Topics in

PAIN MANAGEMENT
Vol. 32, No. 3 Current Concepts and Treatment Strategies October 2016

CONTINUING EDUCATION ACTIVITY

Clinical Assessment and Management of Breastfeeding Pain
Ruth Lucas, PhD, RN, CLS, and Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Learning Objectives/Outcomes: After participating in this CME/CNE activity, the provider should be better able to:
1. Describe factors that contribute to breast pain and nipple soreness in breastfeeding mothers.
2. Summarize evidence-based strategies and intervention for decreasing pain during breastfeeding.
3. Draw conclusions for guiding individualized breast pain management that is supportive of the unique needs of the mother.
Key Words: Nipple pain, Breast pain, Pain, Nipple soreness, Breastfeeding

M ore than 90% of new mothers experience pain during

breastfeeding in the first week after delivery. 1 A
major reason often cited for breastfeeding cessation in the
first 2 weeks after birth is maternal breast and nipple pain.2
Since 1990, the World Health Organization3 has recom-
mended breastfeeding as optimal nutrition for infants for
the first 6 months of life. In turn, breastfeeding initiation
has increased across the world and has recently reached
80% of all infants in the United States.4 Yet, by the time the
infant is 2 weeks old, 20% of breastfeeding mothers will
In This Issue
Clinical Assessment and Management of
Breastfeeding Pain . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CE Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
have discontinued breastfeeding.5 In addition, within the
first 2 weeks after delivery, more than 30% of breastfeeding
mothers seek professional lactation support due to pain. Of
these mothers, 45% continue to have chronic pain, even
with intervention.6
Many women lack the understanding that breast and nipple
pain is “normal” during breastfeeding initiation. In addition,
interventions to manage breast pain are sometimes not an
Dr. Lucas is Assistant Professor, University of Connecticut School of
Nursing, 231 Glenbrook Dr, Unit 4026, Storrs, CT 06269, E-mail: ruth.
lucas@uconn.edu, and Nurse Research Scholar, Connecticut Children’s
Medical Center, Hartford, Connecticut; and Dr. McGrath is Associate
Dean, Research and Scholarship, University of Connecticut School of
Nursing, Storrs, Connecticut, and Director of Nursing Research,
Connecticut Children’s Medical Center, Hartford, Connecticut.
The authors and all staff in a position to control the content of this
CME activity have disclosed that they and their spouses/life partners (if
any) have no financial relationships with, or financial interests in, any
commercial companies pertaining to this educational activity.

CME Accreditation
Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™.
Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME
article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME
activity expires on September 30, 2017.
CNE Accreditation
Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s
Commission on Accreditation. LWW, publisher of Topics in Pain Management, will award 2.0 contact hours for this continuing nursing education activity.
This activity has been assigned 1.0 pharmacology credits. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This
CNE activity expires on October 31, 2018.

1
Topics in Pain Management October 2016

CO-EDITORS emphasis in prenatal education, to avoid discouraging moth-

ers from breastfeeding.7 However, this gap in mothers’
Elizabeth A.M. Frost, MD knowledge endangers continued breastfeeding.2,5 In addition,
Professor of Anesthesiology mothers who are at risk for severe pain during breastfeeding,
Icahn School of Medicine at Mount Sinai such as women with preexisting chronic pain conditions, may
New York, NY need additional consultation and support for breastfeeding
Angela Starkweather, PhD, ACNP-BC, CNRN, FAAN pain management.
Professor of Nursing Acknowledging the nipple/breast pain and working closely
University of Connecticut School of Nursing with the mother to consider strategies that relieve her pain
Storrs, CT are important (Table 1). Nonjudgmental support of mothers
during this time can identify ways to decrease pain while
ASSOCIATE EDITOR
helping them to continue breastfeeding. Wagner et al5 found
Anne Haddad that if mothers’ concerns were not addressed on day 3, moth-
Baltimore, MD ers had a 9 times greater chance of ceasing breastfeeding.
