We have known for many years that many women give up breastfeeding in the first 6 weeks with unresolved nipple pain and damage.
There is currently discussion about the treatment of thrush during breastfeeding and that many cases may be wrongly diagnosed and be caused by dermatitis (eczema).
CKS How should I diagnose the cause of nipple pain? 2022 mentions that:
- Eczema, psoriasis and contact dermatitis of the areola and nipple may cause itching of the skin.
- Eczema typically causes a bilateral red, dry, scaly rash which may have lichenified (thickened) areas, which tend to spare the base of the nipple.
- Psoriasis typically causes red plaques with clearly demarcated borders, which may have a fine overlying scale.
- Irritant dermatitis may occur due to soaps, nipple creams and other substances in direct contact with the breast.
In 2021 Amir et al (including myself) published a paper “Identifying the cause of breast and nipple pain during lactation” https://www.bmj.com/content/374/bmj.n1628
How can we treat nipple pain?
- In babies under 6 weeks assume, until proven otherwise by a breastfeeding expert, that it is due to less than perfect latch/attachment to the breast.
- If there is a white tip to the nipple after feeds optimise the attachment as this is likely to be vasospasm (temporary loss of blood supply to the nipple)
- Check for tongue tie by an expert trained to assess and treat appropriately. A tongue tie can result in the baby having a white tongue as milk does not reach the back of the tongue as it should.
- If the nipple is itchy after breastfeeds optimise attachment but if the nipple skin is dry and sore treat as a dermatitis with suitable moisturiser (does not need to be a specific product labelled to treat and prevent cracked nipples) and apply a smear of hydrocortisone 1% cream (or other low potency steroid) after feeds
- Frequent application of products sold to prevent and treat cracked nipples may contain lanolin and even highly purified forms can cause allergic reactions which increase itchy sensation.
- A mother may be allergic to anything which is in contact with her breasts during lactation as the environment around the nipple is more moist than usual – breast pads, washing powder, creams, soaps. These may produce a red circular area around the nipple.
- If nipple pain begins when the baby is teething, try to optimise latch and re-attach the baby/toddler if pain continues then apply a smear of hydrocortisone cream 1% after feeds to soothe inflammation and chaffing.
- If the mother has a history of poor circulation (usually Raynaud’s phenomenon) the use of nifedipine 10-20mg three times a day is effective. It is associated with side effects of headaches and/or hot flushes for the mother. If it has produced no improvement within 7 days discontinue and reconsider cause of pain. Research suggests that some mothers can stop treatment but still see resolution of symptoms. See https://breastfeeding-and-medication.co.uk/blog/february-is-raynaud-s-awareness-month-www-sruk-co-uk
- Look at other causes of pain by observing the mother and baby as a dyad and watching a complete feed from approach to the nipple to the baby coming off the breast unprompted. Does the baby have an asymmetrical latch? Does it suck the nipple into the mouth rather than having a wide gape? Does the mother take the nipple to the baby by leaning forward rather than lying back? Is the baby supported in the mother’s elbow?
- Is the pain in both breasts and is it the same after every feed?
- Is there a sloughy discharge in the crack suggesting a bacterial infection?
- Only after all these factors have been considered should a diagnosis of thrush be brought into the discussion. I believe thrush on the nipple is rare although it can occur. It should NEVER in my opinion, be the first treatment for sore nipples. A white tongue is not diagnostic of oral thrush nor is pain on one side.
- Paget’s disease can never be discounted as it presents as steadily progressing eczema.
Symptoms of nipple eczema(dermatitis)
Nipple eczema is characterised by redness, crusting, oozing, scales, fissure, blisters, excoriations or lichenification eczema (Core Curriculum for |Lactation Consultant Practice). It is often described by the mother as itching and is usually treated with topical steroids.
In Breastfeeding a Guide for the Medical Profession dermatitis is described as tender, burning, red fissures without exudate or itching, oozing with well-defined plaques. It has a recommendation by Alison Stuebe to culture for aerobic bacteria and yeast. It differentiates between irritant and contact dermatitis.
Breastfeeding Management for the Clinician describes eczema as including erythema, papules, vesicles, oozing, lichenification, skin erosion, fissures, excoriations and scaling associated with itching which differentiates it to candidal infection. It cites Amir 1993 as recommending removal of the irritant and application of topical steroid (beclometasone 0.05%) with awareness that high colony Staph. Aureus may also be present and necessitate use of a topical antibiotic for example Mupirocin (Bactroban ™).
Barrett suggests that the application of topical steroids is the mainstay of treatment for eczema on the nipple and recommends a low or medium strength steroid applied twice a day for 2 weeks with anything residual being wiped off before a feed (not washed as it may further dry the skin of the nipple.
Barankin and Gross suggest that symptoms may appear after the introduction of some solids to the infant’s weaning diet. This can be ameliorated by rinsing the nipple with water or expressed breastmilk after feeds.
Anecdotally I have found that using a solution of 1 teaspoonful of bicarbonate of soda in a pint of water also helps assuming that it alters the pH of the skin transiently before application of the steroid. Please note that there is no published evidence for this, it is merely my experience of supporting breastfeeding mothers.
References
Amir L. Eczema of the Nipple and Breast: A Case Report. Journal of Human Lactation. 1993;9(3):173-175.
Barankin B, Gross MS. Nipple and Areolar Eczema in the Breastfeeding Woman. Journal of Cutaneous Medicine and Surgery. 2004;8(2):126-130.
Barrett ME, Heller MM, Fullerton Stone H, Murase JE. Dermatoses of the breast in lactation. Dermatol Ther. 2013 Jul-Aug;26(4):331-6.
Core Curriculum for Lactation Consultant Practice International Lactation Consultant Association Eds Manuel R, Martens PJ, Walker M. Jones and Bartlett
Douglas P. Re-thinking lactation-related nipple pain and damage. Womens Health (Lond). 2022 Jan-Dec; 18:17455057221087865.
Lawrence RA MD and Lawrence RM Breastfeeding a Guide for the Medical Profession. Elsevier.
Walker M Breastfeeding Management for the Clinician. Jones and Bartlett
Wambach K and Spencer B. Breastfeeding and Human Lactation. Jones and Bartlett
See also.
Thrush and Breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-thrush
What do mothers want healthcare professionals to know about breast and nipple pain in lactation https://breastfeeding-and-medication.co.uk/fact-sheet/what-do-mothers-want-healthcare-professionals-to-know-about-breast-and-nipple-pain-in-lactation
