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Persistent Pain When Breastfeeding

Cindy Garrison, Canonsburg, Pennsylvania, USA

Breastfeeding is not supposed to hurt. Yet many mothers and nursing parents complain of pain associated with breastfeeding, which can be a leading cause for early weaning. When someone calls about persistent nipple pain or breast pain, a Leader can review the most common causes for pain while breastfeeding, such as:

  • Suboptimal latch and positioning (Positioning, LLLI)
  • Teething or nursing acrobatics in an older child (Teething, LLLI)
  • Frequent use of artificial nipples such as pacifiers, bottles or nipple shields as these can affect a baby’s latch (Nipple Confusion, LLLI)
  • Poorly fitting pump flanges or excessively high pressure which can cause trauma to the nipple and/or breast
  • Engorgement or mastitis (Mastitis. LLLI)
  • Pregnancy

If these common causes can be ruled out yet the mother still experiences persistent pain, more investigation will be needed. Leaders should always refer callers with persistent pain to their health care professional. Callers could also be encouraged to contact an International Board Certified Lactation Consultant (IBCLC) where available, for further help with persistent pain issues associated with breastfeeding. If the concerns can still not be resolved, a consultation with a breast specialist is the next step.

Although there are many causes or practices that may lead to persistent pain while breastfeeding, this article will look more closely at:

  • Thrush
  • Mastitis
  • Vasospasm

There are differences of opinion between health professionals around the world concerning some of these conditions, how to treat them, and even what the conditions are called. LLL Leaders can share experiences, published information, and available resources for the mothers’ consideration. Mothers should be encouraged to talk with their health care providers about these and other recommendations and the evidence for them.

Thrush

Thrush, also known as Candidiasis, is a fungal infection caused by a yeast (a type of fungus) and has often been assumed to be the cause of sudden nipple pain. The connection is controversial. Yeast is prevalent on our bodies and a 2017 study by Jiménez et al (Jiménez, 2017) joined a growing body of research showing the role played by yeast in breast and nipple pain was marginal. This research supports that of others that suggest poor positioning, vasospasm, dermatitis, hyperlactation (over production of breast milk), or mammary dysbiosis (also known as subacute mastitis) are the primary causes of nipple pain.

Symptoms often associated with thrush include:

  • Itchy or burning nipples that appear fiery red on lighter skin tones, shiny or flaky.
  • Cracked or damaged nipples.
  • Shooting pains in the breast during or after feedings.
  • Intense nipple or breast pain that is not improved with better latch and positioning.

NOTE: These symptoms are also related to many other conditions.

There are a number of factors that can predispose a mother to thrush:

  • Baby with a thrush infection. White plaques (patches) on baby’s cheek linings or gum tissue or a red, raised rash in the diaper (nappy) area may indicate a thrush infection (Berens et al, 2013)
  • A mother with a history of Candida infections (Berens et al, 2016)
  • A recent course of antibiotics for mother or baby (Berens et al, 2016)
  • Improper cleaning of pump parts, pacifiers, bottles and artificial nipples can also be a source of candidiasis exposure (Eglash et al, 2017)

If thrush is suspected, the mother should be referred to her primary healthcare provider and to the baby’s physician if different, as both mother and baby will usually be treated.

True thrush can be difficult to treat because yeast:

  • Thrives in warm, moist areas, such as a baby’s mouth and diaper area or a mother’s underarms, breast folds, or vaginal area.
  • May be passed back and forth between mother and baby through nursing.
  • Treatments (see below) are often drying or irritating to nipple tissue, making it more difficult to determine if the pain is from thrush or the “cure” itself.

