Causes of Breast and nipple pain

I always feel so sad when I hear of a mother who has stopped breastfeeding due to breast and/or nipple pain because there is almost always a reason and therefore a way to fix it. Many moms hear horror stories of damaged nipples, painful engorgement, plugged ducts, and mastitis before they even have their babies. Unfortunately, this can be a deterrent for some women to even want to try to breastfeed. There is so much misinformation and bad advice out there that when hearing these horror stories, moms don’t realize that most of these problems are preventable in the first place. So, what are some of the reasons for breast and nipple pain?

First and foremost- poor positioning. I have seen mothers nursing their babies in the most contorted positions (which not only will cause breast and nipple pain, but neck, back, shoulder and wrist pain as well!). I’m not talking about nursing an older baby where “stunt” breastfeeding is the norm, but poor positioning in the newborn period. There is so much emphasis on the “Latch” that mothers are often focusing on the wrong thing when putting their babies to breast in the beginning when both are learning. Scrutinizing to the point of practically getting out a protractor to check for the proper angle is not necessary! My experience is that if the positioning is optimized, the latch will be good! (except in the case of oral ties, which I will refer to in a minute). New mothers need someone to show them how to properly position their babies- it is not an innate skill. Sadly, not all nurses in the hospital are experienced with good positioning. I have seen far too many instances of a nurse grabbing the baby, grabbing the mother’s breast and screwing the two together. Not only does that not help either to learn, but neither moms nor babies appreciate this forceful approach. Seeking the help of an experienced lactation consultant soon after birth to show mom how to position baby properly so that he/she can learn to latch comfortably is so important to avoiding problems from the start. Too many mothers wait until their nipples are badly damaged to seek help, and it’s so much wiser to be proactive and not have to fight your way back from pain and damage!

Vasospasms- While not the most common cause for breast/nipple pain, it is certainly not a rare occurrence. A vasospasm is basically a sharp, throbbing pain in the nipple and breast most noticeable right after the baby unlatches at the end of the feeding. Nipples will look white (like the color has been sucked out of them!) and then change to purple and/or red. This change in color is accompanied by the piercing pain. Vasospams are a circulatory issue and are most common (but not confined to) women who have Raynaud’s syndrome. In severe cases, there are medications that are helpful to some women, but often the most comforting and relieving thing is to put heat on the nipples immediately after feeding. Interestingly, many women who experience vasospasm pain will say that their nipples will hurt like that when they go through the freezer section of the grocery store since cold exacerbates the symptoms.

Oral ties- Lip and/or tongue ties (they almost always go together) are a relatively common cause of nipple pain. If the baby does not have normal tongue function and range of motion, they will compensate with an abnormal suck which is not only ineffective, but painful and damaging to nipples. If positioning is good, (remember, poor positioning is the most common reason for nipple pain and damage) and mom is still experiencing nipple trauma, then baby should have their oral anatomy assessed by an experienced lactation consultant. A cursory look into their mouth is not adequate for identifying oral ties, and a full feeding assessment is vitally important to determine the extent of dysfunction. Refer to my article “Breastfeeding and Oral Ties” in an earlier blog entry for more extensive information on this problem.

