Topics in

PAIN MANAGEMENT
Vol. 32, No. 3 Current Concepts and Treatment Strategies October 2016

CONTINUING EDUCATION ACTIVITY

Clinical Assessment and Management of Breastfeeding Pain
Ruth Lucas, PhD, RN, CLS, and Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Learning Objectives/Outcomes: After participating in this CME/CNE activity, the provider should be better able to:
1. Describe factors that contribute to breast pain and nipple soreness in breastfeeding mothers.
2. Summarize evidence-based strategies and intervention for decreasing pain during breastfeeding.
3. Draw conclusions for guiding individualized breast pain management that is supportive of the unique needs of the mother.
Key Words: Nipple pain, Breast pain, Pain, Nipple soreness, Breastfeeding

M ore than 90% of new mothers experience pain during

breastfeeding in the first week after delivery. 1 A
major reason often cited for breastfeeding cessation in the
have discontinued breastfeeding.5 In addition, within the
first 2 weeks after delivery, more than 30% of breastfeeding
mothers seek professional lactation support due to pain. Of
first 2 weeks after birth is maternal breast and nipple pain.2 these mothers, 45% continue to have chronic pain, even
Since 1990, the World Health Organization3 has recom- with intervention.6
mended breastfeeding as optimal nutrition for infants for Many women lack the understanding that breast and nipple
the first 6 months of life. In turn, breastfeeding initiation pain is “normal” during breastfeeding initiation. In addition,
has increased across the world and has recently reached interventions to manage breast pain are sometimes not an
80% of all infants in the United States.4 Yet, by the time the
Dr. Lucas is Assistant Professor, University of Connecticut School of
infant is 2 weeks old, 20% of breastfeeding mothers will Nursing, 231 Glenbrook Dr, Unit 4026, Storrs, CT 06269, E-mail: ruth.
[email protected], and Nurse Research Scholar, Connecticut Children’s
Medical Center, Hartford, Connecticut; and Dr. McGrath is Associate
In This Issue Dean, Research and Scholarship, University of Connecticut School of
Nursing, Storrs, Connecticut, and Director of Nursing Research,
Connecticut Children’s Medical Center, Hartford, Connecticut.
Clinical Assessment and Management of
Breastfeeding Pain . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The authors and all staff in a position to control the content of this
CME activity have disclosed that they and their spouses/life partners (if
CE Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 any) have no financial relationships with, or financial interests in, any
commercial companies pertaining to this educational activity.

CME Accreditation
Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™.
Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME
article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME
activity expires on September 30, 2017.
CNE Accreditation
Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s
Commission on Accreditation. LWW, publisher of Topics in Pain Management, will award 2.0 contact hours for this continuing nursing education activity.
This activity has been assigned 1.0 pharmacology credits. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This
CNE activity expires on October 31, 2018.

