Nipple Soreness is Not Normal

Headaches are common, but they are not normal. There are migraine clinics at most major hospital systems. Joint pain is common but certainly not normal. Orthopedists and rheumatologists are easy to find as well. But when breastfeeding hurts with potential sharp nipple pain, many new parents hear

“Your nipples just have to toughen up”

“It’s normal for the first 2 weeks”

“You’ll get used to it, and you won’t feel it as much”

False.

Body parts don’t hurt with normal use. Breastfeeding is normal. Nipple pain is not normal. Nipple pain can be solved. There is even a specialist for this: the International Board Certified Lactation Consultant.

When any part of the body is in pain, we want to address the symptoms we can immediately, discover the cause of the pain, and then address that root cause. Sometimes the root of the problem needs to be addressed with the adult, sometimes it’s the baby, and sometimes it’s both.

Parent-side problems

This could be bacterial or yeast. Yeast infection of the nipple is a common diagnosis, but newer research shows yeast isn’t often the culprit. (link: https://pubmed.ncbi.nlm.nih.gov/22758357/) Staphylococcus aureus has a creamy golden color that is easily mistaken for the creamy patches of candida associated with nipple thrush. This kind of nipple pain improves pretty quickly once the correct medication is used, often with symptoms reducing the same day. Full relief may take 1-2 weeks. If you are being treated for a nipple or breast infection and symptoms are not improving in 48 hours, it could be that the medicine you have been given does not treat the cause of the infection. Bacterial infections misdiagnosed as yeast are a common example of being prescribed the wrong medicine. Also, as antibiotic-resistant bacteria become more prevalent, some older medications may be less effective.

Inverted nipples are a variation of normal anatomy. There are different types of inversion and all types can function for breastfeeding. Deeply inverted nipples may experience tissue tearing when they evert or “pop-out” to feed the baby. This can be painful, like deep bruising, under the skin. Once the tissue is stretched to its maximum capacity, the tissue will begin to heal. It may take several days to weeks for the parent to experience full relief from this kind of nipple pain. 

This can commonly cause sore nipples. Babies will clamp down in response to having the back of their heads held or pushed. Babies wearing mittens or hand covers are shown to have a harder time opening their mouths wide. Swaddled babies, babies in tummy-up positions, and babies who are not in contact with the parent’s body all struggle to latch. These can all be avoided by keeping your baby tummy to tummy, baby’s forearms to parent’s chest, and giving baby space to control their head. Babies held toward the parent’s body by gravity have the best setup for latch.

Baby-side problems

The human mouth is designed for breastfeeding, however, not all babies are born with their mouths as expected. Most babies experience cranial molding or squeezing of the bones in the head and face during the birth process. This can happen from a long pushing phase, the use of forceps, cesarean birth, breech position, and many birth circumstances that happen every day. Many babies will round out and reshape when they are nursed often and held against their caregiver’s body skin to skin. Some babies take a little longer to recover from the birth process and may benefit from bodywork like physical therapy, chiropractic, cranial-sacral therapy, or osteopathy.
Sometimes babies are born with birth defects like a cleft palate, cleft lip, or tethered oral tissues that make breastfeeding and off-breast feeding more challenging. (link: https://pubmed.ncbi.nlm.nih.gov/30543756/) These oral structure defects are increasingly being recognized by parents and health professionals. Treatment options include surgical procedures, physical therapies, and feeding therapies. Babies with these structural defects will need “oral habilitation” to learn to feed before and after treatment. Working with an International Board Certified Lactation Consultant will give you a specific care plan for teaching your baby feeding skills. Habilitation exercises usually include things like sucking games, infant massage, and skin to skin time with caregivers.

Oral function is closely linked to oral structure. How the body part is shaped dictates how it moves. Babies with oral function problems are often very creative problem solvers. They develop movements called “compensations” to try to make feeding work for them. These compensations can be painful for the parent and the baby. Sometimes babies will stress and strain their facial muscles with compensations so much so that they have a trembling jaw after feeds. These babies can be very fussy.

Prematurity can be both a structure and function problem. Some babies are born before their feeding reflexes are fully developed. They may not have the nervous system development to feel the breast or food in their mouth. Fortunately, with modern technology, we are able to feed these babies and keep them healthy until they can grow and catch up. Most premature babies have a small mouth, making it challenging to open wide and latch to a full breast. Again, the miracle of growth over time will help work this out.

Frequently, there is a parent-side problem and a baby-side problem at the same time. That makes things exponentially harder. Basic nipple care starts out the same, no matter the underlying cause.

Basic first aid for sore and damaged nipples

1. Saline soaks: 1/4 to 1/2 teaspoon of sea salt or table salt to 8 ounces warm water. Make this solution and heat it to desired warmth. Place solution in a shot glass or teacup and invert over nipple. The saltwater will soothe pain, clean any wounds, and promote healing. Soak for about 10 minutes. Rinse afterward with fresh water.
2. Nipple ointment: Using some products can help soothe and repair dry or cracked nipples. Nipples with broken skin need to be kept moisturized to prevent scabbing. Do not air dry. Air drying causes the cracks to contract and then deepen the next time the breast is stimulated for milk removal. 
3. Coconut oil is vegetable-based, making it a good choice for vegan/ vegetarian families. Some families notice it absorbs very quickly causing rebound drying.
4. Olive oil is in most homes. Soaking a cotton ball in olive oil to wear in a bra can give it some staying power on the nipple surface.
5. All-Purpose Nipple Ointment by prescription only. This ointment contains 3 drugs: mupirocin, betamethasone, and miconazole. This product should only be used for 5-7 days to avoid thinning of the skin on the nipple. This is a lot of medicine at once and is usually more medicine than needed.
6. Medihoney is a medical-grade manuka honey for wound healing. It comes in gel or paste. It works well for deep wounds and prevents the dressing from sticking.
7. Lanolin is commonly given out in hospitals and clinics. While it has been implicated in mastitis infection risk, this is likely because of hand hygiene when using this product.
8. Commercial nipple ointments can have a variety of ingredients. Read the label and check for allergens.

Ideally, after nursing or pumping, apply the saline soak. Rinse, then apply nipple ointment. This will give the nipples a rest period to benefit from the treatment. This is basic wound care that can safely be repeated after feeds or pumps.

Watch a video on nipple healing: https://www.youtube.com/watch?v=VO0pETKUE_g

Danielle Downs Spradlin, MFA, IBCLC, CLC, BRMT, NOMAS

Danielle is the lactation consultant behind Oasis Lactation Services. She focuses on whole family wellness solutions for meeting your personal breastfeeding goals. She provides telehealth lactation support globally. Reach her at OasisLactationServices.com