For most mothers, pain peaks by day 3 and subsides by day
EDITORIAL BOARD 7; however, some women continue to have breast pain for up
Jennifer Bolen, JD to 6 weeks.5,6 During the first year, it has been documented
The Legal Side of Pain, Knoxville, TN that the mother-infant dyad makes an average of 36 visits to
Michael DeRosayro, MD health care providers.7 These visits, especially during the
University of Michigan, Ann Arbor, MI first weeks after delivery, are an ideal opportunity to support
James Dexter, MD the mother’s breastfeeding success while assessing and man-
University of Missouri, Columbia, MO aging breastfeeding pain.6,8,9
Claudio A. Feler, MD Mothers experience breastfeeding pain at different points in
University of Tennessee, Memphis, TN time and from different factors. Initial pain is related to
Alvin E. Lake III, PhD increased use (8–12 breastfeeding sessions daily). Nipple and
Michigan Head Pain and Neurological Institute, Ann Arbor, MI breast pain are triggered by infants’ poor latch, bacteria and
Daniel Laskin, DDS, MS yeast infections, sensitivity because of Reynaud syndrome,
Medical College of Virginia, Richmond, VA allergies causing dermatitis, or from a mother’s personal
Vildan Mullin, MD
University of Michigan, Ann Arbor, MI The continuing education activity in Topics in Pain Management is intended for clinical
Alan Rapoport, MD and academic physicians from the specialties of anesthesiology, neurology, psychiatry,
physical and rehabilitative medicine, and neurosurgery as well as residents in those fields
New England Center for Headache, Stamford, CT and other practitioners interested in pain management.
Topics in Pain Management (ISSN
Gary Ruoff, MD 0882-5646) is published monthly by
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Topics in Pain Management
Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating
Breast Pain
Intervention Strategy* Pros/Why Recommend
Prevention of pain
Prenatal education9,17,50 Provided at a time when
mothers may be less
stressed and more ready
to learn
Postpartum education6,9,19,50 To be effective needs to
occur soon after birth
before breast trauma
occurs
Hand hygiene including Improves skin integrity and
good drying of hands and decreases risk of
breast after cleaning9,28 infection
(ie, pacifiers, breasts, and
clothing)
Assessment of pain
Targeted assessment of Assessments need to be
breast with a history of routine and
onset and location of nonjudgmental
breast pain7-9,22
Targeted assessment of Infant latch and position
latch and position during can increase skin
breastfeeding6,13,14 breakdown and breast
trauma
Early pain interventions
Expressed breast milk2,26,29 Easily available; has
antiviral and antibacterial
properties
Lanolin17,21,23,24 Easily available and fairly
inexpensive
Semiocclusive ointment,
promotes epithelial
regrowth, and reduces
pain
©2016 Wolters Kluwer Health, Inc. All rights reserved.
October 2016
Cons/Why Not to
Recommend Other Information
For best outcomes sessions Mothers are unable to
need to individualized implement knowledge
and target to unique until the infant breast-
needs of individual feeds and every infant
mothers breastfeeds differently
May be difficult to deliver Regardless of whether the
with enough emphasis mother had prenatal or
because mother has many postnatal education
other needs at this time continued follow-up is
needed; referral to a
lactation consultant
should be routine
Avoid routine use of soaps Also includes anything that
on areolae to prevent skin touches the breast or
drying infant mouth
Mothers may not always Early on, breasts may
share important appear normal and thus
information; need to ask maternal perceptions are
direct questions. May important
take more time to get Look for redness even with
good information no current report of pain
Needs to be assessed The infant needs to be
during a routine positioned facing the
breastfeeding so that best breast. Entire areola
assessment is achieved needs to be inside the
infant mouth for good
latch. Watch for evidence
of sucking over gumming
Newer studies have not Level 2 Grade B Oxford
found it to be superior to Centre for Evidence-
warm water compresses Based Medicine and
recommended by
UNICEF
Contraindicated for Level 2 Grade B Oxford
mothers allergic to wool Centre for Evidence-
Based Medicine Newest
research recommends
lanolin over breast milk
and hydrogel dressing
(Continues )
3
Topics in Pain Management
Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating
Breast Pain (Continued )
Intervention Strategy*
Warm water compresses9,28
Treatment for acute nipple pain and trauma
Breast shield15,30
Calcium channel-blockers
(nifedipine)5,14
Chlorhexidine spray25
Hydrogel dressing9,25
LED phototherapy lights32
Menthol (peppermint) gel
or oil21,29
4 ©2016 Wolters Kluwer Health, Inc. All rights reserved.
