Introduction
The best treatment of sore nipples is prevention. The best
prevention is latching the baby on properly from the first
day.
Sore nipples are 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. Incidentally,
babies learn to suck properly by getting milk from the
breast when they are latched on well. (They learn by doing).
Fungal infection (due to Candida albicans), may also cause
sore nipples. The soreness caused by poor latching and
ineffective suckle hurts most as you latch the baby on and
usually improves as the baby nurses. The pain from the
fungal infection goes on throughout the feed and may
continue even after the feed is over. Women describe
knifelike pain from the first two causes. The pain of the
fungal infection is often described as burning, but may not
have this character. Sudden, unexplained onset of nipple
pain when feedings had previously been painless is a tipoff
that the pain may be due to a yeast infection, but the pain
may come on gradually or may be superimposed on pain due to
other causes. Cracks may be due to a yeast infection.
Proper Positioning and Latching
It is not uncommon for women to experience difficulty
positioning and latching the baby on. Proper positioning
facilitates a good latch and good latching reduces the
baby's chances of becoming "gassy", and also allows the baby
to control the flow of milk. A lot of what follows under
latching comes automatically if the baby is well positioned
in the first place. Thus, poor latching may also result in
the baby not gaining adequately, or feeding frequently, or
being colicky (Handout #2 "Colic in the Breastfed Baby).
Positioning
For the purposes of explanation, let us assume that you are
feeding on the left breast. At first, it may be easiest to
use the cross cradle hold to position your baby for latching
on. Hold the baby in your right arm, the web between your
thumb and index finger behind the nape of his neck (not
behind his head) with your fingers (except for the thumb)
supporting the baby's face from underneath, and your forearm
supporting his back and buttocks. Hold the baby's buttocks
between your chest and your forearm—this should give you
good control. The baby should be almost horizontal across
your body and should be turned so that his chest, belly and
thighs are against you with a slight tilt 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 handout on
positioning and latching on)
Latching
1. The way to do get the baby to open his mouth wide is to
run your nipple, still pointing to the roof of the baby's
mouth, along the baby's mouth, very lightly, 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. WAIT FOR HIM. As you
bring the baby toward the breast, his chin should touch your
breast first.
2. When the baby opens up his mouth, use the arm that is
holding him to bring him 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. If he
cannot breathe, he will pull away from the breast. Don't be
afraid to be vigorous.
3. If the nipple still hurts, use your index finger to pull
down on the baby's chin in order to bring the lower lip out.
You may have to do this for the duration of the feed, but
this is usually not necessary.
4. The same principles apply whether you are sitting or
lying down with the baby or using the football hold. Get the
baby to open wide, don't let the baby latch onto just the
nipple, but get as much of the areola (brown part of breast)
into the mouth as possible (not necessarily the whole
areola).
5. There is no "normal" length of feeding time. If you have
questions, call the clinic.
6. 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 suckle
The baby learns to suckle properly by nursing 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 (Handout #8 Finger Feeding) may help.
"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 may even blanch
again. The cause would seem to be a spasm of the blood
vessels 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?
1. Pay careful attention to getting the baby to latch onto
the breast properly. This type of pain is almost always
associated with, and probably caused by whatever is causing
your pain during the feeding. The best treatment is the
treatment of the other causes of nipple pain.
2. Heat (hot washcloth, hot water bottle, hair dryer)
applied to the nipple immediately after nursing may prevent
or decrease the reaction. Dry heat is usually better than
wet heat, because wet heat may cause further damage to the
nipples.
3. On occasion, we have had to use a medicated paste
(nitroglycerine) or an oral medication (nifedipine) to
prevent this type of reaction.
General Measures
l. Nipples can be warmed for short periods of time after
each feeding, using a hair dryer on low setting.
2. Nipples should be exposed to air as much as possible.
3. When it is not possible to expose nipples to air, plastic
dome-shaped breast shells (not nipple shields) can be worn
to protect your nipples from rubbing by your clothing.
Nursing 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
shell.
4. Ointments can sometimes be helpful. If you do use an
ointment, use just a very small amount after nursing and do
not wash it off.
5. Do not wash your nipples frequently. Daily bathing is
more than enough.
6. 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. It will help to compress
the breast (Handout #15 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 (Handout #5 Using a Lactation Aid) can be used to
supplement (preferably expressed milk), so that the baby
will finish the feeding on the first side.
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. Use the
technique called "finger feeding" (Handout #8 Finger
Feeding) or cup feeding.
Nipples shields are not recommended for sore nipples,
because, although they may help temporarily, they usually do
not. They may also cut down the milk supply dramatically,
and the baby may become fussy and not gain weight well. Once
the baby is used to them, it may be impossible to get the
baby back onto the breast. In fact, many women who have
tried nipple shields find that they do not help with
soreness. Use as a last resort only, but get help first.
Handout #3. Sore Nipples. Revised January 1998
Written by Jack Newman, MD, FRCPC
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