1
Topics in Pain Management October 2016

CO-EDITORS emphasis in prenatal education, to avoid discouraging moth-

ers from breastfeeding.7 However, this gap in mothers’
Elizabeth A.M. Frost, MD knowledge endangers continued breastfeeding.2,5 In addition,
Professor of Anesthesiology mothers who are at risk for severe pain during breastfeeding,
Icahn School of Medicine at Mount Sinai such as women with preexisting chronic pain conditions, may
New York, NY need additional consultation and support for breastfeeding
Angela Starkweather, PhD, ACNP-BC, CNRN, FAAN pain management.
Professor of Nursing Acknowledging the nipple/breast pain and working closely
University of Connecticut School of Nursing with the mother to consider strategies that relieve her pain
Storrs, CT are important (Table 1). Nonjudgmental support of mothers
during this time can identify ways to decrease pain while
ASSOCIATE EDITOR
helping them to continue breastfeeding. Wagner et al5 found
Anne Haddad that if mothers’ concerns were not addressed on day 3, moth-
Baltimore, MD ers had a 9 times greater chance of ceasing breastfeeding.
For most mothers, pain peaks by day 3 and subsides by day
EDITORIAL BOARD 7; however, some women continue to have breast pain for up
Jennifer Bolen, JD to 6 weeks.5,6 During the first year, it has been documented
The Legal Side of Pain, Knoxville, TN that the mother-infant dyad makes an average of 36 visits to
Michael DeRosayro, MD health care providers.7 These visits, especially during the
University of Michigan, Ann Arbor, MI first weeks after delivery, are an ideal opportunity to support
James Dexter, MD the mother’s breastfeeding success while assessing and man-
University of Missouri, Columbia, MO aging breastfeeding pain.6,8,9
Claudio A. Feler, MD Mothers experience breastfeeding pain at different points in
University of Tennessee, Memphis, TN time and from different factors. Initial pain is related to
Alvin E. Lake III, PhD increased use (8–12 breastfeeding sessions daily). Nipple and
Michigan Head Pain and Neurological Institute, Ann Arbor, MI breast pain are triggered by infants’ poor latch, bacteria and
Daniel Laskin, DDS, MS yeast infections, sensitivity because of Reynaud syndrome,
Medical College of Virginia, Richmond, VA allergies causing dermatitis, or from a mother’s personal
Vildan Mullin, MD
University of Michigan, Ann Arbor, MI The continuing education activity in Topics in Pain Management is intended for clinical
Alan Rapoport, MD and academic physicians from the specialties of anesthesiology, neurology, psychiatry,
physical and rehabilitative medicine, and neurosurgery as well as residents in those fields
New England Center for Headache, Stamford, CT and other practitioners interested in pain management.
Topics in Pain Management (ISSN
Gary Ruoff, MD 0882-5646) is published monthly by
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Topics in Pain Management October 2016

Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating

Breast Pain
Cons/Why Not to
Intervention Strategy* Pros/Why Recommend Recommend Other Information
Prevention of pain
Prenatal education9,17,50 Provided at a time when For best outcomes sessions Mothers are unable to
mothers may be less need to individualized implement knowledge
stressed and more ready and target to unique until the infant breast-
to learn needs of individual feeds and every infant
mothers breastfeeds differently
Postpartum education6,9,19,50 To be effective needs to May be difficult to deliver Regardless of whether the
occur soon after birth with enough emphasis mother had prenatal or
before breast trauma because mother has many postnatal education
occurs other needs at this time continued follow-up is
needed; referral to a
lactation consultant
should be routine
Hand hygiene including Improves skin integrity and Avoid routine use of soaps Also includes anything that
good drying of hands and decreases risk of on areolae to prevent skin touches the breast or
breast after cleaning9,28 infection drying infant mouth
(ie, pacifiers, breasts, and
clothing)
Assessment of pain
Targeted assessment of Assessments need to be Mothers may not always Early on, breasts may
breast with a history of routine and share important appear normal and thus
onset and location of nonjudgmental information; need to ask maternal perceptions are
breast pain7-9,22 direct questions. May important
take more time to get Look for redness even with
good information no current report of pain
Targeted assessment of Infant latch and position Needs to be assessed The infant needs to be
latch and position during can increase skin during a routine positioned facing the
breastfeeding6,13,14 breakdown and breast breastfeeding so that best breast. Entire areola
trauma assessment is achieved needs to be inside the
infant mouth for good
latch. Watch for evidence
of sucking over gumming
Early pain interventions
Expressed breast milk2,26,29 Easily available; has Newer studies have not Level 2 Grade B Oxford
antiviral and antibacterial found it to be superior to Centre for Evidence-
properties warm water compresses Based Medicine and
recommended by
UNICEF
Lanolin17,21,23,24 Easily available and fairly Contraindicated for Level 2 Grade B Oxford
inexpensive mothers allergic to wool Centre for Evidence-
Semiocclusive ointment, Based Medicine Newest
promotes epithelial research recommends
regrowth, and reduces lanolin over breast milk
pain and hydrogel dressing
(Continues )