Pros/Why Recommend
Evidence demonstrates
pain relief and has been
found to be more
effective than other
strategies
Provides space between
breast and clothing for
breast to heal. One study
found when used with
lanolin decreased
maternal pain
Vasodilator, decrease
nipple and breast
vasospasms
Topical antimicrobial spray.
One small study found a
decrease in pain and
increase in healing. Safe
for infant consumption
Effective for early nipple
pain. Moist saline
dressing, cool and
soothing, promotes
epithelial regrowth and
reduces pain
Phototherapy enhances
cellular regeneration,
local vascularization, and
nerve conduction.
Decreased pain after first
treatment
Antimicrobial properties
specifically against
gram-positive bacteria.
One study found
peppermint gel more
effective than peppermint
water or oil for nipple
fissures
Cons/Why Not to
Recommend
During engorgement
compresses should be
used to soften breasts to a
level of comfort. Too
much heat will prolong
engorgement
Not comfortable for some
mothers
Systematic cardiac
side effects of
lightheadedness,
dizziness, low blood
pressure, headaches
Mothers found the spray
uncomfortable to remove
in preparation for next
feeding. Antiseptic spray
is contraindicated with
open wounds
Contraindicated in mothers
with nipple trauma
because of their increased
susceptibility to develop
infections
No commercial prototype
available
No standardized
preparation for
breastfeeding mothers
October 2016
Other Information
Can be provided 4–6 times
daily after breastfeeding
sessions; can be used to
soften plugged milk
sinuses to prevent milk
stagnation
Ineffective in antenatal and
postnatal treatment for
flat nipples
Often Reynaud syndrome
not identified until
conservative treatment
for mastitis has failed
Not recommended by
UNICEF or the American
College of Obstetricians
and Gynecologists
Should be discarded after
24 h
LED lights prototype
adapted for the breast
Traditional therapy for
nipple pain in Iran;
approved by the FDA as
food
(Continues )
Topics in Pain Management
Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating
Breast Pain (Continued )
Intervention Strategy* Pros/Why Recommend
Nipple shields6,15,30 Silicone-vented dome
provides a layer of
protection from direct
infants’ sucking. Dome
provides sensory
stimulation for infants
suck, which elongates
nipple
Polyethylene film Occlusive dressings,
dressing9,25 promotes epithelial
regrowth
Silver cap31 Silver ancient treatment
with antimicrobial
properties. Trilaminate
silver cup creates a moist
environment for
epithelial regrowth and
reduces pain
Tea bag compresses28 Some evidence that pain is
reduced similarly to warn
water compresses. Easily
available and inexpensive
Severe breast pain
Antidepressants7,14 May be important for
breastfeeding support
and increasing sense of
maternal competence
Massage48 Effective for deep breast
pain releasing pectoralis,
inferior aspect, and
serratus anterior muscle
Propranolol46 Effective for treatment of
chronic jaw pain for
women without COMT
polymorphisms
Treatment of infection
Acupuncture39 Provides systematic anti-
inflammatory effect.
Decreased pain from
mastitis 3 d after
treatment compared with
the control group using
oxytocin nasal spray
©2016 Wolters Kluwer Health, Inc. All rights reserved.
Cons/Why Not to
Recommend
Evidence is weak
Removing the dressing is
painful for many mothers
and may increase nipple
trauma
Contraindicated for
mothers with metal
allergies
Astringent properties, dries
nipple tissue
Will require increasing
support and management
No published clinical trial
in breastfeeding mothers
Some mothers refuse
because of fear of
needles
October 2016
Other Information
Requires management by
trained lactation
professionals to maintain
maternal milk volume
Most effective with
infrequent dressing
changes
Has not be tested against
other therapies
Cultural therapy,
recommend warm
compresses as an
alternative
Muscular spasm after
breastfeeding may occur
without nipple pain
Recommended by the
American Breastfeeding
Medicine Practice Group
Target pressure points were
heart 3 (circulation),
gallbladder 21 (relaxation
effect), and spleen 6
(gynecologic effect)
(Continues )
5
Topics in Pain Management October 2016

Table 1. Evidence-Based Nonpharmacologic and Pharmacologic Strategies for Preventing or Treating

Breast Pain (Continued )
Intervention Strategy*
Antibiotics36-38
Nonsteroidal ointment6,14,43
Oral fluconazole
therapy40,41
Probiotics42
*Listed in order of preference.
