Nipple Care Solutions
When breastfeeding is painful it can transform nursing from an enjoyable bonding experience into a tortuous act of self sacrifice. This is evidenced in studies demonstrating that continuing to breastfeed through chronic pain is linked to an increased risk of developing postpartum depression (1), whereas when breastfeeding is going well it is actually protective of a mother's mental health and reduces the incidence and severity of postpartum depression (2).
Below are some common conditions that can cause nipple pain and strategies for healing. Please also seek care from a Lactation Consultant, Breastfeeding Medicine Doctor, or dermatologist for any health concerns you have, especially if you notice signs of bacterial infection including red streaks, oozing/pus, or fever.
1) Mild Soreness
Causes: Mild nipple discomfort is common during the first week of breastfeeding, typically peaking on day 3 postpartum and resolved by day 7. "Normal" nipple soreness feels like mild irritation or chapping and does not cause toe-curling pain. There is no injury to the tissues and minimal pinkness or discoloration is present. As mother's milk production transitions from colostrum to mature breastmilk, nipple irritation tends to improve on its own.
Solutions: Practice getting a deep latch breastfeeding. For mild nipple soreness, breastmilk can be expressed to the surface of the nipple and allowed to absorb into the irritated skin. Soothing hydrogel-pads can also be worn in between feeds.
Rationale: In studies, expressed breastmilk and/or hydrogel pads were effective for healing mild nipple irritation (3). We do not recommend lanolin due to the increased risk of developing infections and allergic dermatitis, and its messy/goopy application (4).
2) Nipple Trauma
Causes: Nipple trauma is the injury of the nipple due to compression or abrasion from baby's incorrect latch/suck or misaligned pump flanges. The nipple may appear more pink or light colored than normal for mother's skin tone and may have cracks, bleeding, scabbing or missing tissue. Once cracks are present, there is greater risk of bacteria entering the fissures. Addressing baby's latch and/or ensuring proper pump fit is essential to resolving nipple trauma. Nipple injury is never a normal part of breastfeeding and the underlying cause of the nipple trauma should always be addressed.
Address the underlying cause of the nipple trauma during a Lactation Consult.
Apply a thin coating of NipDip* or MediHoney to nipples at least three times a day after breastfeeding using clean fingertip or a q-tip. There is no need to wipe off before next feed as both are considered safe for infant consumption.
If open wounds/cracks are present, wash the area with gentle soap and warm water once a day to help prevent infection.
Optionally, soak the area in epsom salt/saline water once a day. This is especially helpful if there is scabbing. Some women will do this using a silicone pump or bowl filled with water. If using epsom salt, dissolve 2 tablespoons of epsom salt into 8 oz of very warm water. For a saline soak, dissolve 1/2 teaspoon of table or sea salt in 8 oz of very warm water. The packets that come with NetiPot rinses can also be used.
Optionally, consider wearing Silverette shells, which have natural anti-fungal and anti-bacterial properties and prevent painful friction from bra/pads.
Schedule an appointment with a physician if there is oozing/pus, red streaks, or mother develops a fever.
Rationale: Moist wound healing allows skin to heal 50% faster than keeping the area dry. Manuka honey has been shown to promote skin regeneration, moist wound healing, and prevent infection (5). However, it is critical that any honey that may come in contact with baby be medical grade, which ensures it has gone through a sterilization process to make it safe for baby. Our two favorite topical treatments for nipple trauma, NipDip* and MediHoney, both contain medical grade manuka honey. We prefer this to a commonly prescribed treatment called All Purpose Nipple Ointment, which contains a mix of antibiotic ointment, steroid cream, and anti-fungal cream. It is our observation that in no other medical situation are a combinations of antibiotics, antifungals and steroids prescribed without having a bacterial and fungal diagnosis warranting it. Instead of applying multiple treatments to a skin injury, we prefer to target specific treatments to specific diagnosis.
