The best treatment of sore nipples is prevention. The best prevention
is latching the baby 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. Incidentally, babies learn to suck
properly by getting milk from the breast when they are latched on
well. (They learn by doing).
Fungal infection (due to Candida albicans), may also cause sore
nipples. The soreness caused by poor latching and ineffective suckle
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.
Sudden, unexplained onset of nipple pain when feedings had previously
been painless is a tipoff that the pain may be due to a yeast infection,
but the pain may come on gradually or may be superimposed on pain
due to other causes. Cracks may be due to a yeast infection.
Proper Positioning and 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. A lot of what
follows under latching comes automatically if the baby is well positioned
in the first place. 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).
For the purposes of explanation, let us assume that you are feeding
on the left breast. 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, the web between your thumb and index finger behind
the nape of his neck (not behind his head) with your fingers (except
for the thumb) supporting the baby's face from underneath, and your
forearm supporting his back and buttocks. Hold the baby's buttocks
between your chest and your forearm—this should give you good control.
The baby should be almost horizontal across your body 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 on positioning and latching on)
1. The way to do get the baby to open his mouth wide is to run
your nipple, still pointing to the roof of the baby's mouth, along
the baby's mouth, very 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.
WAIT FOR HIM. As you bring the baby toward the breast, his chin
should touch your breast first.
2. When the baby opens up his mouth, use the arm that is holding
him to bring him 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
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 just 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.
"My nipple turns white after the baby comes off
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 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 is the treatment of the other causes
of nipple pain.
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 a medicated paste (nitroglycerine)
or an oral medication (nifedipine) to prevent this type of reaction.
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.
5. Do not wash your nipples frequently. Daily bathing is more than
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.
Nipples shields are not recommended for sore nipples, because,
although they may help temporarily, they usually do not. 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.
Handout #3. Sore Nipples. Revised January 1998
Written by Jack Newman, MD, FRCPC
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