Nipple Complications - Physician Guide to Breastfeeding (2023)

A full review of all maternal breast conditions in lactation is available with the new edition of Breastfeeding for Medical Professionals (Lawrence and Lawrence) textbook. We also review the management of common complications in an Obstetrics and Gynecology Clinics invited paper that will be published in February, 2022.

Causes of pain during breastfeeding can range widely, and moms and babies should be evaluated together, with a differential diagnosis (potential causes) formulated based on their history, exam, and time postpartum.

Some moms have initial struggles “learning to breastfeed” in the early postpartum period with engorgement and simply needing to adjust position to enable a comfortable latch. Other pain can result from situations that require medical management such as treatment of hyperlactation (“oversupply”), blebs, and dermatitis. Because of the complex innervation of the nipple, deeper breast pain may present as nipple pain or vice versa. If a mom resumes menstruation, she may notice increased breast and/or nipple sensitivity prior to her cycle. Pregnancy may also produce increased sensitivity. In general, the most common causes of breast pain are outlined in the box below:

• Nipple Conditions
  
  • Trauma (e.g. pump, infant latching to engorged breast)
  • Vasospasm (changes in blood flow that impact the nipple and breast)
  • Dermatitis (allergy causing)
  • Subacute mastitis
  • Nipple bleb
  • Viral infections
• Breast Conditions
  
  • Engorgement
  • Hyperlactation
  • Mastitis
  • Subacute mastitis
  • Neuropathic pain that responds well to the SSRI class of drugs
  • Hormonal fluctuations with menstruation or pregnancy
  • Mondor’s disease

Excessive cleansing, whether prenatally or postpartum, can remove natural oils and predispose skin to breakdown. Care for the nipple like any other surface on your skin. Treat trauma as outlined below and otherwise follow these basic guidelines:

• Do not use drying agents such as antiseptics and alcohol.
• Gentian violet can produce significant tissue ulceration and should never be used on a nipple.
• Some women may lubricate dry skin with nursing balms. They should be aware of potentially allergenic ingredients such as lanolin, petroleum, and coconut.
• Balms containing multiple ingredients may result in dermatitis from allergens.
• Antifungals creams worsen pain and vasospasm, and can cause dermatitis and ulcerate skin. They are not indicated for use on nipples.

Nipple fissuring that began after a mom used nystatin continuously on her nipple

Trauma most commonly results from early postpartum engorgement, feeding too long from a breast that is producing too little milk, infants clamping to stop heavy flow from oversupply, and improperly fitting flanges or pump on high suction. Other causes include soaps, oils, ointments, lubricants that can cause dermatitis and subsequent skin breakdown.

A pump, unlike an infant, has the unique ability to strangulate (literally like putting a rubber band around your finger and tightening it — then adding suction pressure on top) your nipple. I use this example when talking to patients about what happens when you use too small of a flange, too high of suction, or pump for too long a duration of time: Your nipple, just like a fingertip, is going to turn varying shades of red, purple, and white when it doesn’t have enough blood flow. If it hurts, STOP!

Nipple wounds should be lubricated and covered to heal effectively, just like burns or other open wounds on the body. An organic balm coupled with a hydrogel “soothie” pad to “close” the wound can be utilized. Moms should keep nipples covered both day and night to enable uninterrupted wound healing.

It should be noted that the product insert for hydrogels marketed to the lactation community recommends hydrogels be used without any additional ointment. However, surgical literature recommends the use of hydrogels as a wound dressing specifically for the reason that it“can easily be combined with various substances that facilitate wound healing and/or have anti-inflammatory properties.”If a patient has a deep wound or one in an area that the hydrogel won’t contact (e.g. a deep fissure),balm can work synergistically with the hydrogel to provide a moist environment.

If you are recommended to strictly follow the lactation product insert, then it would be preferential to use hydrogel alone rather than nipple balm alone. Hydrogel has important wound healing technology that facilitates more rapid resolution.

