Traumatic Nipple Injury

Traumatic nipple injury is damage to the nipple or areola from a physical cause, including blisters, bruises, abrasions, burns and tears. Common causes are breast pump suction and ill-fitting shields, infant biting, tongue tie, vigorous manual expression, prolonged feeding, tight clothing and the use of creams or herbs that irritate. It matters because the injury causes severe pain, bleeding and infection, and leads to early weaning.

• Risk factors: electric pump use at high suction, wrong shield size, tongue tie, infant teething, rough expression, poor latch, thin or dry skin, topical herbal applications.
• Pump related injuries often appear as a white or bruised ring or a blister.
• Healing takes 3 to 10 days with rest and protection.

Women have pain that starts during or after feeding or pumping, with visible blisters, bruising, blanching, abrasion, erosion or bleeding of the nipple, and sometimes swelling of the nipple tip. The nipple may look pale then purple after a feed.

• Bruised or blistered nipple with a clear border.
• Pain on contact with clothes and during feeds.
• Differential diagnosis: nipple fissure, cracked nipple, nipple vasospasm, nipple candidiasis, herpes simplex, contact dermatitis, eczema, impetigo, milk blister.
• Complications: bacterial infection, mastitis, scarring, nipple deformity, loss of milk supply, early weaning, chronic nipple pain.

The diagnosis is clinical, with a review of the cause of the injury.

• Inspect the nipple and areola before and after a feed or pump session, noting shape, colour, blisters, abrasion and bleeding.
• Review pump settings, shield size and duration of use; observe the latch; examine the infant's mouth for tongue tie and teeth.
• Swab for culture if pus or crust; viral swab for grouped vesicles; temperature and breast examination.
• Biopsy any nipple lesion that does not heal in 3 weeks.

The principle is to remove the cause, rest the injured nipple and promote healing.

• Supportive: stop the injurious action (reduce pump suction to the lowest effective setting, fit the correct shield size, limit sessions to 15 to 20 minutes); rest the injured nipple for 24 to 48 hours by hand expressing or pumping on the other side while feeding from the unaffected breast; resume feeds when pain settles, starting with short feeds; hydrogel dressings or purified lanolin after feeds; cold compress for 10 minutes for swelling; change wet pads; avoid herbal and chemical applications.
• 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; mupirocin 2 percent ointment applied thinly after feeds 3 times daily for 7 days for an open wound; flucloxacillin 500 mg oral 6-hourly for 7 days for cellulitis or fever; clindamycin 300 mg oral 6-hourly for 7 days in penicillin allergy.
• Procedures: unroofing of a large blister with a sterile needle after warm soaking; frenotomy of infant tongue tie; fitting of the correct pump shield by a lactation consultant.
• Special groups: infants who bite or have tongue tie or poor suck need assessment and frenotomy; women with diabetes need early treatment of infection; breastfeeding is compatible with the topical and oral agents used.
• Red flags: fever above 38.5 degrees Celsius, spreading redness, pus, grouped vesicles, nipple turning dusky or necrotic, heavy bleeding, wound not healing by 3 weeks, infant not gaining weight.
• 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.