Nipple pain

Can you tell me about nipple pain?

Nipple pain is common and upsetting. It is also a sign that something needs to be changed. We divide nipple pain into two types (early-onset and late-onset). Nipple pain soon after delivery (early-onset) is very common and is usually related to the mechanics of breastfeeding. Late-onset pain happens after a period of pain-free breastfeeding. Nipple pain can also be divided by the cause: trauma, skin damage, infection, and other. Knowing the cause of nipple pain allows mothers and their  health-care providers to apply proper treatment, prevent complications, and decrease pain.

Consider using our quick assessment tool, “Why do my nipples hurt?” to guide you through this concern.

A) Describing nipple pain

Nipple pain is a sign that something needs to be changed and a warning that skin damage may happen. It can be extremely distressing and is a common reason for weaning.

Pain in the nipples and areolas is most common right after birth, but some mothers develop it after weeks or months of pain-free breastfeeding. In addition to the timing of the onset of the pain, the appearance of the nipple and areola, the location of the pain, the type of pain, and its relationship to breastfeeding can all give clues to its cause.

Knowing the cause of nipple pain allows mothers and their health-care providers to apply proper treatment, prevent complications, and decrease pain. The more severe the pain, the more urgent the need to address it. There can be more than one cause, compounding the pain. In our experience, it is rare that nipple pain does not settle within a few weeks.

The baby’s latch is often erroneously blamed for nipple pain. This results in the baby being re-latched numerous times, frustrating the baby and likely causing more pain in the mothers. While a poor latch can cause pain, it is far from the only cause. 

Sometimes fixing the problem takes time or the pain is severe and mothers need more pain relief. There are a number of options for this.

B) The timing of nipple pain

We divide nipple pain into two groups but there can be some overlap:

1) Early-onset nipple pain

Studies show that as many as 96% of breastfeeding mothers report nipple discomfort during the first 6 to 8 weeks after delivery (Buck 2014; Jiménez Gómez 2021). It is more common in first-time mothers (Johansson 2019). Such pain usually stops within a few weeks of birth as problems are fixed and the nipple gets used to breastfeeding (Dennis 2014; Kent 2015). 

There are many possible causes for this.

In our experience, one common cause of moderate to severe early-onset nipple pain is nipple compression and we have found there are effective tools for treatment and prevention. It generally settles within six weeks after starting treatment.

2) Late-onset nipple pain

Late-onset nipple pain:

  • Is less common.
  • Is less likely to be caused by trauma as the nipple has mostly adapted to breastfeeding.

C) The origin of nipple pain

Nipple pain can also be divided by its origin.

1) Trauma

Cold, heat, friction, stretching, pressure, suction, excess moisture, and sharp objects can work independently or together to result in skin pain and damage and in tenderness of the tissues underneath.

Some of these same forces act on the nipple skin and underlying tissues while breastfeeding or expressing. 

Nipple trauma can be caused by:

  • The baby breastfeeding well.
  • Problems with the breastfeeding technique.
  • The characteristics of the nipple and breast.
  • Abnormalities of the nipple and breast.
  • How the baby sucks and behaves at the breast.
  • Improper use of devices (e.g. nipple shields and breast pumps) or manual expression.

For most first-time mothers, there is no gentle introduction to breastfeeding. Rather the nipples and breasts are suddenly asked to deal with a baby who breastfeeds as often as ten times each day. Nipples are stretched during latching and sucking, experience pressure as the baby’s tongue rises and increased suction as the tongue falls, and are wet during breastfeeding. These forces cause trauma and can result in nipple pain.

2) Skin damage

Nipple skin damage is very painful and takes a while to heal and become pain free. This is most commonly caused by nipple trauma but infection with bacteria and yeast can also cause or extend damage.    

3) Infection

Infection of the nipple is painful and can be caused by bacteria, viruses, and yeast.

The most common bacterial infection of the nipple happens when the skin of the nipple is damaged, creating a portal for bacteria. This can happen when the nipple skin is damaged at the start of breastfeeding, by the baby's teeth, or through a Montgomery gland. Viruses can be transmitted by the baby to the mother’s nipples or may be resting in the mother’s body until stress or another cause activates them. Yeast infections take advantage of the increased moisture created by breastfeeding.

The classic signs of infection include:

  • Pain
  • Heat
  • Redness
  • Swelling
  • Loss of function

4) Other

Nipple pain can have other causes.

Milk pimples (blebs) are common and related to producing milk but how they form is not known.

Skin conditions found elsewhere on the body, such as eczema or psoriasis, can be present on or near the nipple. New problems affecting the skin, such as cancer, can develop while breastfeeding.

Some causes, such as pregnancy or a return of menses, are hormonal in nature. Some have a nervous system component. Nipple vasospasm is caused by over-reactive blood vessels narrowing and can be brought on by nipple trauma. Nipple pain is more common in mothers who are hypersensitive to touch (hypersensitivity syndrome) or have a personal history of abuse

References

Buck ML, Amir LH, Cullinane M, et al. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeed Med. 2014 Mar 1; 9(2): 56–62
 
Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev. 2014 Dec 15;(12):CD007366

Jiménez Gómez MI, Meneses Monroy A, Corrillero Martín J, et al. Prevalence of Nipple Soreness at 48 Hours Postpartum. Breastfeed Med. 2021 Jan 27

Johansson M, Fenwick J, Thies-Lagergren L. Mothers' experiences of pain during breastfeeding in the early postnatal period: A short report in a Swedish context. Am J Hum Biol. 2019 Dec 4;e23363
 
Kent JC, Ashton E, Hardwick CM, et al. Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments. Int J Environ Res Public Health. 2015 Sep 29;12(10):12247-63