Guide to nipple cracks, mastitis and breastfeeding problems

There are times when breastfeeding runs into difficulties, which is why our team of midwives has prepared the following post for you on the most common difficulties in breastfeeding, with this guide to sore nipples, mastitis and breastfeeding problems arising from maternal problems. It could be said that the most common problems that make breastfeeding fail are breast and/or nipple pain and the mum's perception (real or subjective) of a low production of milk. Let's find a solution!

Guide to resolving difficulties during breastfeeding

Cracked nipples

You should know that some nipple discomfort or even mild pain is normal at the start of feeds during the first days of breastfeeding. This is because it is a new experience for the mother and the negative pressure created in the ducts, which are not yet full of milk, may explain this sensation. However, it is not considered normal if this discomfort persists over several days or does not only happen at the start of a feed. This situation requires an assessment of feeding at the breast and advice from your midwife or a breastfeeding specialist. By contrast, cracked nipples are wounds on the nipples that cause pain at the start of the feed; the pain eases during the feed and goes away when your baby lets go of the breast. They can bleed and cause your baby to have bloody vomit because of the presence of this blood in your breast milk.

Causes of cracked nipples

• Poor latch and/or position.
• Pressing the breast to free the baby's nose for fear that they cannot breathe.
• Ankyloglossia (tongue-tie).
• Micrognathia (very small jaw).
• Time limits on feeds.
• Use of soaps with frequent washing of the breast and/or unsuitable creams.
• Using a breast pump with an ill-fitting shield.

Sometimes no obvious reason can be found for the nipple pain. It is worth considering that your baby may have a very vigorous suck, squeezing the nipple, and would benefit from physiotherapy to improve their sucking technique.

Types of cracked nipples

• Crack at the base of the nipple: usually caused by a poor position of the baby.
• Crack at the tip of the nipple: the causes are mainly a poor latch or a poor suck.

Treatment for cracked nipples

Bear in mind that the various treatments are not suitable for all cracked nipples and you will need individual follow-up from your midwife or breastfeeding specialist. The available scientific evidence does not support any standardised treatment. Whatever treatment is used, the pain usually eases to mild levels around day 7 to 10 after birth. The following general measures are therefore proposed:

• Correct your breastfeeding position until you achieve a correct latch.
• Breastfeeding on demand, skin-to-skin, encouraging the baby to latch on spontaneously.
• Encourage a deep latch; you can squeeze your breast during the feed to make it easier for the milk to flow and to keep the feed shorter.
• Vary your position to change the direction of the pressure (rugby ball hold, koala hold…).
• Start the feed from the breast that is least affected, to minimise the pain.
• You can stimulate your nipple to encourage the breast milk to flow before latching on.
• If you have a lot of nipple pain, you can express your breast milk and feed your baby expressed breast milk until things improve.

• You can apply your own breast milk topically if there is no associated infection, and let the breast air-dry.
• If you use breast pads, change them frequently.
• Nipple shells can be useful to prevent friction and improve healing.

• Use nipple shields only in very specific cases and under supervision, as they do not correct the original cause.
• Rely on your midwife or breastfeeding specialist with close follow-up.

Remember that our new method, Happymami Care, is here to heal your cracked nipples without pain and without affecting your breastfeeding.

Breast engorgement

Before we start, it is important to distinguish it from the physiological congestion that occurs when breast milk production begins (lactogenesis II), normally between day 3 and day 5 after birth (“milk coming in”). In this situation there is no difficulty with latching or emptying the breast, and no significant discomfort. Breast engorgement is caused by an imbalance between the production and the removal of breast milk. The breast is tense, hard and shiny, lymphatic drainage is altered, there may be a low-grade fever and the milk does not flow, or flows with difficulty. It can affect the breast alone or also the nipple and areola. Your baby has difficulty latching on to the breast and removing milk, and this makes the situation worse. It can lead to giving up breastfeeding or to mastitis. Find out: how can you tell if my baby is getting enough milk? This breast congestion has two components: on the one hand, the breast milk that has built up in the ducts and, on the other hand, the inflammation and oedema in the interstitial space. The best treatment for breast engorgement is prevention with a correct technique and without restricting feeds.

Causes of breast engorgement

• Incorrect technique.
• Restricted feeding times.
• Separation of mother and baby.
• Giving supplements.

Treatment for breast engorgement

• Use warm water compresses before expressing with a pump if your baby cannot take in the areola (do not use if there is areolar oedema), or by letting your baby suckle, or by hand expression.
• Massage the breast with circular or radial movements towards the nipple to drain the breast milk before and during the feed.
• The reverse pressure softening technique (RPS). It involves applying pressure to the areola around the nipple to move the swelling backwards and into the breast. The time varies until the areolar area is soft enough for your baby to achieve a good latch.
• Cold compresses after expressing.
• Consider using NSAIDs.