©2016 Wolters Kluwer Health, Inc. All rights reserved. 3

Topics in Pain Management October 2016

Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating

Breast Pain (Continued )
Cons/Why Not to
Intervention Strategy* Pros/Why Recommend Recommend Other Information
Warm water compresses9,28 Evidence demonstrates During engorgement Can be provided 4–6 times
pain relief and has been compresses should be daily after breastfeeding
found to be more used to soften breasts to a sessions; can be used to
effective than other level of comfort. Too soften plugged milk
strategies much heat will prolong sinuses to prevent milk
engorgement stagnation
Treatment for acute nipple pain and trauma
Breast shield15,30 Provides space between Not comfortable for some Ineffective in antenatal and
breast and clothing for mothers postnatal treatment for
breast to heal. One study flat nipples
found when used with
lanolin decreased
maternal pain
Calcium channel-blockers Vasodilator, decrease Systematic cardiac Often Reynaud syndrome
(nifedipine)5,14 nipple and breast side effects of not identified until
vasospasms lightheadedness, conservative treatment
dizziness, low blood for mastitis has failed
pressure, headaches
Chlorhexidine spray25 Topical antimicrobial spray. Mothers found the spray Not recommended by
One small study found a uncomfortable to remove UNICEF or the American
decrease in pain and in preparation for next College of Obstetricians
increase in healing. Safe feeding. Antiseptic spray and Gynecologists
for infant consumption is contraindicated with
open wounds
Hydrogel dressing9,25 Effective for early nipple Contraindicated in mothers Should be discarded after
pain. Moist saline with nipple trauma 24 h
dressing, cool and because of their increased
soothing, promotes susceptibility to develop
epithelial regrowth and infections
reduces pain
LED phototherapy lights32 Phototherapy enhances No commercial prototype LED lights prototype
cellular regeneration, available adapted for the breast
local vascularization, and
nerve conduction.
Decreased pain after first
treatment
Menthol (peppermint) gel Antimicrobial properties No standardized Traditional therapy for
or oil21,29 specifically against preparation for nipple pain in Iran;
gram-positive bacteria. breastfeeding mothers approved by the FDA as
One study found food
peppermint gel more
effective than peppermint
water or oil for nipple
fissures
(Continues )

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Topics in Pain Management October 2016

Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating

Breast Pain (Continued )
Cons/Why Not to
Intervention Strategy* Pros/Why Recommend Recommend Other Information
Nipple shields6,15,30 Silicone-vented dome Evidence is weak Requires management by
provides a layer of trained lactation
protection from direct professionals to maintain
infants’ sucking. Dome maternal milk volume
provides sensory
stimulation for infants
suck, which elongates
nipple
Polyethylene film Occlusive dressings, Removing the dressing is Most effective with
dressing9,25 promotes epithelial painful for many mothers infrequent dressing
regrowth and may increase nipple changes
trauma
Silver cap31 Silver ancient treatment Contraindicated for Has not be tested against
with antimicrobial mothers with metal other therapies
properties. Trilaminate allergies
silver cup creates a moist
environment for
epithelial regrowth and
reduces pain
Tea bag compresses28 Some evidence that pain is Astringent properties, dries Cultural therapy,
reduced similarly to warn nipple tissue recommend warm
water compresses. Easily compresses as an
available and inexpensive alternative
Severe breast pain
Antidepressants7,14 May be important for Will require increasing
breastfeeding support support and management
and increasing sense of
maternal competence
Massage48 Effective for deep breast Muscular spasm after
pain releasing pectoralis, breastfeeding may occur
inferior aspect, and without nipple pain
serratus anterior muscle
Propranolol46 Effective for treatment of No published clinical trial Recommended by the
chronic jaw pain for in breastfeeding mothers American Breastfeeding
women without COMT Medicine Practice Group
polymorphisms
Treatment of infection
Acupuncture39 Provides systematic anti- Some mothers refuse Target pressure points were
inflammatory effect. because of fear of heart 3 (circulation),
Decreased pain from needles gallbladder 21 (relaxation
mastitis 3 d after effect), and spleen 6
treatment compared with (gynecologic effect)
the control group using
oxytocin nasal spray
(Continues )

