Painful breastfeeding

What do I do when it hurts too much to breastfeed?

Painful breastfeeding is stressful. Fortunately, most painful breastfeeding problems can be solved which stops the pain. Mothers in pain often benefit from the help of a breastfeeding specialist. Until then, mothers may be able to control the pain by using a nipple shield or a breast shell, by using pain medication, or by expressing occasionally or for every feed. More aggressive options are skipping some breastfeeds without expressing or full weaning.

A) Effects of pain

When breastfeeding goes well, it is often much easier than bottle-feeding expressed milk or infant formula. Pain needs to be controlled and the causes addressed as pain is stressful and can even be traumatic and may interfere with the let-down (Newton 1948). Mothers who feel pain when breastfeeding are more likely to have mood swings, to sleep poorly, to be sad or depressed, and to wean (McClellan 2012; Odom 2013; Watkins 2011).

Babies may sense that the mother is in pain and may become less settled at the breast and start tugging, clamping, or pulling. This can further increase nipple or breast pain. If one breast is particularly painful, a baby may reject it in favour of the less painful one. This is another reason for good pain control.

The good news is that with proper care, most painful breastfeeding problems can be fixed within a few weeks. When discouraged, mothers can consider the following tools:

B) Address the cause of the pain

1) Pain from normal breastfeeding

Pain or discomfort can come from normal breastfeeding. Most symptoms are temporary and fade in the first few months of breastfeeding. Causes include:

2) Pain caused by breastfeeding problems

More severe pain can happen when there are breastfeeding problems. Consider the following steps:

  1. Make sure the baby is getting enough milk.
  2. Figure out the cause of your pain:
    1. Nipple pain.
    2. Nipple damage.
    3. Breast pain.
    4. Painful breast lumps.
  3. Take the necessary steps to deal with the problem.

C) Control the pain

1) Medication

Mothers can use pain medication such as acetaminophen or ibuprofen if they are not allergic. These are generally safe to use while breastfeeding. Mothers should not exceed the maximum dose.

Often breastfeeding pain is worse during the evening fussies when babies feed frequently and are often less settled at the breast. If you are using pain medication for the evening fussies, you can take it about an hour before the fussies start as the pills take a little time to become effective.

2) Nipple shields

If you cannot breastfeed because of nipple pain, you can try breastfeeding with a nipple shield. Note that:

  • Not every baby can use a nipple shield.
  • Many mothers do not get much pain relief with a nipple shield.
  • You don’t want to stop feeding on the naked breast for too long as the baby may not return to the breast after a day or more of using a nipple shield.

3) Breast shells

If you cannot tolerate anything touching your nipples, you can try wearing breast shells between feedings. If the nipples are damaged, you can use breast shells instead of a non-stick dressing

4) Commercial breast gel pads

Commercial breast gel pads are marketed for nipple pain and can provide relief. Pads can be kept in the refrigerator to cool the nipple to provide additional relief. 

D) Expressing to control breastfeeding pain

Expressing can decrease pain if:

  • The nipples are tender. 
  • The nipples are damaged and can also speed healing.
  • The breasts are overfull.

1) Problems created by expressing for pain

Expressing to control pain can have negative effects:

Ideally, you continue to breastfeed for some feeds and expressing for others so that your baby does not reject the breast.

2) Considerations when deciding to express to control pain

To decide whether to express or how often to express, consider the following:

  • How effective are you at expressing?
  • How much pain do you have?
  • If you have nipple damage, how severe is it?
  • How quickly is the pain settling?
  • Can you express enough milk for all of the baby’s needs?
  • What type of milk will be used for replacement feeds?
  • What feeding tools will be used for the baby?

3) How to express to control pain

For every breastfeed you miss, it is extremely important to express. Skipping feeds and not expressing can cause many problems.

a) Expressing once each day for supplements or replacement feeds during the evening fussies

Babies feed frequently during the evening fussies and mothers may find that this is also when they experience the most pain.

Some will choose to express in the morning, when there is more stored milk present in the breast, and use this to supplement the baby during the evening.

b) Expressing for some feeds

If you want to express more than once a day, consider establishing a pattern such as expressing for every second feed or two out of three feeds for a day or two. After that, you can gradually decrease the expressing and increase the feeding as your pain allows.

c) Expressing for all of the baby’s feeds

If you choose to only express and temporarily stop breastfeeding, resume breastfeeding as soon as it is tolerable.

If you stop breastfeeding entirely for a day or more, your baby may not return to the breast. Most babies are flexible, but some aren’t. Also, breastfeeding is generally more effective than expressing, and occasional breastfeeding can help maintain your milk supply and prevent problems caused by overfull breasts.

d) Expressing on one side

If there is only excess pain on one breast, you can express occasionally or at every feed on one side but continue breastfeeding routinely on the healthy side.

This can result in the milk supply decreasing on the expressed breast and increasing on the breastfed side:

  • If there is only a slight or moderate difference, mothers should resume routine breastfeeding and the difference should settle in a few weeks.
  • If there is a marked difference, once mothers return to breastfeeding, they should start feeds on the weaker side until the supply is nearly balanced.
  • The baby may show a preference for the more active breast.

E) Partial or full weaning

A more aggressive option is not breastfeeding and not expressing for some feeds (partial breastfeeding) and then resuming breastfeeding once things are settled. This may result in a temporary or permanent decrease in milk supply and in a number of possible painful breast problems related to overfilling. 

The final option is full weaning, assuming it is safe to do so and you are comfortable with this decision.

References

McClellan HL, Hepworth AR, Garbin CP, et al. Nipple pain during breastfeeding with or without visible trauma. J Hum Lact. 2012 Nov;28(4):511-21

Newton M, Newton NR. The let-down reflex in human lactation. J Pediatr. 1948 Dec;33(6):698-704

Odom EC, Li R, Scanlon KS, Perrine CG, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatrics. 2013 Mar;131(3):e726-32

Watkins S, Meltzer-Brody S, Zolnoun D, et al. Early breastfeeding experiences and postpartum depression. Obstet Gynecol. 2011 Aug;118(2 Pt 1):214-21