Nipple pain is the second-most-common reason for mothers discontinuing breastfeeding.

96% of women in a cohort of 100 experienced sore nipples in the first week and the majority described their pain as moderate to intense.

Causes

  • Nipples are normally tender in the first days after breastfeeding starts. Expect tenderness at the beginning of a breastfeed up until about day 7–10 post-birth with peak tenderness between days 3 and 6. Pain extending into the breastfeed is not normal. Continued nipple pain after 10 days is not normal.
  • Poor positioning and attachment of the baby on the breast.
  • Engorged or too full breasts where the baby is unable to latch easily.
  • When the baby has a tongue tie – a short frenulum may cause damaged nipples due to the baby’s sucking but in some cases the frenulum stretches and difficulties resolve. Approximately up to 5% of babies are reported to be affected.
  • Vasospasm of the nipple – blanched nipple caused by a Raynaud’s-type phenomenon.
  • Infection in the nipple/areola region may cause tenderness without obvious damage being present.
  • Milk blisters – a blocked nipple pore.

Treatment

  • Depends on the cause. There may be multiple factors involved.
  • Reassure mothers about normal tenderness.
  • Assess position and latch and baby’s tongue and oral anatomy or refer to a lactation consultant for assessment.
  • Refer to a supportive paediatrician for treatment of tongue tie if necessary or to a lactation consultant to confirm diagnosis.
  • Treat the nipple infection – check for thrush, use Mupirocin (Bactroban) for staphylococcal infections. Mupirocin is antifungal and antibacterial.
  • Vasospasm of the nipple – the latch and positioning require checking. Exposure to cold should be avoided and warmth may be applied to the breasts. Caffeine and nicotine exposure can exacerbate the condition. Nifedipine 30 mg orally once a day for 2 weeks has been reported as being effective. Ibuprofen may also be useful.
  • Ibuprofen may be useful in all cases of nipple pain apart from the normal early tenderness.
  • If a milk blister is diagnosed (a nipple pore that has been sealed over by the epidermis with milk enclosed and sometimes referred to as a bleb) it is difficult to remove with either expressing or with a baby feeding. Advise to apply moist warmth prior to a feed and try breast compression. If the area does not spontaneously heal by the peeling away of the epidermis then a sterile needle may be used to break the seal. Ibuprofen may be useful.

See also Information on how to treat a milk blister (KellyMom website).