Normal human wound healing time is 8-10 days after traumatic insult. Some moms will question how nipple trauma can heal when an infant continues to stimulate the nipple frequently. The lactating breast and nipple areolar complex are highly vascular and therefore heal well, even in the setting of continued breastfeeding. In fact, continued breastfeeding promotes healing from the enzymatic action of the infant’s saliva as well as healthy bacterial exchange.

Significant trauma may result in deeper fissuring with the development of fluid seepage. Many women and healthcare providers incorrectly believe this fluid to be “infected.” This seepage is NOT infection. It is something called “fibrinous debris.” Surgeons commonly deal with these types of wounds in different parts of the body.

Wounds with significant seepage may benefit from polyurethane matrix pads (e.g. Nursicare) to provide both closed wound healing and absorptive capacity. Unlike hydrogel pads, polyurethane pads or mepilex should not be used with balm as the absorptive surface should contact the skin directly.

Some wounds respond well to medical-grade honey (Medi-Honey), which is irradiated and therefore does not pose risk of botulism to infants who may ingest small amounts.

Open wounds should not be closed with suture or surgical glue. Instead, these wounds should heal following principles of closure by secondary intention. Additionally, surgical glue may pose harm to the breastfeeding infant.

Patients with pain also may be recommended to use nipple shields. Nipple shields are associated with multiple complications, including mastitis, plugging, and significant reductions in milk production and transfer. Many mothers have difficulty weaning infants off the nipple shield once it has been used regularly.

Given these known complications,the breastfeeding dyad should undergo a thorough evaluation prior to introduction of a nipple shield.

Often, nipple shields are introduced when a small infant struggles to latch to a larger, pendulous breast and causes pain. This may instead simply require adjustment of a position that is more amenable to feeding with large breasts, such as the laidback or side lying position.

Infants also may refuse to latch when the flow of milk is very high; adjusting position and treating hyperlactation can address this issue without introducing nipple shields. In other situations, very large nipples as shown in this image to the right preclude any sort of latch due to size and this is a situation in which mom should express breastmilk via a pump.

Persistent pain despite full exploration of etiologies described below requires an integrated treatment approach that addresses not only biological, but psychosocial aspects of pain. Counseling, physiotherapy massage, acupuncture, and other complementary and alternative medicine practices therefore may be helpful.

The SSRI class of drugs can provide significant relief of pain as serotonin receptors are expressed in many parts of the body, including the breast and intestinal tract.

There is no subcutaneous fat behind the areola, so it is common to see dilation of ductal tissue and for patients to even worry they have a mass in this region. If a patient feels a persistent mass in this area, she should undergo physical exam and imaging evaluation.

Montgomery glands are sebaceous (oil producing) glands on the surface of the areola, and are naturally enlarged in pregnancy and lactation. Like other sebaceous glands, they can become blocked and develop pain and a pimple-like appearance. If this occurs, use gentle soap and water, warm compresses to promote opening of the skin for drainage, and an acne cream like salicylic acid or benzyl peroxide that you should wipe off before breastfeeding.

Lubrication of pump flanges with coconut oil is a frequent reason why patients are more commonly developing Montgomery gland blockages. A pump should be comfortable without lubrication, and lubrication often allows women to turn the suction higher than what was intended. If lubrication must be used, it should be wiped off after pumping to decrease the risk of Montgomery Gland obstruction.

Subacute mastitis, also known as breast dysbiosis, represents an imbalance of the breast flora similar to bacterial vaginosis. Women may present with a history of previously treated recurrent acute mastitis, or also may have hyperlactation (oversupply) and painful nipple blebs. Exclusive pumping is another major risk factor. Patients often describe deep, burning breast pain, and painful nipples and latch. This constellation of signs and symptoms is often misdiagnosed as mammary candidiasis, which is not supported by microbiological evidence. Yeast occurs in the tissue below the breast (inframammary fold) or under the arm (axilla).

