There are several possible causes of sore nipples in a breastfeeding mother. The most common of these is when a baby is not latched (attached) to the breast properly—so the baby is “nipple feeding” instead of breastfeeding. Sometimes however, the situation is not as simple as just fixing the latch. Positioning and attachment may look OK but a mother may still have severe pain, soreness, stabbing pains in the breast or perhaps itching or burning pain. In these cases perhaps the baby has poor tongue function resulting in these symptoms. Or, because damaged nipples are susceptible to infection, there may be a bacterial or fungal infection on the nipples causing soreness. This article provides a brief guide to some common causes of sore nipples when breastfeeding.
Causes of sore nipples
#1 Position and attachment
When a baby breastfeeds without a deep mouthful of breast tissue as well as the nipple in their mouth it is known as a shallow latch. A shallow latch can cause painful feeds, blisters, cracks, grazing or bleeding from the mother’s nipples. Once a baby has a big mouthful of breast tissue as well as the nipple in his mouth (a deep latch), sore or cracked nipples can usually heal quickly on their own. See Why Does Breastfeeding Hurt? for an explanation of why the latch is important and more problem solving ideas. The articles Breastfeeding Positions for Newborns, Latching Tips and Breastfeeding Videos have ideas to help with positioning. And an IBCLC lactation consultant or other breastfeeding specialist can be invaluable to help you to find a comfortable position to prevent sore nipples.
#2 Variations in anatomy (mother)
Sometimes a baby’s latch can “look” good but the mother complains of severe discomfort or one or both of her nipples are sore and damaged. If there is pain, something is not quite right whatever the latch looks like. Variations in the particular anatomy of mother or baby can sometimes make it harder to get comfortable. In these cases, an assessment by an IBCLC lactation consultant can be really helpful.
- Nipple size and shape. Nipples come in many shapes and sizes and a mother can have two very differently shaped nipples. Very large, flat, inverted or unusually shaped nipples can sometimes rub in an infants mouth despite paying careful attention to latching on. See Breastfeeding With Inverted Nipples and Flat Nipples and ask your breastfeeding specialist for help with finding the best position for you and your baby. In some situations nipple shields may be helpful (silicone nipple covers with holes for milk to flow). Dimpled or folded nipples may tend to trap moisture after a feed and become sore, but patting them dry after a feed can avoid this.
- Large breasts. A larger cup size can sometimes make positioning more challenging see Breastfeeding With Large Breasts for more ideas.
#3 Variations in anatomy (baby)
Just as mothers are all different, so are babies. Examples of variations in anatomy that could be causes of sore nipples Include:
Sometimes a baby uses their tongue in such a way that it pinches or grazes his mother’s nipples even though the latch “looks good” to an onlooker. Not using a baby’s tongue optimally can stem from various causes including:
- Poor attachment—a deeper latch with more breast tissue in the mouth will stabilise the tongue
- Tension—a baby may have high muscle tone e.g. tension in the neck, jaw or muscles controlling the tongue preventing a full range of movement
- Making the wrong movements—a baby who is used to a bottle teat may be using a bottle feeding technique at the breast. Tongue exercises can often strengthen or improve tongue function (an IBCLC lactation consultant can suggest exercises)
- Tongue-tie—when a baby has restricted tongue movements due to the anatomy under their tongue. See What is a Tongue-Tie? for more information.
A receding chin describes a small chin set back a little into the face and is quite normal in babies. However if the lower jaw is very much shorter than usual this can sometimes make it more difficult to get a deeper latch. Cathy Watson Genna 1 explains that a small lower jaw (micrognathia) can give a baby less strength in the jaw and restricted tongue movements. Small jaws tend to grow forward in time, often by around 12 weeks of age. In the mean time, mothers can explore:
- Paying careful attention to latch and positioning. Reclining or side-lying positions can be helpful
- A nipple shield may be useful short term
- Finger-feeding can help to strengthen tongue movements (Watson Genna, 2016)
Sometimes a baby may seem too small for the size of the nipple or breast they are paired with resulting in sore nipples. Positioning help from a breastfeeding specialist can often help and in a short period of time baby will grow in size.