©2016 Wolters Kluwer Health, Inc. All rights reserved. 5

Topics in Pain Management October 2016

Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating

Breast Pain (Continued )
Cons/Why Not to
Intervention Strategy* Pros/Why Recommend Recommend Other Information
Antibiotics36-38 Resolves deep and severe If providing antibiotic Cultures should be
pain by decreasing treatment be sure to be obtained after 1 wk of
inflammation, S. aureus proactive in preventing persistent pain to rule out
most common organism overgrowth with yeast mastitis
May need treatment for
candidiasis as biofilms
may consist of mixed
fungal and bacterial
colonies
Nonsteroidal ointment6,14,43 Effective for dermatitis of Must be removed before
nipple and breast feedings to decrease
infant exposures
Oral fluconazole Resolves deep and severe Difficult to culture. May begin as skin
therapy40,41 pain by decreasing Predisposes women to inflammation and invade
inflammation mastitis breast sinus causes
bacterial colonization
Probiotics42 Made from human Patented for commercial Treatment with 200 mg
breast milk use in Spain and ∼9 log10 CFU each of
Balances the natural Australia Lactobacillus salivarius
biofilm, effective against CECT5713 and
subclinical S. aureus Lactobacillus gasseri
mastitis CECT5714 capsules
compared with antibiotics
significantly decreased
pain and bacterial count
by day 21
*Listed in order of preference.

decreased pain thresholds. To best support mothers, clinicians • How long does it last?
need a general understanding of what causes breast pain and • Is the pain sharp or dull?
what interventions will help alleviate maternal pain. Generally • Are there areas of the breast that hurt more than others?
speaking, breast pain is related to 4 factors: (1) transition to • Does anything the baby does make the pain worse?
breastfeeding (initiation pain); (2) mechanics of breastfeeding • Does the pain begin or get worse just before breastfeeding,
(latch and positioning); (3) organisms that decrease skin integ- during breastfeeding, or just after breastfeeding the infant?
rity (thrush and infections); and (4) tissue sensitivity, such as • What interventions has the mother already tried?
preexisting dermatologic conditions or Reynaud syndrome.
Breastfeeding pain is an interaction between the mother’s
Pain During Breastfeeding Initiation ability to modulate her central nervous system signaling of
nipple pain while managing her environmental and local stim-
Nipple soreness is for the most part normal during breastfeed-
ulation.8 More specifically, Amir et al8 propose the Breast-
ing initiation. During assessment, the breast and nipple may
feeding Pain Reasoning Model to understand the various
appear normal or slightly pink. However, many mothers are
factors that influence variation in breastfeeding pain. In this
unprepared for the pain and at a loss about how to manage their
model, central nervous system modulation is an interaction
pain between feedings.9 The first step in helping mothers to
between prolonged afferent nerve stimulation from the nipple,
manage pain and soreness is to acknowledge and anticipate the
maternal medical history, including parity or pain tolerance,
problem and ask mothers for details in a non-judgmental style:
and cognitive, emotional, and social state that supports her
• Where exactly is the pain? ability to manage the pain. Mothers need to be assured that
• When does it begin? experiencing pain is “normal” initially and not a reflection of

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Topics in Pain Management October 2016

