Breastfeeding – mastitis and other nipple and breast problems

Nipple or breast pain is not normal

Nipple or breast pain is not a normal part of breastfeeding. Your nipples may be sensitive in the first few days after birth and while breastfeeding, but sore nipples or breasts indicate a problem. If you feel pain, you should seek help immediately.

Blood in breastmilk

If there is a small amount of blood in your breastmilk because of nipple trauma, it will not harm your baby. You can continue to breastfeed unless the pain becomes unbearable.

Breastfeeding parents with some medical conditions (such as hepatitis B or hepatitis C) may be advised to stop breastfeeding temporarily until the nipples have healed and there is no blood in the breastmilk. If this is the case, you can express breastmilk in replacement of a breastfeed to maintain your supply and discard your breastmilk until your nipples have healed.

Tips on caring for your nipples

To prevent nipple problems:

• Ensure correct positioning and attachment of your baby when feeding.
• Avoid soaps and shampoos on the nipples during showering.
• Avoid nipple ointments, powders and tinctures (drug dissolved in alcohol). They may increase nipple problems.
• Leave milk or colostrum to dry on your nipples after breastfeeding. They both contain anti-infective agents.
• Change breast pads frequently. Don’t use pads that hold moisture against the skin.
• If nipple pain or nipple trauma is not improving, seek help from your doctor, lactation consultant or an Australian Breastfeeding Association counsellor.

Some mothers find it more comfortable without a bra. Large-breasted women are usually more comfortable with the support of a properly fitted maternity bra. Breast shells can be used to protect sore nipples. These are silicone with a hard plastic dome to prevent clothing from touching nipples and allowing them to air.

Incorrect attachment is the main cause of nipple problems

Incorrect attachment of the baby onto the breast is the most common cause of nipple pain. Slightly changing the position of the baby on the breast should help. Your midwife, lactation consultant or an Australian Breastfeeding Association counsellor can show you how to attach the baby properly or talk to you about baby-led attachment.

The Australian Breastfeeding Association has resources that explain positioning and attachment for nipple problems.

Breastfeeding with inverted nipples

If you have flat or inverted nipples, patience may be needed while you and your baby learn to breastfeed. Strategies that can help include:

• Breastfeed within the first hour of birth – when the baby is alert and ready to suck.
• Use the baby-led attachment technique – immediately after the birth and in the first few days.
• Express either by hand or with a pump to draw out the nipple – use a cup, spoon or finger to feed the milk to the baby if necessary.
• Avoid the use of bottles and dummies as these involve a different sucking action to breastfeeding.
• Occasionally, the use of a nipple shield for breastfeeding with flat or inverted nipples is helpful – the clear silicone types are the most suitable. Ensure the nipple shield used is the correct size for your nipple. Once the baby is sucking well and the nipple is drawn out, the shield may be removed. When using a nipple shield, the baby should still be correctly positioned and attached to the breast.

Breast and nipple thrush

Breast and nipple thrush (a fungal infection) may occur in the first weeks after birth, but can develop at any time. Signs and symptoms include:

• Severe, burning nipple pain for the entire breastfeed – correct attachment does not alter the pain. Burning nipple pain is continuous, not just during feeds. Breast pain may vary with nipple and/or breast. There may be sharp, shooting, burning, stabbing or radiating pain throughout the breast.
• The nipples may be a brighter pink than normal and may be shiny. They may, however, look normal.
• Thrush in the baby’s mouth or on the buttocks.

How to tell if your baby has thrush

Oral thrush appears as white spots in your baby’s mouth that cannot be wiped away. When thrush occurs around the buttocks, it causes a red rash on the skin with spots around it. Your doctor will be able to assess whether your baby has thrush.