Causes: Thrush is a fungal infection caused by overgrowth of Candida albicans yeast. Women are at higher risk of developing thrush if they have history of vaginal yeast infections or have had antibiotic treatment in the past month. When antibiotics are used, it creates an empty space in the microbiome that are likely to filled by predatory bacteria and fungus. This can lead to a thrush/yeast infection. The hallmark of thrush is an itchy, burning sensation on mother's nipples and white patches on baby's tongue, palate and cheeks. This appears differently than the thin white coating of milk that transiently appears after feeds. Sometimes the nipples appear pink or flakey. It can be tricky to distinguish thrush from other skin conditions, so careful detective work to rule out dermatitis and nipple trauma is critical. Thrush is less common than the other conditions described in this article and it tends to be overdiagnosed (6).
Wash breasts with warm, soapy water once a day. Sanitize pump parts, bottle nipples, and pacifiers once a day until thrush resolves. Wash bras in hot water.
Use disposable breast pads, changed each time they become damp, until thrush resolves. Thrush thrives in damp conditions. Or, consider wearing Silverette shells, which have natural anti-fungal and anti-bacterial properties and prevent friction from bra/pads.
Apply NipDip* or coconut oil after breastfeeding, three times per day. (Both have natural anti-fungal properties.)
Mother can take a high powered women's probiotic to help shift her microbiome to healthy flora and help prevent the recurrence of yeast infections. Baby can take a high powered infant probiotic such as Evivo.
For a mild case (no white patches on baby's cheeks or palate, only slight itching/burning for mother) home remedies can be tried. This includes using a cotton ball to apply 50% diluted vinegar to nipples after each feed followed by either coconut oil or NipDip.
For a significant case (visible white patches in baby's mouth, significant burning or itching for mother and visible nipple rash) then prescription treatment is likely warranted. For mothers, we recommend discussing a 10 day course of fluconazole (100mg/day) with your OBGYN/midwife. For infants, discuss treatment options with the pediatrician. Be aware that while fluconazole has an almost 100% success rate at treating thrush, nystatin and topical creams only have a 32% efficacy rate.(7)
Rationale: Many over the counter treatments commonly prescribed for vaginal yeast infections are not effective for breastfeeding related yeast infections and contain ingredients that were not tested for oral consumption of the infant. For this reason we prefer natural treatment options combined with fluconazole when needed. Another poplar remedy, Gentian Violet, is often confused for a natural treatment option but in fact is a chemical dye named for its purple color; it is considered carcinogenic and can cause skin ulcers and permanent stains; for this reason we prefer to avoid it.
4) Dermatitis & Eczema
Causes: Women can develop dermatitis on their breast or nipples, just as can happen to any other area of skin. Usually these rashes appear raised, red and itchy. Dermatitis is more likely to develop in women with sensitive skin or allergies. It could be a reaction to a soap, lotion, nipple ointment, foods from baby's mouth/saliva, clothing detergents, breast pads, or even the plastic of pump flanges (8).
If dermatitis is suspected, discontinue all topical products (ointments, soaps, vinegar, etc) mother has been using for a few days to sort out the possible reaction. Lanolin is one of the most common causes of breast eczema, especially in women sensitive to wool (lanolin is made from sheep fat). Switch to hypoallergenic clothing detergents and discontinue using soap on breasts.
Assuming mother has not been using coconut oil up to this point (or has taken a few days off of it to ensure it is not the cause of her dermatitis), begin applying NipDip* about three times a day to promote skin healing.
Once other possibilities have been ruled out, consider reactivity to the plastics of pump flanges (this is fairly unusual but happens). Try using silicone flange inserts that cover the part of the breast/nipple with dermatitis.
Schedule an appointment with a dermatologist if rash persists.
Rationale: Sometimes what began as a bit of nipple soreness turns into dermatitis when mothers start applying all kinds of ointments, soaps and topical medications to their breasts. This can create uncomfortable rashes that are only further exacerbated by continuing to apply harsh or reactive "treatment" to the nipples.
