Nipple damage

Can you tell me about nipple scabs, sores, cracks, and wounds?

Breastfeeding sometimes damages the nipple skin and may appear as a scab, sore, crack, or wound. It most commonly develops as soon as the baby starts to breastfeed well but sometimes appears after months of problem-free breastfeeding. The best treatment is an approach called moist-wound healing, which means using an appropriate wound care product such as purified lanolin and covering the damaged area. Mothers also need to monitor the healing, prevent more damage, and make sure the baby grows well. Infection of nipple damage can allow bacteria to enter the breast and cause further pain and damage and lead to mastitis and abscesses. Nipple damage can be frustrating, but the pain can be managed and the damage always heals.

A) Describing nipple damage

A small crack is seen beside a small nubbin. The crack was hidden until the pinch test revealed it.

1) How to look for nipple damage

Nipples are covered with skin. If traumatized, the skin can break down to varying degrees (become damaged). This can appear as a painful scab, blisters, a sore, a crack, or a deeper wound.

Damage can be obvious, it can be hidden in the folds of the nipple skin, or hard to see on the underside of the nipple. Some damage is best seen right after the baby lets go of the nipple. Folds in the skin on the sides of the nipple can be examined by gently pulling the nipple to the sides and up and down to stretch the folds. The pinch test can help when examining the face of a nipple, especially if it is shy or dimpled

Mothers with nipple damage should see their health-care providers.

2) When nipple damage develops

Most nipple damage happens soon after birth (early-onset) and as the baby starts to breastfeed effectively. Premature, sleepy newborn, or sick babies may not suck strongly enough to cause nipple damage.

Mothers who had nipple damage with a previous baby are more likely to have it with the following babies but it is generally less severe and faster to heal (Branger 2019). It can be minimized by breastfeeding for extended periods and through the next pregnancy

Nipple damage can also occur after a period of pain-free breastfeeding (late-onset).

3) Complications of nipple damage

Once damaged, the skin is no longer able to act as a barrier and keep bacteria out which can result in infection. These bacteria can also enter the breast and cause mastitis or an abscess

Nipple damage very rarely causes scarring or long-term problems with the nipples or with breastfeeding. Nipple damage will not block milk ducts as it heals.

B) Dealing with nipple damage

Deep nipple damage (ulcer) with unhealthy yellow tissue in the wound. This wound healed completely in six weeks.

There is relatively little research on how nipple damage develops or how best to treat it. The best treatment is moist-wound healing, which involves:

Other tools for treating nipple damage include:

  • Addressing the cause of the damage.
  • Ensuring the wound is healing.
  • Treating any infections that develop.
  • Ensuring the baby is growing well.

Babies may take in some blood from a damaged nipple when breastfeeding. This generally does not hurt the baby.

C) How to breastfeed with nipple damage

To breastfeed with nipple damage:

  1. Wait for the baby to show hunger signs.
  2. If you are using an antibiotic ointment or other medicated preparation, remove it by gently wiping the area with a clean soft cloth and some breast milk. The nipple does not need to be cleaned if using purified lanolin, hydrogel dressings, or medical grade honey.
  3. Breastfeed your baby.
  4. As soon as the baby comes off the breast, apply the wound care product.
  5. Do not air-dry the nipple.
  6. Place a 3-cm (1-in) square piece of non-stick dressing over the wound care product.
  7. Ensure the dressing is clean if reusing, and only re-use it once. 
  8. Cover the dressing with a breast pad and then your bra. This will keep the non-stick dressing in place and catch any leaked milk.
  9. When the baby is ready to breastfeed, remove the bra, breast pad, and non-stick dressing.
  10. Return to step 1.

If you are expressing, follow the above steps but replace breastfeeding with expressing.

If your nipples are too painful to tolerate a cover, the damage may be infected and you may require oral antibiotics. You may also find it helpful to replace the non-stick dressing and breast pad with a breast shield

D) Nipple damage pain

The pain from nipple damage can be severe and frustrating. We are sending you a virtual hug because we know how hard it can be.

It may be useful to know that:

  • Nipple damage always heals.
  • With proper care, the pain improves each week.
  • There are various ways reduce the pain.
  • The pain will disappear completely about two weeks after the nipple has healed and the healed areas adapt to breastfeeding.

To help the damaged nipple heal and minimize pain, mothers should:

While there can be drawbacks to expressing for pain, expressing to control pain can be very helpful for mothers with nipple damage. The expressed milk is used as a replacement feed for the baby. Expressing can:

  • Reduce
  • Speed healing.
  • Limit further damage from breastfeeding.
  • Be for some or all feeds.

Nipple pain may increase or change for the same reasons that nipple healing may slow or stop. In addition, mothers may develop nipple vasospasm. Unfortunately, this is common but this too, can be managed.

It is very important to have consistent and effective medical help as well as emotional support with this amount of pain. Mothers with severe pain are at an increased risk of sadness and depression. Mothers may benefit from seeing a breastfeeding specialist.  

References

Branger B; Breastfeeding Commission of the Pays de la Loire Birth Safety Network (France). Description of 101 cases of nipple cracks and risk factors via case-control study in eight units of a perinatal network. Arch Pediatr. 2019 Nov 26;S0929-693X(19)30192-7