Breastfeeding – mastitis and other nipple and breast problems

Your nipples may feel sensitive in the first few days after birth and while breastfeeding, but genuinely sore nipples or breasts point to a problem. Nipple or breast pain is not a normal part of breastfeeding, so if you feel pain it is best to seek help promptly.

A small amount of blood in your breastmilk from nipple trauma will not harm your baby, and you can usually keep feeding unless the pain becomes unbearable. If you need to rest the nipples until they heal, you can express milk to keep up your supply and discard that milk until the bleeding stops and the nipples recover.

Caring for your nipples#

To help prevent nipple problems:

• Make sure your baby is correctly positioned and attached at each feed.
• Avoid soaps and shampoos on the nipples while showering.
• Avoid nipple ointments, powders and tinctures, which can make problems worse.
• Leave milk or colostrum to dry on the nipples after a feed, as both contain anti-infective agents.
• Change breast pads frequently and avoid pads that hold moisture against the skin.

Some mothers are more comfortable without a bra, while larger-breasted women often prefer the support of a well-fitted maternity bra. Breast shells (silicone with a hard plastic dome) can protect sore nipples by keeping clothing off them and letting them air.

Attachment and positioning#

Incorrect attachment of the baby onto the breast is the most common cause of nipple pain. Slightly changing the baby’s position at the breast often helps. A midwife, lactation consultant or trained breastfeeding counsellor can show you how to attach the baby properly.

Flat or inverted nipples#

You can breastfeed with flat or inverted nipples, but you and your baby may need patience while you learn. Strategies that can help include:

• Breastfeeding within the first hour after birth, when the baby is alert and ready to suck.
• Using a baby-led attachment technique in the early days.
• Drawing out the nipple before a feed; a cup, spoon or finger can be used to give expressed milk if needed.

Avoid bottles and dummies, which involve a different sucking action. Occasionally a correctly sized, clear silicone nipple shield helps; once the baby is sucking well and the nipple is drawn out, the shield can be removed. Even with a shield, the baby should still be well positioned and attached.

Breast and nipple thrush#

Thrush (a fungal infection) can occur in the first weeks after birth, but may develop at any time. Signs and symptoms include:

• Severe, burning nipple pain throughout the whole feed that correct attachment does not relieve. The pain is often continuous, not just during feeds.
• Sharp, shooting, burning, stabbing or radiating pain through the breast.
• Nipples that may look a brighter pink than normal and shiny, though they can also look normal.
• Thrush in the baby’s mouth (white spots that cannot be wiped away) or a red, spotty rash around the buttocks.

Your doctor can assess whether your baby has thrush. If you or your baby is diagnosed, you will both need treatment. Treatment may include:

• Antifungal nipple gel or cream, such as nystatin or miconazole, applied to the nipple after each feed.
• An oral antifungal such as fluconazole.
• Nystatin liquid or miconazole gel for thrush in the baby’s mouth, and antifungal ointment for thrush around the buttocks.

Good hygiene helps recovery: air the nipples or go without a bra, change breast pads often to keep nipples dry, and wash your hands after touching your breasts, using the toilet or changing nappies. Wash bras, nursing pads and towels separately from nappies in hot soapy water and dry them in the sun where possible. Dummies and teats should be washed and sterilised (by steam steriliser or 5 minutes in boiling water) and, if possible, replaced weekly while thrush is being treated. See your doctor if thrush persists.

When it may not be thrush#

A bacterial infection of the nipples can be mistaken for thrush, or occur alongside it. Treatment with an antibacterial ointment, or a combined antibacterial and antifungal ointment, will often heal a stubborn “thrush”. Your doctor may swab the nipples for culture to identify the most suitable antibiotic, and an oral antibiotic may also be used.

Dermatitis and eczema around the nipple#

Dermatitis around the nipple and areola can be caused by:

• Ointments and creams used on the nipples (stop using them if dermatitis develops).
• Detergents used to wash bras, breast pads or underwear; use pure soap, rinse well and dry in the sun.
• Sensitivity to soaps or shampoo, or a reaction to the fabric of your bra or pads (going without a bra may help).
• Sensitivity to the moisture-absorbing gel in some disposable nursing pads.
• For older babies, a reaction to food left in the baby’s mouth after eating.

Nipple eczema causes inflammation of the skin, with a rash that may be dry or weepy and is usually itchy. It can affect one or both nipples and the areola, and can cause considerable pain. If the rash looks crusty or flaky, a bacterial infection may also be present. See your doctor, who may refer you to a skin specialist; dietary changes and a short, intensive course of cortisone cream can help.

