Felicity, who is breastfeeding nine-week-old Finn, has an exquisitely painful white spot on her nipple

Felicity endures very painful breastfeeding

The mother of a secondborn baby, who is nine weeks old, comes to see me having endured excruciating nipple pain whilst direct breastfeeding from her left breast for the past six weeks, due to a white spot. Since then, Felicity has consistently experienced deep stabbing or throbbing pain into the left breast between feeds.

Amazingly, baby Finn is thriving, contented, and gaining weight beautifully without supplementation. Despite the pain, Felicity feeds Finn from her left breast up to ten times over a 24-hour period (and similarly from the right).

With her first baby, Felicity remembers that she also had a white spot on the same nipple once, which seemed quite different. That white spot had only happened once, and was associated with a painful wedge-shaped lump extending from her nipple up into the breast. Felicity tells me how that time, she'd lifted the roof of the white spot off with her fingernail in the shower, which resulted in a spurt of milk and immediate easing of the painful lump in her breast.

Felicity has tried everything

Here are things Felicity had experimented with over the previous six weeks. None of these things helped.

With the support of her general practitioner and an International Board Certified Lactation Consultant, she tried

1. Unnroofing the white spots

   • Once by her doctor with bevelled needle, without benefit

   • Daily gentle exfoliation of the white spots in the shower, using a facecloth or her fingernail

2. Keeping the white spot as soft as possible by applying olive oil to her breast and nipple between feeds

3. Many different approaches to fit and hold, including football hold, cradle hold, and koala or straddle hold

4. Oral lecithin (ongoing) made from sunflowers

5. An antibiotic

6. Anti-inflammatories

7. Probiotics

8. Cold and warm compresses on her nipple and breast

9. A haaka (to draw out what she'd read was a dysbiosis of her milk causing the spot)

10. A course of steroid cream.

What is actually going on?

I explain to Felicity that her white spot is a hyperkeratosis of the nipple.

I also explain that what she'd experienced when breastfeeding her first child sounds like a milk blister, which was different again. With a milk blister, skin heals up a way that covers a duct opening on the nipple, causing a backup of milk in the area of the breast that drains into that duct.

This time, though, when I examine her, I can see that Felicity has a hyperkeratotic spot.

What are the physiological or mechanical explanations?

Felicity shows me how she's been most commonly feeding, using a 'biological nurturing' (or koala or straddle hold) method of positioning the baby at her breast.

As I watch, I can see a great deal of nipple and breast tissue drag, which is causing repetitive microtrauma to the left nipple skin or epithelium. The high levels of focussed stretching forces on the nipple skin (which results from the nipple and breast tissue drag) have in her case caused this spot of hyperkeratosis on the face of her nipple, also associated with a wedging shape of the nipple when the baby comes off. The continual microtrauma and inflammation of the epidermis in her case as caused a thickening on the nipple, like a callous, which in the Possums approach we call a hyperkeratotic white spot.

I explain to Felicity how the white spot is her body's way of attempting to protect the skin from the high and focussed stretching forces. But once a callous has formed, any pressure on it can result in tenderness or pain, the more so because it's happening on a very sensitive part of the body like the nipple face.

Felicity may also have inflammation of the deep nipple tissue from bending or deformational forces during breastfeeding. Most likely because of both of these effects, on the epidermis and also in the nipple stroma, she is experiencing acute pain with direct breastfeeding, and ongoing radiating inflammatory pain between breastfeeds.

Felicity might have been predisposed to the milk blister when she breastfed her first baby because of nipple and breast tissue drag, too. It's likely that there was an area of epidermal inflammation and epidermal disruption around a milk duct orifice. As it healed, the epithelium which runs a couple of millimetres into the milk duct from the entrance may have fused into an epidermal roof, causing a back up of milk into the branching duct system behind that specific orifice.

A blister on the nipple with a backup of milk in the breast is a serious situation which ideally requires a doctor to lift the roof with a needle, just as quickly as possible. But I acknowledge that lots of women in this situation soak the nipple epidermis with water in a warm shower then remove the roof of the milk blister themselves with their fingernail. The risk if you do this yourself is that it's not actually a milk blister, and you're accidentally worsening a hyperkeratosis! But a hyperkeratotic white spot, which is by far the more common, never has a true, painful build up of milk in the ducts behind it.

What I suggest Felicity tries

We use the gestalt method and Felicity feels immediate improvement in her pain levels during breastfeeding, from a six or seven usually, down to a two.

We then also try a nipple shield, which I am careful to fit with plenty of room (explaining to her why I did that). Felicity tells me as the baby suckles after the nipple shield is on that her nipple pain is now down to a one. Although we kept trying with micromovements, we also know that we may not able to entirely eliminate pain today, even with the nipple shield, because of the pre-existing epithelial damage.

