Sore Nipples in the Early Days of Nursing

on February 19, 2014 in Breastfeeding, Sore Nipples

Many mothers experience some degree of soreness in the early days of nursing.  While some tenderness may be considered normal, seeing signs of irritation, or worse, seeing reddened areas, bruising, or broken skin is a sign of a poor latch technique or a result of a nipple that is in some way out of the ordinary, or due to some abnormality in the baby’s mouth.

Getting a great latch is so important and mothers will do best when observed and taught the optimal way to help the baby onto the breast.  Unfortunately, not all hospital professionals understand what a good latch means and just seeing the baby nursing does not tell the whole story! Evaluating the latch means it needs to be observed before the baby is actively on the breast and sucking.  I have had hundreds of mothers with injured nipples tell me that everyone they had see them nurse said the latch was fine when in fact it was not!  A good latch means that the baby is turned onto his side and is lifted to breast level often by the use of a pillow.  Allowing the baby to self-latch may mean the baby may not attach far behind the nipple especially when mothers have “easy” nipples that protrude well.  A good latch is one that is “off-centered”, meaning that the baby should take in more of the breast below the nipple than above.  It is the baby’s bottom jaw that compresses the nipple against his palate and may cause nipple damage, so if the nipple is centered in the baby’s mouth, the nipple is more likely to be compresses often leading to soreness and in may cases, injury.

Holding the baby’s head with the opposite arm and behind and below his ears, will allow you to guide the baby onto the breast quickly when he opens wide. The baby’s nose, not his mouth, should be close to the nipple, lining up the nipple just above his upper lip with his head slightly tipped backward so that the chin reaches the breast first.  The breast should be compressed just across from where the baby’s nose and chin will land.  It should be compressed the entire time while bringing the baby into the breast.  This will help the baby get more of the breast deeply into his mouth.

With all of this description, actually seeing it may be even more helpful.  There is one video that demonstrates a good latch and the technique that I have described.  Watching them a few times and perhaps with your partner can help sort out minor issues with the latch can help make nursing much more comfortable.  My favorites include Dr. Jane Morton from Stanford University at http://newborns.stanford.edu/Breastfeeding/FifteenMinuteHelper.html You can click on “A Perfect Latch” and watch a wonderful session on getting a baby latched well and pain-free.

Once your milk has come in, you may want to express a little milk to soften the area around the nipple for a good latch.  You can do this by hand or by using a pump for a few minutes.

A good latch may be more difficult to achieve if your nipples are flat or inverted.  You may want to pay special attention to getting the nipple to stand out a bit more by expressing milk by hand or with a pump, especially if your breasts are full.  Remember that the baby does not truly latch onto the nipple but to the area behind the nipple.

If you are reading this and you are already experiencing sore or injured nipples, you may find that you can achieve more comfortable nursing by latching the baby using the techniques described or shown above.  If you can’t, and nursing is simply too painful, there is no reason that you can’t pump for a day or two and feed your baby using another method, including a bottle or spoon.  If you decide to pump your milk, you will want to use a good double pump that has good suction every 2 ½ to 3 hours around the clock to bring in and maintain high milk volumes.  A three day old baby needs about one ounce per feeding.  A four day old needs about 1 ½ ounces per feeding and thereafter most average sized babies need about 2 ½ to 3 ounces per feeding.

If you are struggling with injured, painful nipples, it may be best to have a consultation with an IBCLC, which is an International Board Certified Lactation Consultant.  If you don’t know of one, you can find a local IBCLC by going to ILCA.org and scroll down on their home page to “Find a Lactation Consultant”.  Aside from a latch issue, a lactation consultant may also be able to help identify other issues that may be contributing to nursing soreness and injury.  For example, a baby may be tongue-tied causing nipple pain in addition to a poor latch.  Most insurance carriers are mandated by “The Affordable Care Act” to cover breastfeeding help.  If you are a WIC participant, many WIC programs have lactation help there as well.

Some mothers turn to using a nipple shield to nurse with injured nipples.  This may or may not help with painful nursing and since there are different sizes of shields, they may not allow for good milk transfer and could jeopardize your milk supply and compromise how much milk the baby is getting at each feeding.  I would only suggest using these if you are under the care of a lactation consultant.