maternal competence. This is especially important because pression, it releases inflammatory markers such as histamines,
self-rated maternal competence and the presence of maternal bradykinins, and substance P.17 When these markers are liber-
postpartum depression can be closely tied to breastfeeding suc- ated, they cause nociceptive responses in small nonmyelinated
cess.10 Providing support and encouragement during this diffi- C fibers.15 Other conditions that predispose mothers to skin
cult time are important to long-term breastfeeding outcomes.11 breakdown and pain sensation include dermatitis, and vasos-
These questions also assess external stimuli that predispose pasm from Raynaud syndrome.17 Whenever there is skin
mothers to pain, such as a flat nipple, an infant’s shallow latch, breakdown on the breast or nipples, mothers are at much
which traumatizes the nipple, or the use of a breast pump.8,12 greater risk for infections. Health care professionals should
Mothers with flat or inverted nipples (10% of all mothers) encourage mothers to continue to breastfeeding as their nipple
require interventions to elongate the nipple, including the best heals. Mothers need to be followed up closely during this time
practice of pumping before breastfeeding and using a nipple to prevent nipple yeast and mastitis. Each of these 3 factors
shield during feeding and rubber bands.13-16 Many mothers also influences the level and intensity of pain experienced during
use a breast pump to establish maternal milk supply. If mothers breastfeeding. See Figure 1 for other issues to consider during
are provided with too small a flange for the breast size, the are- provision of a supportive breastfeeding pain assessment.
ola and nipple will rub against the flange throughout the pump-
ing session.13,14 Constant rubbing may irritate or in extreme Treatment for Nipple Pain and Trauma
cases cause a friction burn.13,14 The nipple shield, a soft sili- Once a comprehensive assessment with history of onset is
cone-vented dome placed over the nipple, provides a solid sur- completed, clinical interventions to reduce maternal pain must
face for infants to latch, and protects the nipple as the nipple become the focus of breastfeeding management. The challenge
elongates from infants’ suction and from infants who create is that most topical pain relievers are contraindicated for infant
and sustain over 200 mm Hg of negative intraoral pressure dur- consumption. Even if mothers remove the ointment before feed-
ing feeding.12-15 Lastly, rubber bands have been used to pro- ing, it is unknown how much infants might receive from the
trude the flat nipple; however, none of the findings addressed skin and the friction to the nipples will be an additional irritant
maternal pain from the intervention.16 Even with these strate- to skin integrity. Thus, management of nipple pain consists of
gies, the mother may experience pain as the nipple tissue is nonpharmacologic topical interventions and preventative educa-
stretched or adhesions broken with the infant’s sucking. tion. Pharmacologic intervention is used for inflammatory con-
The evidence is clear that antenatal breastfeeding education ditions such as mastitis, candidiasis, or breast dermatitis.
prepares mothers to solve issues with infants’ position, latch,
and sucking effort.6,9 Although postpartum education is timely, it Lanolin and Expressed Breast Milk
is important to note that nipple pain and trauma may occur with If the maternal nipple and breast is intact, clinical interventions
only 1 poor breastfeeding session.6,9,17 Correct positioning of the will focus on maintaining skin integrity. Evidence supports the
infant is critical, because if the infant’s mouth is misaligned with use of nipple massage after application of medical grade lanolin
the nipple, the infant will gum the nipple instead of sucking. In or expressed breast milk17,19-25 after every feeding. Purified lano-
addition, if infants’ lips are not flanged out, the tongue can lin is a yellowish white, fat-based moisturizing ointment derived
retract, and the infant may gum or strip the nipple against the from sheep fleece. Lanolin should be applied with 3-mm thick-
hard palate instead of the soft palate, both causing nipple dam- ness, which provides protection from clothing and is semiocclu-
age. Finally, if infants have a short frenulum or tongue-tie, they sive, which keeps the nipple moist between feedings, promotes
may not be able to stretch the tongue to the soft palate, thus epithelial regrowth, and reduces pain.17 Expressed breast milk is
stripping the nipple against the hard palate causing nipple pain also applied after each feeding and has antibacterial and antiviral
and damage.18 All of these factors contribute to the nipples properties.22,23 Both interventions have demonstrated a reduction
appearing reddened, cracked, fissured, scabbed, and bleeding. in maternal pain within 14 days. Several systematic reviews have
Mothers should be reminded to make sure the breast is kept evaluated both interventions. Vieira et al25 identified both inter-
dry and clean between breastfeeding sessions to prevent ventions as level 2 evidence based on criteria from the Oxford
infection. During infants’ initial latch, most mothers with nip- Center for Evidence-Based Medicine, but they and Lochner
ple trauma experience severe “toe-curling” pain that subsides et al26 found lanolin to be more effective in reducing pain. In
or dissipates during feeding.6,14 However, if mothers experi- contrast, a Cochrane review23 reported that no method was sig-
ence severe pain throughout breastfeeding, they may need to nificantly better at reducing pain.
pump and provide breast milk until their nipples heal. If
Nonpharmacologic Interventions
mothers notice infants have blood in their mouth or observe
blood in their pumped milk, reassure mothers that infants will The use of warm compresses before feeding has been found
not be adversely affected by swallowing maternal blood. effective in decreasing maternal pain from engorgement and
Lastly, local stimulation refers to mechanical stimulation. after feeding, and for soothing nipple irritation.9,14 Extra virgin
When nipple tissue is traumatized, such as with nipple com- olive oil (EVOO) has immunological and anti-inflammatory

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Topics in Pain Management October 2016

Figure 1. Assessment of breastfeeding pain.

