Sore Nipples

When it comes to nipple pain, it doesn’t do any good to “soldier through” the pain by ignoring it.  Pain is a warning signal our bodies give that something isn’t right.  No matter what you may have heard, it is not normal for breastfeeding to hurt.  If it was, we wouldn’t have survived as a species because, like other mammals, most mothers will not continue to breastfeed through pain.  Until just a hundred years ago, unless there was another lactating woman nearby who was willing to help, there were few options for feeding a baby who couldn’t feed from his own mother.

Fortunately, in most cases, breastfeeding can be made comfortable by finding out what the problem is and fixing it.  It may be that baby is simply being brought to breast in a way that does not allow him to latch deeply.  If that is the case, a deeper latching technique should help get things back on track.  If it doesn't, the pain could be caused by one of the baby-related problems, which will require the help of a lactation consultant and your pediatrician to determine and treat. 

Sometimes it isn’t possible to get a completely pain-free latch because the nipple tissue is so abraded and sensitive that any touch is painful.  In these cases, it is important to help the tissue heal as quickly as possible.  The first step in doing this is to wash the wounded nipple gently twice a day with a mild, non-antibacterial soap (anti-bacterial soap is very drying and irritating) and water, rinsing well, as one would care for any wound.  Although purified lanolin has been shown to be safe for babies and is commonly recommended for treating sore nipple, research has shown that a mother’s own milk, gently rubbed into the wound, is just as soothing and actually accelerates healing better.(1), (2) In addition to purified lanolin, there are many creams and ointments that are marketed for soothing and healing sore nipples.  Even though they may be advertised to be safe for breastfeeding, some ingredients can be toxic or trigger allergic reactions when babies ingest them.  Vitamin E, in particular, can be toxic to your baby. 

Some mothers find that water and glycerin based hydrogel dressings designed specifically for nipple healing, such as Ameda’s ComfortGel™ hyrdogel pads, Maternimates™, Mothermates™, and Soothies™, are very soothing to traumatized nipple tissue and accelerate healing,(3) using the same wound-healing technology used by hospitals.  The high water content in hydrogel pads also has a cooling effect that provides pain relief.  Unlike hydrogel dressings designed for wounds elsewhere on the body, these special products can be removed several times a day to allow breastfeeding without disrupting the healing process.  If you use hydrogel dressings to help soothe and heal your sore nipples, it is important to avoid touching the nipple and areola area with your hands just before applying them, which includes massaging your milk into your nipples, because your hands can introduce bacteria and fungus that is trapped under the dressing and could result in a bacterial or fungal infection.(4)

If your nipples do not heal in a few days, they may be infected with bacteria or yeast, which will require a prescription topical ointment that is safe for breastfeeding.  Most do not need to be removed prior to feeding and may also contain a small amount of steroid to further accelerate healing.(5), (6), (7), (8), (9)   Dr. Jack Newman recommends an ointment containing a combination of three ingredients that seems to help for many causes of sore nipples, including poor latch, yeast or bacterial infections, and dermatologic conditions. The ointment, which he calls the “All-Purpose Nipple Ointment” is not available as a pre-packaged product, but can made up by prescription at a compounding pharmacy.  There are also over-the-counter substitutions for each ingredient, which may not be quite as effective, but may work well for most mothers. 

This combination of prescription antibacterial, steroid, and anti-fungal ointments or creams, with over-the-counter substitutions, is also described in a case report by Janice Porter, RD, MPH, IBCLC, and Barbra Schach, RN, BSN, IBCLC about their work in a breastfeeding clinic at the University of California, Davis, Medical Center in Sacramento, California.(10)

Dr. Newman recommends mixing all ingredients and applying as a single ointment.  Janice Porter and Barbra Schach have a different approach, suggesting that mothers use only the ointment or cream that they feel targets the problem they are having.  For example, the antibiotic is used when there is a suspected bacterial infection, the steroid is used when the nipple tissue is irritated and to speed healing, and the anti-fungal is used when there is a suspected topical yeast infection.  Of course, it is often hard to know if the infection is bacterial or fungal (they also can happen together), and irritation almost always accompanies infection, so it may be necessary to use two or all three ingredients at the same time.  If you have an allergic skin reaction to the combined ingredients, using them individually at least once should help you determine the culprit.

The ointments and creams should be applied in very small amounts so that they are fully absorbed into the skin and there is no noticeable residue (although the tissue will appear to be moisturized), 3-4 times a day for up to 14 days. (11)   In most cases, the active ingredients in these ointments and creams are fully absorbed by the time of the next feeding, so it is not necessary to wipe them off prior to breastfeeding even if there is residue.  In fact, the abrasive action of removing them can disrupt the healing of delicate tissue in a way that breastfeeding normally does not, with the exception of shallow latching and tongue restriction.

If breastfeeding is simply too painful to bear and the wounds never heal because they reopen each time baby breastfeeds, it may be beneficial to take a short 2-3 day break from breastfeeding to allow your nipples to heal.  During this time, baby can be fed away from the breast.  It will be important to keep your milk production up by expressing milk as often as baby would feed by hand expressing or using a high-quality pump, preferably rental-grade, which will be less traumatic for your wounds than a lower quality pump.   This will also provide milk for your baby, even if you also need to give formula.  If you like, you can nurse your baby once or twice each day to keep the connection going.  If that idea is painful to you, wait until your nipples are better healed before nursing.