Treating thrush – mother

Treatment includes:

• Nipple and breast thrush is treated with antifungal medicine and antifungal nipple gel or creams. Antifungal gels and creams include nystatin, clotrimazole and miconazole. These are applied to the nipple after each feed. Oral antifungal treatment such as fluconazole may also be used.
• Air the nipples or go without a bra.
• Change breast pads frequently to keep your nipples dry.
• Good hygiene – wash your hands after touching your breasts, using the toilet or changing nappies.
• Vaginal antifungal pessaries, if you also have vaginal thrush. It is advisable to consult your doctor.
• Wash bras and nursing pads and towels separately from nappies in hot soapy water and dry all of them in the sun where possible.

Some mothers find it helps to reduce sugar and yeast in their diet. See your doctor or other medical advisor if thrush persists.

If you or your baby have been diagnosed with thrush you will both need to be treated.

Treating thrush – baby

Treatment includes:

• Nystatin liquid or miconazole gel for oral thrush.
• Antifungal ointments for thrush around the buttocks.
• If you use dummies or teats these should be washed thoroughly after use and sterilised either by using a steam steriliser or by placing the dummies and teats in boiling water for 5 minutes. If possible, replace the dummies and teats weekly if you or your baby has thrush.

Bacterial infection of the nipples

Research has found that a bacterial infection of the nipples can be mistakenly diagnosed as nipple thrush or may be present in conjunction with thrush.

Treatment with an antibacterial ointment or a combination antibacterial and antifungal ointment will often heal unresolved ‘thrush’. A combination ointment like kenacomb may be recommended or an antibacterial such as mupirocin. An oral antibiotic can also be used.

Your doctor may send a swab of the nipples to be cultured, to identify the most appropriate antibiotic to use.

Dermatitis (skin irritation) around the nipple

Dermatitis around the nipple and areola can be caused by:

• Ointments and creams you are using on the nipples – stop using them if you develop dermatitis.
• Detergents used to wash your bra, breast pads or undergarments – use pure soap, rinse well and dry in the sun.
• Sensitivity to soaps or shampoo.
• Reaction to the fabric of your bra or bra pads – it may be helpful to go without a bra.
• Sensitivity to the moisture-absorbing gel in some disposable nursing pads.
• Sometimes you may react to complementary foods remaining in your older baby’s mouth after they have eaten.

Nipple eczema can cause considerable pain

Eczema may occur on the nipple and areola. Nipple eczema can cause considerable pain and discomfort for a few women.

Eczema causes inflammation of the skin, with a rash that may be dry or weepy. The rash is usually itchy and may be on both nipples and/or areola or just one. If the rash looks crusty or flaky a bacterial infection may also be present.

You will need to see your doctor and may need a referral to a skin specialist if you develop eczema. Dietary changes and a short, intensive course of cortisone cream may help.

Mastitis and breastfeeding

Mastitis means inflammation of the breast. It can be caused by blocked milk ducts (non-infective mastitis) or a bacterial infection (infective mastitis).

If a blocked milk duct is not cleared, flu-like symptoms such as fever, body aches and pains may develop. Milk duct blockages cause milk to pool in the breast and inflammation (pain and swelling). A cracked nipple can allow bacteria to enter the breast and cause an infection.

Symptoms of mastitis

Mastitis causes the breast or parts of the breast to become:

• tender or painful
• hot
• reddened
• hard and swollen.

Other symptoms can include:

• The skin may appear tight and shiny, and be streaked with red.
• You feel very ill (‘fluey’) and have a high temperature (over 38 °C).

How mastitis develops

Factors that predispose a woman to blocked milk ducts, which can lead to mastitis, include:

• Poor drainage of the breast – this can be caused by poor attachment of the baby at your breast or limiting your baby’s time at the breast.
• Engorgement of your breast due to a missed feed or delaying a feed.
• A tight or ill-fitting bra or consistently lying in one position during sleep.
• Holding your breast too tightly during feeding.
• Trauma such as a kick from a toddler or pressure from a seatbelt.

Other factors that predispose a woman to mastitis include:

• Poor physical health, being unwell and being anaemic.
• Using a nipple shield.
• Previous or recurrent blocked ducts.
• Nipple trauma caused by incorrect attachment of the baby during feeds.
• Interrupting feeds, cutting feeds short, by limiting feed times.
• The use of nipple creams, which can harbour bacteria.
• Secondary infection like thrush.

Preventing mastitis

To help prevent mastitis:

• Mothers and midwives should thoroughly wash their hands before touching the breasts after a nappy change.
• Make sure the baby is positioned and attached properly on the breast to assist in thorough breastmilk drainage.
• Avoid long periods between feeds. Feed frequently. Avoid skipping feeds, if replacing a breastfeed with a bottle, express to avoid blocked milk ducts or a reduction in your breastmilk supply.
• Wear loose, comfortable clothing. Bras, if worn, should be properly fitted.
• Avoid nipple creams, ointments and prolonged use of nipple pads.
• If the mother has been unwell, see a GP to rule out anaemia.

Treatment for mastitis

It is important to treat blocked milk ducts so they do not progress to mastitis. Options include:

• Making sure the baby is feeding well on the affected breast – offering the affected breast first can help.
• The application of heat for a few minutes before a feed, gentle massage of the affected area during feeding, and cold packs after a feed and between feeds for comfort.
• A change in feeding position.
• Frequent drainage of the breast using breast compression through breastfeeding and expressing.

If the blockage does not clear within 8 to 12 hours or you start to feel unwell, see your doctor.

Treatment for mastitis should begin immediately. Your doctor may not immediately be able to distinguish between simple inflammation and a bacterial infection, but will usually treat you as if it is infected.

Treatment includes:

• Continued breastfeeding and/or expressing to drain the breast. It is important to continue breastfeeding or expressing from both breasts. Start by offering the affected breast first to help clear the blockage. Your breastmilk is safe for your baby even if you have mastitis.
• Gentle massage toward the nipple when breastfeeding or expressing.
• Antibiotics (such as flucloxacillin or cephalexin).
• Anti-inflammatory medication (such as ibuprofen) and/or analgesia (such as paracetamol) to relieve pain, if necessary.
• Rest and adequate fluid intake.
• A warm cloth or heat pack on the affected area may help the milk flow before feeding or expressing. Make sure the cloth or heat pack is not too hot.
• Applying a cold pack wrapped in a cloth after breastfeeding or expressing may help to reduce the inflammation and pain.
• Varying the feeding position to increase breast drainage.

If you wish to stop breastfeeding, it is important to wait until the mastitis has cleared up. Rapid weaning may lead to a breast abscess.

Other causes of nipple and breast problems

Nipple trauma can occur when a breast pump has been used incorrectly or from failing to break the suction before removing the baby from the breast (this is done by sliding a clean finger into the corner of your baby’s mouth).

Nipple vasospasm occurs when blood vessels tighten causing pain during, immediately after, or between breastfeeds. It is usually worse when you are cold or have a history of Raynaud’s phenomenon. Nipple vasospasm can cause intense nipple pain. With nipple vasospasm you may see colour changes in your nipple from whitened to purple or red, then back to normal colour. Speak to your doctor, midwife or a lactation consultant if you think you may have nipple vasospasm.

Tongue-tie is a condition in which the thin piece of tissue under a baby’s tongue is abnormally short and may restrict the movement of the tongue. It may interfere with a baby’s ability to latch and suckle at the breast, leading to nipple pain and trauma. If you are concerned that your baby may have tongue-tie which is affecting breastfeeding speak with your doctor, paediatrician, midwife, maternal and child health nurse or lactation consultant.

Where to get help

• Your midwife
• Your GP (doctor)
• A lactation consultant – contact Lactation Consultants of Australia and New Zealand (LCANZ) Tel. (02) 9431 8621
• Australian Breastfeeding Association Breastfeeding Hotline Tel. 1800 686 268
• Your maternal and child health nurse
• Maternal and Child Health Line Tel. 13 22 29 (24 hours)
• Breastfeeding clinics – many hospitals have programs which assist women with infant feeding problems
• The Royal Women’s Hospital Breastfeeding Service Tel. (03) 8345 2400
• NURSE-ON-CALL Tel. 1300 606 024 – for expert health information and advice (24 hours, 7 days)