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Identifying the cause of breast and nipple pain during lactation

BMJ 2021; 374 doi: (Published 13 July 2021) Cite this as: BMJ 2021;374:n1628
  1. Lisa H Amir, medical officer, principal research fellow12,
  2. Carmela Baeza, family doctor and International Board Certified lactation consultant3,
  3. Jayne R Charlamb, clinical associate professor4,
  4. Wendy Jones, pharmacist with a special interest in breastfeeding and medication5
  1. 1Breastfeeding Service, Royal Women’s Hospital, Parkville, Australia
  2. 2Judith Lumley Centre, La Trobe University, Victoria, Australia
  3. 3Raices Family Wellness Clinic, Madrid, Spain
  4. 4Division of Breast Health & Breastfeeding Medicine, Department of Obstetrics & Gynecology, SUNY Upstate Medical University, Syracuse, NY, USA
  5. 5Portsmouth, UK
  1. Correspondence to L Amir l.amir{at}

What you need to know

  • The most frequent cause of nipple pain in breastfeeding women is poor latch or attachment to the breast

  • An itchy, erythematous rash on the nipple, areola area, or breast is likely to be eczema, and should not automatically be diagnosed as nipple thrush

  • Persistent nipple and breast pain during lactation is usually multifactorial. Elicit factors from maternal, infant, medical, mental, and psychosocial health, as well as from mechanical trauma or infection

A first time mother developed left nipple pain 24 hours after the birth. This persisted despite trying nipple shields and topical lanolin. On day 7 she developed mastitis in her left breast and was prescribed flucloxacillin, but the nipple and breast pain continued. Her friend suggested oral probiotics, to no effect. At the breastfeeding clinic (6 weeks postpartum) the left breast pain was excruciating and a burning pain had started in her right breast. She was also concerned about her baby’s slow weight gain. On examination, her nipples were sensitive to light touch and examination of the baby indicated torticollis. When observing a feed, good positioning and attachment was seen on the right but the infant’s torticollis made it difficult for him to attach on the left side and the mother quickly took him off her breast because it was too painful. The left nipple was flattened after the feed.

More than 70% of first time mothers report nipple and/or breast pain in the first week post partum.1 This is frequently nipple pain resulting from inadequate latching; however, multiple diagnoses should be considered.2

This article helps clinicians promptly identify and resolve the underlying cause(s) of pain so that premature cessation of breastfeeding can be avoided and the breastfeeding relationship becomes enjoyable for mother and baby. We explain the three elements of assessment—the mother’s health, the infant’s …

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