Kay Hoover, MEd and IBCLC, was the keynote speaker at the recent ACLI conference held in Limerick. Kay’s presentation on the Friday was titled “Painful nipples during breastfeeding” where she addressed the multiple root causes for nipple pain and highlighted the need to not just manage the symptoms.

Kay’s objectives for the presentation were that the delegates could;

• List 5 causes of nipple pain
• List 5 dermatological conditions
• Draw up a care plan for damaged nipples

Kay spoke from her experience that it can be normal for mums to experience approximately 20 seconds of discomfort with the initial latch but that after this mothers should be able to relax and be less tense throughout the duration of the feed. Days 3-5 post-partum are often the peak of nipple pain and that this is expected to subside by days 7-10 however from experience it is seen that a large percentage of mothers have ongoing pain for a significant period of time.

Kay highlighted that we know hormonal changes such as the menstrual cycle causes breast changes and nipple tenderness, so therefore with the post-partum hormonal shift it is not surprising that we see this peak at days 3-5 post-partum in nipple pain. Kay spoke that there is limited research to back up this theory, however from what we understand about hormones and their impact we can better equip mothers in their expectations in these early post-partum days.

Maternal problems that can lead to nipple pain include the following:

• Long nipples – causing infant to gag or pull off the breast frequently
• Large nipples (diameter) making it more difficult to achieve a deep latch
• Inverted nipples – pain in extracting the nipple to feed
• Skin tags on nipples – potential for repeated trauma each time infant feeds
• Blebs and blocked ducts
• Vasospasm (Raynaud’s syndrome) – often seen on the face of then nipple, unusual to be the whole nipple – can cause a burning sensation in both the nipple and breast. Once blood flow restores the pain is expected to settle

Kay stressed the importance of asking the mother “how does that feel for you?” as our interpretation of what would cause pain during a feed may not be significant for the mother experiencing it.

Trauma can cause blanching, alongside a stinging or burning sensation. Amir et al., (2014) found vasospasm was the reason in 22-23% of breastfeeding mothers as a cause of pain.

Blanching can be on part of the nipple with the associated pain – squeezing blood back into the nipple (which often looks like hand expression) reduces the time the mother is in pain as it increases the blood flow to the affected area and is found to work quicker than warm compresses. These mothers are advised to keep warm – hats, sweaters etc. to minimise risk.

Medications that reduce vasoconstriction could be considered for these mothers – fish oil and evening primrose oil are longer term treatments and don’t provide immediate relief.

Oral Nephetamine (30mg slow release OD x 4 weeks or 5mg TDS) has been used with good effect

Injury or trauma – unrelated to breastfeeding

• The baby with a strong suck – nipple shields as a temporary solution have been used in studies as increased vacuum is cause of pain, however this could cause further pain as the nipple can be pulled through the shield – always important to solve the cause of the pain
• Incorrect use of a pump at its highest suction – pump should be used at highest “comfortable” setting. Also important to ensure appropriately sized flange and that the nipple is centred in the flange
• Pre-natal “preparation” – i.e. rolling of nipples to “toughen them”
• Baby not unlatched properly
• Long distance runners can have chaffing
• Incorrect fitting bra/seam or pressure
• Breast pads sticking to nipple
• “Spot” on nipple (sebaceous cyst) or varicose vein causing pain near nipple

Dermatological conditions on nipple causing pain

• Dry skin (irritation)
• Moisture – causing tissue breakdown
• Infant food/medication causing maternal eczema due to change in saliva
• Teething – acidic saliva (nappy rash and nipple pain)
• Reaction to treatment
• Poison Ivy of nipple
• Psoriasis of nipple or breast tissue – some mothers require steroid cream or light treatment, others might not have any problems
• Bloody discharge from nipple – 3% Breast cancer diagnosis (Paget’s disease)
• Staph infection or streptococcus infection (could be on one or both breast – get cultures)
• Herpes simplex (cold sore virus) – baby to mum transfer is ok, but if herpes lesion on mum could be fatal to infant (handwashing, not kissing baby as treatment)
• Hand foot and mouth from toddler
• Yeast infection – shooting pain, feels like “shards of glass” burning sensation, some mums cannot hold baby, or describe it hurts to wear clothing (shells can be helpful)

Key question to ask “Is this the normal look of your breasts or nipple?”

Kay then moved on to explain how to draw up a treatment plan for healing damaged nipples.

If nipples are lipstick shaped post feed work on a deeper latch, teach mum how to do suck training with baby, work on positioning to reduce pinching (Kay explained she uses plasters to show placement of hands for shaping breast).

If infant gagging and coming off too soon work on desensitising gag reflect with finger exercises in infant mouth moving back gradually to dampen response.

If mum has large nipples or there is suspected frenulum tie – i.e. nipping from baby address this issue, this may be evident as baby losing milk out of corner of mouth as unable to create seal and vacuum.

Kay explained that with a breast wound and suspected infections or mastitis important to remember that the yellow pus from this wound is not necessarily the infection but the leukocytes starting the healing process and stressed that if a mother is in pain, to use appropriate pain medications whilst breastfeeding to reduce the discomfort. Other strategies to reduce pain –

• Reduce duration of feed (hand express into babies mouth)
• Use breast shells
• Pump exclusively until the damage heals

There are many treatment options and often no consistency with the research

• Hand express and add Expressed milk to nipple
• Warm compresses
• Salt soaks (Epsom salts)
• Lanolin (purified) – thin coat on face of nipple
• Gel pads (hydrogel or glycerine gel) have been associated with increased risk of mastitis as source of infection so ensure washing between use, however others have found these to be extremely helpful
• Cotton, breathable clothing
• Air drying nipples – avoiding retraction in those with inverted nipples (dimpled nipple ring – Velcro, which holds nipple out whilst allowing it to air dry
• Warm soap/water destroys the biofilm – soap has a drying effect therefore wash daily if not twice daily
• Sometimes needs to advise the mum to stop what she has currently been doing – ointments, treatments etc
• Antifungal preparations to be added topically – nystatin and hydrocortisone cream. Ensure systemically and topically treat to reduce poor outcomes

If believed to be an infection best treatment course is wash with warm soapy water, advise culture from primary care provider and find out source and treat accordingly.

Severe mastitis = might not present with temperatures look at breasts singularly and together – patterns in infection – MRSA, step and Staph

If suspected fungal infection check babies cheeks not tongue, and often the mothers nipple has  a “shiny complexion”

Impetigo – highly contagious – use topical +/- oral treatment, wash regularly and ask if too painful to feed and draw up treatment plan accordingly, some mothers can feed fine and others need to express until healed.

There is some research to suggest silver caps are more effective than breastmilk for nipple damage

Kay finished off by highlighting the importance of not dismissing nipple pain as it was in the top 2 reasons why mothers end breastfeeding before they had planned

• perceived low supply
• Sore nipples
• Baby wouldn’t latch

Jennifer Ashcroft October 2019.

Jennifer received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.