Some mothers use soothing gel pads, but one study showed more cases of mastitis after using these as compared with the use of ointments as well. Other studies have found that the use of tea bags or expressed breast milk rubbed into the nipple does little to heal nipples.

Treating damaged nipples in recent past decades has meant using “moist wound healing” rather than drying measures.  And this usually means using some sort of ointment.  Many mothers use lanolin. It is believed that purified lanolin creates an air-permeable temporary skin barrier, and has been demonstrated to have anti-inflammatory, antimicrobial, skin-protecting, and barrier repair properties.  Some mothers prefer using coconut oil for tender or injured nipples.  Coconut oil is believed to be a natural antimicrobial, anti-fungal and anti-inflammatory substance.

It is VERY important to do thorough hand washing before nursing and when using any product on injured nipples! Dirty fingers applying anything to tender, raw nipples is asking for trouble.  Thorough hand washing before touching the nipples is a must!

Many lactation professionals now recommend washing the nipples in the daily shower with a mild soap, nothing antibacterial. Using Polysporin twice a day for one or two days along with as rinsing the nipples in clear water can help prevent biofilms from forming. A biofilm is a group of microorganisms in which cells stick to each other and encourage infections to develop, which can be more difficult to treat.

One of my personal favorite nipple ointments for healing sore or injured nipples is Mother Love’s Nipple Cream that contains a few healing herbs, contains no lanolin and has a soft, buttery consistency.  Mother Love’s Nipple Cream includes extra virgin olive oil, beeswax, shea butter, marshmallow root, and calendula flower for their healing properties.

Several years ago, two Canadian Pediatricians did a study on mothers who had injured nipples past 5 days after giving birth. They found that about 75% of mothers with cracked, wounded nipples went on to develop mastitis, a breast infection.  They strongly suggest that wounded nipples be treated with oral antibiotics not only to prevent getting mastitis, but to speed the healing of open nipples.  When nipples are cracked or obviously injured, bacteria from surrounding skin and hands slow the healing process.  So if you are beyond 5 days post partum and are suffering with injured nipples, it may be best to speak with your midwife or OB about getting antibiotic treatment.

Another ointment recommended for sore, injured nipples is known as “APNO”.  This nipple ointment is also known as the “all purpose” nipple ointment and was developed by Canadian Pediatrician, Dr. Jack Newman.  It was developed to treat nipple soreness or injury stemming from any number of underlying causes including bacteria, yeast and inflammation.  This ointment needs to be mixed by a pharmacist usually in a compounding pharmacy.  It also needs to be ordered by a midwife or physician.  It contains the antibiotic, 2% Bactroban, which is helpful in destroying many bacteria, especially Staphylococcus aureus which is commonly found in injured nipples.  It may also have some effectiveness against yeast.  The second ingredient is 1% Betamethasone ointment, a corticosteroid which decreases inflammation.  It is well absorbed into the skin and the baby will not take in very much at all.  The final ingredient is 2 or 3% Miconazole powder, an effective ingredient against yeast, Candida albicans.  Miconazole cream or gel should not be used in this mixture as this can cause separation of the mixture.

Dr. Newman writes the prescription this way

1.  Mupirocin ointment 2%: 15 grams

2.  Betamethasone ointment 0.1%: 15 grams

3.  To which is added miconazole powder to a concentration of 2% miconazole

Total: about 30 grams combined.  The mixture is to be used sparingly after each feeding and not wiped or washed off prior to nursings, although rinsing both nipples after nursing and before applying the ointment is still recommended by lactation consultants.

Another treatment now being used to treat injured nipples is ‘medical grade’ Manuka Honey, which has been irradiated to destroy any botulism  spores and therefore is safe to use while nursing a newborn.  Manuka honey comes from New Zealand and is well known for its healing properties.  This honey protects against the damage caused by bacteria and also stimulates the production of special cells that can repair tissue damaged by infection. In addition, honey has an anti-inflammatory action that can quickly reduce pain and inflammation once it is applied. There are a couple of companies in the US that sell medical grade manuka honey including Derma Sciences Medihoney, which can be ordered on-line.  A ½ ounce tube costs about ten dollars.