When treating for thrush, it is usually recommended to treat both mother and baby together even if one has no apparent symptoms. Physicians may prescribe:

  • Topical antifungal ointment or creams in the azole family, such as miconazole and clotrimazole, (which also inhibit the growth of Staphylococcus species) on nipples (Berens et al 2016).
  • Nystatin suspension or miconazole oral gel for infant’s mouth (Berens et al 2016)
  • Oral fluconazole for resistant cases. (Berens et al 2016) NOTE: Fluconazole may also worsen symptoms of vasospasm (Nipple Vasospasm Patient Handout 2019. Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic
  • A combination topical cream combining antifungal, antibiotic and anti inflammatory ingredients (Newman, 2017)

NOTE: Gentian violet (less than 0.5% aqueous solution), which has been used historically as a treatment of thrush, has recently been identified as a cause of concern (Wambach and Spencer, 2021). Both the World Health Organization (WHO) and Health Canada advise against its use. Use only if prescribed by your healthcare provider.

It is important to remember that medications can affect one person differently than another. Leaders should always caution callers to check with healthcare professionals regarding medications and other treatment options. 

Although freezing expressed human milk does not kill yeast the Academy of Breastfeeding Medicine says there is no evidence to suggest discarding milk is necessary (Eglash et al, 2017)

Good hygiene, such as changing damp breast pads or bras frequently, washing underwear in very hot water and/or bleach to kill spores, and wearing breathable clothing can be helpful for some mothers. Other suggestions are to eat fewer foods high in sugar and/or that contain yeast, to use condoms to avoid cross-contamination with a partner until nipple pain is resolved, and to wash anything that goes in baby’s mouth (toys, pacifiers, bottle nipples, etc.) in hot, soapy water and rinse well.

Mastitis

Mastitis (inflammation or infection of the breast) is another common source of pain. Mastitis often comes on suddenly and may follow nipple trauma, a plugged duct, or a baby sleeping longer that usual, resulting in engorgement. Mastitis may be associated with a bacterial infection but not all inflammation signals an infection.

The following symptoms commonly present with mastitis:

  • A tender, hot, swollen area in the breast that can often be wedge-shaped.
  • Fever over 101º F (38.5º C)
  • Chills
  • Sweats
  • Flu-like symptoms
  • Pain radiating deep into the breast
  • Cracked, fissured nipples
  • Baby refusing to nurse on affected side which may be due to slower flow/a salty taste from increased sodium levels or “thickened” milk due to milk components leaking into surrounding tissue due to pressure build up in ducts (Mohrbacher, 2020 p 757, 760)

Important features of management include:

  • Bed rest—extremely important and often undervalued.
  • Help at home, if possible
  • Frequent breastfeeding with adequate drainage of the breasts. Breastfeeding is part of the treatment.
  • If baby refuses to nurse on the affected side, hand expression/pumping will be needed to keep the breast comfortable
  • Anti-inflammatory medication
  • Avoiding tight clothing or bras
  • Alternating warm to the breast before feeding/pumping (to encourage better milk flow) with cold compresses after feeds (for pain relief)
  • Gentle massage during breastfeeds starting above the tender area and moving toward the nipple, if tolerated
  • Expressing after the feed by hand or pump may be helpful to empty the breast further, making sure pump equipment is a good fit and kept very clean (Eglash et al, 2017)
  • Vary feeding positions: have baby’s nose/chin pointed toward the tender area for better milk removal (Mohrbacher, 2020 p 761) or
    bring baby up to the breast to avoid hunching over to the baby (Positioning, LLLI)

If there is no improvement in 24 hours, or if the symptoms are getting worse, a bacterial infection could be a consideration. Mothers should be referred to their healthcare provider. If antibiotics are prescribed, they will normally be for longer than a standard 5-day course (Wambach and Spencer, 2021). If mastitis is not improving after 48 hours of first-line treatment with antibiotics or the mother is experiencing repeated cases of mastitis, it would be practical for her to request having her milk cultured to better determine, or rule out, other possible causes.

Vasospasms

Vasospasms are constrictions of the blood vessels which may relate to compression on the nipple due to a poor latch but more commonly occur as a result of exposure to cold. Vasospasm may relate to Raynaud’s phenomenon or connective tissue disorders. It is more common in females than males. It may also be more noticeable in women with a history of migraines.