I advise Felicity to allow her nipples to be exposed to the air as much as possible, at the same time as she continues a very active life outside the home. This is because overhydrated skin is much more vulnerable to mechanical injury during breastfeeding (or pumping). In particular, I recommend

• Never trying to remove the white spot or 'exfoliate' it

• Not using the olive oil

• Sleeping without a bra at nights, using a towel to catch milk leakage

• Not allowing her damaged nipple to rub inside the breast pad, which may mean using protection such as a hydrogel disc, lanolin, or silverette when she does need to wear a bra.

I explain that lecithin, probiotics, and antibiotics won't help. We discuss trialling another course of steroid cream but Felicity feels that the results with the gestalt method and nipple shield combination are so positive in the consultation (and there was no benefit from steroid when she tried it previously) that she wouldn't use a steroid application again for now.

I explain to this courageous breastfeeding woman that

• Hyperkeratosis is how the skin of her nipple attempts to protect her from high stretching forces. The epithelium thickens in response to repeated microtrauma.

• Attempts to lift the roof of an area of hyperkeratosis and to exfoliate it unfortunately actually worsen the hyperkeratosis, because any abrasion or needle intervention worsens epithelial damage and worsens the thickening response by the epithelium.

• A complete rest of the left breast would facilitate the quickest healing, with some hand expression to manage milk build up and prevent mastitis. Then she could start again on the left, this time with the gestalt method.

Felicity decides to

1. Experiment with the gestalt method

2. Use the nipple shield on the left, still offering regularly

3. Keep her nipples as dry as possible, ensuring protection and safety of the right nipple as necessary.

I recommend review in a week, after a period of experimenting with the gestalt method, so that we can continue to work together as she experiments with this new approach.

When Felicity and her baby come back the following week not much has changed

Unfortunately, not much has changed a week later, when we meet again. The nipple shield hasn't worked because the baby kept knocking it off or it kept slipping off, and for Felicity the shield just seemed to make everything harder rather than easier. I completely understand this, though I do mention that there are tricks for dealing with these challenges with the shield, which are common at first.

I suggest that one option is to keep on trying the shield every now and then, because in my view it still offers the possibility of protecting the white spots from the mechanical pressures. But I can also see how important it is not to put any pressure on Felicity, who really is at the end of what has been a very long and distressing road of pain.

Felicity had been experimenting bravely with the gestalt method on the right (but found it easiest to continue with her usual straddle hold on the left, which had always worked well for her and the baby on that side). Despite trying, she hadn't been able to achieve the same decrease in pain that she'd experienced in our initial consultation together. Again, this is quite commonly the case, and I find it can take a couple of sessions working together on fit and hold to turn the corner when a woman has nipple pain. I can see when she breastfeeds this time that the baby is still feeding too far off to the side, relative to the location of her left nipple. We work together on the gestalt method again.

Felicity is discouraged, though, by the lack of quick progress, and demoralised by constaint pain.

We discuss in greater detail the options that are available to her. I explain how healing up a hyperkeratosis of the nipple can take weeks, how it is like waiting for a callous to be absorbed by the body once the repetitive mechanical pressures which cause it have ceased or eased. But Felicity is seriously exhausted by the ongoing pain, and considering either weaning, or at least resting the right breast and introducing some commercial milk formula to compensate. We discuss various options in depth, knowing that there is no right or wrong path forward concerning the use of commercial milk formula. There is only the consideration of what Felicity can now manage. All the while, I communicate my view that she's been extraordinarily courageous in the face of severe difficulty, and that it's important to celebrate the way she's given her baby amazing gut and immune protection so far, despite everything.

When we say goodbye, we decide not to make a followup appointment, as Felicity feels she now has the tools she needs, and is ready to find her own path forward now, day by day. Two months later, I run into her in the waiting room. She tells me, with some pride, that she completely rested the left breast just hand expressing for two weeks, used some formula while she was doing that, and then gradually returned to breastfeeding on the left. After a while, she was back to exclusively breastfeeding baby Finn, and remained completely painfree. How happy I was to hear how it had all ended up for Felicity! But how completely I would have understood it if she had decided to wean Finn altogether, because of the pain.

This story is blended from multiple presentations of nipple white spots over the years, and no individual patient is able to be identified from this story.

Recommended resources

Diagnosing persistent lactation-related nipple pain as neuropathic pain nociplastic pain or central sensitisation is inaccurate and risks inappropriate treatments and their side effects

Nipple white spot during breastfeeding #1: hyperkeratosis

Nipple white spot during breastfeeding #2: epidermal inclusion cyst

Nipple white spot during breastfeeding #3: milk blister

Selected references

Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health. 2022;18:17455057221087865.

Douglas PS. Does the Academy of Breastfeeding Medicine Clinical Protocol #36 'The Mastitis Spectrum' promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary. International Breastfeeding Journal. 2023;18:Article no. 51 https://doi.org/10.1186/s13006-13023-00588-13008.

Hu Y, Hell L, Kendibacher RA. Human milk triggers coagulation via tissue factor–exposing extracellular vesicles. Blood Advances. 2020;4(24):6274-6282.