation and breastfeeding medicine expertise. She is an IBCLC and a registered dietitian who is a Fellow of the American Academy of Pediatrics (AAP) and the Academy of Breastfeeding Medicine. She is the Editor-in-Chief of the AAP’s New Mother’s Guide to Breastfeeding, now in its 4th edition. Dr. Meek has counseled many breastfeeding families and trained healthcare professionals in breastfeeding support.