Nipple soreness is one of the most common reasons new mothers give for discontinuing breastfeeding, often during the first week of nursing. Read the first part of this article here.
Anne Smith, IBCLC

Other causes of soreness
Most cases of nipple soreness are caused by improper latch on and positioning and will heal within a matter of days once the baby is nursing properly. There are other causes of soreness, however, which are less common. These include:

Engorgement: When the breasts become so full of milk that they are hard and tight, the nipple may flatten out (imagine a water balloon) and difficult for the baby to grasp. The baby may not be able to pull the nipple far enough back in his mouth to effectively compress the sinuses behind the areola.

Try to avoid engorgement by nursing frequently. When your nipples are sore, there is a tendency to avoid nursing often, but this only compounds the problem. If your breasts do become engorged, try massaging your breasts, applying heat and expressing a small amount of milk before offering the breast to soften the areola and make it easier for him to grasp hold of.

Nipple confusion: Some babies switch back and forth from breast and bottle beautifully from day one with no complications. However, the mechanics of breast and bottle-feeding are quite different, and it is best to avoid introducing artificial nipples until the baby has mastered the mechanics of nursing at the breast.

With an artificial nipple, the baby uses his tongue to press against the hard rubber to control the steady flow of milk, and may try to do the same thing when he pulls his mom's soft, mushy nipple into his mouth. This can cause his tongue to rub against the nipple and make it sore. It is best, if possible, to avoid the use of bottle nipples or pacifiers until the baby has become well established at breastfeeding -- usually after the first several weeks.

Flat or inverted nipples: Truly inverted nipples (when pinched, these nipples retract and disappear) are very rare. Flat nipples are more common, but the baby's sucking can usually draw them out. Flat nipples will usually protrude gradually during the pregnancy, and the baby's sucking often draws them out with no problems.

If flat or inverted nipples are diagnosed during pregnancy, wearing breast shells inside your bra may help correct the problem. If flat nipples present problems with latch on, pumping before feedings can help draw the nipple out. Use of a nipple shield (a clear silicone shield shaped like a nipple that is worn over the breast during feedings) may be useful, but only if used under the guidance of a knowledgeable lactation professional, as improper use can create problems.

Removing the baby from the breast improperly: Once your milk comes in and the baby is effectively nursing, he will usually fall off the breast in a drunken stupor as he falls asleep, often with milk drooling out the side of his mouth. If you need to end the feeding before he decides he is finished, don't try to pull him off. Instead, break the suction by pulling down on his chin, pressing down on your breast near his mouth, or putting your finger in the corner of his mouth to break the suction.

Medical causes: These include thrush, or yeast ( a very common, but often undiagnosed cause of nipple pain), Eczema, Herpes, Impetigo, Staph infections, improper use of breast pumps (there are some absolutely terrible pumps on the market), allergies, and pregnancy (yes, it is possible to become pregnant while nursing -- highly unlikely while exclusively breastfeeding, but possible?), and Anklyoglossia (more commonly known as "tongue-tie")

Treatment
Treatment for nipple soreness varies. What follows is a treatment plan for the common, transient soreness that most often occurs during the early days of nursing. If this plan doesn't work for you, or if soreness persists or worsens after the initial breastfeeding period, consult a lactation professional who can evaluate the situation and see if additional help is needed. Remember, breastfeeding is not supposed to hurt!

  • Vary nursing positions to put pressure on different parts of the nipple.
  • Begin nursing on the least sore side first until the milk lets down, then gently switch to the other breast. Use relaxation breathing until your milk lets down. You may want to use massage, warm compresses and gentle hand expression to stimulate the let-down before you put baby on the breast so that he doesn't have to suck vigorously while he waits for the milk to let down.
  • Express a little colostrum or milk onto your nipples after nursing and let it dry. Human milk has anti-bacterial properties.
  • If your nipple has cracked, dab some hydrogen peroxide onto the crack with a Q-tip. This will help kill the bacteria from the baby's mouth which can enter through the opening in the skin and cause infection. Don't be shocked if your nipples bleed and your baby swallows some of the blood. As gross as this may sound, the small amount of blood will not hurt the baby. I mention this only because the blood may show up in the baby's stool or spit up, and before you panic, be aware that if your nipples are cracked and bleeding, the blood is probably yours and not the baby's. You should always call the doctor if blood appears in your baby's spit-up or stool, as it may be due to other causes, such as ulcers or allergies. If you see bright red blood, clotted blood or large amounts of blood you should contact your doctor or go to the emergency room right away.
  • Applying modified anhydrous lanolin after nursing (Lansinoh or Purelan are the brands to look for) may aid in healing. Surface wetness can contribute to soreness and cracking if the nipple remains moist after nursing, sort of like the way your chapped lips get worse if you lick them. Avoid using other creams on your nipples, including Bag Balm (great for cows, not for humans) and Vitamin E. Don't use soap on your nipples as it can dry the skin. Bathing with clear water is all you need to keep your nipples clean.
  • A new product called "Soothies" is now available to help soothe and speed the healing of sore nipples. This is an amazing product: round hydro-gel pads that you store in the fridge and wear between feedings.
  • Expose your nipples to air as much as possible. Leave the flaps on your bra down, and if the weather permits, expose them to sunlight for a few minutes each day. I emphasize FEW minutes -- there are few things more painful than sunburned breasts.
  • Try to keep your perspective when dealing with nipple soreness. It usually clears up within a few days, and rarely reoccurs once your baby and you get the hang of nursing effectively as a team. It always makes me sad when mothers quit nursing because of soreness, because the long-term benefits of breastfeeding far outweigh the short-term pain. It really is worth hanging in there -- ask any nursing mother, and she'll tell you she's glad she didn't give up when the going got rough.PregnancyAndBaby.com

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