best treatment of sore nipples is prevention. The best prevention is
getting the baby to latch on properly from the first day. Mother and
baby skin to skin contact immediately after birth for at least the
first hour or two will frequently result in a baby latching on all by
himself with a good latch. See the information sheets Breastfeeding—Starting Out Right and The Importance of Skin to Skin Contact.
Early onset nipple pain is 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 infections of the
nipple (due to Candida albicans) may also cause sore nipples.
Vasospasm (which is due to irritation of the blood vessels in the
nipple from poor latching and/or a fungal infection) may also cause
sore nipples (see the information sheet Vasospasm and Raynaud’s Phenomenon).
The soreness caused by poor latching and ineffective suckling hurts
most as you latch the baby on and usually improves as the baby
breastfeeds. However, if damage is severe, the soreness of a poor latch
and/or ineffective suckling may go on throughout the feeding. The pain
from the fungal infection often goes on throughout the feed and may
continue even after the feed is over. Women describe knifelike pain
from the a poor latch or ineffective sucking. The pain of the fungal
infection is often described as burning but it does not have to be
burning in nature. A new onset of nipple pain when feedings had
previously been painless is a tip off that the pain may be due to a
Candidal infection, but a Candidal infection may also be superimposed
on other causes of nipple pain, so there was never a pain free period.
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 information sheet When Latching)
is not uncommon for women to experience difficulty positioning and
latching the baby on. If the mother positions the baby well, she
facilitates the baby’s getting a good latch and a good latch not only
decreases the risk of the mother becoming sore, but also reduces the
baby’s chances of becoming “gassy” because a good latch allows the baby
to control the flow of milk better. Thus, poor latching may also result
in the baby not gaining adequately, or feeding frequently, or being
colicky (see the information sheet Colic in the Breastfed Baby).
See also nbci.ca 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
(See information sheet When Latching and the videos at nbci.ca)
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 for many mothers 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 (towards the
ceiling). This will help you support his body more easily as the baby’s
weight is on your forearm rather than your wrist or hand. Holding the
baby like this also will 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 upwards
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 the video clips at the website nbci.ca
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, just a tickle, 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, only his
chin should touch your breast. Do not scoop him around so that
the nipple points to the middle of his mouth. Instead the nipple should
still be pointing to the roof of the baby’s mouth.
- When the baby opens up his mouth, use the arm that is holding
him to bring him straight (not scooped around) 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 since his nose will be
far away from the breast. If he cannot breathe, he will pull away from
the breast. If he cannot breathe, he is not latched properly. Don’t be
afraid to be quick.
- If the nipple still hurts, use your index finger to pull down
on the baby’s chin; this will bring more of your breast into the baby’s
mouth. You may have to do this for the duration of the feed, but not
usually. The pain should 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, and the baby and you
will both be frustrated. Adjust the latch when putting him to the other breast, or at the next feeding.
- The same principles apply whether you are sitting or lying
down with the baby or using the football or cradle 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).
- There is no “normal” length of feeding time. If you have questions, call the clinic.
- 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 Suck
The baby learns to suckle properly by breastfeeding 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 (See the information sheet Finger and Cup 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.
Vasospasm: “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 then the nipple may turn
white again and the process repeats itself. 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?
careful attention to getting the baby to latch onto the breast as best
possible. 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 usually disappears.
- Heat (hot washcloth, hot water bottle, hair dryer) applied to
the nipple immediately after breastfeeding may prevent or decrease the
reaction. Dry heat is usually better than wet heat, because wet heat
may cause further damage to the nipples.
- Vitamin B6 multi complex can also be used, as can magnesium
with calcium. On occasion, we have had to use an oral medication
(nifedipine) to prevent this type of reaction. For more on these
treatments see the information sheet Vasospasm and Raynaud’s Phenomenon)
General Measures for Nipple Soreness
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. Feed the baby with a cup or use the technique called
“finger feeding” (see the information sheet Finger an Cup Feeding).
Once again, it should be emphasized that this is a last resort and
taking a baby off the breast should not be taken lightly. Furthermore,
it often doesn’t work.
- Nipples can be warmed for short periods of time after each feeding, using a hair dryer on low setting.
- Nipples should be exposed to air as much as possible, except when there is vasospasm.
- When it is not possible to expose nipples to air, plastic
dome-shaped breast shells (not nipple shields which are not, in our
opinion, a good treatment for sore nipples or any breastfeeding problem
for that matter) can be worn to protect your nipples from rubbing by
your clothing (use the largest hole available so your nipple is not
rubbing against the plastic). Breastfeeding 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
- Ointments can sometimes be helpful. If using our ointment, use just a very small amount after breastfeeding and do not wash it off. We use an “all purpose nipple ointment” (APNO) that we find very useful. See the information sheet Candida Protocol for the recipe. Note, once any ointment or cream is applied to the nipples they are no longer air drying.
- Do not wash your nipples frequently. Daily bathing is more than enough.
- 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, but be careful, not all mothers can feed a baby on only one
breast at every feeding or even at all. See the video clips at the
website nbci.ca so that you know when the baby is drinking (or
not). It will help to compress the breast (see the information sheet 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 (see the
information sheet Lactation Aid) can be used to supplement (preferably expressed milk), so that the baby will finish the feeding on the first side. Taking the baby off the breast is a last resort.
We do not recommend nipple shields
because, although they sometimes help temporarily, they often do not.
In fact, they may often increase the degree of trauma to the nipples.
They may also cut down the milk supply dramatically, and the baby may
become fussy and/or not gain weight well. Once the baby is used to
them, it may be impossible to get the baby back onto the breast. Use as
a last resort only but get help first.
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.
To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.
Sore Nipples, 2009©
Written and revised (under other names) by Jack Newman MD, FRCPC, 1995-2005©
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman IBCLC, 2008, 2009©