Pros/Why Recommend
Resolves deep and severe
pain by decreasing
inflammation, S. aureus
most common organism
Effective for dermatitis of
nipple and breast
Resolves deep and severe
pain by decreasing
inflammation
Made from human
breast milk
Balances the natural
biofilm, effective against
subclinical S. aureus
mastitis
Cons/Why Not to
Recommend
If providing antibiotic
treatment be sure to be
proactive in preventing
overgrowth with yeast
May need treatment for
candidiasis as biofilms
may consist of mixed
fungal and bacterial
colonies
Must be removed before
feedings to decrease
infant exposures
Difficult to culture.
Predisposes women to
mastitis
Patented for commercial
use in Spain and
Australia
Other Information
Cultures should be
obtained after 1 wk of
persistent pain to rule out
mastitis
May begin as skin
inflammation and invade
breast sinus causes
bacterial colonization
Treatment with 200 mg
∼9 log10 CFU each of
Lactobacillus salivarius
CECT5713 and
Lactobacillus gasseri
CECT5714 capsules
compared with antibiotics
significantly decreased
pain and bacterial count
by day 21

decreased pain thresholds. To best support mothers, clinicians
need a general understanding of what causes breast pain and
what interventions will help alleviate maternal pain. Generally
speaking, breast pain is related to 4 factors: (1) transition to
breastfeeding (initiation pain); (2) mechanics of breastfeeding
(latch and positioning); (3) organisms that decrease skin integ-
rity (thrush and infections); and (4) tissue sensitivity, such as
preexisting dermatologic conditions or Reynaud syndrome.
Pain During Breastfeeding Initiation
Nipple soreness is for the most part normal during breastfeed-
ing initiation. During assessment, the breast and nipple may
appear normal or slightly pink. However, many mothers are
unprepared for the pain and at a loss about how to manage their
pain between feedings.9 The first step in helping mothers to
manage pain and soreness is to acknowledge and anticipate the
problem and ask mothers for details in a non-judgmental style:
• Where exactly is the pain?
• When does it begin?
• How long does it last?
• Is the pain sharp or dull?
• Are there areas of the breast that hurt more than others?
• Does anything the baby does make the pain worse?
• Does the pain begin or get worse just before breastfeeding,
during breastfeeding, or just after breastfeeding the infant?
• What interventions has the mother already tried?
Breastfeeding pain is an interaction between the mother’s
ability to modulate her central nervous system signaling of
nipple pain while managing her environmental and local stim-
ulation.8 More specifically, Amir et al8 propose the Breast-
feeding Pain Reasoning Model to understand the various
factors that influence variation in breastfeeding pain. In this
model, central nervous system modulation is an interaction
between prolonged afferent nerve stimulation from the nipple,
maternal medical history, including parity or pain tolerance,
and cognitive, emotional, and social state that supports her
ability to manage the pain. Mothers need to be assured that
experiencing pain is “normal” initially and not a reflection of

6 ©2016 Wolters Kluwer Health, Inc. All rights reserved.

Topics in Pain Management
maternal competence. This is especially important because
self-rated maternal competence and the presence of maternal
postpartum depression can be closely tied to breastfeeding suc-
cess.10 Providing support and encouragement during this diffi-
cult time are important to long-term breastfeeding outcomes.11
These questions also assess external stimuli that predispose
mothers to pain, such as a flat nipple, an infant’s shallow latch,
which traumatizes the nipple, or the use of a breast pump.8,12
Mothers with flat or inverted nipples (10% of all mothers)
require interventions to elongate the nipple, including the best
practice of pumping before breastfeeding and using a nipple
shield during feeding and rubber bands.13-16 Many mothers also
use a breast pump to establish maternal milk supply. If mothers
are provided with too small a flange for the breast size, the are-
ola and nipple will rub against the flange throughout the pump-
ing session.13,14 Constant rubbing may irritate or in extreme
cases cause a friction burn.13,14 The nipple shield, a soft sili-
cone-vented dome placed over the nipple, provides a solid sur-
face for infants to latch, and protects the nipple as the nipple
elongates from infants’ suction and from infants who create
and sustain over 200 mm Hg of negative intraoral pressure dur-
ing feeding.12-15 Lastly, rubber bands have been used to pro-
trude the flat nipple; however, none of the findings addressed
maternal pain from the intervention.16 Even with these strate-
gies, the mother may experience pain as the nipple tissue is
stretched or adhesions broken with the infant’s sucking.