5) Nipple Blisters/Blebs
Causes: Nipple blisters/blebs may develop as a result of repeated friction, compression or dysbiosis. The hallmark is excruciatingly painful small blister(s) appearing as bumps on the nipple, covering milk pores. Often plugged ducts occur in conjunction with blebs if the milk pore is being covered/blocked by the blister.
Follow the same suggestions as the nipple trauma section, including addressing infant's latch.
Soak the affected nipple in a saline solution once a day (a long shower or bath may also be substituted). If using epsom salt, dissolve 2 tablespoons of epsom salt into 8 oz of very warm water. For a saline soak, dissolve 1/2 teaspoon of table or sea salt in 8 oz of very warm water. The packets that come with NetiPot rinses can also be used. After soaking, use a clean washcloth to gently exfoliate the nipple. After the soak and washcloth exfoliation, immediately pump or breastfeed. If the blister lifts, apply a thin coat of antibiotic ointment or NipDip* until fully healed.
If blister is not resolving with home treatment, schedule an appointment with a Breastfeeding Medicine Doctor who may be able to lift the blister with a sterilized needle.
If no known nipple trauma has occurred or blebs are persistent, take a women's probiotic as some cases may be caused by dysbiosis. If the issues persists, request a skin culture by a Breastfeeding Medicine Doctor, dermatologist, or OBGYN as antibiotics may be warranted.
Rationale: Just as friction blisters on your foot may occur from shoes that rub the skin repeatedly, the same may occur if the mechanics of baby's latch are causing repeated injury; to prevent recurrence of friction blisters it is essential for baby's latch and oral function to be thoroughly assessed. Blisters can also occur as a result of breast dysbiosis(9) - this is most likely when the blisters are recurrent and happen in the absence or any latch or suck problems. Some studies indicate targeted probiotics(10) may help resolve breast dysbiosis, but at times a culture to assess for antibiotic sensitivity may be needed.
6) Pump Related Discomfort
Causes: If the incorrect flange size is used, nipple and areola discomfort may occur. The areola may appear puffy and may have a visible ring around it after pumping. Excessive vacuum suction can also exacerbate this problem.
Flange diameter should be closely matched to nipple diameter, with no more than 1mm air space around the nipple in the flange tunnel before pumping. Ideally, areola should not be pulling into the tunnel. Try measuring your nipple diameter using a mm ruler and order flanges the same size or 1mm bigger.
Ensure nipple is centered in flange. Consider lubricating nipples with an oil based balm before pumping.
Use the maximum vacuum setting that is comfortable. On a Spectra, vacuum setting 4-8 is usually adequate.
While we hope the above information is useful as you start sorting through any nipple pain you may be experiencing, please also consider seeking help from a Lactation Consultant, Breastfeeding Medicine Doctor, or dermatologist. Breastfeeding should not be painful or cause nipple injury. Finding the underlying cause and targeted solutions can help you and your baby experience a positive breastfeeding relationship for many months to come.
Mamas in the north Charlotte and Lake Norman area, we encourage you to setup a home visit so we can help you address these issues. If you are out of our travel area, you can setup a virtual consult with us or google "lactation consultant near me" to find local help.
*NipDip is also available for pick-up from our office 7 days a week.
3) Milk Therapy: Unexpected Uses for Human Breast Milk, Nutrients 2019
4) Comparing the Use of Hydrogel Dressings to Lanolin Ointment With Lactating Mothers, Journal of Ob, GYN, and Neonatal Nursing 2006
4) Does Lanolin Use Increase the Risk for Infection in Breastfeeding Women?, Clinical Lactation 2014
5) Honey-Based Templates in Wound Healing and Tissue Engineering, Bioengineering 2018
6) Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women, Women's Health Journal, 2021
7) Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants, The Pediatric Infection Disease Journal 2002
8) Nipple and areolar eczema in the breastfeeding woman, Journal of Cutaneous Medical Surgery 2004
9) Mammary Dysbiosis and Nipple Blebs Treated With Intravenous Daptomycin and Dalbavancin, Journal of Human Lactation 2019
10) Mammary Dysbiosis, Clinical Lactation 2018