Normal nipple tenderness peaks at around the third to sixth day postpartum and then resolves by the end of the second week. Any damage to the skin of the breast or nipple should receive immediate attention to avoid further damage or infection.

Painful breastfeeding is not normal.  It is very important to resolve the situation causing the damage (see Latch and Positioning hand-out).  If nursing is too painful, even with careful attention to latch and positioning, consider the use of a nipple shield to protect nipples, until damage is resolved (see Using a Nipple Shield hand-out).

Washing and Rinsing  Washing and rinsing damaged nipples can help prevent bacterial infection.  When bacteria invade a wound, they create a bio-film that does not allow anything to penetrate.  Baby’s saliva also encourages this bio-film.  Washing and rinsing help to remove bio-film and allows nipples to heal faster.

Nipple Cracks/Fissures  If nipple is cracked, wash 2x a day with a gentle fragrance free soap that is not antibacterial.  Discontinue use of soap on nipples when healed.  After every feed, rinse nipples with clean water or saline rinse.  Saline rinse is ¼ rounded teaspoon of sea salt mixed with 8 ounces warm water.  Nipples can be soaked n this solution for no longer than 1 minute.  Longer times may over hydrate skin and increase cracking.

Moist Wound Healing  Pat dry after soaking and apply antimicrobial ointment of choice.  Options include virgin coconut oil, triple nipple ointment, purified lanolin (although lanolin has been associated with increased infection risk), and medihoney.  It is important to keep cracks covered with some type of ointment to promote moist wound healing.  A non-stick wound pad may be placed over the ointment to keep nipples from sticking to bra or clothing.  If any ointment is left when baby feeds, wipe off very gently.  Avoid the use of disposable nursing pads as these do not allow for good air flow.  Wool breast pads are recommended, due to antibacterial and air flow properties.

Watch for Infection  Contact physician and Lactation Consultant if there are any signs of infection such as increasing redness, pus or fever. Studies show that bacterial infection of the nipple may require oral antibiotics. There is also research suggesting that a bacterial infection of the breast may be treated with probiotics containing lactobacillus fermentum and lactobacillus salivarius.

Thrush Studies show that the most common infection of the breast is bacterial, not candida. Candida infected nipples often look very pink and shiny.  There may be red dots or even tiny blisters.  Pain may be sharp and stabbing.  If this is suspected, both parent and baby must be treated for two weeks past symptoms clearing.  While Nystatin is commonly prescribed for baby’s mouth, studies show that it may not be effective.  In one recent study, it was only effective in 32% of cases, while fluconazole oral suspension was effective in 100% of the cases.  Miconazole and clotrimazole are also effective.

Triple nipple ointment (APNO) is often prescribed for thrush on nipples.  If treatment continues for more than 2-3 weeks, consider a different preparation.  This ointment contains a steroid and prolonged use can lead to thinning of the skin. A recent study shows that virgin coconut oil is as effective as Diflucan for treating thrush.  Medihoney is another option.

After each feed, remember to rinse off baby’s saliva before applying nipple ointment.   When candida is present, the rinse may be especially effective if it includes white distilled vinegar in a mixture of 1 part vinegar to 4 parts water.  Nipples can be soaked in this mixture for a minute before air drying and applying antifungal ointment.

Parent may also take a refrigerated probiotic.  This is available at health food stores (locally, Better Health, Foods for Living, East Lansing Food Co-op).  Preferably find a non-dairy version.  This can also be rubbed in baby’s mouth.  Continue the probiotic for two weeks after thrush treatment ends.

Raw garlic can also be used to augment treatment of thrush or bacterial infection.  2-4 raw cloves are consumed per day.  Crush garlic and remove inner core.  Chop and let set for 15 minutes or take right away if preferred.  Do not use medicinal garlic if parent is on any blood thinning product, has a clotting disorder, or is planning surgery.

Wash and sanitize anything that comes into contact with nipples or baby’s mouth while  treating thrush.  Boiling is the preferred method.  Soak anything that cannot be boiled, in a solution of vinegar and water for 30 minutes.

Nipple Blebs  Another painful nipple condition is the milk blister, or “bleb.”  This is a white dot that forms on the tip of the nipple and plugs the duct that is behind the blister.  To remove the plug, use very warm, wet compresses of clear water or salt solution.  Keep the compresses as warm as possible and use for 10 minutes.  Then massage the nipple with olive oil or coconut oil to try to loosen the plug.  After massage, use gentle hand expression or nurse your baby.  When the bleb releases, you may notice a stringy plug of milk that comes through the nipple before milk flows freely.

If the warm compress, massage and expression/nursing do not release the bleb, you can also use a warm, wet terry cloth washcloth to provide gentle friction to the end of the nipple and then hand express or nurse.  These steps may need to be repeated a few times for relief.

If all else fails, a sterile needle can be used to gently lift the edges of the bleb (do not poke the needle into the blister).  This is best done by your health care provider in order to avoid infection.  If a needle is used, wash the nipple at least once a day with soap and water, rinse after feeds and apply antimicrobial/antibiotic ointment on the nipple, until it heals.  Once a bleb has formed, it may reform, so continue using gentle massage with a wet washcloth, once a day, after the bleb has released, until the nipple fully heals.

According to a study from The Academy of Breastfeeding Medicine (MaryAnn O’Hara, MD, MPH 2012) blebs may be due to a localized tissue reaction to milk that has leaked from ducts into surrounding tissues.  In this study, persistent blebs were successfully treated with a short daily course of a very thin layer of a mid-potency steroid under occlusion to enhance penetration into the inflamed tissue.

©2012 Laura Spitzfaden IBCLC: revised 2013

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