Identifying the cause of breast and nipple pain during lactation

Lisa H Amir; Carmela Baeza; Jayne R Charlamb; Wendy Jones

doi:10.1136/bmj.n1628

Practice Practice pointer

Identifying the cause of breast and nipple pain during lactation

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1628 (Published 13 July 2021) Cite this as: BMJ 2021;374:n1628

Lisa H Amir, medical officer, principal research fellow1 2,
Carmela Baeza, family doctor and International Board Certified lactation consultant3,
Jayne R Charlamb, clinical associate professor4,
Wendy Jones, pharmacist with a special interest in breastfeeding and medication5

¹Breastfeeding Service, Royal Women’s Hospital, Parkville, Australia
²Judith Lumley Centre, La Trobe University, Victoria, Australia
³Raices Family Wellness Clinic, Madrid, Spain
⁴Division of Breast Health & Breastfeeding Medicine, Department of Obstetrics & Gynecology, SUNY Upstate Medical University, Syracuse, NY, USA
⁵Portsmouth, UK

Correspondence to L Amir l.amir{at}latrobe.edu.au

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 health, and the dyadic interaction between the two—and hope to encourage clinicians to further their training in breastfeeding medicine. Detailed management is beyond the scope of this article but a summary table is provided, including information to guide referral.

We have used evidence from systematic reviews and large cohort studies, where available, but evidence in this field is lacking. Generally, consensus is poor on definitions and diagnoses, but we have used information from clinical guidelines, including the National Institute for Health and Care Excellence (NICE) and the Academy of Breastfeeding Medicine (ABM).3

How do you diagnose the cause of breast or nipple pain?

Use a respectful, individualised, family centred approach to address the mother’s concerns, and to assess mother and infant separately and together (fig 1).4 5 Formulate the likely diagnosis/diagnoses (from the causes in box 1) by obtaining a clear timeline and description of the problem.

Fig 1

Assessment of mother and baby for breast or nipple pain in the mother

Box 1

Causes of nipple and breast pain during lactation

Nipple pain

Inadequate latch

Can cause mechanical damage to the nipple

Infant oral anatomy

For example, an asymmetric jaw or a restricted frenulum (tongue tie), or excessive intra-oral vacuum during sucking6 7

Poor milk expression technique

Breast pumps can cause nipple damage if the breast pump flange is too small, or if the pressure is too high or prolonged

Nipple bleb/white spot

A superficial, inflammatory fibrinous lesion, appearing as a white spot on the nipple tip which may block a nipple opening, causing mild to severe nipple pain (fig 2) (This can lead to a blocked duct8)

Nipple vasospasm/Raynaud’s

Can be a primary cause of pain. Or can be a secondary response to pain or nipple trauma (damaged nipples or thrush). Usually in individuals with poor circulation who experience cold hands/feet

Nipple dermatitis

May be atopic, irritant (from nipple creams (fig 3) or complementary foods remaining in infant’s mouth) or contact dermatitis (from breast pads) or psoriasis

Bacterial nipple infection

Nipple damage that is present for >24 hours is commonly colonised with Staphylococcus aureus (fig 4)

Dimple nipple

Uncommon. A nipple tip which folds in on itself can lead to ongoing pain as the skin inside the fold is fragile, and may become macerated9 (fig 5). The macerated skin fails to heal, unless the nipple tip can be kept everted after feeds

Herpes simplex infection

Occurs when infection is transferred to the nipple/areola from an infected source, eg visitor with cold sore touches mother’s hand and is transferred to nipple; or in later months the child may develop herpes stomatitis from contact at childcare, and transfer from mouth to nipple10

Causes of breast pain

Engorgement

Can occur at 2-10 days post partum when the milk “comes in,” or if breastfeeding is stopped abruptly, or if many hours pass without removing milk from the breast3

Blocked (or plugged) duct

Pain usually lessens after a feed. No systemic symptoms.11 May lead to mastitis3 (fig 6)

Mastitis

May be non-infectious (eg, when the infant sleeps through the night for the first time), but can progress to infection, especially if nipple damage is present and bacteria can enter breast tissue (usually in first eight weeks post partum).

