Breastmilk engorgement is a common breastfeeding problem. In the time leading up to birth, a pregnant…
Nipple problems during breastfeeding
What are nipple problems during breastfeeding?
Breastmilk is the recommended nutrition for a baby. Evidence shows that breastfed babies enjoy better health outcomes than babies who are fed with alternative foodstuffs, such as formula.
Breastfeeding is a natural act, practised for over 200 million years by all mammals. However, it is also a learned skill. Problems with breastfeeding are common and many new mothers can benefit from expert guidance. Even under ideal circumstances, breastfeeding does not always go smoothly. All mothers experience problems during breastfeeding at one point or another. These problems can cause distress to the mother, baby and family and may not always have fast or easy solutions.
Among the more common breastfeeding problems are problems with the mother's nipples.
Signs and symptoms
Nipple pain is one of the most common breastfeeding problems,  and can often persist for several weeks. It is commonly the result of incorrect attachment of the baby to the breast. If breastfeeding is painful, it is a sign that something is wrong. A well-attached baby will suckle easily, ensuring a good milk flow. For the mother, good attachment prevents problems such as sore or cracked nipples, mastitis and blocked milk ducts.
Nipple pain should be distinguished from normal nipple sensitivity - the nipples of newly breastfeeding mothers are often sensitive in the first days of breastfeeding. The difference between normal nipple sensitivity and nipple pain is that nipple sensitivity gets better during the first few minutes of every feed - it should also get better after a few days of breastfeeding. Nipple pain, however, remains or worsens when your baby feeds.
In some cases, incorrect attachment, or other factors, can cause the skin of the nipple to break. Feeding a baby from this 'cracked nipple', especially when the skin is dry, can be painful.
There are many conditions that can lead to nipple problems with breastfeeding. These include:
Milk ducts in the breast can become blocked, often as a result of incorrect attachment of the baby to the breast. Blocked milk ducts can cause soreness and pain and may lead to inflammation of the nipple, termed mastitis. The inflamed area of the breast can appear swollen, red and feel hot.
Continuing to breastfeed, with correct attachment, can help relieve blocked ducts and mastitis.
If mastitis does not clear up within a day or so, it might be the result of infection. In this case, it is best to consult your doctor.
Mastitis is commonly treated with antibiotics or anti-inflammatory medication. Pain-relief medications can also be used to relieve pain and fever. Heat packs or icepacks can also provide pain relief. It may also help to relieve any blocked ducts and allow the condition to improve sooner.
It is normally safe to continue breastfeeding your baby from an infected nipple, as breastmilk contains immune factors that help protect your baby.
Thrush, also known as candidiasis, is a common fungal infection. It is mostly found in the mouth or vagina, but can also occur in and around the nipples. A cracked nipple or blocked duct can also be infected by thrush. A nipple with thrush can look red and shiny, and feel itchy. Skin can peel and flake off.
Nipple thrush can cause sharp, piercing pain to the mother, and may also infect the infant's mouth and cause them pain and discomfort when suckling. Thrush is treated with antifungal medication.
Creams, lotions, soaps or shampoos, washing detergents and certain clothing fabrics (especially bras) can sometimes cause skin around the nipple to become irritated and sore. This is termed contact dermatitis. Treatment usually involves avoiding exposure to the irritant.
Inverted or flat nipples
Many expectant mothers worry that, if their nipples appear flat or inverted and do not stick out from the breast, they will have problems breastfeeding.
A mother with inverted or flat nipples can breastfeed successfully, but will benefit from expert advice from healthcare professionals. They can advise the mother on techniques to correct the situation and enable successful attachment and feeding. 'Rolling' the nipple, or using a breast pump or syringe to pull out the nipple, before feeding, can help.  Some breastfeeding positions (with the nipple pointing downwards) are better than others. For some, nipple shields can also help in the first stages of breastfeeding.
Raynaud's phenomenon (vasospasm)
Raynaud's phenomenon is a disorder in which blood vessels suddenly constrict and temporarily cut off the blood supply to a body extremity. It generally occurs in response to cold temperatures, stress or emotional upset. Substances such as caffeine or nicotine can also contribute to blood vessel constriction.
