Rockville Lactation

Lynnette Hafken, MA, IBCLC

Lactation Consultant

text (fastest response) or call: (240) 888-2123

email: [email protected]

se habla español

Nipple Pain

If you have not already, please review Positioning & Latch, since most causes of nipple pain can be attributed to a latch issue. However, there are other causes that should be explored if you continue to have pain.


Breast or Nipple Infections

Bacteria, fungi, and viruses are everywhere, and it is increasingly recognized that a healthy "microbiome" (the normal balance of microorganisms in and on your body) has a role in protecting people from disease. Both your nipples and your milk are colonized by healthy microorganisms, but sometimes pathological organisms can overwhelm this normal balance. This is called dysbiosis or infection. Some common types are fungal, bacterial, and viral infections. These require treatment from a physician, and in some cases both mother and baby should be treated. 


Current science on appropriate treatments for nipple infections can be found in the Academy of Breastfeeding Medicine's 2016 protocol on Persistent Pain With Breastfeeding, which you can print and share with your and your baby's doctor. 

Bacterial Infection

[under construction]

Although a number of studies have attempted to identify what, if any, microbe may cause persistent nipple/breast pain during lactation, the roles of bacteria and yeast remain unclear. Both Staphylococcus sp and Candida can be found on nipples and in breast milk of women with no symptoms.) Additional theories suggest a role for virulence traits that make detection and elimination of potentially causative microbes extremely difficult. These include biofilm

formation, consisting of bacteria alone24,25 (III, III animal/in vitro studies) or mixed species of Staphylococcus sp and Candida,26,27 (III, III animal/in vitro studies), as well as intracellular infection by small colony variants.28 (III animal/

in vitro studies)

1. Bacterial B Superficial bacterial infection in setting of skin trauma: Infection secondary to damaged skin, especially

around the nipple–areolar complex, is a common occurrence. Impetigo and cellulitis may occur alone or

concurrent with an underlying dermatitis.18

B Bacterial dysbiosis and lactiferous duct infection:

Bacterial overgrowth combined with biofilm formed

by bacteria (possibly in conjunction with Candida sp)

may lead to narrowed lactiferous ducts and inflamed epithelium. (III) A relatively constant, dull, deep

aching pain in both breasts is characteristic of this

inflammation as well as tenderness to palpation on

breast examination.29 (II-3) Milk flow and ejection

cause increased pressure and sharp shooting pain

during milk ejection and breastfeeding. Recurrent

blocked ducts, engorgement and oversupply, and

nipple cracks and fissures may also be associated with

this condition.30 (III)


Factors that are thought to predispose a woman to

developing dysbiosis and ductal infection include the

following:

- History of similar symptoms during prior lactations29

- Previous episodes of acute mastitis

- Nipple cracks or lesions29

- Recent treatment with antifungals and/or antibiotics

Judicious use of antibiotics is encouraged and so the

workup should include29 (Table 2) the following:

- Nipple and breast milk cultures

- Wound culture if crack/fissure present


Thrush

Thrush is an overgrowth of Candida albicans, a fungus which commonly resides in warm, moist environments. It is the same organism that causes yeast infections of the vagina and other body parts (jock itch, athlete's foot, ringworm).

Candida infection can affect the skin on the surface of the nipple, as well as the baby's mouth, and it has been proposed that yeast can enter the milk ducts causing a condition called "ductal thrush." It is often associated with infant oral thrush and diaper rash, other yeast infections (such as vaginal), and in mothers prone to yeast infections.


A yeast infection on the nipple skin typically shows the following symptoms: 

  • Pink nipple/areola area
  • Shiny or flaky appearance of the nipple 
  • Nipple pain out of proportion to the clinical findings
  • Burning nipple pain and pain radiating into the breast

Research on Candida infections inside the breast (ductal thrush) has shown conflicting results; the Academy of Breastfeeding Medicine states that “[d]espite the common perception that yeasts cause ‘candida mastitis,’ no scientific evidence exists to support this diagnosis…” (2016 protocol on Persistent Pain With Breastfeeding.) Mastitis (breast inflammation or infection) is discussed in a separate section

What to do: If you or your lactation consultant suspect you may have a bacterial or thrush infection, see your OB, who will probably prescribe a topical cream that is safe for your baby. Your baby should also be treated to avoid passing the infection back and forth, and in some cases. In severe cases, oral medicine might need to be given. See the protocol for recommendations to share with your doctor.

Viral Infection

Viruses such as Herpes Simplex and Herpes Zoster can cause lesions on the nipples. Avoid breastfeeding or giving pumped milk until the lesions have cleared.


Dermatosis

Eczema and psoriasis can affect nipples and the surrounding skin. An emollient can be used to keep the skin supple and reduce discomfort due to dryness. Additional medical help may be required. Contact dermatitis can result from irritants such as fragrances, rough clothing, nipple ointments, and allergic reactions (some mothers react to residues of solid food in their babies' mouths).  


If the skin becomes broken or fissured, infection can set in, which would also need to be treated. See your doctor if you notice weeping, yellow crusting, blisters, or swelling.


Damage to Nipples/Areolas

Baby:

  • shallow latch (most common)
  • biting
  • tongue tie

Breast pump injury: 

  • suction is too high
  • flange (cone-shaped part that goes on your breast) doesn't fit well
  • nipple is off-center while pumping (often happens at night or when tired)
  • abrasion - try lubricating flange with nipple ointment or olive oil
  • pumping for too long (>20 minutes)




Blebs/Milk Blisters



Vasospasm



Allodynia/Functional Nipple Pain

The Academy of Breastfeeding Medicine uses this term for “the sensation of pain in response to a stimulus, such as light touch, which would not normally elicit pain.” There is little known about the physical source of this pain, but the ABM states that it sometimes co-occurs with other chronic pain conditions such as irritable bowel syndrome (IBS), fibromyalgia, interstitial cystitis, migraines, temporomandibular joint disorders (TMJ), and pain with intercourse—or just by itself. 


Research shows that people with chronic pain who are also experiencing depression, anxiety, or other distressing psychological symptoms have a less effective response to treatment; so although you are experiencing real physical pain that no one should imply is “all in your head,” treatment for psychological symptoms can improve your physical response to treatment.