One in five breastfeeding women are diagnosed with mastitis,12 and the usual organism is S aureus.13 Signs and symptoms are similar to a blocked duct but women usually also have systemic illness (figs 6, 7). Breast cellulitis is a type of mastitis and may be caused by a Streptococcus spp infection rather than the typical S aureus.14

Breast abscess

A collection of pus within the breast tissue, usually (but not always) occurring after mastitis. Occurs in 3% of women with mastitis15

Breast cyst or galactocele

A fluid or milk filled cyst within the breast may present as a tender swelling/lump11

External trauma to breast

Vigorous massage of the breast can cause bruising, as can a bump from toddler’s foot or similar hard knock

Non-lactation related skin conditions

Any skin condition can occur on the breast during lactation—eg, breast eczema (fig 8). Likewise exogenous effects like sunburn—just as they may at any other time

Conditions that can cause breast and/or nipple pain

Thrush

Occurs when there is an overgrowth of Candida spp on nipple and or breast; may start on one side and spread to the other nipple/breast (not related to engorgement/mastitis). Antibiotics may have been used previously.16 Burning nipple pain is continuous, not just during feeds; breast pain may be described as radiating. Nipple soreness may develop after months of pain free breastfeeding in women predisposed to vaginal candidiasis.17 18 Avoid diagnosing thrush solely on the mother’s description of radiating/shooting pain, ie, unless it clearly follows a course of antibiotics in a patient prone to vaginal thrush, consider all other diagnoses

Herpes zoster

May occur anywhere on the nipple/breast/chest in a dermatomal distribution. Occurs infrequently and pain may be present for several days prior to onset of rash

Breast cancer (unusual cause, doesn’t usually present as pain alone)

Inflammatory breast cancer

Mastitis symptoms which persist despite antibiotic treatment, especially with peau d’orange appearance. Occurs infrequently

Paget’s disease of the nipple

An uncommon type of breast cancer that appears similar to eczema on the breast or nipple.19 Occurs infrequently

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What to cover in the mother’s history

Take a general health and medical history and, in multiparous mothers, a previous lactation history.

Pain could be from scarring following previous breast surgery, or dermatological conditions (eczema, psoriasis, or other skin issues)
Autoimmune conditions such as thyroiditis, diabetes, and other autoimmune conditions can target the mammary gland.20 Depression, fibromyalgia,21 or other chronic pain conditions can cause exacerbated perception of breast or nipple pain that may or may not be related to breastfeeding, ie, the person may experience breast fullness as severe pain
Vulvovaginal symptoms could be linked as there are similarities between the skin of the nipple and the vulva:
History of recurrent vulvovaginal candidiasis might indicate nipple or breast thrush, or vulvodynia (a chronic pain condition)
Previous lactation experiences may indicate the mother’s attitude towards breastfeeding. Were they able to breastfeed for as long as they wished to previously?
A mother who previously breastfed for more than 12 months is likely to persevere during early problems
Did the mother have similar problems previously? Was it owing to nipple anatomy (eg, flat/inverted/dimpled nipples)?
A sensitivity to cold (the woman might describe “poor circulation”) or history of Raynaud’s disease in herself or family, could suggest nipple vasospasm (Raynaud’s phenomenon of the nipple) as a primary cause or contributing factor to her pain.22

Ask about the pain

Consider nipple and breast pain separately, although patients often use the terms interchangeably.

What is the location of the pain? Is it in the nipple or the breast, deep versus superficial, unilateral- versus bilateral, non-breast structure (could it be chest wall or internal, eg, pleurisy?)
If the site of the pain is indicated by a finger pointing to the sternal edge, costochondritis (inflammation of the costochondral junction) is likely23
What is the character of the pain?
Achy pain is present with the continuum of engorgement, blocked duct, and mastitis
Other characteristics, such as shooting, burning, or needle-like pain, can indicate the source of the pain is from the breast ducts, even in a non-lactating breast.23 This type of pain may be present in breast thrush, but is not pathognomonic of this condition. If burning nipple pain occurs only on latching or only with direct breastfeeding, the diagnosis is more likely caused by attachment difficulty
When does the pain occur?
If pain is continuous it could be owing to a nipple or areolar skin condition; infection; or a severely damaged nipple
See below “Assessment of dyadic interaction” for pain during or after a feed.

Severity acknowledges the importance of mothers’ discomfort and can be useful to monitor management, but does not indicate the cause of pain.