Evaluation can include a sterile breastmilk culture; this is different from swabbing the surface of the nipple, which will grow any number of organisms that naturally colonize the skin. Sunflower lecithin can reduce ductal inflammation and nipple blebs, and probiotics directed at the breast flora (as described in section on acute mastitis) may resolve pain; however, no published data on this approach exist. Hyperlactation should be addressed and treated, and pumping eliminated if possible. While no western medicine data exist to support the use of homeopathy, clinical experience suggests staphloccocinum may reduce bleb formation and other persistent subacute mastitis symptomatology. Therapeutic ultrasound performed by a healthcare provider in the clinical setting can reduce pain and decrease inflammation.

Often described as a “white dot” or a “scab,” nipple blebs are lesions on the surface of a single or multiple nipple orifices that reflect underlying ductal inflammation. They can cause exquisite pain when the baby breastfeeds. They also can cause obstruction of milk flow through the nipple orifice. Blebs have no association with candida (yeast), but are associated with hyperlactation, subacute mastitis/dysbiosis, pumping, and localized breast tissue swelling. Some appear and regress and new ones reappear. Other patients experience one persistent bleb in one location.

Do NOT unroof with a sterile needle or by “popping” the bleb. This may cause temporary relief, but it will worsen inflammation and eventually cause chronic scarring. Infants may release a superficial bleb while nursing, or more tenacious blebs may persist regardless of interventions.

Blebs are not related to surface trauma or infant latch. Infants may pull off the breast in the setting of oversupply, and patients assume this caused the bleb. Instead, it’s the oversupply that causes the ductal inflammation that causes the bleb. And the infant is simply pulling off the breast because of being choked by high flow in high supply. Other infants may pull at the breast due to distraction or frustration with lower flow. Though less common, blebs are possible with low supply in the setting of subacute mastitis.

Appropriate treatment includes utilization of 0.1% triamcinolone crème (over the counter products such as hydrocortisone are not potent enough to be effective) on the surface of the nipple to reduce inflammation. Sunflower lecithin by mouth reduces underlying ductal congestion and inflammation. Therapeutic ultrasound is also helpful. Underlying hyperlactation also must be treated.

It should be noted that blebs are different from the sucking blister that appears early in lactation and results from vigorous suckling, malposition, or high pump suction. This type of blister covers a larger area, appears more blister-like with a thin membrane and underlying fluid, and is not associated with underlying associated conditions as described above.

Vasospasm may be more common in those with a history of Raynaud’s phenomenon of the fingers. Secondary vasospasm may occur following trauma to the nipples. Persistent vasospasm can result in a cycle that potentiates trauma, due to vasoconstriction and inability to heal in the setting of chronic alterations in blood flow. Mammary blood vessels are exquisitely sensitive to epinephrine and norepinephrine. Serotonin and PGF20C as vasoconstrictive agents also play a role.

Treatment of vasospasm involves the following:

• Resolve any underlying persistent trauma. Women with larger breasts and/or history of breast augmentation benefit from laid back or side lying nursing positions to reduce trauma from superficial latch.
• Keep nipples at all times (wear a bra at night) with pads made of wool, ThinsulateTM, Flectalon®, or fleece.
• For additional warmth, use heating pads or reusable heated products such as microwaveable rice packs or hand warmers on top of the pads; these products should not be applied directly to the skin due to risk of burns.
• While the calcium channel blocker agents such as nifedipine traditionally have been recommended for intractable vasospasm, the SSRI class of drugs such as sertraline demonstrate remarkable resolution of pain in most patients without the side effects of headache, fatigue, and low blood pressure that the calcium channel blocker class of drug risks. The effectiveness of the SSRI class of drugs is likely due to the activity of serotonin in the breast.

