Sensitive nipples are very common, especially during the first week of breastfeeding. However, breastfeeding should not be painful. If your nipples are sore, your baby may not be attached effectively when feeding. Attachment is the term used to describe how your baby takes your breast into their mouth. Ineffective positioning and attachment will not only cause sore nipples and painful feeding, but it will also prevent your baby from taking enough milk, and as a result they may be unsettled after feeds. You may find the following UNICEF UK Baby Friendly Initiative video about positioning and attachment helpful:
www.youtube.com/watch?v=3nbTEG1fOrE
Sore nipples can also be caused by:
• thrush (for more information about this, please read the section on thrush below)
• tongue-tie (for more information about this, please speak to your midwife or health visitor).
Signs to look out for
Signs of ineffective attachment, which is the most common cause of sore nipples, include:
• sore, painful nipples during feeds
• painful breastfeeding
• your nipple seems flattened or pinched after breastfeeding
• your breasts feel full and heavy after feeds
Self-help measures
To ease the discomfort of sore nipples, you may find it helps to:
• express a few drops of breast milk onto your nipple after each feed (breast milk contains substances which encourage healing and prevent infection)
• change your breast pads after every feed
• wear a well-fitting bra (preferably a cotton, non-underwired bra)
• apply a small amount of a moisturiser, such as petroleum jelly or purified lanolin, to your nipples if they are dry or cracked
Please be aware that although there are many nipple creams and sprays available, they will
not work unless the cause of your nipple pain is treated first.
It is important not to shorten your baby’s feeds because of sore nipples, as this is unlikely to
ease your pain and is more likely to reduce your milk supply.
When to seek medical advice
If you are having trouble breastfeeding your baby due to sore nipples, please ask your
midwife, health visitor or a member of our infant feeding team for support.
Prevention
You can help prevent future episodes of sore nipples by making sure your baby’s positioning
and attachment are effective. For more information about this, please speak to your midwife
or health visitor.
Breast engorgement is the term used to describe an increase in the volume of milk within your breasts, which together with an increased blood supply to your breasts, can cause your breasts to feel warm, heavy and tender. It can also make breastfeeding challenging.
Causes
During pregnancy, high levels of the hormones oestrogen and progesterone cause your breasts to grow and develop in preparation for breastfeeding. These hormones are also responsible for producing colostrum (your baby’s first milk).
After you deliver your placenta (after giving birth to your baby), your hormone levels change again, and your levels of oestrogen and progesterone slowly start to decrease. This change allows your level of prolactin (the milk-making hormone) to gradually rise. Prolactin increases the amount of milk your breasts produce. This is why it is common for your breasts to feel engorged approximately three days after the birth of your baby. After this, a ‘demand and
supply’ method of making milk allows your body to produce the right amount of milk for your
baby. Your body will begin producing milk (creating a supply) in response to your baby’s
needs (demands). This means the more you feed your baby and/or express your breast milk,
the more milk your breasts will produce.
Engorgement can also happen if:
• your baby is ineffectively attached and positioned when breastfeeding. You may find the UNICEF UK Baby Friendly Initiative video about positioning and attachment helpful: www.youtube.com/watch?v=3nbTEG1fOrE
• your baby is not breastfeeding as frequently. For example, when you return to work or when your baby starts having solid foods (this is called weaning).
You may also experience engorgement if you decide not to breastfeed your baby. If you do not breastfeed your baby or express your breast milk, your body will naturally stop producing milk after a few weeks.
Signs of engorgement include:
• full, hard, heavy breasts
• tender or painful breasts
• flat nipples
The symptoms of engorgement will usually settle within a few days, as your body produces milk in response to your baby’s needs. You may feel uncomfortable while this happens, but the self-help measures below can help with this.
