Lactational Nipple Pain

Lactational nipple pain is pain in one or both nipples during or between feeds in breastfeeding women. The common causes are poor latch, nipple damage, infection (bacterial and candida), vasospasm, dermatitis, tongue tie, engorgement and incorrect pump use. It is very common in the first weeks, and it matters because pain is a common reason for stopping breastfeeding early.

• Risk factors: first baby, poor positioning, tongue tie, flat or inverted nipples, engorgement, nipple trauma, infection, Raynaud phenomenon, eczema, cold exposure, smoking.
• Normal early tenderness settles by 7 to 10 days; pain beyond 2 weeks is not normal.
• Pain pattern guides the cause.

Women report pain that is sharp at latching and eases during the feed (latch problem), pinching, burning pain after feeds with colour change white then blue then red (vasospasm), burning, itching pain with pink shiny skin (candida), or a cracked or bleeding nipple (trauma). Itching and a dry red rash suggest dermatitis.

• Nipple shape distortion (lipstick shape) after feeds.
• Blanching of the nipple after a feed in vasospasm.
• Differential diagnosis: nipple fissure, cracked nipple, traumatic injury, nipple candidiasis, bacterial infection, vasospasm (Raynaud phenomenon of the nipple), eczema, contact dermatitis, herpes simplex, blocked duct, mastitis, Paget disease, referred pain.
• Complications: poor milk removal, reduced supply, mastitis, early weaning, depression, fear of feeding, chronic nipple pain.

The approach is a structured history, observation of a feed and examination of mother and infant.

• Pain timing and character, trigger by cold, colour change, itching, recent antibiotics, creams and pump use.
• Inspect the nipple, areola and breast before and after a feed; observe latch and positioning; examine the infant's mouth for thrush and tongue tie.
• Swab for bacteria or Candida if skin broken or pain persists; viral swab if vesicles.
• Biopsy for nipple lesion not healing by 3 weeks; check for Raynaud phenomenon in the fingers.

The principle is to find the cause and treat it, starting with correction of latch.

• Supportive: correct positioning and attachment at every feed; break suction before removing the baby; keep nipples warm after feeds (warm compress, dry clothes, avoid cold exposure); stop smoking and limit caffeine in vasospasm; air dry; hydrogel dressings or purified lanolin for broken skin; avoid soap and harsh creams.
• Pharmacological:
  • Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours).
  • Ibuprofen 400 mg oral 8-hourly with food for 3 to 5 days.
  • Vasospasm: nifedipine modified release 30 mg oral once daily for 14 days, increased to 60 mg once daily if no relief (maximum 60 mg daily), continued for 2 to 4 weeks after pain stops then stopped.
  • Bacterial infection: mupirocin 2 percent ointment thinly after feeds 3 times daily for 7 days, with flucloxacillin 500 mg oral 6-hourly for 7 to 10 days for spreading cellulitis.
  • Candida: miconazole 2 percent cream after feeds 3 to 4 times daily for 14 days with infant treatment (nystatin 100,000 units/mL, 1 mL placed in the mouth 4 times daily for 14 days).
  • Candida with ductal involvement: fluconazole 400 mg oral loading then 100 mg once daily for 14 to 21 days.
  • Dermatitis: hydrocortisone 1 percent cream applied thinly to the nipple after feeds twice daily for up to 7 days.
• Procedures: frenotomy of infant tongue tie; fitting of the correct pump shield; temporary nipple shield with lactation guidance.
• Special groups: women with Raynaud phenomenon or connective tissue disease have nifedipine and a rheumatology review; women with hypotension avoid nifedipine; infants with tongue tie or poor suck need assessment; breastfeeding is compatible with nifedipine, fluconazole, mupirocin and the antibiotics used.
• Red flags: fever above 38.5 degrees Celsius, spreading redness, pus, grouped vesicles, nipple turning dusky, lesion not healing by 3 weeks, nipple eczema that does not respond, infant poor weight gain.
• Follow-up: review at 1 week with infant weight; review at 2 weeks if no improvement; stop nifedipine after 2 to 4 weeks pain free; breast examination at 6 weeks; biopsy for nonhealing lesion.