#4 Vasopasm of the nipple
A vasospasm is a sudden constriction (vasoconstriction) or narrowing of the blood vessels in the nipple and it can be extremely painful. You may notice blanching of the nipples (when the tips of the nipples look white after a feed) and the pain may be felt a short time after breastfeeding or in between feeds. Vasospasm tends to be caused by;
- A shallow latch—getting your baby latched deeply at the breast will be helpful.
- Raynaud’s phenomenon—this is a condition where the mother may experience similar symptoms in her fingers and toes, often triggered by feeling cold.
Vasopasm or vasoconstriction of the nipple can also cause Mammary Constriction Syndrome (deep breast and muscle pain). See Vasospasm Symptoms for more information on causes, symptoms and treatments for nipple blanching and vasospasm.
#5 Bacterial infection
Another possible cause of sore nipples is bacterial infection, often by Staphylococcus aureus (S. aureus); a bacteria commonly found on skin. Lactation consultant Marsha Walker explains:
Once the integrity of the nipple skin has been breached, it becomes highly susceptible to colonization and infection by bacteria such as S. aureus. This can lead to prolonged nipple pain, delayed healing, complications, and the need for more aggressive interventions.
Wash damaged nipples daily with plain soap
Washing damaged nipples daily with ordinary mild soap (not antibacterial) reduces the number of bacteria present and breaks down their protective shield. There’s no need to wash healthy nipples with soap. See Treatments for Sore Nipples for treatment options if you have a bacterial infection or Staph, MRSA and Breastfeeding for more information about S aureus infections.
Similar symptoms to thrush
Graves et al found Staph aureus can cause an infection of the nipples and lactiferous ducts within the breast with symptoms similar to those previously assumed to be “breast thrush” (see #6 below)2. And Jiménez et al 3 also identified strains of bacteria that can cause inflammation in the ductal system giving rise to the characteristic shooting and burning pains often assumed to be thrush.
#6 Fungal infection (thrush)
Thrush is a fungal infection caused by an overgrowth of Candida albicans. A breastfeeding mother can get a thrush infection on her nipples and a baby can get one inside his mouth (often seen as white patches that can’t be scraped away inside the cheeks). Thrush is thought to be normally kept in check by friendly bacteria in our bodies but a mother may be susceptible to thrush if she has cracked or damaged nipples or if mother or baby are on antibiotics (antibiotics kill the friendly bacteria that keep thrush in check). The symptoms of thrush are similar to those experienced when a baby is not latched correctly causing vasospasm of the nipple (#4 above) and also of bacterial infection of the nipples (#5). Mothers describe itching or burning pain after a breastfeed and sharp pains deep in the breast in between feeds. For a full description of causes, symptoms and the latest treatment recommendations see Thrush on Nipples.
#7 Sensitivity to topical creams or food allergens
Nipples may be sore due to an allergy to a cream or remedy that mothers may be using on their nipples. Even purified lanolin—a popular choice for soothing nipples—can cause a reaction in some mothers. If there is an overgrowth of bacteria or fungi on the nipples this can increase the sensitisation of skin to food allergens 4. See Treatments for Sore Nipples for more information.
#8 If baby has a food allergy/pain
When a baby is uncomfortable or has a pain e.g. when they have tummy ache or an inflamed gullet (oesophagus) as can be seen with food allergies, they may find it hard to breastfeed normally. Lactation consultant and author Robyn Noble explains that as a result of their discomfort a baby can tend to clamp down or “bite” at the breast. This can compress the nipple causing soreness and often a marked ridge or crease will be seen across the nipple after the feed. Noble calls this a hypertonic bite response and makes suggestions to improve comfort and positioning for these babies in her book Breastfeeding Works! Even With Allergies, 2015. Babies with food allergy will usually have other symptoms, see Milk Allergy in Babies for more information.
#9 Milk blisters or blebs
If one of the little openings in the nipple (pores) gets blocked with thickened milk or a layer of skin it can cause a very sore nipple. In this situation you may see a little white spot on the nipple which is called a milk blister or bleb. See Blisters on Nipples for ideas to free the blockage.