To ease the discomfort of engorgement, you may find it helps to:
• have a warm bath or shower, or apply a warm compress (for example, a warm flannel) to your breast just before you feed your baby or express your breast milk (the warmth will stimulate your ‘let-down’ reflex and encourage your milk to flow, but you should avoid applying a warm compress between feeds as this may increase the swelling within your breast)
• hand express a small amount of milk before your baby feeds (this will soften the breast tissue around your nipple and make it easier for your baby to attach to your breast), and collect this in a sterilised container and store it in the fridge or freezer for future use (for more information about expressing and storing breast milk, please download a copy of the ‘Off to the best start’ booklet from www.unicef.org.uk)
• massage your breast as your baby feeds (this will encourage your milk to flow and may relieve the tight sensation within your breast)
• use different positions to feed your baby (by choosing to feed your baby in a different position every time you feed, you will make sure milk is drained effectively from all areas of your breasts)
• place a cold compress (ice or frozen vegetables wrapped in a towel) or chilled green cabbage leaves (keep a green cabbage in your fridge and remove and wash the leaves as needed) on your breasts just after feeding your baby or expressing your breast milk to reduce swelling and ease pain (do not use the cabbage leaves beyond the period of time when your breasts are engorged as excessive use can reduce your milk supply)
• take paracetamol or ibuprofen at the recommended dose to ease the pain and reduce the swelling (unless you have been advised not to do so)
• wear a supportive bra
• have plenty of rest
If engorgement is not treated, it can lead to other complications, such as milk stasis and blocked ducts, which in turn can cause a low milk supply and/or mastitis to develop. If your symptoms do not improve after trying the self-help measures above, please speak to your midwife or health visitor.
You can help prevent future episodes of engorgement by:
• responsively breastfeeding (for more information about this, please speak to your midwife or health visitor)
• making sure your baby’s positioning and attachment are effective (you may need the support of your midwife or health visitor to do this)
• avoiding giving your baby infant formula milk (as this replaces breastfeeds) and dummies (as these can reduce your baby’s natural urge to breastfeed)
Breast and nipple pain in breastfeeding women is sometimes caused by thrush. Thrush is a fungal infection caused by a yeast called candida albicans. The yeast (candida albicans) is normally found on your skin and in your mouth, intestines and vagina. However, excessive growth of this yeast can lead to an infection.
A thrush infection in your breast can happen if:
• you do not change your breast pads and bra regularly (the perfect environment for thrush to grow and spread is somewhere warm and moist, which is why it is important to keep your breasts and nipples as dry as possible between feeds)
• your nipples are sore or cracked
• you or your baby have recently had a course of antibiotics (antibiotics can alter the balance of organisms, including yeast and bacteria, on your skin)
A thrush infection is easily spread, and if you are breastfeeding, you and your baby can pass it
back and forth to each other (from your breast to their mouth and from their mouth to your breast)
You may have a thrush infection if:
• you start to feel pain in both of your nipples and/or breasts after you have fed your baby (pain as a result of thrush usually occurs after a period of pain-free breastfeeding)
• the pain is quite severe (it is often described as a burning or a shooting pain, and can last for an hour or more after every feed has finished)
• your nipples are shiny, red or pink
• your nipples and/or areola (the darker area of skin around the nipple) are itchy or flaky
• your nipples are cracked and do not heal
Thrush is unlikely to be the cause of your pain if:
• you are experiencing pain in one breast or nipple
• your experience of breastfeeding has never been pain-free
• your nipples change shape and/or colour after a feed
• the pain you experience differs at different times of the day
• your baby has a tongue-tie and you are waiting for them to have this divided (a frenulotomy)
Your baby may have a thrush infection if they:
• have creamy, white spots (plaques) on their tongue, gums, the inside of their cheeks or the roof of their mouth (these spots cannot be rubbed off)
• have a white gloss on their tongue or lips
• have a sore mouth
• have a sore bottom
• feed for shorter periods, or seem unsettled during and between feeds
Diagnosis
Before receiving treatment for thrush, it is important to arrange an appointment with your
midwife, health visitor, GP or a member of your infant feeding team. This will enable them to:
• observe your baby feeding and make sure your baby’s positioning and attachment are effective. They will also be able to look at the shape and colour of your nipples after your baby has fed and determine whether or not thrush is the cause of your breast and/or nipple pain.
• take a swab from both your nipple and your baby’s mouth. The swabs will then be cultured for fungal and bacterial infections to confirm the presence of thrush before you start treatment.
Treatment
Thrush is treated with anti-fungal medications. To prevent you and your baby from re-infecting one another, you will both need to be treated at the same time. Your GP may prescribe you an anti-fungal cream (to be applied to your nipples after every feed) or oral tablets, depending on the severity of your symptoms. Your GP may prescribe your baby a gel or a cream (to be applied to the infected area, including their mouth). Please speak to your GP if you have any questions or concerns about the medications they prescribe.