Bloody nipple discharge may occur in up to 20 percent of women in the pregnant and early postpartum period. It is related to breast growth, increased blood flow, and preparation of the breast to make milk. It generally occurs in both breasts and from several nipple orifices, and will worsen with nipple stimulation. If you have any concern, you should seek evaluation by your healthcare provider. More concerning discharge is from one breast and one nipple orifice.

Mothers with hyperlactation or those taking blood thinning medications may also experience transient bloody milk. These cases should be evaluated carefully with history and exam, and also may warrant imaging. Serratia marcesans also has been demonstrated to turn expressed milk pink, and this should be considered.

Dermatitis (or eczema) of the nipples, areolae, and breasts, presents as a red, burning, painful flaking rash. Often, patients are misdiagnosed with a “yeast infection” when in fact the etiology of their symptoms is dermatitis. One breast may be affected and not the other, without good explanation. Dermatitis can result from countless potential allergens, but the most common scenarios in breastfeeding are these:

• Topical anti-fungal and antibacterial agents such as those contained in APNO, petroleum, lanolin, coconut, and emollients contained in creams, lotions, or ointments.
• Pump parts, nursing bras, nursing pads, new detergents or soaps, and nipple shields
• Substances that children are ingesting or touching, including antibiotics and complementary foods

Treatment involves the following:

• All potential allergens should be explored and eliminated
• A short course of prescription steroid (e.g. 0.1% triamcinolone) will clear a persistent case in a few days.
• Oral antihistamine medication or steroids used in cases of severe allergy may not affect milk production in most women, patients should watch for changes in output, particularly those with lower baseline milk production. However, the vast majority of the time, these oral agents are not necessary.

The lactating breast and nipple areolar complex are highly vascular and therefore heal well and are unlikely to develop bacterial infection. However, viral infections with herpes and warts from HPV are more common.

Herpes simplex virus (HSV) infection (“cold sores”) of the nipple areolar complex presents as a cluster of tender vesicles. The virus can pass between mom and baby, andcan be dangerous to neonates with immature immune systems under three months of age. If a neonate under the age of three months presents with suspected neonatal herpes, the infant should undergo blood and spinal fluid testing for HSV to confirm diagnosis, and begin immediate treatment with acyclovir. Diagnosis in the mom can be confirmed using a skin swab culture or blood testing.

Moms with a herpes outbreak undergo treatment with a five to seven day course of acyclovir, which is safe in lactation. If a momexperiences a herpes outbreak on one breast, she can continue to express and discard the milk to maintain milk production. However, she should keep this breast covered until lesions scab over, and the infant should nurse only from the unaffected breast. There is no recommendation for routine suppression in breastfeeding mothers with a history of HSV-1 to prevent transmission to infants.

The varicella zoster virus remains dormant in nerve tissue of individuals with a history of chickenpox. Reactivation of the virus results in herpes zoster, a contagious rash in a specific “dermatomal” distribution. Until lesions are crusted over, women with vesicles on the nipple areolar complex should avoid breastfeeding from the affected breast. During that time, milk should be expressed to maintain production, but is not safe to feed to the infant.

Viral warts (verruca vulgaris) are benign (non-cancerous) tumors that arise from infection of the skin or mucosal cells (e.g. mouth, vagina) from infection with the HPV virus. They may clear spontaneously, or may need excision if large and on the areola. Other therapies include salicylic acid, cryotherapy, and laser treatment.

The most common superficial fungal infection of the skin of the lactating breast is Candida intertrigo, which presents as an itchy, beefy red rash located in the inframammary fold (the skin underneath the breast that can get sweaty and chaffed during hot weather) or under the arm (axilla).

Candida is not contagious just as vaginal yeast infections are not contagious. Therefore, if an infant is diagnosed with thrush (which is also unlikely in the absence of formula feeding, prematurity, repeated antibiotics, and other risk factors for significant immunosuppression), the mother’s breast and nipple does not require treatment. In fact, anti-fungals on the nipple of the breast are highly irritating and may produce a contact dermatitis.