Friction blisters—clear or blood filled—on the nipple may be caused by your baby feeding in a shallow latch and rubbing your nipple against their hard palate. See Blisters on Nipples for more information. Painful blisters may also be viral in origin e.g. caused by herpes simplex or the varicella-zoster virus see Herpes and Breastfeeding for further reading.
#10 Pumping equipment
The part of the pump that rests against the breast is called a flange and includes a narrow nipple tunnel which is held over your nipple. If the nipple tunnel is too small or too large this can cause sore or damaged nipples. If the pump vacuum is too high this can also cause trauma to the nipples. See How to Increase Milk Supply When Pumping for help in choosing the right sized nipple tunnel and details of a new type of pump (Haakaa Silicon Breast Pump) which some mothers have found to be a comfortable alternative to a regular pump when they have damaged nipples.
#11 Breastfeeding gadgets
Occasionally the very products that are supposed to prevent sore nipples can be the cause of them:
- Nipple shields. Although these can be a great help in many cases, if they are not a good fit and are rubbing the nipple these can worsen sore nipples. See Nipple Shields Good or Bad?
- Silver cups. Small silver cups are sold to wear over sore nipples and help with healing owing to the antibacterial and antifungal properties of silver. Some mothers find them helpful, others find these cups keep nipples wet and soggy all day long and prevent them from healing.
- Breast pads. As above, if pads are wet and soggy all the time this can interfere with healing.
#12 Eczema, dermatitis and psoriasis
Other causes of sore nipples include the skin conditions; eczema, dermatitis and psoriasis. Contact your health professional for diagnosis and medication compatible with breastfeeding and see Treatments for Sore Nipples? for more information.
There are several dermatological conditions that can affect the nipples and areolas; the three ingredients in our all-purpose nipple ointment (APNO) should cover all these possibilities. The corticosteroid will help decrease the inflammation of most dermatological conditions. Sometimes eczema or contact dermatitis is aggravated by bacterial infection (especially Staphylococcus aureus) or perhaps Candida (yeast, thrush), which is why the other two ingredients are included.
#13 Paget’s disease (rare)
Paget’s disease of the nipple is a skin condition that looks like eczema but is due to an underlying cancer. Dr Jack Newman says:
It is quite uncommon in women of childbearing age but it can occur. Paget’s disease is easily mistaken for eczema because of the flaking skin and itching. Most mothers with eczema get it on both breasts though, while Paget’s disease usually involves only one. If treatment with a steroid ointment does not result in rapid resolution (within a week) of the problem, the mother should see her doctor. The diagnosis is made by biopsy of the nipple. This does not mean the mother should stop breastfeeding on that side—she cannot transfer cancer to the baby by breastfeeding.
#14 Complicated cases
Sometimes it can be very difficult to determine the root cause of sore nipples because several factors may be involved at the same time. An IBCLC lactation consultant can be a valuable member of your healthcare team to help to identify likely causes and management strategies 5.
Sore nipples and an older baby
If breastfeeding becomes painful when your baby is a little older it can sometimes be a mystery to find the reason why you suddenly have sore nipples. Why Does Breastfeeding Hurt? has a section with ideas for this situation.
What can I put on sore nipples?
Marsha Walker, IBCLC (breastfeeding advocate and author) and Jack Newman, MD (Canadian paediatrician and breastfeeding expert) favour combination treatments of antibacterial, antifungal and anti-inflammatory ingredients to quickly deal with the problem, irrespective of the cause. See Treatments for Sore Nipples for more information about all the treatment options for sore nipples that aren’t healing.
Sore nipples are most commonly associated with poor positioning or latch. It doesn’t take many feeds in a shallow latch before nipples become sore, grazed, blistered or deeply cracked and, once damaged, there is a risk of bacterial or fungal infection as well. Breastfeeding is not supposed to hurt—if it is painful, seek urgent help from your breastfeeding specialist or IBCLC lactation consultant to find the cause of your sore nipples. Correcting the latch or your baby’s tongue function is a priority to prevent repeated damage. Your health care provider will advise on the most appropriate treatment for your sore nipples.