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Up to nine in ten breastfeeding women have sore nipples at some time, especially early on, and particularly in the first week.
About a quarter have severe pain or a crack. While it isn't always possible to prevent soreness, several things can help, and it nearly always improves with time.
Some sore nipples appear undamaged; more often the skin is roughened, and there's reddening and swelling of the small projections (papillae) on top. There may also be a crescent-shaped stripe across each nipple, composed of tiny blood spots in the skin (petechiae). This occurs on the part of the nipple that's been exposed to maximum suction, with his palate above the stripe and his tongue below. Women with no visible damage may have tougher skin that resists suction better. If the skin is broken it may be crusted too.
A sore nipple hurts most when the baby starts feeding, but this pain generally lasts only a minute or two, provided the skin isn't too damaged, because the baby no longer needs to suck so strongly when the milk lets down. If you are breastfeeding on demand, soreness is usually worst on the third day and starts decreasing on the fourth day. Schedule-fed babies may damage nipple skin more as they tend to get more hungry and therefore suck more strongly. Large babies may cause more soreness for the same reason.
The pain from a sore nipple is usually described as feeling as if the baby were biting. It usually goes as soon as the milk lets down, so it's nearly always less in the second breast.
There are several possible explanations for soreness. The most likely is that your nipples are unaccustomed to being sucked, and the good news is that their skin toughens as the days go by. Or your baby may have been feeding with the breast poorly positioned perhaps because you've been holding him awkwardly, or you have poorly protractile nipples or engorged breasts, or he's been snoozing at the breast and letting it half slip out) - in which case he has to suck particularly hard to try to get milk and/or keep the breast in his mouth. Or you may be feeling stressed and therefore taking a long time to let down your milk, which could be a problem as a baby sucks especially strongly before milk lets down. Or your baby could be sucking and milking the breast very strongly at the beginning of a feed out of frustration because so little milk is available. After your milk comes in, this shouldn't be a problem, as there should always be some foremilk in the reservoirs when he starts to feed. If not, it could be because your milk ducts are constricted and not allowing milk through because you're cold, in which case have a warm shower or bath before feeding, put on some more clothes, heat the room, or bathe your breasts with warm water.
Here are some useful tips for overcoming soreness...
Twenty Steps for Treating Sore NipplesSteps 1-10 are for everyone but you can pick and choose from the rest.
The cardinal rule is, DON'T STOP FEEDING!
1. Change your feeding position several times a day so no one part of the nipple takes the full force of the baby's suction every time. For example, in the morning, sit up and hold your baby on your lap; in the afternoon and evening: sit up and use the 'football' hold; and at night: lie on your side, with your baby lying facing you; by adjusting your position you can feed from your lower or upper breast.
2. Make sure your baby is well positioned. If your nipples look sore, with stripes across them, your baby is highly likely to be sucking very strongly simply to hold on to the breast. He's unlikely to have enough breast in his mouth, so the nipple endures all the force of his sucking and milking. This draws the nipple in and out of his mouth, which soon makes it sore. Also, and most important, a poorly positioned baby doesn't stimulate the breasts well, so milk production and flow are poor, and milk doesn't flow into his mouth quickly enough to fill the vacuum and reduce the high suction pressure on the nipple. Some experts believe nearly all nipple soreness results from poor positioning!
3. Feed your baby frequently. This encourages mature milk to come in sooner and makes your let-down reflex more reliable. You may get sore nipples sooner than a schedule-feeding woman, but your soreness will disappear before hers, your breastfeeding will almost certainly be more successful, and you'll be less likely to have a blocked duct or breast infection.
4. Don't limit drinking time but limit total suckling time. Taking your baby off the breast when he's finished drinking may help by limiting his total sucking time but not his actual drinking time. It isn't always easy to know when babies have finished drinking, because they have breaks between bouts of sucking. But if your baby spends long at the breast without swallowing regularly and sucking purposefully at a rate of one suck per minute - even though you are trying to keep him alert and interested by encouraging your let-down - then it's time to stop. As soreness eases over the next day or two, go back to letting your baby suck for as long as he wants, or your milk supply may diminish.
