Nipple Pain in Breastfeeding

By Jessica Martin-Weber

This post is generously made possible by Bamboobies

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All kinds of advice and myths abound when it comes to breastfeeding and preparing nipples for the experience or what to do when there is pain. Dire warnings and emphasis on getting a “good latch” can make it seem as though it is tricky, inevitably painful, and consuming. (Do you need to worry about your baby’s latch? See here for more on what to look for in a good latch and what to do if it is causing problems.)

But there’s good news! While some do experience nipple pain, many do not and for those that have pain, there is usually an answer and steps that can help resolve the underlying cause. Breastfeeding shouldn’t hurt but that doesn’t mean it won’t and it doesn’t mean that if it does it is your fault or that you did something wrong. Seeing a professional breastfeeding helper such as an IBCLC (International Board Certified Lactation Consultant) may help identify the cause of the pain and find a resolution that will help you reach your breastfeeding goals.

Here are a few points on nipple pain in breastfeeding and tips for how to handle such pain. It is our hope that nobody goes through pain in feeding their babies but if you do, most of the time it doesn’t have to stay that way.

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Is it serious? Figure out if this is the type of pain that indicates an issue or is within the range of normal sensitivity with initial latch. If it lasts for 30 seconds or so and doesn’t bother you when you’re not breastfeeding or pumping then it is possible it isn’t serious and just an adjustment period while your nipples are a little sensitive. If it is toe-curling, swear-worthy pain that makes you hold your breath and try not to scream obscenities or toss your baby far, far away from you, then it is serious and you need to be seen by an expert professional breastfeeding helper. Any tissue damage, cracking, bleeding, scabbing, inflammation, bloody expressed milk, etc., will require proactive treatment and you need to see a health care provider. Keep in mind that if your pain tolerance is high, you may push through pain that is a warning sign that something is wrong, don’t wait too long to get help from a breastfeeding helper such as an IBCLC.

What is the cause? It could be a number of causes from baby’s physiology such as a high palate or tongue-tie (frenulum restriction) to your anatomy such as flat or inverted nipples, bifurcated nipples, or Raynaud’s syndrome (vasospasms), or from a pathology such as a bacterial infection or yeast overgrowth, to a damaging latch. Unfortunately sometimes the case is baby just needs to grow more and it will take time but there may be ways to improve things until that time comes and a breastfeeding helper should be able to help you with that.

What’s the treatment? Working with an experienced breastfeeding helper, once the cause is determined, the first step is to address the underlying cause. This may mean changing positioning and learning latch techniques (such as this “Flipple” technique for latching), a prescription to treat thrush or a bacterial infection, using a device to pull flat or inverted nipples out, a procedure to correct frenulum restriction, therapeutic suck training, and a number of other possibilities. We should start with the easiest to implement first, such as positioning and latch but an early diagnosis can mean resolving the underlying cause for the nipple pain quickly and getting back to reaching those breastfeeding goals.

How to heal? Pain, particularly pain that was ongoing for a while, usually means some tissue damage that’s going to need to heal and until it does, the pain will continue. Treating the underlying cause of the pain is essential for complete healing but there are ways to encourage healing even as the cause is addressed.

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Air drying is important for healing, as much as possible, allow your nipples to air dry before closing up your bra. Air is healing and having the area dry prevents bacteria and yeast from growing in a dark, damp environment. Additionally, rinsing them several times a day (not after each feeding but frequently) can also reduce possible irritation from baby’s saliva.

A good nipple cream, one that is plant based, breathable, and safe enough to leave on during breastfeeding can not only help with healing but can prevent chapping in the early days of breastfeeding as a preventative measure. Wiping off an ointment from sensitive and damaged tissue is painful and can cause further injury so picking one that is safe for baby to ingest in tiny amounts is ideal. Apply after every feeding after allowing the area to dry and pick nursing pads that won’t stick to damaged tissue and your nipple cream.

Your own breastmilk may help your nipples heal. Breastmilk is full of good things that can expedite healing, including stem cells! Be careful though, the sugars in breastmilk will feed a yeast overgrowth, making thrush worse.

Air and sunlight may help nipples healing from thrush as yeast thrives best in dark, damp areas. Make the environment hostile for yeast by exposing your nipples to sunlight and taking a probiotic and cutting out refined sugar.

Heat or cold packs can provide comforting relief, it’s personal, some will love these and others will find them uncomfortable for addressing nipple pain. For those with Raynaud’s Syndrome there is no cure or way to permanently resolve the problem but a heat pack like this one may help minimize the symptoms, apply immediately after feeding.

Cold shredded carrots in the bra (will stain!) promotes healing and is soothing. After breastfeeding or pumping, put shredded carrots stored in the refrigerator in your bra (if you don’t mind your nursing pad turning orange, they can help hold the carrots in place).

Protect the nipples with a nipple shield may be necessary. Nipple shields should be used with caution and hopefully with the guidance of an experienced breastfeeding helper such as an IBCLC because there is a risk of lowering milk supply with using a breast shield (not everyone experiences this, just a factor to be aware is a possibility), but they can be a good option for some to help with tissue healing for a short time.

