Pain: if breastfeeding hurts

Pain in your nipples or breasts whilst breastfeeding is most often linked to how you are holding your baby and bringing them to your breast (often referred to as positioning and attachment). Before considering any alternative reasons for experiencing pain whilst breastfeeding please use our guide to positioning and attachment to rule this out as a cause of pain. Even if there is another medical basis for the pain, getting positioning and attachment as comfortable as possible will still help.

When you first start breastfeeding, it is common to experience a strong and sometimes uncomfortable sensation for the first few seconds of your baby latching on. However, this should pass quickly, and feeding should become comfortable. If this is not the case, trying some small changes to your positioning and attachment could help make feeding more comfortable for you.

If the pain is not improved after trying some of the ideas in our guide on positioning and attachment, please seek support from a breastfeeding supporter. They can observe and assess a full feed. You can also find a local support group here or contact the National Breastfeeding Helpline.

If your nipple is damaged, use moist wound healing within the wound (avoid applying cream to whole nipple) to stop a scab forming, which will deepen the wound. You can continue to breastfeed on a damaged nipple as it will still be able to heal, but it is very important to get support with positioning and attachment to prevent further damage occurring.

If a breastfeeding practitioner has helped you adjust your positioning and attachment and you still have pain or nipple damage, your baby may need to be assessed for a tongue tie or other issues that might be making breastfeeding harder.

Other causes of pain in breastfeeding:

Allergy

If your nipples are itchy (which may be triggered by warmth) or changed in colour (which may show as redness on lighter skin tones) but you do not see any change in the shape of your nipples and are not experiencing pain, the problem may be an allergy to something in contact with your nipples, such as nipple cream or breast pads. Try eliminating these to identify the cause. If disposable breast pads are causing irritation, you could try washable ones instead.

The symptoms may be relieved by a non-sedating antihistamine and hydrocortisone 1% cream applied sparingly. See our factsheet on antihistamines for more information on taking these whilst breastfeeding.

Vasospasm

If your nipple turns white at tip after breastfeeds and pain or itchiness, and redness on some skin tones, occurs immediately at end of feed when blood returns, vasospasm could be the cause.

This is due to restricted circulation from compression of the nipple by the baby squashing it between their tongue and the roof of their mouth during a feed. It can be relieved by help with attachment from a specialist breastfeeding practitioner. Vasospasm can occur in one or both breasts. It does not respond to medication which is unnecessary, but can be improved by adjusting positioning and attachment.

Raynaud’s Phenomenon

If the pain is worst at the end of or after a feed and your nipples change colour rapidly after breastfeeds from white to purple then red (this might not be visible on all skin tones), you may be experiencing Raynaud’s Phenomenon.

If you have a history of circulation problems or migraine and pain is triggered or made worse by cold, Raynaud’s Phenomenon is more likely. Pain can be immediately after a feed but may also be delayed or can be triggered by cold even when not feeding.

You may be able to improve your symptoms by avoiding breastfeeding in cold places, covering your nipple as soon as a feed is finished and applying warmth after feeds. If this is not effective, consider asking GP to prescribe nifedipine 10mg three times a day or nifedipine LA 30mg daily. Treatment for two weeks may be sufficient or may be needed long term. You can find more detail in our Raynaud’s phenomenon factsheet.

A white spot, bleb or blocked nipple pore.

If pain is worst at the end of or after a feed and you can point to a discrete spot (which may be white, yellow or pale pink) on your nipple as the origin of the pain, this is likely to be due to a white spot, also called a bleb, blocked nipple pore or milk blister. Symptoms may return periodically.

A white spot is thought to be caused by a thin bit of skin growing over a milk duct opening, and milk backing up behind it.

You can continue to feed with a white spot, and feeding may cause it to clear spontaneously. If it does not clear, the skin overgrowth can sometimes be removed by soaking the nipple in warm water and rubbing gently with a clean, moist washcloth. You can also try softening the skin with an oil such as olive oil. If this doesn’t work, the skin may require removal by a healthcare professional using a sterile needle. Antibiotic cream may be required if a significant wound results. If you squeeze just behind the blister some toothpaste-like thickened milk may come out through the now opened blister.

Expressing milk

If your nipple is sore or damaged and you are using a breast pump rather than feeding directly, you may need to reduce the strength of the suction on your pump or you may be using a flange that is the wrong size.  Speak to your health visitor, midwife or peer supporter to get support with expressing your milk if needed.

Strong let-down

If the pain is strongest at start of feed or just before a feed and there is a sharp intense pain in your breast(s), often described as squeezing pain, this can be due to the let down or milk ejection reflex. Pain can be worse on fuller breast.

If it is associated with leaking milk, you can reduce this by applying firm hand pressure to your breast at the time of leaking.

If your baby also makes a clicking noise during feeds or pulls away choking once the feed has started, the fast flow of milk may mean your baby is struggling to attach well. Further support from a skilled breastfeeding practitioner to improve attachment may be useful.

You may find it helpful to express a small amount of milk just before a feed if your breasts are full, to get past the powerful let-down before starting the feed, or to use a laid-back breastfeeding position, so that the milk flow is less overwhelming for your baby.

Engorgement

If your breasts are painfully hard and full, and feeding or expressing milk relieves this sensation, your breasts may be engorged. This may be worst first thing in the morning, especially if you have not fed frequently through the night. You can avoid engorgement by feeding frequently and responsively, including at night time. Consider offering your baby a feed whenever your breasts start to feel full or uncomfortable. If you are unable to feed at that time, or if your baby refuses a feed, you can express just enough milk to relieve the discomfort. Avoid expressing more milk than necessary, as this could trigger an increase in your milk supply and make the engorgement worse. Allowing your breasts to remain engorged could lead to your breasts becoming inflamed (mastitis), or a reduction in your milk supply, so it is best to avoid this whenever possible.

If you find it hard to latch your baby on when your breasts become very full, you may like to try reverse pressure softening. Reverse pressure softening is a way to soften your areola. It can help make latching and removing milk easier when your areola is very swollen and engorged by temporarily relieving firmness and swelling.

It can be particularly helpful if you have some oedema or swelling due to IV fluids or drugs given during labour and birth, especially if you had a caesarean section. Breast engorgement in the early days can be caused by your milk coming in or by a combination of fluid held in the breast tissue around the milk ducts as well as by milk within the breast.

Reverse pressure softening briefly moves mild or firmer swelling away from under your areola, slightly backward into your breast for a short period of 5-10 minutes.   This allows your areola to change shape and makes latching easier as your baby is able to get more of your areola and breast tissue into their mouth.

Reverse pressure softening also causes a ‘let-down’ reflex, making it easier for your baby to get milk or for you to remove milk by hand expressing or expressing with a breast pump.

Reverse pressure softening should not be used if you have mastitis, plugged ducts or a breast abscess.

Blocked ducts and Mastitis

If there is a sore, lumpy area on your breast that may also feel hot and can appear red on lighter skin tones, you may have a blocked duct or mastitis. Mastitis is an inflammation of the breast. It may be accompanied by flu-like symptoms. Continue to feed responsively and seek support from a specialist breastfeeding practitioner as soon as possible.  Blocked ducts or mastitis may be triggered by feeding infrequently, allowing your breasts to become overfull or other situations that increase pressure on your breast, for example, wearing a bra that is too tight or wearing your baby in a sling for longer than usual. Adjusting the way you hold your baby and bring them to your breast when feeding (positioning and attachment) may also help.

You can take ibuprofen 400mg as anti-inflammatory if appropriate (i.e. if you have no contra-indications such as asthma or stomach ulcer), and also paracetamol for pain or fever.  Antibiotics are not usually required if self-help measures are started quickly, but you should see a doctor if your symptoms persist. You can read our factsheets on pain relief medicines and breastfeeding and mastitis for more detailed information.

Abscess

An abscess is a rare complication of mastitis. You might want to consider whether you have an abscess if mastitis has not resolved following frequent, effective feeding and a course of antibiotics and if the skin on your breast looks like orange peel.  A milk sample should be taken to ascertain the micro-organism involved in the infection to help decide which antibiotic might be most appropriate. An ultra sound investigation may be required to diagnose an abscess. Drainage of pus by needle aspiration or surgical drainage together with appropriate antibiotic might be offered. Abscess formation is a rare complication of infectious mastitis and may involve MRSA. You may benefit from emotional support from a breastfeeding supporter alongside specialist support from medical staff.

Thrush

Signs of thrush in you

Thrush (Candida albicans) infection can affect your breast while you are breastfeeding.  Symptoms of thrush are a sudden start of breast and/or nipple pain in BOTH breasts after some weeks of pain free breastfeeding – pain is severe and can last for an hour after EVERY breastfeed.  It should be confirmed by a swab of your nipples.

Thrush in the first few weeks of feeding is rare unless the mother had vaginal thrush at delivery or had deep breast thrush at the end of a previous lactation.  Less than perfect positioning and attachment with consequent damage are more likely to cause the pain at this stage.

Signs of thrush in your baby

• Creamy white patches in your baby’s mouth, on the tongue and may be far back or in the cheeks. Patches do not rub off.
• Baby’s tongue/lips may have a white gloss

It should be confirmed by a swab of the baby’s mouth.

If you think you have thrush:

Before treating either you or your baby you should ask the person supporting you with breastfeeding to watch a full breastfeed from the moment the baby goes to the breast to the moment he/she comes away from the breast at the end of the feed.  They need to look at your nipples at the end of the feed to look for change in colour and shape

If your baby has a white tongue but you are not experiencing pain, be aware of the risk of thrush but do not treat either of you immediately.  Some babies have white tongues in the first few weeks after birth or this may be associated with tongue tie where the milk is not thrown to the back of the mouth.

Diagnosis should be confirmed by nipple swabs cultured for fungal and bacterial infection.

Breastfeeding should be pain free from the point of attachment (the moment the baby goes to the breast) onwards.  Pain from thrush begins after a feed.  There should be no change in the shape or colour of the nipple after a feed.  Even good attachment can often be improved and help to relieve symptoms of pain. Be aware of the other causes of nipple and breast pain described on this page, and exclude them first.

Self-help measures

• Thrush can be passed between you and your baby – and also between you, your partner and other children
• Anecdotally, some mothers find acidophilus capsules can help to restore bacteria which can keep thrush under control (available from health food stores or chemists)
• It is necessary to be very careful with hygiene in order to get rid of thrush completely – be sure to wash your hands well after each nappy change
• Use a separate towel for each person in the family
• Anecdotally, some mothers find reducing the level of sugar and yeast in their diet helps

If a thrush infection is confirmed, to make sure that you get rid of it, both you and your baby need treatment, prescribed by a doctor.  Usually, once treatment begins the pain and other symptoms will begin to improve within 2 or 3 days. It may take longer for full recovery.

If there is no improvement at all after 7 days, consult your breastfeeding helper again as the cause of the pain may not be thrush.

Treatment

Ongoing attention to positioning and attachment is important because even the best latch can slip a little sometimes.

• Miconazole cream applied to your nipples after every feed – sparingly and without washing off before the next feed
• Miconazole oral gel applied gently to your baby’s mouth 4 times a day a small amount at a time

If symptoms persist you may need fluconazole 150-400mg as a loading dose followed by 100-200mg daily for at least ten days.  This is rarely necessary if your baby is less than 6 weeks old and could cause vomiting and stomach pains.

For more information, see our detailed factsheet on thrush and our factsheet on miconazole oral gel and the breastfed baby with oral thrush.