Thrush- Thrush is a fungal yeast infection of the baby’s mouth and the mother’s nipples. With the use of antibiotics in labor for treating moms that are positive for Group B strep, as well as their administration to the mother during a c/section, thrush is becoming a very common cause for breast and nipple pain. While antibiotics kill bad bacteria like Group B strep, they also kill good bacteria that keep fungus like yeast from growing. Breastfeeding is very conducive to yeast growth because everything is warm and dark and wet and sweet- just the environment that yeast loves to grow and flourish in! In the baby, it will manifest itself in a white, velvety coating on their tongue. Babies can have white on their tongues since their diet is milk- often what you’re seeing is just milk residue. But thrush is usually a thicker coating that won’t wipe off if you try to scrape it off the baby’s tongue. They will sometimes have it on the insides of their cheeks as well, but not always. Babies can also get an angry fungal diaper rash when yeast is present. The skin on their little bottoms will be very red and raw, sometimes even to the point of bleeding. In the mother, nipples will look extra pink and sometimes a bit shiny, with burning stinging pain. Water hitting them in the shower will be uncomfortable and even your clothing rubbing against them can be irritating. This is different than nipple pain from poor positioning. One or the other of the mother/baby pair can be asymptomatic, but both will need to be treated or you will just keep passing it back and forth. Call your pediatrician for advice on how to treat the baby- they will usually prescribe an oral solution to use in the baby’s mouth. Moms can start by using an over the counter anti-fungal cream (either vaginal cream or athlete’s foot cream will work!) for their nipples, however, if you get sharp, shooting pains deep in your breast, you may need an oral antifungal which would be prescribed for you by your OB. Some mothers find that taking a good probiotic (either starting before birth or immediately after) can help to prevent thrush from happening because it puts back some of the good bacteria that deters yeast from growing.

Plugged ducts/Mastitis- Plugged ducts occur when thickened milk blocks the duct preventing the flow of milk from the glands that make it to the outside of the breast through the nipple. This can occur when the baby starts to sleep longer at night and you miss a feeding, or when going back to work and nursing less, wearing underwire bras or even sleeping on your stomach (anything that reduces the flow of milk). Some moms have it happen when the baby gets to the distractible age where they keep pulling off to look around instead of settling in and nursing nicely! Moms will notice a plugged duct when they feel a tender, bruise-like place on their breast, often with a whole quadrant of the breast behind it where the breast is firm and full because that part can’t empty. Inflammation can ensue, which is ultimately what can lead to mastitis. I have found that almost all plugged ducts can be resolved with proper treatment without becoming a full-blown breast infection. Cold on the breast in between feedings can help to reduce inflammation, but heat before feeding can soften the thickened milk and make it easier to get it out of the breast. Gentle massage (go easy! no vibrators or electric toothbrushes please!), leaning over baby and “dangling” your breast to let gravity help while stroking gently downward toward the nipple can be very effective. Sometimes, it will feel like instantaneous relief like the dams opening, or sometimes more gradual, where you have to work on it for a little while before it resolves completely. Some moms find that castor oil compresses or soaking in epsom salt is helpful. If you develop angry redness, unresolved or worsening pain, fever, chills, body aches etc (you feel like you’ve been hit by a truck!) then it is becoming mastitis and you need to call your OB for treatment. I wouldn’t recommend going to an ER or walk-in clinic as they often don’t have much experience with dealing with mastitis. Mastitis can also be caused by nipple trauma where bacteria gets into the breast through broken/macerated skin on the nipple. See the section on proper positioning to avoid this problem!

Teething- many babies will chomp on the breast at least once when teething- no viciousness intended, just a natural reaction when their gums are sore. Usually watching them like a hawk while nursing can avoid this from occurring since babies can’t bite when they are actively suckling since the tongue covers the bottom gumline when they are feeding. If they stop nutritively suckling, getting your finger in between their gums before they can clamp down can avoid the bite. If they do manage to nip you, saying “no biting, that hurts mommy” then putting them down every time they do it will work with some kids. You don’t want to be too vehement in your admonishing, because sensitive babies will become upset (especially if you scream, which is sometimes a natural reaction when someone bites your sensitive nipple!). Other more feisty babies will look at you and laugh when you react (little buggers!), but usually trying to avoid the bite to begin with is your best tactic. Fortunately, this is usually not a prolonged problem for most kids and giving them lots of things to bite down on in between nursings can help (frozen damp washcloths or breastmilk popsicles are favorites!)

Breastfeeding should not be painful. Learning about these potential pitfalls before you have your baby can usually avoid pain! If you do experience painful feeding, please seek help. As I’ve stated, these issues can either be avoided or remedied with a skilled lactation consultant to assess both mother and baby and give you strategies and suggestions to treat the problem. Nursing your baby should be a comfortable, enjoyable experience for both parts of the team!