The evidence is clear that antenatal breastfeeding education
prepares mothers to solve issues with infants’ position, latch,
and sucking effort.6,9 Although postpartum education is timely, it
is important to note that nipple pain and trauma may occur with
only 1 poor breastfeeding session.6,9,17 Correct positioning of the
infant is critical, because if the infant’s mouth is misaligned with
the nipple, the infant will gum the nipple instead of sucking. In
addition, if infants’ lips are not flanged out, the tongue can
retract, and the infant may gum or strip the nipple against the
hard palate instead of the soft palate, both causing nipple dam-
age. Finally, if infants have a short frenulum or tongue-tie, they
may not be able to stretch the tongue to the soft palate, thus
stripping the nipple against the hard palate causing nipple pain
and damage.18 All of these factors contribute to the nipples
appearing reddened, cracked, fissured, scabbed, and bleeding.
Mothers should be reminded to make sure the breast is kept
dry and clean between breastfeeding sessions to prevent
infection. During infants’ initial latch, most mothers with nip-
ple trauma experience severe “toe-curling” pain that subsides
or dissipates during feeding.6,14 However, if mothers experi-
ence severe pain throughout breastfeeding, they may need to
pump and provide breast milk until their nipples heal. If
mothers notice infants have blood in their mouth or observe
blood in their pumped milk, reassure mothers that infants will
not be adversely affected by swallowing maternal blood.
Lastly, local stimulation refers to mechanical stimulation.
When nipple tissue is traumatized, such as with nipple com-
©2016 Wolters Kluwer Health, Inc. All rights reserved.
October 2016
pression, it releases inflammatory markers such as histamines,
bradykinins, and substance P.17 When these markers are liber-
ated, they cause nociceptive responses in small nonmyelinated
C fibers.15 Other conditions that predispose mothers to skin
breakdown and pain sensation include dermatitis, and vasos-
pasm from Raynaud syndrome.17 Whenever there is skin
breakdown on the breast or nipples, mothers are at much
greater risk for infections. Health care professionals should
encourage mothers to continue to breastfeeding as their nipple
heals. Mothers need to be followed up closely during this time
to prevent nipple yeast and mastitis. Each of these 3 factors
influences the level and intensity of pain experienced during
breastfeeding. See Figure 1 for other issues to consider during
provision of a supportive breastfeeding pain assessment.
Treatment for Nipple Pain and Trauma
Once a comprehensive assessment with history of onset is
completed, clinical interventions to reduce maternal pain must
become the focus of breastfeeding management. The challenge
is that most topical pain relievers are contraindicated for infant
consumption. Even if mothers remove the ointment before feed-
ing, it is unknown how much infants might receive from the
skin and the friction to the nipples will be an additional irritant
to skin integrity. Thus, management of nipple pain consists of
nonpharmacologic topical interventions and preventative educa-
tion. Pharmacologic intervention is used for inflammatory con-
ditions such as mastitis, candidiasis, or breast dermatitis.
Lanolin and Expressed Breast Milk
If the maternal nipple and breast is intact, clinical interventions
will focus on maintaining skin integrity. Evidence supports the
use of nipple massage after application of medical grade lanolin
or expressed breast milk17,19-25 after every feeding. Purified lano-
lin is a yellowish white, fat-based moisturizing ointment derived
from sheep fleece. Lanolin should be applied with 3-mm thick-
ness, which provides protection from clothing and is semiocclu-
sive, which keeps the nipple moist between feedings, promotes
epithelial regrowth, and reduces pain.17 Expressed breast milk is
also applied after each feeding and has antibacterial and antiviral
properties.22,23 Both interventions have demonstrated a reduction
in maternal pain within 14 days. Several systematic reviews have
evaluated both interventions. Vieira et al25 identified both inter-
ventions as level 2 evidence based on criteria from the Oxford
Center for Evidence-Based Medicine, but they and Lochner
et al26 found lanolin to be more effective in reducing pain. In
contrast, a Cochrane review23 reported that no method was sig-
nificantly better at reducing pain.