Take a break if you need to. Sometimes damaged tissue just can’t heal until it has the chance to rest. Regularly empty your breast to protect your supply and have breastmilk for your baby, be sure that you’re using the proper flange size so as not to potentially cause more damage.

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What are your tips for preventing and healing nipple pain and tissue damage?

Share with us in the comments, together we can support each other in reaching our baby feeding goals.

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Drawing from a diverse background in the performing arts and midwifery, Jessica Martin-Weber supports women and families, creating spaces for open dialogue. Writer and speaker, Jessica is the creator of TheLeakyBoob.com, co-creator of BeyondMoi.com, and creator and author of the children’s book and community of What Love Tastes Like, supporter of A Girl With A View, and co-founder of Milk: An Infant Feeding Conference. She co-parents her 6 daughters with her husband of 19 years and is currently writing her first creative non-fiction book.
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The Basics of Tongue and Lip Tie: Related Issues, Assessment and Treatment

By Melissa Cole, IBCLC, RLC and Bobby Ghaheri, MD., Portland OR.

“Tongue-tie” has become quite a buzz word in some circles and is still quite unknown in others.  Tongue-tie, professionally known as ankyloglossia, is a congenital condition in which the lingual (tongue) or labial (lip) frenulum is too tight, causing restrictions in movement that can cause significant difficulty with breastfeeding and, in some instances, other health concerns like dental, digestive and speech issues.  Mothers of infants dealing with feeding challenges are often desperate to find solutions; as awareness increases about tongue and lip tie, some mothers wonder if this is something their baby may be coping with.

Parents often want to know what some typical signs of tongue/lip tie are.  Each mother/baby dyad is very unique and therefore tongue/lip tie issues can present differently for everyone.  Some common symptoms that may point to the infant being tongue/ lip tied include: poor latch/inability to latch, sliding off the nipple, fatigue during feeds ,sleepy feeds, poor weight gain, clicking during a feed , maternal nipple pain/damage (can feel like the infant is compressing, chewing, gumming, pinching, scraping the nipple, etc), increased maternal nipple/breast infections, compromised maternal milk supply, dribbling milk at the breast/bottle, digestive issues (increased gassiness, reflux, etc due to extra are being swallowed and poor control of the milk during a swallow), and various other feeding related challenges. Some mothers and babies may cope with some of these issues, all of these issues or even none of these issues when a tongue/lip tie presents. We must keep in mind having a frenulum is not the problem; compromised tongue mobility and functionality that cause problems for the mother and/or baby are the problem!

Mothers are tech-savvy and often turn to the computer first to research what might be causing their feeding concerns. When moms go online, they will most likely encounter some discussion about how tongue and/or lip ties can cause feeding issues.  If parents suspect a tongue/ lip tie then families will often want to see a provider in-person to have their baby evaluated and treated.  Sometimes families are lucky enough to have a local provider well-versed in evaluating and treating oral restrictions like tongue and lip tie.  However, many mothers may not have access to this expertise in their local communities. If you suspect that your infant may have a tongue or lip tie and you’re not able to find a provider in your community to evaluate and treat this condition, consider connecting with a local international board certified lactation consultant (IBCLC) that should be able to help connect you with additional resources. Another resource is the website for the International Affiliation of Tongue-Tie Professionals (IATP) (please note that the website is just about to be launched and may or may not be live at present, do check back if needed).

Tongue Tie

Tongue tie, released

Tongue and lip ties come in various shapes and sizes and can present uniquely in every baby.  Many providers have only been trained to look for very prominent, classic tongue ties that often create a heart-shaped tongue.  However, tongue ties can be sneaky and restrictions that are more posterior (toward the base of the tongue) cannot be easily visualized.  Proper assessment and evaluation are key when identifying these types of ties because they can easily be missed at first glance.  Not all providers know how to properly assess for all types of tongue and lip restrictions.  While there are various assessment tools and tongue-tied classification scales that have been published, there is still no universally accepted standard of assessment and care when it comes to tongue and lip tie.  This fluctuation in assessment and treatment standards can be extremely frustrating for parents trying to seek evaluation and care for their potentially tongue and lip tied infant.  If you are unsure of whether or not your provider is adept at assessing or treating various types of tongue and lip tie you may want to ask your provider the following questions:

  • How do you assess for tongue/lip tie?
  • How often do you treat tongue/lip tie in your practice?
  • Do you treat posterior tongue ties?
  • How do you perform the procedure?
  • What type of follow-up care to recommend after the procedure?

Providers that routinely assess and treat babies for tongue and lip tie should be able to easily answer these questions and provide parents with enough information so that they can make an informed decision.  Providers that may not be the best to assess or treat your baby include ones that rarely assess or treat for this condition, tell parents that the tongue tie will stretch or that it’s not a big deal, tell parents that they have never heard of it posterior tongue tie, or tell parents that this must be done under general anesthesia.  Parents should always feel empowered to seek additional opinions and advocate for the needs of their child if they are struggling to find a provider that understands and treat oral restrictions.