The reduction in blood flow to the tissue can cause color changes and occurs most commonly in the fingers and toes but can involve the entire hands or feet. When noticed in the nipple, the changes can range from white upon the exposure to the cooler air to bright red/purple when blood flow returns as the vasospasm eases. The return of blood flow can be accompanied by throbbing pain that radiates from the nipple into the breast and may even extend into the back of the breast. For some, the pain can be so intense, they may consider stopping breastfeeding entirely.

Leaders can share that:

  • Applying dry heat to the nipple, for example a warmed breast pad or heating pad to the breast as soon as the baby unlatches, can help stop the sudden constriction of the blood vessels with exposure to the cooler air.
  • Reducing or eliminating caffeine helps some mothers
  • Over-the-counter pain medication such as might be used for a headache is compatible with breastfeeding (Nipple Vasospasm Patient Handout 2019)
  • In severe cases of Raynaud’s, a healthcare professional might prescribe a medication that helps dilate the blood vessels e.g. nifedipine (Nipple Vasospasm Patient Handout 2019)
  • Once the pain is resolved, many mothers are able to gradually decrease their dose until they are able to discontinue it altogether. Others may need to stay on the medication for a more extended time to maintain relief.

The distinction between thrush and vasospasm as a cause of nipple pain is particularly important because fluconazole, which may be used to treat thrush, can exacerbate vasospasm (Nipple Vasospasm Patient Handout 2019).

Conclusion

There are a number of possible causes for persistent pain in breastfeeding. A Leader’s role is to provide information on common breastfeeding-related reasons for pain and to refer mothers to their health professional for diagnosis or treatment. When pain seems to go beyond the normal course of breastfeeding callers may be encouraged to consult with an International Board Certified Lactation consultant for additional suggestions.

References:

Amir L. et al. Academy of Breastfeeding Medicine, Protocol #4.
Amir L. et al. Does candida and/or staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne Australia
Berens P et al. Academy of Breast-feeding Medicine, Protocol #26. Academy of Breastfeeding Medicine. 2016 –
Barrett ME, Heller MM, Fullerton Stone H, et al. Dermatoses of the breast in lactation. Dermatol Ther 2013;26:331–336.
Betts RC, Johnson HM, English A, Mitchell KB. It’s not Yeast Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain. Breastfeeding Medicine. 2021
Eglash A et al. Academy of Breastfeeding Medicine, Protocol #8 Academy of Breastfeeding Medicine. 2017 –
Garrison CP. Nipple vasospasms, Raynaud’s syndrome and nifedipine. Journal of Human Lactation
Genna CW. Supporting Sucking Skills in Breastfeeding Infants. Sudbury, MA 2008
Hale TW. Medications and Mothers’ Milk, New York, NY, 2019
Jiménez et al. Mammary candidiasis: A medical condition without scientific evidence? 2017
Kennerman E. Severe breast pain resolved with pectoral muscle massage. Journal of Human Lactation. 2014
LLLI – Wiessinger D. West D, Pitman T. The Womanly Art of Breastfeeding, USA, 2010
Mayo Clinic Staff. (2015, September 18). Yeast infection (vaginal)

Mohrbacher N. Breastfeeding Answers: a Guide for Helping Families, Arlington Heights, IL, 2020
Newman. Candida Protocol. International Breastfeeding Centre. 2017
Nipple Vasospasm Patient Handout 2019. Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic
Wambach K and Spencer B. Breastfeeding and Human Lactation 6th ed. Burlington, MA 2021
Wilson-Clay B and Hoover K. The Breastfeeding Atlas, 6th ed. Manchaca, TX, 2017

Further reading

Cindy Garrison, BS, IBCLC, has been a La Leche League Leader for almost 46 years and an IBCLC since 1985, working as a lactation consultant in a Pittsburgh, Pennsylvania, USA, hospital for nearly 28 years. She has held many roles in LLLI, including co-Chair of the Board of Directors and Interim Director of the Leader Accreditation Department (LAD). She currently serves as an Associate Professional Liaison Department Administrator for LLL of Alliance, co-Chairs the Program Services Committee, and is a LAD Council Advisor. Cindy and her husband, Dave, have three grown sons, two daughters-in-law, and seven grandchildren ranging from 24 to 7 years old.