Blocked ducts

You may also find that you have blocked ducts. They are areas where breast milk builds up inside a duct, causing distension of the breast tissue, with a painful lump that can be felt, sometimes with redness of the skin in that area. If it cannot be drained, it may turn into mastitis. Blocked ducts do not cause systemic symptoms like mastitis, and there may be a low-grade fever.

Causes of blocked ducts

• Previous breast surgery.
• Poor technique.
• Hypergalactia (higher production of breast milk)
• Milk blister due to suction from your baby. It is a blockage at the opening of a pore in the nipple and appears as a round, regular shape. It does not need treatment unless it causes pain, in which case it would be drained by lifting the skin with a needle using a sterile technique.
• Tight clothing or anything that can put constant pressure on the area (car seat belt, handbag, tight bra, sleeping position…).
• Returning to work.
• Rigid schedules.
• Intraductal infections. They can cause milk blisters on the nipple caused by infection; they are irregular in shape and should be assessed by a professional to decide whether a milk culture is needed.

Treatment for blocked ducts

• Correct any known possible causes.
• Massage before feeds and use warm compresses during them.
• Position your baby so that their chin points towards the blockage.
• Increase how often you feed and make sure the breast is drained, even with a pump or by hand if necessary.
• NSAIDs if needed.

Mastitis

Mastitis can be infectious or inflammatory in origin, as the term itself refers to an inflammation of the breast tissue, although we usually use it to refer to acute mastitis. Other forms include chronic mastitis, candida mastitis and granulomatous mastitis.

It is estimated that between 3 and 20% of breastfeeding mothers have acute mastitis and most of the time it happens in the first 6 weeks. Diagnosis is mainly clinical, with breast pain and inflammation (heat, redness and erythema) and systemic symptoms similar to flu of varying intensity (fever above 38.5 °C, fatigue, joint pain, chills…).

Taking a breast milk culture is only indicated if it does not respond to empirical antibiotic treatment, or if you, as a mum, are allergic to several antibiotics, or if it is a severe infection acquired in hospital.

Causes of mastitis

• Blocked ducts due to the causes set out above.
• Reduced maternal defences.
• Malnutrition.
• Cracked nipples.
• Poor hygiene when handling the nipple.
• Routine use of creams to prevent cracked nipples.

Treatment for mastitis

• Support and counselling in breastfeeding.
• Rest and adequate nutrition and hydration.
• Frequent, effective removal of milk, ideally by your baby or, failing that, with a pump.
• Empirical antibiotic treatment if symptoms persist for more than 24 h.
• Anti-inflammatories (preferably ibuprofen).

Breast abscess

It is a complication of mastitis. An area of the breast stays hard, red and painful (this happens 3% of the time). See your midwife or your gynaecologist. The general symptoms and the fever may have disappeared.

Treatment for breast abscess

Two possible treatments:

• Needle aspiration and subsequent analysis of the fluid or pus aspirated to determine the appropriate antibiotic;
• Surgical drainage if it is very large or if there are multiple abscesses.

After treatment there is no contraindication to continuing with breastfeeding if your baby does not come into contact with the wound or the secretions.

Flat or inverted nipples

Most flat or inverted nipples are not a problem for breastfeeding; babies do not suck from the nipple but from the breast.

Treatment for flat or inverted nipples

• Stimulation methods during pregnancy do not work. It is recommended to stimulate the nipple by rubbing it with an ice cube or a little cold water just before feeding your baby.

• Start breastfeeding within the first 2 h after birth.
• Start the baby's first feed on the flat or inverted nipple (this creates an imprint).
• If there is no nipple, stimulate the corners of the baby's mouth with a finger so that they open their mouth as if yawning.
• Point the nipple towards the baby's palate and put the breast into their mouth, holding the breast behind the areola (sandwich hold).
• Once the baby has latched on, keep holding the breast until they have sucked a couple of times and enough suction has built up for the nipple to sit behind the palate and the breast does not slip out.
• Avoid engorgement. An engorged breast with a flat nipple becomes a ball, with nothing for the baby to latch on to.
• If you still cannot get the baby to latch on, the koala hold and holding the breast with the sandwich technique can help. If that does not work either, nipple shields may be needed for a while, until the baby forms the nipple through their sucking.

Conclusion: guide to sore nipples, mastitis and breastfeeding problems

As we always say, every case is unique, and if you have the slightest doubt, turn to your midwife, or to a specialist in breastfeeding. There are also breastfeeding support groups that will certainly give you a lot during this stage. Take heart, because you are offering your baby the best food!