Ask about onset and associated, exacerbating, or relieving features

Was the onset with illness (missed feed?), teething (baby feeding poorly), menses, or a new pregnancy (hormonal sensititivity)?
Itching and rash on other areas of the body is suggestive of eczema/dermatitis
Chills, flu-like aching, malaise, and systemic illness is suggestive of mastitis3
Pain exacerbated by cold surroundings (eg, freezer section of supermarket, or being exposed to cold wind), or relieved by heat (eg, heat packs, warm shower, or even warming the breast with their hand) could indicate nipple vasospasm or Raynaud’s phenomenon of the nipple
Coexisting pain and past painful conditions can be associated with central sensitisation, which can amplify pain24 25 26
Management history—have any remedies or treatments suggested by friends, family, social media, or other healthcare professionals helped?
If the obstetric/postnatal history includes antibiotic use, consider nipple/breast thrush
Oral probiotics and topical lanolin are commonly tried for pain during lactation, despite minimal evidence for their effectiveness27 28
If nipple creams or pads have worsened symptoms, consider irritant or contact dermatitis (fig 2)
If topical steroids have had no effect, consider the rare Paget’s disease of the nipple19
If mastitis has not responded to antibiotics in individuals with autoimmune conditions,20 consider autoimmune mastitis (uncommon).

Fig 2

White spot on nipple after feed

Mothers’ concerns might offer clues to diagnosis/es

She may have been assured her that breast implants would not affect breastfeeding; however, implants can be associated with pain during lactation29
A common fear is that breast changes are cancer related; however, most commonly, new lumps are caused by a blocked duct, mastitis, or abscess
If pain is ongoing, assess the psychosocial impact on the mother and the family.5 30
Does the mother have adequate support (physical and emotional)?
Does she feel conflicted, powerless, frightened, or depressed? Does anxiety or uncertainty related to pain cause resentment of the infant, the breastfeeding process, or motherhood itself? Consider asking about past or present physical or emotional abuse. These factors exacerbate symptoms for some25
Breastfeeding aversion can manifest as breast or nipple pain during lactation.31

What to cover in the mother’s examination

On inspection, how is the mother’s overall appearance? If she looks unwell, consider mastitis. If she looks pale, consider anaemia (which may contribute to fatigue or exhaustion, exacerbating pain). Dry skin or signs of dermatitis may be visible on face or hands.

It is common for pain to cause worry; however, consider safety, financial, and/or mental wellbeing concerns if the mother appears overly anxious.

Visually assess both breasts and/or nipples, being aware that skin lesions may differ according to skin pigmentation.32 33

Surgical scars or nipple piercing may be evident (and may cause localised pain)
Look for nipple damage34 and other signs that may suggest the cause of the pain (there may be none):
Both very long nipples and poorly protractile (“flat” or inverted) nipples can be painful, if mother cannot latch baby deeply onto the breast
Visible white spots or “nipple blebs” may be present on the nipple tip (fig 3)8
Eczema/dermatitis/psoriasis is usually an itchy erythematous well defined rash on the nipple or areola (fig 2). If crusty or flaky, a secondary bacterial infection may be present35 (fig 4)
Yellow crusting or exudate could indicate bacterial infection; there will also be evidence of nipple damage and/or eczema (fig 4)
On people with darker skin tones, nipple dermatitis tends to have a brown, violaceous or grey-coloured hue—history can help with the diagnosis if examination findings are unclear (eg, history of childhood eczema or sudden onset of itchiness)36
Post-inflammatory hypopigmentation following areolar dermatitis can be more profound in people with darker skin tones36
Herpes simplex presents as extremely painful small red or fluid-filled blisters, or open sores35; typical presentation is mother of a toddler with herpes stomatitis with lesions where the baby’s mouth comes in contact with the mother’s nipple/areola10
An anatomical variant of the nipple where the centre is folded in, dimple nipple (fig 5) might be seen, which is a prompt to examine inside the fold for macerated skin, which can be slow to heal9
The nipple tip may turn white when exposed to the cold, indicating nipple vasospasm. It is more common for the vasospasm to be caused by a tendency to poor circulation22; however, Raynaud’s disease might be causing the pain
Bleeding from the nipple is usually due to nipple damage.
Look for breast signs (there may be none):
Bilateral fullness might indicate engorgement. Redness might indicate blocked duct/mastitis (figs 6, 7). If swelling and redness is marked, and spreading across the breast/chest, it is cellulitis. In darker skin tones, erythema may not be obvious (consider other markers37)
Peau d’orange appearance might indicate cellulitis, or rarely inflammatory breast cancer
Well demarcated itchy erythematous lesions extending from areola onto the breast could be breast eczema; crusty appearance suggests S aureus colonisation (fig 8)
If breasts have been exposed to the sun, painful red appearance might be caused by sunburn.

