Nipple pain in breastfeeding

Nipple pain is a common symptom of pain at the nipple that occurs in women during breastfeeding after childbirth. The pain shows the highest intensity during the third to the seventh day postpartum and becomes most severe on the third day postpartum. Nipple pain can result from many conditions. Early nipple pain in breastfeeding is usually caused by improper positioning and latch while breastfeeding. Other causes may include blocked milk ducts, tongue-tie, cracked nipples and nipple infections by yeasts, bacteria or viruses. Complications in nursing women involve an increase in nipple sensitivity or breast engorgement, leading to mastitis and subsequent pain. Common diagnostic approaches include quantifying pain by the numerical rating scale (NRS) and maternal breast or infant mouth examinations. Nipple pain may hinder breastfeeding and is the most common reason for early weaning. General management such as positioning and latch adjustment and thermal intervention can be administered for pain alleviation. Appropriate treatment of nipple pain is given based on the underlying cause.

Causes Causes of nipple pain in breastfeeding are classified into three factors: physiological, mechanical and infectious. They are interrelated and possibly happen simultaneously.

Physiological factors Physiological changes in nursing women, including an unusual milk supply and blocked milk ducts, cause nipple or breast ache. An oversupply of breast milk is caused by overactive milk expression. Hence, the excess milk accumulates, leading to breast engorgement and pain. On the other hand, milk supply will be lowered by prolonged breastfeeding, high pumping pressure and overly vigorous breast massage. Blocked milk ducts refers to lactiferous ducts' blockage at the nipple pore or deeper breast tissue. It hampers an adequate drainage of milk and causes breast mass, engorgement, redness, a nipple bleb and subsequent pain.

Mechanical factors

Nipple trauma Cracked nipples, including nipple blisters and fissure, increase the nipple pain frequency and intensity during the first week postpartum. Traumas may break down the skin integrity of the nipple and serve as routes for infections. A common complication is mastitis due to bacterial infections.

Poor positioning Poor positioning or poor latching of infants refers to the infant's inappropriate fastening onto the mother's nipple in breastfeeding. It is the most common cause of early and persistent nipple soreness. During breastfeeding, if the infant's mouth is not in the same plane as the mother's nipple and the infant's ears, shoulders and hips are not in parallel, the child cannot grasp enough portion of the nipple and areola into the mouth nor receive enough milk. The infant will sip more vigorously and thus reduce blood flow (ischemia) at the nipple which leads to vasospasm and blanched nipples.

Abnormal tongue motion Abnormal tongue motion of infants is commonly caused by nipple confusion. When infants are given a rubber nipple and pacifier, they may sip at the maternal nipple as if it was a rubber nipple. The tongue movements used in breastfeeding and bottle-feeding are different: infants use a wave-like motion to remove breast milk in breastfeeding and thrusting action against the latex nipple to control milk flow in bottle-feeding. If the infant pinches and presses the nipple with the gums repeatedly, it creates a large friction and results in nipple soreness and bruising.

Tongue-tie Tongue-tie (Ankyloglossia or Tight frenulum) refers to an abnormally short and thick lingual frenulum that hinders the child from curving the tongue around the nipple. Hence, the infant drains insufficient breast milk and rubs harder against the nipple which causes nipple abrasion. It leads to suboptimal weight gain in babies and mechanical nipple injuries associated with nipple soreness and pain in mothers. Other congenital mouth abnormalities like cleft palate in infants can cause nipple irritation and increase the risk of nipple dermatitis in mothers.

Infectious factors Nursing mothers diagnosed with yeast, bacterial, viral infections or dermatitis are susceptible to nipple pain. A type of yeast infection called candidiasis caused by a type of fungus called Candida will lead to itching, erythema of the nipple and areola, burning and stabbing nipple pain. It happens when the infant's mouth is infected by a Candida species called Candida albicans, the child may transmit the yeast to the mother's nipple during breastfeeding. Bacterial infection by Staphylococcus aureus (S.aureus) will give rise to mastitis which refers to an inflammation of the mammary gland. About half of the breastfeeding mothers reporting nipple ache were infected with S.aureus. They usually experienced a sudden onset and systemic symptoms including nipple pain, fever, flu-like symptoms, myalgia and fatigue. The risk of infections increases with an inhibition of mammary gland drainage. Viral infection with Herpes simplex virus (HSV) causes nipple ulceration, soreness and pain. Infants feeding on an HSV infected nipple can develop a life-threatening complication affecting the brain called encephalitis. Breastfeeding women with dermatitis problems, including psoriasis and eczema at the nipple, suffer from erythema, scaling lesion and pain. Nursing mothers with psoriasis may develop Koebner phenomenon upon further nipple abrasion by infants in prolonged breastfeeding. Eczema at the nipple can be caused by direct chemical contact or allergic condition. It affects the areola and sometimes extends to the breast.

Diagnosis The diagnosis of nipple pain in breastfeeding can be divided into three major parts: the measurement of pain intensity, a physical examination on the breastfeeding mother and the infant to identify the cause of pain and the study of the psychological impact of pain in the breastfeeding woman.

Pain scale Acute or chronic pain can be directly measured by pain scales such as the numerical rating scale (NRS) and visual analog scale (VAS). A serial pain scale from 0 (no pain) to 10 (worst pain imaginable) can quantify pain intensity. It can also monitor symptom improvement in nursing women who experience persistent nipple pain for at least two weeks postpartum.

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