Causes and treatment of nipple and areolar pain soon after birth

Why have my nipples hurt since the first week after birth and what can I do about it?

If a mother's nipples are mildly tender in the early days of breastfeeding, they are probably just adapting to the process. They are not used to having a baby latching on them for 20 minutes every 3 hours. This type of pain is usually at its worst in the early days and is gone by a few weeks. More severe pain, and possibly damage, may be caused by problems with technique such as poor positioning, poor latching, or excessively long feeds. There may be an abnormality with the nipple itself or a bacterial infection that damages the skin. Other causes of nipple pain include expressing or using a nipple shield. Some babies can have a strong suction, compress the nipple, clamp or tug at the breast, or have a tongue-tie. It is important to find the cause(s) of the pain. It is a sign that something needs to be changed.

A) Describing early-onset nipple pain

It is common for mothers to have nipple pain soon after the birth of the baby (early-onset). Mothers can also develop nipple pain after a period of pain-free breastfeeding. This is called late-onset pain.

Early-onset pain often:

  • Is worst with the latch.
  • Settles slightly during the feed.
  • Can leave the mother with slight burning or tenderness after the feed.

Nipple compression pain can increase with each suck toward the end of the feed.

Early-onset nipple pain nearly always settles with time. Without proper care, a few mothers will go on to develop nipple damage and of those, a few will have an infection of the damage. Both are very painful and will take some time to settle.

Mothers who find they are in too much pain may, in addition to fixing the problem, consider various tools to decrease pain. 

B) Mild breastfeeding pain during the first week

When mothers start breastfeeding, the nipples can be traumatized as they are suddenly asked to deal with a baby who latches on every 3 hours for about 20 minutes. Normal breastfeeding can result in some tenderness of the whole nipple as it goes through the normal process of adaptation.

This type of pain is usually worst by Days 3 to 5 and then steadily gets better. It is gone by a few weeks.

Mothers should ensure that:

Mothers with full, swollen, or engorged breasts often find the sandwich technique to be helpful in reducing pain. Alternatively, mothers can try the laid-back hold. These tools will also support the baby's breastfeeding efforts.

C) Poor breastfeeding technique

1) Excessive breastfeeding

Just as normal breastfeeding can cause nipple tenderness, excessive breastfeeding can result in more pain.

Excessive breastfeeding can happen if:

Excessive breastfeeding can traumatize the whole nipple and also make the pain caused by other problems such as poor positioning and nipple compression worse.

2) Poor positioning

a) How poor positioning can hurt

Poor positioning is a common cause of nipple pain (Cadwell 2004). When properly positioned at the breast, the nipple is in front of the baby’s mouth and points to the back of the baby’s mouth.

If the baby’s mouth is not directly lined up with the nipple while breastfeeding but rather is pulling the nipple to one side, the opposite nipple side and bottom are stretched excessively causing pain and even nipple damage.

b) Checking for poor positioning

Mothers can easily test for proper positioning by looking at the alignment of the baby’s mouth with the nipple at the moment the baby comes off the breast.

Ideally, the nipple should remain directly in front of the baby’s mouth. The nipple should not move more than one centimetre (one half inch) away from the mouth as the baby comes off. The nipple should point straight into the baby’s mouth.

If this is not happening, the baby has likely been pulling on the nipple, and the positioning should be addressed.

3) Poor latching

Some babies will struggle to bring the nipple deep enough into the mouth if the nipple root is very firm. This is solved by softening the root and using the sandwich technique or the laid-back hold.

Some babies are unable to latch and will clamp on the nipple with their gums or latch onto the areola when trying to latch.

Poor latching can cause generalized nipple tenderness or make nipple compression worse.

4) The location of the pain

Poor breastfeeding technique can affect one part of the nipple more than others. The location of the pain can give a clue as to the cause of the pain. Mothers can gently press on different areas of the nipple and areola using a clean finger to look for tender spots. The following table links the location of the pain to possible causes. 

Table: Nipple Pain or Damage Caused by Poor Positioning and Affecting Certain Areas of the Nipple and Areola

(Links to more information about the topics in the above table: larger breasts; the under-arm hold; outer side of the breast; cradle hold.)

D) Nipple characteristics

Nipple compression is the most common cause of moderate to severe nipple pain soon after starting breastfeeding and results in a tender line across the center or the edge of the nipple face.

Slightly inverted, shy, dimpled, and abnormal nipples can be especially sensitive to breastfeeding as they are pulled well out of their usual position by the baby latching and sucking. The tenderness is generally present on the nipple face.

On rare occasions, very large nipples can result in difficulty latching the baby and nipple pain.

Larger Montgomery glands may be pushed around during breastfeeding, leaving them slightly tender. This settles in a few days or weeks after starting breastfeeding.

E) The role of the baby

There is still a lot we don’t know about the baby’s role in causing nipple pain. It is possible that different latching and sucking patterns can result in more or less pain. For example, some babies allow the nipple to move up and down in their mouths more than others (Jacobs 2007; Sakalidis 2013).

Some babies have a particularly strong suction that can traumatize the nipple (McClellan 2007). Weak babies, such as those born premature, are less likely to cause nipple pain.

When mothers have a large milk supply, their babies can tug and clamp at the breast, causing nipple pain. There are number of options for settling this behaviour. They may also tug and clamp when the milk supply is low.

Babies with tongue-ties can cause nipple pain.

The shape of the roof of the baby’s mouth (palate) likely has a role in nipple pain (Mills 2020).

G) Nipple pain with no obvious cause

A few mothers have ongoing nipple pain without any identifiable causes. This may be related to:

  • Mothers who are hypersensitive to touch (hypersensitivity syndrome). This may be genetic in origin (Lucas 2020). 
  • A personal history of abuse.

H) Worsening of early-onset nipple pain

Nipple trauma can lead to nipple damage and then to nipple infection. At each step the pain increases. Infection can also further extend nipple damage (Bukowski 2010).

Once the nipples are traumatized, mothers may develop nipple vasospasm that can compound their pain. This is fairly common.

Mothers can also go on to develop other painful problems such as milk pimples or nipple yeast.

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
 
Bukowski M, Wladyka B, Dubin G. Exfoliative toxins of Staphylococcus aureus. Toxins (Basel). 2010 May;2(5):1148-65

Cadwell K, Turner-Maffei C, Blair A, et al. Pain reduction and treatment of sore nipples in nursing mothers. J Perinat Educ. 2004 Winter;13(1):29-35

Jacobs LA, Dickinson JE, Hart PD, et al. Normal nipple position in term infants measured on breastfeeding ultrasound. J Hum Lact. 2007 Feb;23(1):52-9

Lucas R, Zhang Y, Walsh SJ, et al. OXTR rs53576 Variation with Breast and Nipple Pain in Breastfeeding Women. Pain Manag Nurs. 2020 Dec 7:S1524-9042(20)30196-X

McClellan H, Geddes D, Kent J, et al. Infants of mothers with persistent nipple pain exert strong sucking vacuums. Acta Paediatr. 2008 Sep;97(9):1205-9

Mills N, Lydon AM, Davies-Payne D, et al. Imaging the breastfeeding swallow: Pilot study utilizing real-time MRI. Laryngoscope Investig Otolaryngol. 2020 May 20;5(3):572-579 

Sakalidis VS, Williams TM, Garbin CP, et al. Ultrasound imaging of infant sucking dynamics during the establishment of lactation. J Hum Lact. 2013 May;29(2):205-13