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Breast Feeding
Breastfeeding is now widely recognized as the ideal source of infant nutrition and nurturing. The American Academy of Pediatrics recommends breastfeeding exclusively for the first 6 months of an infant's life, with continuation as the infant's primary source of nutrition for the first year. However, although an increasing numbers of women are initiating breastfeeding, many stop well before 6 months. The most commonly reported problem with breastfeeding is sore nipples, and the resultant discomfort or pain is frequently associated with discontinuance. A degree of transient soreness postpartum is accepted as normal by some lactation specialists, but soreness should be mild and completely gone by the end of the second week. If nipple pain is more intense than mild tenderness and/or if pain occurs between feedings or lasts longer than a week or two, the cause of the pain needs to be addressed. Treating sore nipples in breastfeeding mothers quickly and effectively is important in improving the duration of breastfeeding beyond a few weeks.
Causes of Sore Nipples
Causes of sore nipples include, but are not limited to:
- Mechanical Trauma
- Bacterial Infections and Mastitis
- Candidiasis or Yeast Infection
- Dermatitis and Other Skin Conditions
- Vasospasm
Mechanical Trauma
The most common source of mechanical trauma to the nipple is improper latch-on, where, typically, the nipple is not drawn back far enough into the baby?s mouth and is subject to compression or abrasion. This is often due to problems in positioning the baby at the breast or latch-on technique, especially in the early weeks. More rarely, palatal anomalies or tongue-tie in the baby, anatomical mismatch between mother and baby (eg, large-diameter nipple or extremely long nipple) or inverted nipples are factors
These mechanics can prevent the mother?s nipple from being drawn back far enough into the mouth. Other sources of mechanical trauma are: Breast engorgement, which can stretch nipple tissue, thereby increasing its fragility and susceptibility to trauma and making latch-on more difficult; use of a breast pump with a suction level too high or maintained too long; and pump flanges too narrow for the nipple.
Infection
Most cracked nipples and breast infections occur during the first 2 weeks after childbirth when pathogens from the hospital may be present in wounds. When nipple pain cannot be resolved in a few days by good positioning and latch-on techniques, infection should be considered.
Dermatitis and Other Skin Conditions
Eczema, dermatitis, impetigo, psoriasis and poison ivy can occur on the nipple, as well as other skin surfaces. Postpartum women can be especially sensitive to contact irritants, which can include nipple creams and ointments, the plastic on breast shells (hard plastic rings with a hole for the nipple, worn inside the bra) or flanges, cologne, deodorant, hair spray or powder used near the nipple/areola, and laundry detergent. Dermatitis can be mistaken for a fungal infection and is typically suspected when nipple pain persists despite good latch-on and positioning, a nipple crack or fissure is healing slowly, there is no response to treatment for candidiasis after several days, or any other unusual skin condition exists on the nipple.
Vasospasm
Vasospasm (spasm of the blood vessels) in the nipple can cause pain. Risk factors include poor latch-on, damage to the nipple and/or a history of Raynaud?s phenomenon.
Treatments
There are a variety of approaches for treating sore nipples, but no ?single? method has been shown to be most effective.
Correction of Positioning or Latch-on Difficulties
As stated, the most common reason for sore nipples is positioning or latch-on difficulties. Current understanding of latch-on emphasizes the importance of placing the baby?s lower jaw as far behind the nipple as possible, causing the baby to take more of the lower areola into his or her mouth than the upper (the asymmetric latch). Lactation specialists can help with this problem. The most important consideration is for the mother to seek help early, before extensive nipple damage occurs.
Comfort Measures
Alleviating the pain of sore nipples while the underlying cause is being corrected can save the breastfeeding relationship. Simple breastfeeding management strategies can minimize infant sucking at the breast when milk flow is low:
- ? Stimulating the let-down reflex before the baby latches on;
- ? Nursing on the less sore side first;
- ? Enhancing milk intake by manual expression while the baby is nursing (breast compression).
Lanolin. Many mothers find that the application of USP-modified lanolin on their nipples is soothing. The reduction of free lanolin alcohols and detergent residues has been shown to reduce allergic response in lanolin-sensitive patients. Two hypoallergenic brands marketed to breastfeeding mothers are Lansinoh and PureLan 100. These can be applied sparingly between feedings and do not need to be removed before feeding.
Breast Shells. Breast shells can be worn between feedings to keep the pressure of a bra or clothing off sore nipples. The hole should be large enough for good air circulation around the nipple; and, to prevent the risk of mastitis, the shells and bra should fit so that there is not too much pressure on the areola. A combination of breast shells and lanolin has been shown to reduce pain.
Analgesic. An analgesic (pain reliever) compatible with breastfeeding is an option. However, if a mother feels she needs an analgesic to continue breastfeeding, she should be strongly encouraged to contact an lactation consultant for help in correcting the cause of the problem.
Temporary Cessation. Mothers who find breastfeeding so painful that they delay or avoid feeding can temporarily stop breastfeeding on the sore breast while the nipple heals. However, they should pump to maintain the milk supply on that breast and to prevent engorgement.
Nipple Wound Care. Although cleaning intact nipple skin is unnecessary, a daily, gentle cleansing of nipple wounds with warm, soapy water (avoiding antibacterial soaps) followed by a warm water rinse can help prevent infection by pathogens found on the skin and in the baby?s mouth. Wounded nipples can additionally be rinsed in warm water after each feeding.
Moist Wound Healing. Not long ago, drying techniques, such as using a hair dryer or a sun lamp, were routinely suggested for sore nipples. More recently, however, moist wound-healing theory has changed strategies to aim for maintenance of the internal moisture of the skin (not surface wetness). A popular over-the-counter moisture barrier is USP-modified lanolin, such as Lansinoh or PureLan 100.
All-Purpose Nipple Ointments. Jack Newman, MD, a Canadian pediatrician who is a widely recognized expert in breastfeeding, developed an ointment for sore nipples that combines an antibiotic (mupirocin) with an anti-inflammatory agent (betamethasone) and antifungals (nystatin and clotrimazole, or miconazole). The ointment is applied sparingly after each feeding and does not have to be wiped off before the next nursing. As with most powerful steroid ointments, use should be limited. In one case, use of a nipple cream for 2 months resulted in signs of corticosteroid excess in an infant.
Treatments for Candidiasis. Most lactation specialists suggest simultaneous treatment of mother and baby if nipple or breast candidiasis is diagnosed, even if the baby shows no symptoms. Common treatments include topical antifungals or gentian violet for the mother?s nipples and baby?s mouth
Treatment for Mastitis. Antibiotics effective against Staphylococcus aureus are usually used to treat mastitis. A breastfeeding mother should complete the full course of antibiotic to prevent recurrence. |
