By Alison Heyerdahl

Cracked and painful nipples are one of the most common reasons women prematurely stop breastfeeding.  Around 32% of breastfeeding women experience nipple pain and/or cracked nipples in the first 30 days postpartum.  According to recent studies, 35% of women stop breastfeeding within a week of birth because of nipple trauma, and 30% stop breastfeeding between weeks 1 and 4 postpartum.  It stands to reason then, with such high levels of breastfeeding cessation, that finding a solution for cracked and painful nipples is a high priority for mothers who wish to breastfeed their babies for a longer period. 

What Causes Cracked/Painful Nipples?

Many factors have been identified to cause cracked or painful nipples.  The most common determinants include:

• Poor breastfeeding technique, position, or latch.

• Malformed, semi-protruding, or inverted nipples.

• Breast engorgement.

• The use of a feeding bottle (which will be explained below).

• The improper use of breast pumps (wrong suction or flange size)

• Nipple hypersensitivity.

Understanding the various factors that cause painful and cracked nipples is important in establishing preventative measures, especially because the available treatment options are seldom effective. In addressing these underlying issues, many mothers have found relief.  

Poor Attachment or Incorrect Positioning

Many mothers are surprised at just how painful, awkward, and complicated breastfeeding can be. What they may not realise though, is that breastfeeding is a learned skill.  As with any new skill, breastfeeding can take some time to get used to.  Oftentimes, mothers have been told to position their babies in a specific way that feels uncomfortable, which may lead to the baby squashing the nipple as they feed.  Squashed nipples often rub until they become damaged and restrict the flow of milk. 

Babies have an instinct about the way they want to feed at the breast.  They may become distracted and frustrated if we interfere with how they naturally want to position themselves.  If breastfeeding feels unnatural or like you are having to fight with your baby, it may be time to let your baby lead the way. In order for breastfeeding to be successful, the following conditions have to be met:

• The baby should face the mother’s body

• The baby’s mouth should be wide open

• The baby should have a deep latch

• The baby’s chin should touch the breast

• The baby’s lips should be turned outwards

• The nipple presents in an elongated, but still round shape after the feed

• Nipple pain is absent

With baby-led attachment to the breast, mothers may be concerned that it will worsen their nipple pain.  However, even with very painful or damaged nipples, once the baby attaches correctly and deeply to the breast, breastfeeding becomes more comfortable. 

Another cause of nipple pain is failing to correctly break the suction before removing your baby from your breast.  This is done by sliding a clean finger into the corner of your baby’s mouth and breaking the seal between your baby’s tongue and nipple to avoid causing further trauma to your nipple. 

Breast Engorgement

Breast engorgement is another major factor that contributes to painful and cracked nipples.  Breast engorgement often occurs within the first 2 – 6 days after birth when the milk comes in.  Breast engorgement changes the shape of the breast and nipples, hindering the latching process due to the swelling and flattening of the nipples.  Engorgement is caused by a build-up of milk, blood, and other fluids in the breast tissue, making it difficult for the baby to latch.

In order to prevent engorgement, mothers may try the following:

• Feed your baby often in the first few weeks after birth and throughout the night.

• Don’t restrict your baby’s time at the breast

To relieve engorgement, mothers may try the following techniques:

• Remove your bra completely when breastfeeding

• Massage the breast or use a warm pack before feeding to trigger the let-down reflex

• Hand express or pump out some of the milk before breastfeeding so that the breasts are soft for latching (lactation consultants recommend hand expression over pumping so as not to exacerbate the engorgement cycle)

• Use cold packs for inflammation relief

• In severe cases, some mothers may need to take anti-inflammatories to relieve the pain and inflammation that can occur with engorgement

Breastfeeding with flat, malformed, or inverted nipples

Nipple sizes and shapes vary drastically from mother to mother.  Many moms with flat or inverted nipples are able to breastfeed effectively, but others will need extra support to do so.  Remember that baby’s don’t just latch onto the nipple when breastfeeding, but to a large proportion of the areola too.  When nipples are flat or inverted, they may not reach the roof of the baby’s mouth, which makes it difficult to trigger the sucking reflex.  This could make it difficult for the baby to latch or stay latched on for long enough for effective milk transfer.

One effective way to improve nipple shape is to wear nipple formers.  These are soft, silicone discs that fit snuggly into your bra, placing a small amount of pressure on the nipples, drawing them outwards.  Nipple formers can be worn inside the bra for 30 – 60 minutes before breastfeeding. 

Mothers can also try the following techniques:

• Rolling your nipple between your fingers to encourage it to stick out

• Touching your nipple with a cold pack or ice to encourage it to stick out

• Hand expressing or pumping before breastfeeding to draw the nipple out

Nipple shields can be used, but only as a short-term solution. They are made from thin, flexible silicone with holes in them designed to allow the milk to pass through.  It offers your baby a larger, firmer target that stimulates the palate to encourage the sucking reflex.  Over time, as your baby’s suck gets stronger, you can transition to feeding without nipple shields. Before starting with a nipple shield, moms should have a lactation consultant evaluate the situation, the feeding technique with a nipple shield, the baby’s latch, and when/how to transition back to the bare nipple. 

Other Factors that Cause Nipple Pain

As mentioned above, other factors that cause nipple pain is the use of feeding bottles early on in your breastfeeding journey.  Bottle-feeding and breastfeeding require very different actions of your baby.  When your baby latches to your breast, their mouth has to be wide open so that the nipple and areola reach deep inside the baby’s mouth.  They then use their tongue and jaw to hold the breast tissue against the roof of their mouth. Drinking from a bottle requires a very different technique.  Firstly, milk flows no matter what the baby does because of gravity.  They also don’t have to open their mouths as wide or draw the bottle nipple as deeply into their mouths. 

Overall, it’s clear that feeding from a bottle can create nipple confusion and cause a poor latch trying to breastfeed again. 

Incorrect pumping techniques can also cause nipple trauma.  If the breast is not correctly positioned in the pump, the flange sizes are incorrect, or you have the wrong suction settings, it can result in nipple damage. 

Nipple hypersensitivity is another cause of nipple pain.  Nipple hypersensitivity usually subsides within the first few weeks of breastfeeding.  Some lactation consultants liken nipple hypersensitivity to working out for the first time after a long inactive period.  In the beginning, your muscles will be sore, but eventually, they become used to the pain.  The same thing happens with your nipples – with time the pain improves. 

The following are some suggestions to help whilst your cracked nipples are healing:

1. Offer your baby the breast before they are frustrated and frantic with hunger. This will ensure that they are relaxed and can get a deep latch.

2. Get comfortable and relaxed before you start breastfeeding.

3. Massage your breasts and apply gentle heat to your breasts to get the milk flowing.

4. Always offer your baby the less sore side first.

5. Ensure that your baby is latching correctly

6. Try different positions until you find one that works for both you and your baby.

7. After feeds express a few drops of milk and smear these onto the nipple

8. Don’t use anything on your nipples that may dry them out or damage the nipple skin (eg. Alcohol-based products or rough towels).

9. Don’t use breast pumps that have a strong suction that hurts your nipples.

Conclusion

Cracked and painful nipples are one of the most common reasons mothers prematurely stop breastfeeding.  Many factors have been identified to cause painful or damaged nipples, including poor breastfeeding technique or latch, breast engorgement, inverted/malformed nipples, bottle feeding, nipple hypersensitivity, and inappropriate breast pumps.  This article has outlined some of the most effective ways to correct and resolve these issues.