5. Encourage your milk to let down before putting your baby to the breast by going through a routine of preparing for a feed, by keeping warm, and, perhaps, by gently massaging your breast; your baby then won't have to suck and milk your breasts so strongly and for so long to stimulate the let-down. This is also wise because both fear of pain, and actual pain, can delay the let-down.
6. Always offer the less sore nipple first. By the time you offer the other one, your milk should be flowing well and you may have little or no pain.
7. Distract yourself to take your mind off the pain during the first part of a feed when your nipples feel most sore. Try reading, watching TV, or doing breathing exercises or other relaxation techniques.
8. Care for your nipple skin.
9. Express some milk after each feed, rub it on your nipples and let it dry. This is a successful, simple and traditional tip for helping sore nipples heal. Breast milk contains various factors that are soothing and anti-infective, and encourage cells to grow.
10. If you have to stop your baby feeding, break the suction by putting a fingertip into the corner of his mouth and pushing the nipple to one side. Pulling him off may increase soreness.
11. Treat any engorgement, as a baby finds it difficult to get a good mouthful of an engorged breast, so is more likely to chew the nipple.
12. If your nipples don't stand out well, try using breast shells for half an hour before a feed. This lets your baby take a bigger mouthful of breast and thereby avoid sucking on the nipple alone.
Be sure to keep shells clean, so they can't infect damaged skin.
13. Apply lanolin cream. This encourages 'moist healing', which has been shown to be better sore nipples than keeping them dry.
14. Apply a warm moist compress to soothe any soreness lasting between feeds.
15. Consider applying hydrogel dressings to encourage 'moist healing', though not if you suspect any infection.
16. Cool your nipples immediately before feeding your baby. Do this by splashing them with cold water, or applying a cloth-wrapped cool-pack (from the fridge) or polythene bag of crushed ice or ice cubes. It's best to encourage your let-down to start working first since coldness can hinder the let-down.
17. Have a small alcoholic drink 20 minutes before a feed if you think pain is likely to hinder your let-down, though don't repeat this if you think it makes your baby less keen to drink your milk.
18. Consider whether you could have a skin sensitivity. If your nipples feel sore throughout a feed, you could have contact dermatitis from sensitivity to washing powder, fabric softener, a toiletry (for example, soap, shampoo or deodorant), a cream or other remedy for sore nipples, food particles in your baby's mouth, or the plastic of a breast shell or pump. Either stop using each suspect one by one, for a week at a time each, so you discover what's to blame, then avoid it in future. Or avoid all suspects at once. Sometimes a teething baby's saliva triggers soreness. And some women with continuing soreness need treatment for thrush, eczema, psoriasis, or seborrhoeic dermatitis. If your doctor prescribes any topical treatment, wash it off before your baby feeds.
19. Avoid antiseptic sprays. Some women spray their nipples with the antiseptic chlorhexidine, thinking it will prevent sore nipples, nipple cracks and mastitis. However, there's no evidence that this is useful for preventing or treating soreness.
20. If all else fails, try a very thin rubber nipple shield. This has a teat for the baby to suck, but it's recommended only as a very last resort, as it has so many potential drawbacks. First, it may not help. Second, if not properly cleaned after each use it can harbour bacteria or fungi and infect damaged skin. Third, it can reduce the milk supply because milk production and the establishment of a reliable let-down depend on the baby stimulating nerve endings in the skin of the nipple and areola, and a shield reduces such stimulation. Fourth, it can prevent a baby getting all the milk; the thinnest shield keeps back 22 per cent, while thicker ones keep back up to 65 per cent! Fifth, some babies get so used to a shield that they won't take the breast without one.
It's best not to use a shield unless you absolutely have to. If you do, stop as soon as possible. If your baby is reluctant to breastfeed without a shield, cut away a little more of the rubber before each feed so he gradually becomes used to the feel and taste of your skin again. Or try slipping it out once he's sucking well.
Rarely, a sore nipple bleeds and the baby swallows tiny amounts of blood. This can look horrifying if regurgitated in a mouthful of milk, but your blood won't harm your baby, so just treat the soreness and carry on feeding.
Dr. Penny Stanway
You can buy Dr. Stanway's book 'Breast is Best' here
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