Nipple Fissure

Nipple fissure is a linear tear or split in the skin of the nipple or at its base, typically in the first 2 weeks of breastfeeding. It results from poor attachment, a shallow latch, infant tongue tie, incorrect removal from the breast, and excessive pumping suction. It is common, and matters because pain leads to poor milk removal, reduced supply, infection and early weaning.

• Risk factors: first baby, flat or inverted nipples, infant tongue tie or high palate, engorgement, prolonged feeds, use of soap or alcohol on the nipple, poor positioning, ill-fitting breast pump shield.
• Pain is worst on latching and eases during the feed if the latch is corrected.
• Most heal within 7 to 14 days with correction of the cause.

Women have sharp pain at the start of feeds and between feeds, with a visible crack or split on the nipple tip or base, sometimes with a scab or bleeding. The nipple may be pinched, flattened or wedge-shaped after a feed.

• Linear split on the nipple, often at the nipple base or tip.
• Blood in the infant's mouth or milk.
• Differential diagnosis: nipple candidiasis, bacterial infection (Staphylococcus aureus), eczema or dermatitis, herpes simplex, vasospasm, milk blister, Paget disease of the breast, impetigo, traumatic injury from a pump.
• Complications: bacterial infection, mastitis, bleeding, nipple pain with reduced milk supply, early weaning, scar formation.

The diagnosis is clinical, with observation of a feed.

• Inspect the nipple before and after a feed for position and shape of the fissure, bleeding, scabs and signs of infection.
• Observe latch, positioning and infant suck; examine the infant's mouth and under the tongue for tongue tie and palate.
• Swab for culture if there is pus, honey coloured crusts or slow healing; viral swab if grouped blisters.
• Examine the breast for mastitis and take temperature; biopsy any nipple lesion that does not heal in 3 weeks (to exclude Paget disease).

The principle is to correct the latch, protect the wound while it heals, and treat infection.

• Supportive: correct positioning (baby's nose to the nipple, wide open mouth, asymmetric latch with chin deep in the breast); break suction with a finger before removing the baby; feed from the less sore side first, or express by hand for 24 to 48 hours if the pain is severe; air dry the nipple after feeds; apply a few drops of expressed milk to the nipple after feeds; purified lanolin or hydrogel dressings after feeds; change wet breast pads; avoid soap, alcohol and creams that need removal before feeds; fit pump shields correctly and use low suction.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) or ibuprofen 400 mg oral 8-hourly with food 30 minutes before feeds for 3 to 5 days; mupirocin 2 percent ointment applied in a thin layer after feeds 3 times daily for 7 days for a fissure with signs of bacterial infection; flucloxacillin 500 mg oral 6-hourly for 7 days for spreading cellulitis or fever; clindamycin 300 mg oral 6-hourly for 7 days in penicillin allergy; miconazole 2 percent cream thinly after feeds 3 to 4 times daily for 14 days only if burning pain with a pink shiny nipple suggests candidiasis.
• Procedures: frenotomy of the infant tongue tie by a trained provider when it limits tongue movement and causes poor latch; nipple shield (temporary) under lactation guidance.
• Special groups: infants with tongue tie or poor suck need assessment and frenotomy; women with diabetes need good glucose control and early treatment of infection; breastfeeding continues with these topical agents and antibiotics unless the wound is infected with herpes.
• Red flags: fever above 38.5 degrees Celsius, spreading redness, pus, grouped vesicles, fissure not healing after 3 weeks, nipple bleeding that is heavy, eczema like rash with skin change, infant with poor weight gain.
• Follow-up: review at 48 hours and 1 week; infant weight at 1 week; swab results; breast examination at 6 weeks; biopsy for nonhealing lesion.