Nonpharmacologic Interventions
The use of warm compresses before feeding has been found
effective in decreasing maternal pain from engorgement and
after feeding, and for soothing nipple irritation.9,14 Extra virgin
olive oil (EVOO) has immunological and anti-inflammatory
7
Topics in Pain Management
Figure 1. Assessment of breastfeeding pain.
properties. In one randomized trial, 2.7% of mothers who
treated their nipples with a drop of EVOO, compared with 44%
of mothers who treated their nipples with breast milk after
breastfeeding, exhibited cracked nipples, which was significant
(p < 0.000).27 EVOO has not been compared to lanolin. Other
moist dressings are not recommended, including tea bags, due to
astringent and drying effect,28 and hydrogels, which, although
soothing, are associated with a high incidence of breast and nip-
ple infections.14
Menthol (peppermint) gel or oil is considered safe during
pregnancy and lactation by the FDA and is a household remedy
in the Middle East to treat nipple fissures.21,29 Menthol demon-
strates antimicrobial properties specifically against gram-posi-
tive bacteria, and in both small studies performed in Iran,
decreased nipple pain and healed nipple fissures in signifi-
cantly shorter time than lanolin and expressed breast milk.21,29
Breast shields, a vented plastic dome whose base has an
opening for the maternal nipple, has been used with or without
lanolin to protect the nipple from rubbing against the maternal
bra and promote air flow for healing.31 Another form of shield
is a nonvented dome composed of trilaminate silver. Silver ions
8 ©2016 Wolters Kluwer Health, Inc. All rights reserved.
October 2016
are a natural antibiotic and have emerged as an alternative to
antibiotic treatment.31 Mothers place the cap on the breast
between feedings. One pilot study found mothers experience a
significant decrease in maternal pain within 7 days of a nipple
fissure compared with no treatment.28 Lastly, one study used
light-emitting diode (LED) phototherapy lights and its ability
to promote local vascularization and decrease pain twice a
week to treat nipple fissures. For mothers in the treatment
group, nipple fissures healed within 4 biweekly visits com-
pared with 8 biweekly visits for controls.29
Engorgement
Breastfeeding pain has been characterized as transient or pro-
longed.9 The transient pain occurs at 48 to 72 hours after delivery
when release of lactogenesis II results in engorgement of breast
sinuses. This is a normal physiologic response, even if the mother
reports the pain as severe.5,6,14 Engorgement typically lasts 72
hours. As the infant feeds, the neurohormonal pathway gives bio-
feedback as to the volume of milk the infant requires for growth.
Although it is normal, engorgement can be uncomfortable to very
painful for mothers. Treatment is a careful balance to support
Topics in Pain Management
infants’ ability to latch on a full breast and decrease maternal
pain. Before breastfeeding, mothers may use warm compresses
or a breast pump to soften the breast enough for the infant to latch
and stimulate milk let down. Although warmth provides comfort,
use of warm compresses or warm showers should be cautious as
removal of excess milk beyond the infants’ need will trigger the
neurohormonal pathway to provide additional milk, thus continu-
ing engorgement.14 Maternal massage of the breast to release
plugged milk sinus during feeding is imperative, as stagnate milk
is a source for bacterial infections.33 Cold compresses, such as a
bag of frozen peas or leaves of green cabbage, after feeding can
be used to reduce breast swelling and pain.6,14
For some mothers, pain from oversupply persists beyond the
first week. Milk oversupply also has nutritional implications for
the infant. Infants may become full on the foremilk composed of
low milk fat and water and obtain less of the high-fat hind milk
needed for growth and development. Interventions to decrease
milk supply include tea made from sage, a member of the mint
herbal family, careful use of pseudoephedrine, and oral contra-
ceptive pills containing estrogen.14
Pain or engorgement, past the first week, is considered
abnormal and should be evaluated by a lactation health care
professional.
Organisms That Decrease Skin Integrity
Leading to Pain
Diagnosing nipple pain related to infections requires a thor-
ough inspection of the breast, and a good discussion with the
mother about the history of onset. Depending on the causative
agent, topical or oral antibiotics (Staphylococcus aureus) may
be considered. If the causative agent is Candida, antifungals
might be prescribed.9,25,34,36 When there is evidence of an
infection, expressed breast milk should not be used as a topical
agent nor should nipple ointments, gels, creams, or dressings
be used.9,25,34,36 The latest research does not support their con-
tinued use. Increasing the opportunity for a warm moist envi-
ronment increases the susceptibility of the mother-infant dyad
to poorer skin integrity and potential for increased infections or
recurring infections.9,35
Mastitis or breast infection is typically triggered by a break
in skin integrity or stagnation of milk within the milk sinuses,
allowing bacteria such as S. aureus to proliferate.14,36 It is usu-
ally occurs after the second or third week of breastfeeding and
is characterized by soreness and reddened areas of the breast.
