Nipple Vasospasm and Breastfeeding

A vasospasm is a sudden narrowing (or constriction) of blood vessels. If the blood vessels in the nipple have a vasospasm this can cause nipple pain and sometimes deeper breast pain. A breastfeeding baby can trigger a nipple vasospasm if they are not attached (latched) to the breast comfortably ie with a big mouthful of breast tissue as well as the nipple. A nipple vasospasm can also be connected with Raynaud’s phenomenon (a condition affecting blood supply).  This article looks at the symptoms, causes and possible treatments for easing nipple vasospasm.

Nipple vasospasm and breastfeeding

If a nipple is flattened or compressed because a baby is pinching the nipple during a breastfeed, this may trigger a nipple vasospasm. The nipple may look pointed or slanted like the top of a new lipstick straight after a feed and, since the blood vessels in the nipple are narrowed, less blood can flow and the nipple can temporarily turn white. When the blood flows back to the nipple after each breastfeed, mothers may feel a painful burning or throbbing sensation.

What are the symptoms of nipple vasospasm?

Symptoms of nipple vasospasm include:

• Painful nipples—the pain is often described as burning, stabbing or itching and may be felt a short time after breastfeeding and/or in between feeds.
• Sore nipples—nipple vasospasm is associated with misshapen nipples and sore nipples or previously damaged nipples that are healing.¹
• White nipples—nipple tips may look white (blanched) after a feed or mothers may notice other colour changes in their nipples e.g. blue or dark red (also associated with Raynaud’s Phenomenon—see below)
• Deep breast pain—some mothers may feel deep breast pain or shooting pains deep in the breast sometimes referred to as Mammary Constriction Syndrome.
• Cold temperatures and stress may worsen the pain or trigger it.

 

Not vasospasm? Other causes of pain

There are many causes of sore nipples or pain during breastfeeding and for a complete overview see Causes of Sore Nipples and Why Does Breastfeeding Hurt? Vasospasm symptoms such as burning pain and soreness can be very similar to those of a bacterial infection (e.g. a Staph infection) or a fungal infection (e.g. thrush).  Note that a misdiagnosis of thrush and resulting unnecessary prescription medication, may make vasospasm symptoms worse.²

What causes nipple vasospasm?

There are a number of risk factors that seem to make nipple vasospasm more likely:

• A shallow latch. In breastfeeding mothers, the main trigger for nipple vasospasm is likely to be a poor latch (the way a baby attaches to the breast). If a baby breastfeeds with mostly only the nipple in their mouth and not a good deep mouthful of breast tissue as well, this is often called a shallow latch. In a shallow latch the nipple is more likely to get pinched between baby’s tongue and the roof of their mouth and trigger the vasospasm. Some babies also learn that pinching the nipples is a good way to slow the milk flow in a fast let-down.
• Sore nipples. Sore nipples, damaged or cracked nipples, and nipples that are healing are associated with poor positioning at the breast and are risk factors for vasospasm (Thomas, 2013).
• Cold temperatures. Exposure to cold temperatures and climates, or the sudden drop in temperature when a baby lets go of the nipple is a risk factor for a nipple vasospasm.³
• Severe stress. Severe emotional stress is a risk factor for nipple vasospasm and a history of migraines may be a risk factor (Goldfarb, 2019).
• Medical conditions. An existing history of autoimmune disease eg lupus, rheumatoid arthritis, thyroid dysfunction, scleroderma, or previous diagnosis of Raynaud’s syndrome increases the likelihood of nipple vasospasm.⁴
• Cigarette smoking. Exposure to cigarette smoke, second-hand smoke or nicotine can be triggers for nipple vasospasm (Goldfarb, 2013).⁵
• Medications. Certain medications including fluconazole (prescribed for thrush), some decongestants, or birth control medication are risk factors for nipple vasospasm (Goldfarb, 2019; Breastfeeding Network, 2019) also beta-blockers, or vasoconstrictor medications which narrow blood vessels (Douglas, Vol 18: 1–29 2022).
• Caffeine may be a trigger for vasospasm (Goldfarb, 2019; Breastfeeding Network, 2019) however Douglas says there is no clear evidence linking caffeine intake to secondary Raynaud’s syndrome (vasospasm without existing Raynaud’s) (Douglas, Vol 18: 1–29 2022).

How can I avoid vasospasm symptoms?

Minimising the risk factors can work very well to help prevent symptoms of nipple vasospasm, namely:

• Get help with positioning from an International Board Certified Lactation Consultant so that your baby’s latch is not triggering vasospasm. A poorly latched baby, an ineffective suck or the baby clamping on the nipple can all cause nipple blanching. Babies with high muscle tone or those with tummy ache (e.g. from a food allergy) may seem to “bite” at the breast and can cause a nipple vasospasm. A baby needs to attach to the breast deeply with a big mouthful of breast as well as the nipple. See Breastfeeding Positioning for Newborns, Latching Tips and Why Does Breastfeeding Hurt? for more information and see your breastfeeding specialist for one to one help.
• Check pumping equipment. A poorly fitted pump flange could cause nipple damage and vasospasm symptoms, conversely pumping with a well fitted pump may offer relief to symptoms compared to breastfeeding for some women until they can get help with positioning.
• Keep warm; breastfeed in a warm room and cover the nipple as soon as a breastfeed ends. Don’t leave nipples to air dry as they will get colder that way. Keep breastpads dry, some mothers use woollen or fleecy breastpads for warmth. Try to avoid sudden temperature changes.⁶
• Avoid latching a baby while the nipple is having a vasospasm, as this may cause damage to the nipple, try warming the breast and repeatedly squeezing the nipple to help blood flow back into this area before latching (Hills, accessed Oct 2022).
• Gentle massage. Try massaging the nipples with warm olive oil after a breastfeed to stop a nipple vasospasm.⁷⁸ Repeatedly squeezing the nipple during a vasospasm helps blood flow return to the nipple and can improve recovery time.⁹
• Rule out a bacterial infection or thrush—check with your health professional that you don’t have any other causes of burning pain and sore nipples.
• Avoid potential triggers: cigarette smoke and smoking, nicotine, caffeine, or any medications that promote vasoconstriction e.g. some decongestants¹⁰ and avoid stress where possible.
• Keep active with aerobic exercise.

Raynaud’s phenomenon

Raynaud’s is a disorder of the tiny blood vessels of the extremities which reduces blood flow. Cold temperatures or strong emotions cause the blood vessels in the extremities to go into spasms, which may cause pain, numbness, throbbing and tingling. Some women who have Raynaud’s in the fingers and toes may find they get Raynaud’s of the nipple when they breastfeed. This might be because breastfeeding affords lots of opportunities for nipples to get cold e.g. just before and after latching. Painful breastfeeding can also be stressful. Raynaud’s is often misdiagnosed as thrush or a poor latch .¹¹

Diagnosis of Raynaud’s

Raynaud’s symptoms affecting the nipple may be difficult to distinguish from nipple vasospasm caused by a poor latch:

• Symptoms can be triggered by cold and may still occur in spite of a good latch.
• Colour changes of the nipples e.g. from white to blue to red/purple may be seen with lighter skin tones.
• Raynaud’s may be linked with a history of migraines or a history of poor circulation ¹².
• May be associated with previous breast surgery and nipple damage¹³¹⁴

Treatments for nipple vasospasm

In addition to using the above ideas to avoid getting vasospasm symptoms, there are a number of treatment options for nipple vasospasm that still persists after a poor latch has been corrected and other infections ruled out. Treatments options are discussed in the following patient information handout from the Goldfarb Breastfeeding Clinic and include pain relief, dietary supplements (calcium, magnesium and vitamin B6), omega fatty acids and prescription medication:

• The use of Advil™ or Motrin™ (ibuprofen) and/or Tylenol™ (acetaminophen) may be very useful to treat the pain of nipple vasospasm. These medications are safe during breastfeeding.
• Your health professional may suggest high doses of calcium and magnesium, and vitamin B6. Please consult your health professionals for doses specific to your case.
• Omega fatty acids may also help. Evening primrose oil (up to 12 capsules a day) and fish oil capsules are rich sources of omega fatty acids.
• Nifedipine (Adalat™) […] normally used for high blood pressure, can also be used for nipple vasospasm, and is safe for breastfeeding mothers and infants.

Nifedipine

Refer to the full Goldfarb article online for precautions regarding nifedipine and share this with your health care professional. The Breastfeeding Network discusses doses and side effects of nifedipine in their fact sheet Raynaud’s Phenomenon in Breastfeeding Mothers and for more places to find information about the safety of nifedipine online see Medications and Breastfeeding. Always discuss medications or medicinal doses of supplements with your health care provider.

Treatment tips from Dr Jack Newman

Jack Newman, a Canadian paediatrician and breastfeeding expert, has a protocol for treating vasospasm; see Vasospasm on his website. In addition to a discussion of certain vitamin and mineral supplements (also referred to in the patient handout quoted above), Dr Newman advocates:

• All Purpose Nipple Ointment (APNO), a topical cream with antibacterial, antifungal and anti-inflammatory ingredients to help with soreness.
• Massaging olive oil into the nipples as an alternative to APNO.
• Pectoral muscle massage see Mammary Constriction Syndrome.

Complementary medicine

Scleroderma and Raynaud’s UK (SRUD) discuss natural and over the counter complementary medicine for scleroderma and Raynaud’s in Natural Therapies.  They discuss how vitamin C, vitamin E, gamolenic acid (GLA), ginkgo bilboa and ginger may help symptoms in the general population but note this article is not specific to breastfeeding mothers.  For the latest recommendations on the compatibility of individual supplements with breastfeeding check online at e-Lactancia or LactMed. Always discuss taking therapeutic doses of supplements with your qualified health professional to make sure they are compatible with your medical history and existing medication.

The Breastfeeding Network fact sheet for Raynaud’s adds that it may be helpful to include ginger in the mother’s diet e.g. drink ginger tea, or even add a spoonful of ground ginger to bath water.

Summary

Nipple vasospasm is a narrowing of blood vessels in the nipple. It can be triggered by a baby breastfeeding in a shallow latch and can cause burning, stabbing or itching pain in the nipples after a breastfeed. Nipple vasospasm can also be associated with Raynaud’s phenomenon and can also cause Mammary Constriction Syndrome or deep breast pain. Treatment involves improving a baby’s latch and positioning at the breast, and avoiding the triggers of nipple vasospasm. Some medications and natural remedies may help symptoms.