You can also take over-the-counter pain relief, such as paracetamol or ibuprofen, to help ease your pain, unless you have been told not to. Always read the label or instructions before taking any medication.
Thrush symptoms will usually start to improve within two to three days after starting treatment.
Please speak to your midwife, health visitor or GP if you have any questions or concerns.
Self-help Measures
Thrush can also spread to other members of your family. To minimise the spread of infection,
it is important that you and your family:
• wash your hands thoroughly (especially after nappy changes)
• use separate towels
• wash and sterilise dummies, teats, and any toys your baby may put in their mouth
• change your breast pads and bra regularly
• wash all towels, baby clothes, bras and anything that comes into contact with the infected area on a hot wash cycle (ironing can also help to kill the thrush spores)
If you are able to continue breastfeeding, it is important to do so. If feeding your baby is too painful, try expressing your milk instead. Expressing your milk will ensure you maintain your milk supply until you are able to breastfeed your baby again. You can give your baby freshly expressed milk, but you should discard any leftover milk. Freezing your milk does not destroy the thrush spores and giving this milk to your baby in the future could re-infect your baby with thrush.
If you think you or your baby has thrush, make an appointment with your GP as soon as possible.
The first weeks with your baby are vital for establishing a good breast milk supply in the long term. The more frequently your baby breastfeeds, the more milk you will make, through a process of supply and demand. Each time milk is removed from your breasts, either by your baby feeding or by you expressing, you will make more.
However, there are certain factors which can temporarily affect how much breast milk you
produce. Reasons for low milk supply include:
• ineffective attachment and positioning
• your baby is not feeding often enough
• giving your baby infant formula milk in addition to breast milk (your baby may want to breastfeed less frequently if you are topping up with infant formula milk)
• your baby having a tongue-tie (for more information about this, please speak to your midwife or health visitor.
Even if your baby’s attachment and positioning are effective, there are some other factors that
can affect your milk supply. You may have a lower milk supply if:
• you have had a recent episode of mastitis
• you lost an excessive amount of blood (more than 500ml) after the birth of your baby
• a fragment of placenta remains in your womb (this can delay your milk ‘coming in’)
• you have a history of polycystic ovarian syndrome, diabetes, thyroid or other hormonal conditions
• you have had previous breast surgery or trauma (although the majority of women who have had breast surgery are able to breastfeed successfully)
• you are taking oral contraceptive pills containing oestrogen
• you smoke (please ask your midwife or health visitor for more information about the smoking cessation services available in your area)
• you have mammary hypoplasia (a rare condition in which there isn’t enough milk-producing glandular tissue within the breast)
• you take certain medications (always ask your GP or pharmacist for advice before taking any new over-the-counter medications or herbal remedies)
With appropriate help and support, lots of these problems can be sorted out quite easily. If you have concerns about how much milk your baby is receiving, it is important to ask for help as soon as possible. Speak to your midwife, health visitor, or your local support group for advice.
You can help increase your milk supply by:
• having more skin-to-skin time with your baby (holding your baby naked or dressed only in a nappy against your skin, usually under your top or under a blanket)
• responsively feeding (for more information about this, please speak to your midwife or health visitor)
• breastfeeding your baby more often
• expressing breast milk after a feed
• compressing or massaging your breasts when you are breastfeeding or expressing your breast milk
• giving your baby expressed breast milk rather than infant formula milk if they need extra milk (seek advice from your midwife or health visitor before giving your baby infant formula milk)
Contact your midwife or health visitor for advice if:
• your baby consistently feeds for less than five minutes at each feed
• your baby consistently feeds for longer than 40 minutes at each feed
• your baby always falls asleep on your breast and/or never finishes a feed
• you feel you need to give your baby infant formula milk
• you think your baby needs a dummy
These can be signs that your baby isn’t receiving enough milk.
