Author Name:
Dr Jack Newman MD, FRCPC

Biography:
Dr. Jack Newman is a Toronto pediatrician who has practiced medicine since 1970. In 1984 he established the first hospital-based breastfeeding clinic in Canada, at Toronto's Hospital for Sick Children. He now holds breastfeeding clinics in several hospitals in the Toronto area. Jack is a consultant with UNICEF's Baby Friendly Hospital Initiative and is a popular speaker at breastfeeding conferences across North America and beyond. He is the father of three children, all breastfed.

Article:
Sore Nipples

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 www.thebirthden.com/Newman.html for 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 at www.thebirthden.com/Newman/html )

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 #3bTreatments 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 violatedTreatments for sore nipples and sore breasts

1. “All purpose nipple ointment”

This combination of 3 ingredients seems to help for many causes of sore nipples, including poor latch, Candida (yeast), dermatologic conditions, infections of the nipple with bacteria and possibly other causes as well. It is always good, however, to try to assure the best latch possible, because improving the latch helps with any cause of pain.

mupirocin 2% ointment (not cream): 15 grams
betamethasone 0.1% ointment (not cream): 15 grams. If betamethasone ointment is unavailable, mometasone ointment (15 grams) can be used instead. It is better not to mix creams and ointments.

To which is added miconazole powder so that the final concentration is 2% miconazole. Sometimes it is helpful to add ibuprofen powder as well, so that the final concentration of ibuprofen is 2%.

This combination gives a total volume of approximately 30 grams. Clotrimazole powder to a final concentration of 2% may be substituted if miconazole powder is unavailable, but both exist (the pharmacist may have to order it in). I believe clotrimazole is not as good as miconazole, but I have no proof of that. Using powder gives a better concentration of antifungal agent (miconazole or clotrimazole) and the concentrations of the mupirocin and betamethasone remain higher.

The combination is applied sparingly after each feeding (except the feeding when the mother uses gentian violet). Do not wash or wipe it off, even if the pharmacist asks you to. In Canada, Kenacomb (easier to find) or Viaderm KC (less expensive) ointments (not cream) can be substituted for the above combination, but are distinctly inferior. I used to use nystatin ointment or miconazole cream (15 grams) as part of the mixture, and these work well, but I believe the use of powdered miconazole (or clotrimazole powder) gives better results.

Any pharmacist should be able to make up this ointment, but not all want to. Not all pharmacies carry all the ingredients. If you are having difficulties, ask the pharmacist for the nearest compounding pharmacy.

2. Gentian violet for treating Candida is discussed in handout #6. See also Candida Protocol.

3. Grapefruit seed extract (See Candida Protocol)

Grapefruit seed extract can also be used for treating Candida as well. It can be used directly on the nipples and/or orally. If used directly on the nipples, it should be diluted (5 to 15 drops, occasionally up to 25 drops, in 30 ml or 1 ounce of water), applied on the nipples with a Q-tip or cotton ball, allowed to dry, and then covered, sparingly, with the all purpose nipple ointment. By mouth, grapefruit seed extract can be taken as a pill, 250 mg three times a day.

4. Treatments for Raynaud’s phenomenon (blanching of the nipple)

Raynaud’s phenomenon is due to spasm of blood vessels preventing blood from getting to a particular area of the body. It occurs in response to a drop in temperature. Most commonly, Raynaud’s phenomenon will occur in the fingers, typically when someone goes outside from a warm house on a cool day. The fingers will turn white and the lack of blood getting to the tips of the fingers will cause pain. Raynaud’s phenomenon occurs more commonly in women than men, and is often associated with illnesses such as rheumatoid arthritis.

Raynaud’s phenomenon can also occur in nipples. In fact, it is much more common than generally believed. It can occur along with any cause of sore nipples, is, in fact, probably a result of damage, but it may also, on occasion, occur without any other kind of nipple pain at all.

Typically, Raynaud’s phenomenon occurs after the feeding is over, once the baby is already off the breast. Presumably, the outside air is cooler than the inside of the baby’s mouth. When the baby comes off the breast, the nipple is its usual colour, but soon, within minutes or even seconds, the nipple will start to turn white. Mothers generally describe a burning pain when the nipple turns white. After turning white for a while, the nipple may actually turn back to its normal colour (as blood starts to flow back to the nipple), and the mother will notice a throbbing pain. The nipple may go back and forth between colours (and types of pain) for several minutes or even an hour or two.

The treatment for Raynaud’s phenomenon is to fix the original cause of the pain (poor latch, Candida etc). Almost always, as the nipple soreness from another cause is getting better, so will the pain from Raynaud’s phenomenon get better, but more slowly. Fixing the original cause of the pain (improving the latch, treating Candida etc) should be the focus of treatment. However, some mothers no longer have pain during the feeding, or never had it at all. Indeed, some start having Raynaud’s phenomenon during the pregnancy. If the pain is mild, there may be no reason to treat, and reassurance is all that is necessary. However, in some cases it is worth treating, especially if severe, and especially if the pain during the feeding does not improve, as severe restriction of blood supply to the nipple may delay healing.

The first choice for treatment is:

• Vitamin B6. This has shown to work by trial and error, but it does seem to work. There is no scientific evidence that it works, but it does nevertheless. It is safe and will do no harm. The dose is 150-200 mg/day once a day for four days, followed by 25 mg/day once a day. The mother continues it until she is pain free for a few weeks. It can be restarted if necessary. If the pain resolves with the larger dose but returns with the smaller dose, you can go back to the higher dose. If you have been pain free for a week or two, try going off the vitamin B6. If vitamin B6 does not work within a few days, it probably won’t. It is then useful to try:
• Nifedipine. This is a drug used for hypertension. One 30 mg tablet of the slow release formulation once a day often takes away the pain of Raynaud’s phenomenon. After two weeks, stop the medication. If pain returns (about 10% of mothers), start it again. After two weeks, stop the medication. If pain returns (a very small number of mothers), start it again. No mothers I am aware of took more than three, two week courses. Side effects are uncommon, but headache may occur. It is a prescription drug. The dose can be increased if 1 tablet is insufficient.
• Nitroglycerin paste. We no longer recommend it, as severe headache associated with its use is fairly common. It also does not work more than about 50% of the time.

5. Fluconazole for treating Candida is covered in its own handout #20.

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 #3b. Treatments for sore nipples and sore breasts. 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