The occurrence is most often unilateral, although bilateral and
repeat infections can occur. Signs and symptoms of mastitis
include chills, increased temperature, and maternal
fatigue.36-38 Treatment may include the use of antibiotics and
analgesics and rest and hydration.14,36,37 Mothers are encour-
aged to breastfeed frequently and apply warm compresses
after feeding. An alternative approach, using acupuncture
compared with standard treatment for mastitis, found a signif-
icant decrease in breast pain at 3 and 4 days of treatment.39
©2016 Wolters Kluwer Health, Inc. All rights reserved.
October 2016
Regardless of any treatment, the breast should be cleaned and
kept dry until the next feeding. Breastfeeding through the
mastitis episode can be difficult for the mother, yet providing
extra support and encouragement is important to long-term
breastfeeding outcomes.14,34,36,37
Candidiasis occurs as an overgrowth of naturally occurring
yeast that lives normally on the skin and mucous mem-
branes.40,41 The warm and moist environment found in the
infant’s mouth and on the mother’s breast increases the risk
for yeast to overgrow. Candidiasis infections can occur at any
time during breastfeeding; however, it is important to note
that if the mother or infant has been treated with antibiotics,
the risk is increased and more intense assessments need to
occur.38,40,41 Diagnosis is by clinical symptoms, although a
DNA and polymerase chain reaction (PCR) assay for candidi-
asis are becoming readily available.14,36,41 When there is a
delay in treatment, because of the need to work up other dif-
ferentials, it is important to keep good communication with
the mother.36,40,41
With candidiasis there is persistent soreness and redness in the
nipples; burning and itching may also be present. In addition,
mothers often report that pain is increased during breastfeeding
and may seem to radiate into the breast. It is important to begin
treatment as soon as a diagnosis is made and to treat both the
mother and the infant and other family members who may have
symptoms. Many strategies may be used concurrently, such as:
(1) initially, nipple ointments and topical antifungal agents and/
or Gentian violet (<0.5% aqueous solution) may be used daily
for no more than 7 days; (2) nystatin suspension or miconazole
oral gel for the infant’s mouth; and (3) human milk probiotics
to treat subclinical mastitis. Vigilant hand hygiene is critical,
along with hygienic care of the breasts between feedings. This
includes cleaning and care of anything that goes into the
infant’s mouth. If resistant, oral fluconazole (200 mg once, then
100 mg daily for 7–10 days) may be prescribed.14,36,41,42 Lastly,
acidophilus can be added to the mother’s daily intake to help
balance the normal flora growth. Reinfection is common, so it
is important to work with the mother to appreciate the course of
infections and best understand what makes the mother-infant
dyad more susceptible to infections so the cycle can be broken.
Helping mothers not only to understand the need for acute
immediate care strategies but to also consider the bigger picture
of what is occurring long term will help with working through
this process.36,40,41
Preexisting Dermatologic Conditions and
Pain Sensitivity
Mothers with preexisting skin allergies such as eczema, pso-
riasis, or other dermatologic conditions are at increased risk
for breast pain because of the potential for decreased skin
integrity.43 They need even greater support, including good
hygiene and drying the breast between feedings, and the rou-
tine use of a topical corticosteroid to relieve symptoms.