Fig 3

Flaky, itchy right nipple/areola dermatitis. Initially treated as thrush but worsened with miconazole gel. Baby 17 months

Fig 4

Scab and crack on tip of nipple with yellowish crust/exudate, indicating bacterial nipple infection. Baby had black bowel motion (bleeding from nipple)

Fig 5

Dimple nipple (damage inside the dimple). Ongoing nipple pain at 3 months

Fig 6

Blocked duct/early mastitis: redness on left breast. Baby 3 months

Fig 7

Mastitis in right breast. Mother 36 weeks’ pregnant, with symptoms for two days

Fig 8

Eczema lesions on lateral breast. History of eczema on hands

Palpation is not always necessary. Palpate the breast if the mother has reported “lumps,” nodules, or swellings in her breast/s, or if you see any bulging area. This could indicate blocked duct, mastitis, galactocele, abscess or in very rare cases, malignancy.

With engorgement, both breasts can be tender, tense, and “full.” A blocked duct or mastitis may cause localised tenderness in a section of one breast that may be swollen or hard. With mastitis, the breast might be inflamed, firm, and lumpy. Breast abscess may cause a localised, tender, and firm or fluctuant swelling or lump; but this may not be palpable if it is deep within the breast. Localised heat and tenderness are also useful indicators of mastitis, especially in darker skin tones when erythema might not be obvious.37

If the breast is red and tender, take the mother’s temperature. ABM advises considering mastitis if the woman has a fever of 38.5°C or greater (this may be affected by recent analgesia). However, women with a breast abscess may have no fever, ie, their temperature is likely to be less than 38.5°C.

Perform a full breast examination where a blocked duct or mastitis recurs in the same location, to exclude a persistent mass that might be suggestive of malignancy.

Take a history about the infant’s health

Birth history may reveal prematurity or other reasons for poor feeding
Do not miss low infant weight gain by solely focusing on maternal pain; ask about growth and weight gain
Inquire if infant tongue-tie has been suggested by other health professionals so you can address this in your examination (see ‘‘Common pitfalls’’ below)
Has the infant been vomiting fresh blood or black stools? This suggests bleeding from nipple trauma but is not harmful to the infant.

What to cover in the infant examination

Asymmetric body/neck/head posture in the infant (eg, in torticollis) makes comfortable breast attachment difficult. Facial asymmetries or fractured clavicle after a traumatic birth may also cause difficulties with latching.

Assess for “classic tongue-tie.” NICE defines this as when the lingual frenulum restricts tongue movement.38 The Tongue-tie and Breastfed Babies assessment tool is helpful in determining severity of tongue tie.39

Look for white patches inside cheeks or lips, which are suggestive of oral thrush. However, a mother can be diagnosed with nipple thrush without any signs in her infant, and white tongue alone in an infant is usually just a “coated tongue.”40

Assessment of suck can detect mechanical issues (suboptimal tongue movement, high palate, high or low intraoral muscle tone) which could be the cause of pain, but using this technique for diagnosis requires training.

How to assess the interaction between mother and baby

Ask about any pregnancy or birth complications that led to early separation of mother and baby, ie, disruption of postpartum skin-to-skin and early breastfeeding practices. For example, did maternal diabetes in pregnancy lead to infant hypoglycaemia and early supplementation with infant formula? Was admission to the neonatal/special care unit needed?

Ask about current feeding practices:

How often are breastfeeds? One or both breasts? For how long?
Are supplementary feeds given?
With expressed breast milk, infant formula, other?

Complete assessment includes observing a breastfeed—if your time or skills are restricted, refer to a local lactation consultant/breastfeeding support for this.

Check positioning and attachment (box 2). Awkward feeding positions involving maternal thoracic rotation and flexion may cause thoracic musculoskeletal strain42
Does infant pathology (eg, fractured clavicle) or asymmetry affect latch and feeding position?

Box 2

How to assess breastfeeding positioning and attachment

Check that the infant is being held close to the mother, facing the breast with wide open mouth so that they latch on to the breast, not the nipple41
Check for awkward positions involving mother rotating and flexing her thoracic area.42 Mother should be leaning back slightly, like on a deck chair, with her feet on the floor/supported and shoulders symmetrical and relaxed25 (fig 9)
Check that the mother is bringing the baby to the breast (not breast to baby), and that the baby’s chin is pressing into the breast with nose free. If baby’s nose is buried in the breast, bring baby’s bottom in closer
Baby’s cheeks should be round (not sucked in), and jaw opens and closes as baby swallows43
Initial sucks are quick until the milk lets down, and then sucking should be rhythmical

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Fig 9

Comfortable position for breastfeeding: mother leaning back and supporting baby’s body with her own body. Baby’s body is facing mother’s body with head and neck in line with spine, one arm either side of the breast so baby’s hand is in contact with breast

Assess pain during and after the feed. Pain present only at the start of a feed usually indicates nipple trauma from sub-optimal attachment, which could be related to nipple anatomy or infant anatomy. Pain after a feed could be nipple vasospasm, white spot causing blockage and local duct spasm, or breast thrush. Blocked duct pain usually lessens after a feed.

