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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 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 #3b Treatments
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
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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