properties. In one randomized trial, 2.7% of mothers who are a natural antibiotic and have emerged as an alternative to
treated their nipples with a drop of EVOO, compared with 44% antibiotic treatment.31 Mothers place the cap on the breast
of mothers who treated their nipples with breast milk after between feedings. One pilot study found mothers experience a
breastfeeding, exhibited cracked nipples, which was significant significant decrease in maternal pain within 7 days of a nipple
(p < 0.000).27 EVOO has not been compared to lanolin. Other fissure compared with no treatment.28 Lastly, one study used
moist dressings are not recommended, including tea bags, due to light-emitting diode (LED) phototherapy lights and its ability
astringent and drying effect,28 and hydrogels, which, although to promote local vascularization and decrease pain twice a
soothing, are associated with a high incidence of breast and nip- week to treat nipple fissures. For mothers in the treatment
ple infections.14 group, nipple fissures healed within 4 biweekly visits com-
Menthol (peppermint) gel or oil is considered safe during pared with 8 biweekly visits for controls.29
pregnancy and lactation by the FDA and is a household remedy
in the Middle East to treat nipple fissures.21,29 Menthol demon- Engorgement
strates antimicrobial properties specifically against gram-posi- Breastfeeding pain has been characterized as transient or pro-
tive bacteria, and in both small studies performed in Iran, longed.9 The transient pain occurs at 48 to 72 hours after delivery
decreased nipple pain and healed nipple fissures in signifi- when release of lactogenesis II results in engorgement of breast
cantly shorter time than lanolin and expressed breast milk.21,29 sinuses. This is a normal physiologic response, even if the mother
Breast shields, a vented plastic dome whose base has an reports the pain as severe.5,6,14 Engorgement typically lasts 72
opening for the maternal nipple, has been used with or without hours. As the infant feeds, the neurohormonal pathway gives bio-
lanolin to protect the nipple from rubbing against the maternal feedback as to the volume of milk the infant requires for growth.
bra and promote air flow for healing.31 Another form of shield Although it is normal, engorgement can be uncomfortable to very
is a nonvented dome composed of trilaminate silver. Silver ions painful for mothers. Treatment is a careful balance to support

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Topics in Pain Management October 2016

