The Breastfeeding Couple: Sore, Cracked Nipples

In the first few days of breastfeeding many women will have sore nipples. Breastfeeding with a sore or cracked nipple can be very painful.

The most common cause of sore or cracked nipples is poor breastfeeding technique. In many cases the baby is sucking only on the nipple. The mother is not getting good let- down and the baby is sucking harder in an attempt to get more milk. Mothers need to make sure that the baby opens his or her mouth wide with the tongue down before they put the baby to breast. This will allow the baby to grab the areola into his or her mouth. When the baby sucks on the areola they compress the milk ducts. This helps cause milk let-down. At times during the feeding, if the mother's arms get tired the baby will start to slip off and end up sucking on the nipple. Mothers need to be encouraged to use some support underneath the baby to help hold up the baby so that this does not happen ( Freed, 1991 ). Mothers with sore, cracked nipples need to have their breastfeeding techniques evaluated by a skilled professional. This includes examination of the breasts and nipples, observation of a feeding and examination of the infants mouth and sucking.

Sore cracked nipples can also occur in infants with ankyloglossia (tongue-tie). Infants with a tight frenulum, especially if it attaches to the ridge of the gum and causes a heart shaped indentation at the tip of the tongue, may be able to suck only on the nipple due to limited tongue movement. This causes poor latch on and sore cracked nipples. Frenuloplasty may alleviate this problem. ( Ballard, 2002 ). Nipples can also become sore and cracked if the mother does not release the baby's suction before taking him or her off the breast ( Freed, 1991 ). Guidelines for the Evaluation and Treatment of Neonatal Ankyoglossia and its Complications in the Breastfeeding Dyad have been developed by the physicians of the Academy of Breastfeeding Medicine.

A candida infection (thrush) can cause sore nipples. If the baby has white plaques in his or her mouth indicative of a yeast infection, the mother may have candida on her nipples. This can cause nipples to become red and very tender and may be associated with a burning sensation. When an infant has a yeast infection in their mouth the mother can prophylactically put Nystatin suspension on her nipples at the end of the feeding and allow the medication to dry. This does not have to be washed off prior to the next feeding. If the mother's nipples are very red and shiny the suspension may not be effective. A topical antifungal cream or ointment or systemic antifungal drug may need to be prescribed by a doctor or nurse.

Women who have moderate to severe nipple pain, along with cracks, fissures, ulcers or exudates on the nipple, and good technique, may have a bacterial superinfection (most commonly Staphylococcus aureus). The infection may contribute to delayed healing ( Livingstone, 1996 ). A bacterial culture followed by treatment with appropriate oral antibiotics may be needed ( Livingstone, 1999 ).

At times women's sore, cracked nipples are so painful that the baby cannot nurse on them. These mothers may need to pump for 24 to 48 hours in order to allow the nipples to heal and the baby needs to be fed in another manner (See Supplementing breastfed infants in a physiologic manner).

If a woman has mild sore or cracked nipples that are worse on one breast than the other, the mother should let the baby nurse first on the less sore breast, and second on the sore breast. The baby will suckle less vigorously on the second breast and this may allow the nipple to heal.

Maternal breast milk placed on the nipples is the best treatment. The use of breast shells between feedings may also help in the healing ( Brent, 1998 ).

Researchers in Australia compared the vacuum generated by the infant's sucking during breastfeeding in mothers with persistent nipple pain with the vacuum created by the infant whose mothers had no pain while breastfeeding. Infants whose mothers complained of pain applied significantly higher vacuum pressure during sucking and when pausing. There was no difference in active sucking times between the 2 groups. However, infants whose mothers had pain during breastfeeding got less milk during the feeding than the infants whose mothers were pain-free. Further study in this area is needed to help mothers with persistent pain during breastfeeding ( McClellan, 2008 ).