Also check for nipple colour change after a feed. If the nipple is white and malformed (flattened, creased, pointed, etc) immediately upon coming out of baby’s mouth this is owing to compression from poor attachment. In nipple vasospasm, the nipple tip, or part of the nipple tip, turns white shortly after the feed and is associated with throbbing pain; mothers who hold breast in their hand may be warming the nipple to reduce pain. In classic Raynaud’s phenomenon of the nipple, the nipple tip turns white, followed by blue or red and blue, ie, biphasic or triphasic colour changes.22

Consider primary care diagnostic tools

ABM3 recommends milk culture when mastitis is not responding to first line antibiotics, is recurrent, bilateral, or unusual.3

S aureus is usually present when the nipple/areola is damaged,2 44 45 46 therefore routine skin swabs are not usually done. However, consider skin swabs for persistent infection to rule out meticillin-resistant S aureus or an unusual organism, such as herpes simplex.35

Box 3 summarises common diagnostic pitfalls.

Box 3

How to avoid common diagnostic pitfalls

Misdiagnosis and missed diagnosis occurs when clinicians have little education in breastfeeding medicine. To avoid common pitfalls:

Recognise that pain could be due to a poor latch
Don’t assume a diagnosis of nipple or breast thrush if the pain is described as burning47 48
Acknowledge overdiagnosis of tongue-tie, ie, when normal oral anatomy is diagnosed as tongue-tie and released unnecessarily. Become familiar with infant oral anatomy and explain to parents that the presence of a lingual frenulum is not synonymous with “tongue-tie.” Be aware that in some settings posterior tongue-tie is being diagnosed and treated on the basis of “a tight, non-visible submucosal band of tissue at the very base of the ventral tongue that is palpated rather than seen”; treatment involves invasive deep submucosal dissection which is potentially harmful, and not evidence based49
Recognise there may be multiple contributing factors35
Recognise that management options may be contributing to symptoms (eg, irritant dermatitis secondary to using topical nipple agent25; trauma from too small nipple shield or pump flange; overly vigorous breast massage)
Assess infant growth and health as well as mother health
Be aware of conditions where breast pain or perception of breast pain is unrelated to breastfeeding, eg, fibromyalgia,21musculoskeletal strain,42 breastfeeding aversion31

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What are the primary care management options, including referral advice?

Support parents to maintain breast milk feeding, while recognising their infant feeding plans.50 51 Use a respectful, individualised, family centred approach to inform and support the mother and family, empowering them to make decisions suitable for their situation and cultural preferences.5

Refer to an infant feeding expert for prompt, immediate assistance when the woman has nipple pain after the first week or so; and if a multiparous mother has a history of early breastfeeding cessation (eg, within the first month). Further primary care management options, including referral advice, are summarised in box 4.

Box 4

Summary of primary care management and when to refer

Inadequate latch, nipple damage, poor milk expression technique, and/or nipple blanching and malformation immediately after feed

Refer to local infant feeding specialist for practical help, including finding comfortable feeding positions for mother and baby. Mother may consider expressing by hand or with a hospital grade breast pump until nipples heal

Classic tongue-tie

A simple scissor frenotomy in the early months can reduce pain if the infant frenulum is tight and impairing breastfeeding (evidence from the NICE guideline and a recent US meta-analysis).38 52 No evidence suggests that infants need treatment for upper labial or “buccal” ties.6 49 53

Nipple eczema

Apply a strong steroid ointment, sparingly, to the affected area after breastfeeding, for up to 10 days (absorption by the infant should be minimal if steroid is used as directed). Avoid soap or shampoo on breasts. An emollient can be used on nipples (eg, purified lanolin). Reassure patients that post-inflammatory nipple hypopigmentation, which is not uncommon in darker skin after areolar dermatitis, is usually temporary35 54

Bacterial nipple infection or infected eczema

Consider topical antibiotic ointment, eg, mupirocin, if wound is not healing; or oral antibiotic if infection is spreading to the breast (ie, mastitis/cellulitis)