infants’ ability to latch on a full breast and decrease maternal Regardless of any treatment, the breast should be cleaned and
pain. Before breastfeeding, mothers may use warm compresses kept dry until the next feeding. Breastfeeding through the
or a breast pump to soften the breast enough for the infant to latch mastitis episode can be difficult for the mother, yet providing
and stimulate milk let down. Although warmth provides comfort, extra support and encouragement is important to long-term
use of warm compresses or warm showers should be cautious as breastfeeding outcomes.14,34,36,37
removal of excess milk beyond the infants’ need will trigger the Candidiasis occurs as an overgrowth of naturally occurring
neurohormonal pathway to provide additional milk, thus continu- yeast that lives normally on the skin and mucous mem-
ing engorgement.14 Maternal massage of the breast to release branes.40,41 The warm and moist environment found in the
plugged milk sinus during feeding is imperative, as stagnate milk infant’s mouth and on the mother’s breast increases the risk
is a source for bacterial infections.33 Cold compresses, such as a for yeast to overgrow. Candidiasis infections can occur at any
bag of frozen peas or leaves of green cabbage, after feeding can time during breastfeeding; however, it is important to note
be used to reduce breast swelling and pain.6,14 that if the mother or infant has been treated with antibiotics,
For some mothers, pain from oversupply persists beyond the the risk is increased and more intense assessments need to
first week. Milk oversupply also has nutritional implications for occur.38,40,41 Diagnosis is by clinical symptoms, although a
the infant. Infants may become full on the foremilk composed of DNA and polymerase chain reaction (PCR) assay for candidi-
low milk fat and water and obtain less of the high-fat hind milk asis are becoming readily available.14,36,41 When there is a
needed for growth and development. Interventions to decrease delay in treatment, because of the need to work up other dif-
milk supply include tea made from sage, a member of the mint ferentials, it is important to keep good communication with
herbal family, careful use of pseudoephedrine, and oral contra- the mother.36,40,41
ceptive pills containing estrogen.14 With candidiasis there is persistent soreness and redness in the
Pain or engorgement, past the first week, is considered nipples; burning and itching may also be present. In addition,
abnormal and should be evaluated by a lactation health care mothers often report that pain is increased during breastfeeding
professional. and may seem to radiate into the breast. It is important to begin
treatment as soon as a diagnosis is made and to treat both the
Organisms That Decrease Skin Integrity mother and the infant and other family members who may have
Leading to Pain symptoms. Many strategies may be used concurrently, such as:
Diagnosing nipple pain related to infections requires a thor- (1) initially, nipple ointments and topical antifungal agents and/
ough inspection of the breast, and a good discussion with the or Gentian violet (<0.5% aqueous solution) may be used daily
mother about the history of onset. Depending on the causative for no more than 7 days; (2) nystatin suspension or miconazole
agent, topical or oral antibiotics (Staphylococcus aureus) may oral gel for the infant’s mouth; and (3) human milk probiotics
be considered. If the causative agent is Candida, antifungals to treat subclinical mastitis. Vigilant hand hygiene is critical,
might be prescribed.9,25,34,36 When there is evidence of an along with hygienic care of the breasts between feedings. This
infection, expressed breast milk should not be used as a topical includes cleaning and care of anything that goes into the
agent nor should nipple ointments, gels, creams, or dressings infant’s mouth. If resistant, oral fluconazole (200 mg once, then
be used.9,25,34,36 The latest research does not support their con- 100 mg daily for 7–10 days) may be prescribed.14,36,41,42 Lastly,
tinued use. Increasing the opportunity for a warm moist envi- acidophilus can be added to the mother’s daily intake to help
ronment increases the susceptibility of the mother-infant dyad balance the normal flora growth. Reinfection is common, so it
to poorer skin integrity and potential for increased infections or is important to work with the mother to appreciate the course of
recurring infections.9,35 infections and best understand what makes the mother-infant
Mastitis or breast infection is typically triggered by a break dyad more susceptible to infections so the cycle can be broken.
in skin integrity or stagnation of milk within the milk sinuses, Helping mothers not only to understand the need for acute
allowing bacteria such as S. aureus to proliferate.14,36 It is usu- immediate care strategies but to also consider the bigger picture
ally occurs after the second or third week of breastfeeding and of what is occurring long term will help with working through
is characterized by soreness and reddened areas of the breast. this process.36,40,41
The occurrence is most often unilateral, although bilateral and
repeat infections can occur. Signs and symptoms of mastitis Preexisting Dermatologic Conditions and
include chills, increased temperature, and maternal Pain Sensitivity
fatigue.36-38 Treatment may include the use of antibiotics and Mothers with preexisting skin allergies such as eczema, pso-
analgesics and rest and hydration.14,36,37 Mothers are encour- riasis, or other dermatologic conditions are at increased risk
aged to breastfeed frequently and apply warm compresses for breast pain because of the potential for decreased skin
after feeding. An alternative approach, using acupuncture integrity.43 They need even greater support, including good
compared with standard treatment for mastitis, found a signif- hygiene and drying the breast between feedings, and the rou-
icant decrease in breast pain at 3 and 4 days of treatment.39 tine use of a topical corticosteroid to relieve symptoms.