Mastitis#

Mastitis means inflammation of the breast. It can be caused by blocked milk ducts (non-infective mastitis) or a bacterial infection (infective mastitis). Blocked ducts cause milk to pool, leading to pain and swelling, and a cracked nipple can let bacteria in.

Mastitis makes the breast, or part of it, hard and swollen. Other symptoms include:

• Skin that looks tight and shiny, and may be streaked with red.
• Feeling very unwell or “fluey”, with a temperature over 38°C (100.4°F) and body aches.

What makes mastitis more likely#

Factors that predispose to blocked ducts and mastitis include:

• Poor drainage of the breast, from poor attachment or limiting time at the breast.
• Engorgement from a missed or delayed feed.
• A tight or ill-fitting bra, or consistently lying in one position during sleep.
• Holding the breast too tightly during feeding.
• Trauma, such as a kick from a toddler or pressure from a seatbelt.
• Using a nipple shield, previous or recurrent blocked ducts, or nipple trauma from poor attachment.
• Interrupting or cutting feeds short, using nipple creams (which can harbour bacteria), or a secondary infection such as thrush.
• Being run down, unwell or anaemic.

Preventing mastitis#

• Wash hands before touching the breasts, especially after a nappy change.
• Make sure the baby is well positioned and attached so the breast drains thoroughly.
• Feed frequently and avoid long gaps between feeds; if you replace a breastfeed with a bottle, express to avoid blocked ducts or a drop in supply.
• Wear loose, comfortable clothing, and make sure any bra is properly fitted.
• Avoid nipple creams, ointments and prolonged use of nipple pads.

Clearing a blocked duct#

It is important to treat blocked ducts before they progress to mastitis:

• Make sure the baby feeds well on the affected breast, offering it first.
• Apply heat for a few minutes before a feed and gently massage the affected area during feeding.
• Use cold packs after and between feeds for comfort.
• Try a change of feeding position, and drain the breast frequently using breast compression while feeding or expressing.

If the blockage does not clear within 8 to 12 hours, or you start to feel unwell, see your doctor.

Treating mastitis#

Treatment should begin promptly. Your doctor may not be able to tell simple inflammation from infection straight away, and will usually treat you as if it is infected. Treatment includes:

• Continuing to breastfeed and/or express to drain both breasts. Your milk is safe for your baby even with mastitis. Offer the affected breast first, and massage gently toward the nipple while feeding or expressing.
• Antibiotics, such as flucloxacillin or cephalexin.
• Anti-inflammatory medicine (such as ibuprofen) and/or pain relief (such as paracetamol) if needed.
• Rest and plenty of fluids.
• A warm cloth or heat pack (not too hot) before a feed to help the milk flow, and a cold pack wrapped in cloth afterwards to ease inflammation and pain.
• Varying the feeding position to improve drainage.

If you want to stop breastfeeding, wait until the mastitis has cleared, because rapid weaning may lead to a breast abscess.

Other causes of nipple and breast pain#

• Nipple trauma can result from a breast pump used incorrectly, or from removing the baby without first breaking the suction (slide a clean finger into the corner of the baby’s mouth).
• Nipple vasospasm happens when blood vessels tighten, causing intense pain during, just after, or between feeds. It is often worse when you are cold or have a history of Raynaud’s phenomenon, and you may see the nipple change colour from white to purple or red, then back to normal. Speak to your doctor, midwife or lactation consultant if you think you have it.
• Tongue-tie is when the thin piece of tissue under the baby’s tongue is unusually short and limits tongue movement. It can affect the baby’s ability to latch and suckle, causing nipple pain and trauma. If you are concerned, speak with your doctor, paediatrician, midwife, child health nurse or lactation consultant.

Many hospitals run breastfeeding clinics that help with infant feeding problems. If nipple pain or trauma is not improving, seek help from your doctor, midwife or a lactation consultant. Some parents with certain medical conditions (such as hepatitis B or hepatitis C) should also discuss feeding with their healthcare provider.

Key points#

• Nipple or breast pain is not a normal part of breastfeeding, so seek help if it occurs.
• A small amount of blood in breastmilk from nipple trauma will not harm your baby.
• Incorrect attachment is the most common cause of nipple problems; good positioning helps prevent them.
• Thrush, dermatitis, eczema, mastitis, vasospasm and tongue-tie are all treatable causes of pain.
• With mastitis, keep breastfeeding or expressing, as your milk is still safe for your baby.

Where to get help#