Cracked Nipples

Cracked nipples are superficial or deep skin damage with splits, cracks, abrasions or blisters on the nipple or areola during lactation, causing pain with feeding. Affects 30 to 90 percent of breastfeeding women, usually in the first 2 weeks.

• Causes:
  • Poor positioning and attachment (commonest), shallow latch, nipple pulled out of the mouth without breaking suction.
  • Infant factors: ankyloglossia (tongue tie), high palate, retrognathia, sucking dysfunction, biting with teeth.
  • Maternal: flat or inverted nipples, engorged breasts, vasospasm, eczema or contact dermatitis (creams, soaps, nipple pads, lanolin allergy), psoriasis, herpes simplex, thrush, bacterial infection (Staphylococcus aureus), over washing, wet nursing pads left on, pump trauma (flange size, high suction).
• Complications: nipple pain, bleeding, reduced milk removal, mastitis, early weaning, secondary infection (S. aureus including MRSA, Candida).
• Normal tenderness for the first few days is common; pain lasting beyond 30 seconds into the feed or tissue damage needs correction.

• Burning, stinging or sharp nipple pain during and between feeds, visible splits or cracks across or at the base of the nipple, scabs, blisters, bleeding, nipple distortion (lipstick shape or flattened tip after the feed), pale or white nipple (vasospasm).
• Signs of infection: yellow crusting, pus, spreading erythema, fever.
• Candida: deep burning breast pain after feeds, shiny pink nipple, white patches in the infant's mouth or nappy rash.
• Red flags: unilateral nipple eczema not responding to treatment in 2 weeks (Paget disease), blood stained nipple discharge, vesicles (herpes), systemic illness, spreading cellulitis, poor infant weight gain.

• Clinical, including observation of a full feed (latch, positioning, infant oral anatomy, tongue mobility).
• Nipple swab for bacterial culture and Candida PCR if signs of infection or non-healing after 1 to 2 weeks.
• Herpes PCR for vesicular lesions. Skin biopsy for non-healing unilateral eczematous change.
• Infant oral examination for tongue tie and thrush.

• Correct attachment and positioning with skilled help: wide open mouth, asymmetric latch with chin pressed into the breast, nose free, nipple aimed to the roof of the mouth, breaking suction with a finger before removing the baby; try laid back or football holds.
• Treat tongue tie (frenotomy) when function is impaired.
• Pain relief and healing:
  • Express a few drops of breast milk onto the nipple after feeds and air dry; purified lanolin or hydrogel dressings (moist wound healing) applied after feeds; avoid soap and alcohol wipes; change breast pads often; avoid occlusive plastic liners.
  • Start feeds on the less sore side; shorten but increase the frequency of feeds; if the feed is too painful, hand express and cup or spoon feed for 24 to 48 hours.
  • Paracetamol 1 g orally every 6 hours; ibuprofen 400 mg three times daily with food.
  • Nipple shield temporarily, only with lactation support, to avoid reduced milk removal.
• Bacterial infection (honey coloured crusts, pus): topical mupirocin 2 percent ointment applied thinly to the nipple twice daily for 7 days (wipe off before feeding if advised); flucloxacillin 500 mg orally four times daily for 10 to 14 days when mastitis coexists (7 days for cellulitis alone) (clarithromycin 250 to 500 mg twice daily or clindamycin 300 mg four times daily if penicillin allergic); MRSA: doxycycline or trimethoprim-sulfamethoxazole chosen by sensitivities, with paediatric advice.
• Candida: miconazole 2 percent cream applied thinly to the nipple after each feed for 7 to 14 days, with the infant treated simultaneously (miconazole oral gel 1.25 mL four times daily after feeds (infants 4 months and over only) for 7 days and continued for 2 days after clearance, or nystatin 100,000 units/mL 1 mL four times daily); oral fluconazole 400 mg on day 1 then 100 to 200 mg once daily for 14 days for deep breast pain (specialist advice, check the infant's age and liver function).
• Vasospasm (blanching, throbbing): keep warm, avoid cold, nifedipine modified release 30 mg orally once daily for up to 2 weeks (specialist advice); stop caffeine and nicotine.
• Eczema or contact dermatitis: remove the irritant, hydrocortisone 1 percent ointment thinly twice daily for 7 days (applied after the feed and wiped off before the next); emollients.
• Herpes: aciclovir 400 mg orally three times daily for 5 days; do not feed from the affected breast while lesions are open.
• Refer for non-healing unilateral nipple change over 2 weeks (to exclude Paget disease with mammography and biopsy).
• Review in 48 hours and at 1 week.