©2016 Wolters Kluwer Health, Inc. All rights reserved. 9

Topics in Pain Management October 2016

Before feeding the infant, corticosteroid creams need to be Conclusions

removed to decrease infant exposure. Mothers who are more
A majority of women who breastfeed will experience nipple
susceptible to allergic reactions could be more likely to expe-
and breast pain, particularly during breastfeeding initiation.
rience breast pain if they use ointments or creams as a sup-
Preparing women to develop strategies for managing pain dur-
portive measure while breastfeeding. Once allergic reactions
ing breastfeeding is ideally a focus of antenatal breastfeeding
occur, the irritant (ointment or cream) needs to be discontin-
education. However, not all women are able to attend or com-
ued and the area kept clean and dry.9,14
plete educational sessions before birth. With greater recogni-
Sometimes mothers experience nipple vasospasms with tion, acknowledgment, and support for dealing with nipple and
breastfeeding that can be acutely painful. These spasms are breast pain during breastfeeding, there is a better chance that
due to a reduction in circulation and can cause blanching of mothers will continue breastfeeding up to or beyond the recom-
the nipple or nipple discoloration. Sometimes the pain radi- mended duration. Clinicians’ assessment of the pain and poten-
ates into the breast, as with Candida. As such the cause of the tial contributing factors can provide direction for interventions
pain can be easily misdiagnosed. Occurrence is greater in the focused on supporting the mother to continue breastfeeding.
winter months and in thin women with poorer circulation and More intensive follow-up should take place for women who
a family history of Reynaud syndrome.41 Because the syn- have mastitis or candidiasis to ensure that symptoms resolve
drome is often affected by temperature, the most effective and to increase the likelihood of good breastfeeding outcomes.
intervention is making sure the environment is not cold dur- Mothers at risk for severe pain during breastfeeding, such as
ing breastfeeding and applying warm water compresses after women with preexisting dermatologic or chronic pain condi-
breastfeeding. If these interventions are not effective, nifedi- tions, may need additional consultation and support. Ultimately,
pine 30 to 60 mg sustained release daily, or immediate release the time and effort provided in helping mothers to achieve bet-
10 to 20 mg thrice a day, for 2 weeks, may be prescribed.14,45 ter breastfeeding outcomes will contribute to infant health and
Mothers with a history of pain disorder may experience long-term population health outcomes. ■
excruciating pain with breastfeeding, light touch, or drying with
a tool. These mothers may require pharmacologic management References
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Topics in Pain Management October 2016

Topics in Pain Management CE Quiz

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1. Assessing breastfeeding pain is important because 6. Which of the following topical interventions for treatment
A. breastfeeding pain is always associated with infection of nipple pain are supported by Oxford Center for
B. pain is a common reason for cessation of breastfeeding Evidence-Based Medicine level 2 evidence?
C. breastfeeding pain is a key indicator of engorgement A. Peppermint and purified lanolin
D. neurohormones released into breast milk are harmful B. Trilaminate silver and warm compresses
2. Breastfeeding pain C. Purified lanolin and expressed breast milk
A. usually peaks during the first 3 days after birth D. Petroleum jelly and shea butter
B. is normal after the first week 7. The Breastfeeding Pain Reasoning Model proposes that
C. is not important information during a breastfeeding assessment maternal pain during breastfeeding is affected by
D. is abnormal only if the pain has neuropathic features A. maternal social, emotional, and cognitive state
3. Individualized counseling for managing breastfeeding pain B. maternal nipple shape
needs to include C. positioning during breastfeeding
A. assessment of skin integrity, history of onset and symp- D. maternal age, race, and ethnicity
toms, characterization of the pain, treatment of pain 8. Although all mothers are at risk for nipple pain and trauma
with antibiotics, analgesics, and/or antifungals during the first week of the infant’s life, which one of the
B. assessment of skin integrity, history of onset, pain following indicates increased risk?
intensity, other symptoms that accompany the pain, dis- A. First-time mothers
cussion of “normal” versus “abnormal” pain B. History of preexisting dermatologic conditions
C. assessment, history of onset and symptoms, apprecia- C. History of antibiotic use
tion of the mother’s perception of her pain, understand- D. History of diabetes
ing of strategies already tried by the mother, and
acknowledgment of maternal competence 9. Engorgement occurs within 72 hours after delivery and is
D. history of onset and symptoms, characterization of the characterized as
pain, discussion about seeing the lactation specialist A. severe pain
B. neurohormonal pathway regulation of milk supply
4. Interventions for infection should include
C. filling of milk sinuses
A. analgesics prescribed along with antibiotics
D. an abnormal physiologic process
B. after 24 hours of antibiotic therapy, resume breastfeeding
C. use of breastmilk on the nipples after feedings to 10. Mothers who persist with severe pain during breastfeeding
increase immune function after treatment with antifungals and antibiotics should be
D. resume breastfeeding only after infection clears evaluated for
A. Reynaud syndrome
5. Antenatal breastfeeding education significantly decreases
B. eczema
breastfeeding pain by providing
C. mastitis
A. strategies to maintain nipple integrity
D. fibromyalgia
B. instruction on proper infant positioning and latch
C. management of lactogenesis II
D. medications to increase or decrease the milk supply

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