9
Topics in Pain Management
Before feeding the infant, corticosteroid creams need to be
removed to decrease infant exposure. Mothers who are more
susceptible to allergic reactions could be more likely to expe-
rience breast pain if they use ointments or creams as a sup-
portive measure while breastfeeding. Once allergic reactions
occur, the irritant (ointment or cream) needs to be discontin-
ued and the area kept clean and dry.9,14
Sometimes mothers experience nipple vasospasms with
breastfeeding that can be acutely painful. These spasms are
due to a reduction in circulation and can cause blanching of
the nipple or nipple discoloration. Sometimes the pain radi-
ates into the breast, as with Candida. As such the cause of the
pain can be easily misdiagnosed. Occurrence is greater in the
winter months and in thin women with poorer circulation and
a family history of Reynaud syndrome.41 Because the syn-
drome is often affected by temperature, the most effective
intervention is making sure the environment is not cold dur-
ing breastfeeding and applying warm water compresses after
breastfeeding. If these interventions are not effective, nifedi-
pine 30 to 60 mg sustained release daily, or immediate release
10 to 20 mg thrice a day, for 2 weeks, may be prescribed.14,45
Mothers with a history of pain disorder may experience
excruciating pain with breastfeeding, light touch, or drying with
a tool. These mothers may require pharmacologic management
of round-the-clock nonsteroidal anti-inflammatory ointments.26
If mothers do not respond well, additional therapy of proprano-
lol beginning at 20 mg 3 times a day and antidepressants may
be needed.43,44 Lastly, one study found that massage therapy tar-
geting problematic areas is effective.45
Clinicians may not understand the severity of pain mothers
experience during breastfeeding. In part because there is no
standardized assessment for maternal pain, systematic assess-
ment of breastfeeding pain has been scarce. In addition, many
studies had small samples in varying populations, making it
difficult to compare or combine results. Conducting research
in this area is difficult, yet it is very important to the continua-
tion of breastfeeding for the first year of life.
In general, if health care clinicians expect mothers to con-
tinue breastfeeding their infant, management strategies need
to be quick and effective. Breastfeeding pain needs to be
acknowledged and accompanied by individualized counseling
that addresses the unique needs of the mother given her cur-
rent condition and history with breastfeeding strategies. Pain
management needs to include both nonpharmacologic and
pharmacologic strategies. In a retrospective chart review,
Strong49 found that prescription of medications was used
most frequently for management of breast pain. Counseling
and nonpharmacologic measures were rarely documented.
There were also few referrals to lactation support services.
Health professionals must use the best evidence to guide
assessment and management of breastfeeding pain, particu-
larly because conflicting advice is known to be a contributing
factor in breastfeeding cessation.50
10
October 2016
Conclusions
A majority of women who breastfeed will experience nipple
and breast pain, particularly during breastfeeding initiation.
Preparing women to develop strategies for managing pain dur-
ing breastfeeding is ideally a focus of antenatal breastfeeding
education. However, not all women are able to attend or com-
plete educational sessions before birth. With greater recogni-
tion, acknowledgment, and support for dealing with nipple and
breast pain during breastfeeding, there is a better chance that
mothers will continue breastfeeding up to or beyond the recom-
mended duration. Clinicians’ assessment of the pain and poten-
tial contributing factors can provide direction for interventions
focused on supporting the mother to continue breastfeeding.
More intensive follow-up should take place for women who
have mastitis or candidiasis to ensure that symptoms resolve
and to increase the likelihood of good breastfeeding outcomes.
Mothers at risk for severe pain during breastfeeding, such as
women with preexisting dermatologic or chronic pain condi-
tions, may need additional consultation and support. Ultimately,
the time and effort provided in helping mothers to achieve bet-
ter breastfeeding outcomes will contribute to infant health and
long-term population health outcomes. ■
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11
Topics in Pain Management
Topics in Pain Management CE Quiz
To earn CME credit using the enclosed form, you must read the
CME article and complete the quiz and evaluation assessment survey on
the enclosed form, answering at least 70% of the quiz questions correctly.
Select the best answer and use a blue or black pen to completely fill
in the corresponding box on the enclosed answer form. Please indi-
cate any name and address changes directly on the answer form. If your
name and address do not appear on the answer form, please print that
information in the blank space at the top left of the page. Make a photo-
copy of the completed answer form for your own files and mail the orig-
inal answer form in the enclosed postage-paid business reply envelope.
Your answer form must be received by Lippincott CME Institute by
September 30, 2017. Only two entries will be considered for credit.
Online CME quiz instructions: Go to http://cme.lww.com and click
on “Newsletters,” then select Topics in Pain Management. Enter your
username and password. First-time users must register. After log-in,
follow the instructions on the quiz site. You may print your official
1. Assessing breastfeeding pain is important because
A. breastfeeding pain is always associated with infection
B. pain is a common reason for cessation of breastfeeding
C. breastfeeding pain is a key indicator of engorgement
D. neurohormones released into breast milk are harmful
2. Breastfeeding pain
A. usually peaks during the first 3 days after birth
B. is normal after the first week
C. is not important information during a breastfeeding assessment
D. is abnormal only if the pain has neuropathic features
3. