Nipple pain in lactation: management summary
Primary interventions when a breastfeeding woman has nipple pain
Key management principle #1
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Aim to eliminate mechanical microtrauma in breastfeeding, here.
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Aim to eliminate mechanical microtrauma in mechanical milk removal (pumping), here.
Key management principle #2
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Educate the lactating woman about the risks of overhydration and moisture-associated skin damage, here. This is so that she can make informed decisions as she finds her way through, deciding when she needs to wear a bra and when she can expose her nipples to the air.
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Explain the benefits of exposing the nipples to the air as much as is possible or practical. Importantly, explain to the woman why exposing her nipples during the air while she sleeps at night is beneficial. This is likely to require sleeping on a soft towel, placed over the sheet, and tolerating milk leakage in the night.
Secondary interventions when a breastfeeding woman has nipple pain
Management principle #3. Prevent further damage from clothing
Encourage very gentle nipple care, educating the woman about protecting her nipples from mechanical friction or rubbing from garments between feeds, and also from compressive or deformational forces inside the bra, depending on the shape of her nipple. Breast pads need to be as soft and non-irritating as possible.
Management principle #4. Nipple shields
Consider nipple shield use, here.
Management principle #5. Partial or complete nipple rest
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Make sure the little one is not drowsing at the breast and suckling with minimal milk transfer for long periods - take baby off when not actively transferring milk.
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Direct breastfeed less often. This is likely to require complementary use of the bottle (with either expressed breast milk, donor milk, or formula).
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Check use of pump for mechanical trauma. The pump is likely to perpetuate the microtrauma and inflammation. It is likely to be less kind to nipples than the baby directly breastfeeding, once we've addressed the nipple and breast tissue drag.
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The pain may be so severe and constant, even in the absence of nipple wounds, that complete nipple rest is required for healing. You can find out about nipple rest here.
Management principle #6. Breast milk application
There is no reason to specifically advise that a woman with nipple pain smear breastmilk over her nipple, because a nipple that is exposed to either direct breastfeeding or pumping is inevitably washed in breastmilk many times each day (and night).
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There is also no reason to advise against hand expressing and applying some breast milk if she wants to, because breastmilk is an immune-rich living tissue which contains anti-inflammatories and myriad immune factors which promote wound-healing.
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Our intention is to make life as easy as possible for women, and to introduce clinical recommendations only when they are likely to be helpful. Each new recommendation that we give her as health professionals (like 'having' to apply breast milk to her nipples regularly) adds to her mental and occupational burden.
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If the breastfeeding woman is taking a complete nipple rest, and her nipples are no longer being washed regularly throughout the day and night with breast milk, then she may consider regular application of breast milk to her nipples.
Management principle #7. Photobiomodulation therapy
Consider light therapy if the nipple pain persists once comprehensive interventions have been applied, starting here.
Recommended resources
Nipple wounds in lactation: management, including exudate, scabs, and nipple rest
Nipple shields and breastfeeding support in the clinic
Interventions which don't help lactation-related nipple pain and wounds
Case study: Manon has nipple damage from the first week of her baby's life