If Raynaud's phenomenon affects the nipple, it can cause severe pain. The nipple can turn a bluish or white colour, returning to a normal pink after it passes. It can be mistaken for thrush.
Raynaud's phenomenon is treated by avoiding cold temperatures and the abovementioned substances. Vasodilator drugs, such as nifepidine, can also help relieve the condition. 
White spot on the nipple
A white spot on the nipple can be caused by a blockage at the end of a milk duct. The blockage can be caused by thickened milk, milk fat or skin cells. A white spot typically causes pain when feeding.
A white spot often resolves on its own if breastfeeding is continued. If the white spot persists, soaking the nipple in warm water or gently rubbing or massaging it can unblock the duct. If these measures do not help, a health professional can unblock the duct by gently using a sterile needle.
Baby-related nipple problems
Some babies are harder to feed than others. Breastfeeding relies on the baby creating a suction force when attached to the breast. Babies with certain problems such as cleft lip and palate, tongue-tie (restricted tongue movement caused by an unusually short membrane connecting it to the floor of the mouth) or torticollis (an abnormally twisted neck) can find it hard to attach correctly to the breast and create good suction.
Pulling on the nipple
When a feed is over, some babies will not detach from the breast, but will 'pull' on the nipple, which may cause nipple damage. If you need to stop your baby feeding, break the suction by inserting your little finger gently between the corner of your baby's mouth and the breast.
Chewing or biting
Some babies tend to chew or bite on the nipple, which can be painful to the mother and damage the nipple. Babies can be gradually discouraged from this behaviour if the mother firmly and immediately stops the feed for a short while whenever the baby bites or chews. Note that this behaviour often occurs either near the end of a feed, when the baby is no longer very hungry, or at the start, when the baby is not attached correctly and is trying to suck.
Attachment of the baby to the breast is a crucial part of breastfeeding. A well-attached baby will suckle easily, ensuring a good milk flow. For the mother, good attachment prevents problems such as sore or cracked nipples, mastitis and blocked milk ducts. Health professionals can help improve your attachment and can advise you when and how to best breastfeed your baby.
Recognising and enabling good attachment
Achieving good attachment of your baby during breastfeeding involves a combination of factors:
- Attachment is easiest when your baby is calm, especially during the first days;
- There is no one 'right' way to hold your baby when breastfeeding - every mother and child settle into the position that suits them;
- Your baby should not have to strain, stretch, or turn its head to suckle;
- Skin-to-skin contact calms your baby and encourages milk release and feeding;
- Baby's head will be tilted slightly backwards when feeding, with the chin digging into the breast. When the nipple brushes against the baby's upper lip, the baby will open its mouth wide and close it around the nipple and some of the breast around it. When feeding, the nipple is near the back of baby's mouth;
- A baby who is well attached to the breast will look calm and content. You will hear swallowing sounds, not sucking sounds;
- Your nipples should not be painful after feeding;
- If you need to stop your baby feeding, break the suction by inserting your little finger gently between the corner of your baby's mouth and the breast, and;
- Nipple shields, when used correctly, can help a baby attach the right way in some cases where attachment is a problem.
'Baby-led attachment' is the technique of allowing your baby to follow its instincts and find the correct position for feeding. Some babies latch onto the breast quickly, while others take more time to find their ideal position.
Healthy newborn babies will display 'feeding cues' when they are ready to feed. They will 'search' for the breast, moving their heads, sticking out their tongues and putting their hands to their mouth.
'Mother-led attachment' is a more active way for the mother to facilitate breastfeeding. The mother leads the baby to the breast and brushes the nose and upper lip against the nipple, causing the baby to open the mouth wide. At that point the mother inserts the nipple into baby's mouth.
When nipples are sore or cracked, it is recommended that you stop the feeding, correct the attachment if possible, relieve your pain with a few drops of breastmilk, olive oil, or a soothing ointment such as paraffin and let your nipples dry. Nipple shields are also sometimes used to help your nipple heal, although their use is debated. 
Healthcare professionals can help you improve your attachment. They will advise you when and how to best continue to breastfeed your baby while your nipple is healing.