Seek medical advice immediately if you notice any of the following:
• your baby is more than 24 hours old but continues to be sleepy and has had less than six feeds in a 24-hour period
• your baby comes on and off your breast frequently during feeds or refuses to breastfeed
• your baby is not having enough wet and dirty nappies (for more information, please speak to your midwife or health visitor
• your baby appears to be dehydrated (signs of dehydration include dark-coloured urine, a dry mouth, lethargy (little or no energy), jaundice (yellow discolouration of the eyes or skin) and a reluctance to feed)
These are all signs that your baby isn’t receiving enough milk and may need urgent medical attention.
Mastitis is the term used to describe inflammation of the breast. It makes the breast feel swollen, hot and painful. It is usually caused when the milk in your breast builds up faster than it’s being removed. This creates a blockage in your milk ducts (known as ‘milk stasis’) and can occur if:
• your baby’s position and/or attachment are not effective, or your baby is having difficulty feeding
• an area of your breast is placed under increased pressure (this may be due to tight fitting clothing, particularly your bra, or due to a finger pressing into your breast during a feed)
• your breasts are engorged
• there are sudden changes in the frequency of your baby’s feeds or the frequency with which you are expressing milk
• you are feeding from one breast more often than the other
• an injury has damaged one or more of your milk ducts or glands
You may have mastitis if:
• your breast feels lumpy, hot, swollen or painful
• your breast changes colour or an area of your breast appears red (this will depend on your skin tone)
• your whole breast aches
• you experience flu-like symptoms
• you feel tired and tearful
Follow the self-help measures below as soon as you notice any lumpy or swollen areas within
your breast:
• continue to feed your baby (or express milk) from the affected breast (this is the quickest way to unblock and empty your milk ducts)
• check your baby is well-positioned and effectively attached to your breast during each feed (you may need the support of your midwife or health visitor to do this)
• try feeding your baby in different positions (this will make sure milk is drained effectively from all areas of your breasts)
• massage your breast gently over the lumpy area and towards your nipple to help the milk flow during a feed
• express a little milk from your breast before feeding your baby (this may help your baby to attach more effectively to your breast)
• feed your baby more often or express between feeds if your breasts feel uncomfortably full place a warm compress (for example, a warm flannel) on your breasts before feeding your baby (this will encourage your milk to flow)
• place a cold compress (for example, ice or frozen vegetables wrapped in a towel) on your breasts after feeding your baby or expressing your breast milk (this can reduce swelling and provide significant pain relief)
• take paracetamol or ibuprofen at the recommended dose to ease any pain you may be experiencing (unless you have been advised not to do so)
• wear loose-fitting clothing and avoid wearing a bra
You should feel some improvement within 24 hours after trying the self-help measures above. If you do not start to feel better, or you begin to feel worse, contact your GP straight away, as you may need antibiotics. If you need antibiotics, your GP will prescribe antibiotics that are safe to take while breastfeeding. It is important that you finish the whole course of antibiotics, even if you start to feel better.
Very rarely, mastitis can develop into an abscess (a painful collection of pus) or sepsis (a life-threatening reaction to an infection). Sepsis needs treatment in hospital straight away because it can quickly get worse.
Please seek urgent medical attention if you:
To help prevent mastitis from occurring again, you should:
• make sure your baby’s position and attachment are effective (you may need the support of your midwife or health visitor to do this)
• feed your baby frequently (this will stop your breasts from becoming too full)
• avoid wearing tight-fitting clothing (including bras) that put pressure on your breasts
• cut down on your feeds gradually when you want to stop breastfeeding (don’t suddenly increase the length between feeds)
If you feel the symptoms of mastitis beginning again, start the self-help measures listed above
straight away and ask your midwife or health visitor for support.
• www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/breastfeeding-problems/common-problems
• www.nhs.uk/start4life/baby/feeding-your-baby/breastfeeding
• www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2010/11/otbs_leaflet.pdf
• www.bliss.org.uk/parents/about-your-baby/feeding/complications-with-breastfeedingand-expressing
• www.babycentre.co.uk/c545887/breastfeeding-problems-and-solutions
• www.unicef.org.uk/babyfriendly/support-for-parents
• www.nct.org.uk/baby-toddler/feeding/common-concerns/breastfeeding-problems-andconcerns-early-days
• www.breastfeedingnetwork.org.uk
• www.laleche.org.uk
• www.kellymom.com
• www.firststepsnutrition.org
• globalhealthmedia.org/videos/positions-for-breastfeeding
