Pain in one breast
There is greater possibility of pain being due to attachment
Pain in both breasts
Always consider improving attachment, even if there is a medical basis for pain.(Click on the links below which are relevant to your condition)
Is the pain strongest at start of feed or just before a feed?
If there is a sharp intense pain in breast(s) often described as squeezing pain this can be due to the let down or milk ejection reflex. Pain can be worse on fuller breast.
If it is associated with;
- leaking milk,
- a baby who makes a clicking noise during feeds
- or pulls away choking once the feed has started,
the leaking can be reduced by applying firm hand pressure to the breast at the time of leaking.
The fast flow of milk may mean the baby uses sub-optimal attachment and therefore further support from a skilled breastfeeding practitioner to improve attachment may be useful.
Is the pain strongest at the start of the feed (on both sides)?
Consider sub-optimal attachment as the most likely cause. Needs to be assessed by specialist breastfeeding practitioner.
Signs of sub-optimal attachment include:
- If the nipple changes shape after breastfeeding – either lipstick shaped or flattened, or
- baby slurps onto nipple rather than attaching with open gape or
- if the nipple changes colour after the breastfeed – classically a white tip to the nipple
Is the pain reduced by feeding?
If there is a lumpy area on the breast that may also feel hot and can appear red on some skin tones:
Treat as blocked duct or early symptom of mastitis (click here to view leaflet). Feed frequently and seek support from a specialist breastfeeding practitioner as soon as possible. Take ibuprofen 400mg as anti-inflammatory if appropriate (i.e. no contra-indications such as asthma or stomach ulcer)
Is the pain worse in the morning and reduced by feeding?
May be linked with attempts to restrict feeds or attachment that could be improved. Seek support from specialist breastfeeding practitioner
Are the nipples damaged?
Use moist wound healing within wound [avoid applying cream to whole nipple] to stop scab formation which will deepen the wound. Attachment needs to be assessed by specialist practitioner as soon as possible
Are the nipples damaged and you are using a breast pump rather than feeding directly?
Check for a high setting on the suction or you may be using a flange which is too small
Are nipples itchy with no change in shape or colour (may appear as redness on some skin tones)
Does warmth causes increased itching?
Consider an allergy to nipple cream, breast pads etc
Take non- sedating antihistamine (Click to view the Antihistamine fact sheet). Hydrocortisone 1% cream can be applied sparingly to the nipples and areolar after feeds
Do nipples change colour rapidly after breastfeeds from white to purple then red (this might not be visible on all skin tones)?
- If you have a history of circulation problems or migraine and
- pain is precipitated by cold eg walking down freezer aisle in supermarket
Possible diagnosis is Raynaud’s Phenomenon. (Click to view Raynaud’s factsheet). Pain can be immediately after a feed but may also be delayed or be triggered by cold
If massage and application of warmth after feeds does not resolve symptoms. Consider asking GP to prescribe nifedipine 10mg three times a day or nifedipine LA 30mg daily. Treatment for 2 weeks may be sufficient or may be needed long term.
Is the pain worse at the end of a feed after a period of pain-free feeding?
- Re-check there is no change in nipple colour or shape after breastfeeds to eliminate return of sub-optimal attachment.
- Ask GP to swab your nipples and your baby’s mouth to identify any bacterial or fungal infection
If culture positive for bacterial infection, nipples should be treated with topical antibiotic first line before considering oral therapy.
If culture positive for fungal infection
- nipples should be treated with topical miconazole cream sparingly after every feed (Clotrimazole is linked with allergic reactions and is less effective than miconazole) and
- baby’s mouth with miconazole gel 4 times a day as first line. (Nystatin suspension is less effective than miconazole)
If no resolution of symptoms consider asking GP to prescribe 7-10 days of oral fluconazole for mother in addition to ongoing topical treatment for both. If symptoms still present after a further 10 days, re-assess diagnosis.