Lip Tie

Lip tie, released

If a tongue or lip tie is present and parents wish to seek treatment, what can parents expect?  Various types of providers treat tongue and lip tie including: ear nose throat doctors (ENTs), pediatric dentist, oral surgeons, pediatricians, naturopathic physicians, and others qualified to do minor surgery.  In most all cases, releasing the frenulum for infants is an in-office procedure, with no sedation needed.  In some rare cases, or in cases with older children, sometimes light sedation is used if the parents or provider feel that the older child would be too stressed while alert, but in infants this is usually not necessary at all.  Some providers release the frenulum with sterile scissors, others use laser technology. The availability and types of providers in any given community will vary as will the course of treatment.  In general, this is what we tell parents coming to our practice to expect (please note that other providers may perform the treatment slightly different ways):

What to expect when your baby needs a frenotomy/frenectomy:

In general, the procedure is very well tolerated by babies.  We take every measure to ensure that pain is minimized.

1)    For a typical frenotomy (an incision of the frenulum), a topical numbing gel is applied once or twice and occasionally, if a frenectomy (frenulum tissue is removed) is needed, a small amount of local anesthetic is injected.  Often, ice chips are applied directly to the area before (and sometimes after), as this helps numb the area.

2)    Crying and fussiness are quite common, and most children lose only a small amount of blood.  They will frequently drool afterwards until the numbing medicine wears off.

3)    Pressure and ice are held to help minimize any bleeding, and the child will be returned back to you, where you have the option of immediate breastfeeding, bottle feeding or soothing depending on your preference.

4)    Tylenol may be used afterwards but is often not even needed.

5)    You may notice some dark brown stools or spit-ups afterwards as some blood may get swallowed after the procedure.

There is very little risk involved with the frenotomy/frenectomy procedure.  The biggest risk of the procedure is the potential for re-attachment to occur.  In order to prevent this from happening, we work with the patient’s in our practice to keep the newly-released area open and healing well by encouraging specific mouth-work after the procedure.  We encourage gently massaging/stretching the incised area, targeted oral motor work to help the tongue and mouth learning patterns, supportive bodywork, and other complementary healing modalities.  By incorporating this type of gentle aftercare, we do see a reduction in reattachment and better progress overall.

Over the decades, it is no doubt that many breastfeeding relationships have probably suffered greatly due to undiagnosed tongue or lip restrictions.  While more providers and parents are becoming educated about ties, we must be mindful not to think that every feeding challenge is created by a tongue or lip tie or that releasing restrictions will immediately improve the feeding situation.  Sometimes there is immediate improvement after the procedure and sometimes it is a gradual process as the tongue is supported in moving in new ways.  Feeding challenges can be complex and involve layers of issues.  In addition, tongue/lip tie can create other issues that may need to be proactively addressed.  Infants and mothers may cope with muscular tightness, nipple damage/pain, milk supply issues, infant weight gain concerns, etc. that need further support before and after a tongue/lip tie is evaluated and treated.  Working with a qualified, experienced board certified lactation consultant or other care providers that are familiar with oral restrictions is highly suggested.  Coping with feeding challenges in a tongue/lip tied infant can be an emotional and physical roller coaster for families.  It is our goal in writing this article that all mothers and babies receive the care they need and that awareness in regards to tongue/lip tie issues will continue to increase worldwide.

For additional resources on tongue and lip tie, please visit Luna Lactation’s website resource page and scroll down to the tongue tie section.

 

Biographies

Melissa Cole, IBCLC, RLC is a board certified lactation consultant in private practice.  Melissa has been passionate about providing comprehensive, holistic lactation care and education to parents and healthcare professionals for over a decade.  She is an Adjunct Professor at Birthingway College of Midwifery in Portland, OR where she teaches advanced clinical lactation skills.  She is active with several lactation and healthcare professional associations including La Leche League and the International Affiliation of Tongue-Tie Professionals.  To contact Melissa feel free to email her at [email protected] or follow her on Facebook and Twitter @LunaLactation.  You can read more from Melissa at lunalactation.com.

 

 

Bobby Ghaheri, MD is a board certified ear, nose and throat specialist with The Oregon Clinic in Portland, OR. His interest in treating children with tongue and lip-tie stems from his ardent support of breastfeeding and was furthered by his personal experiences, as his youngest child benefited from treatment for it. He enjoys working with children and has an interest in traditional and non-traditional approaches to pediatric pain control. To communicate with him, feel free to email him at [email protected] or follow him on Twitter at @DrGhaheri.  You can read more from Dr. Ghaheri at The Wrinkle Whisperer.
References

Coryllos, E., Genna, C. W., & Salloum, A. C. (2004). Congenital tongue-tie and its impact on breastfeeding.  Retrieved from http://www2.aap.org/breastfeeding/files/pdf/bbm-8-27%20Newsletter.pdf.

Ghaheri, B., & Cole, M. (2012). General Information about Frenulum Procedures for the Infant (pp. 2).

Hazelbaker, A. K. (2010). Tongue-Tie: Morphogenesis, Impact, Assessment and Treatment: Aidan and Eva Press.

Kotlow, L. (2011). Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers. European archives of paediatric dentistry : official journal of the European Academy of Paediatric Dentistry, 12(2), 106-112.

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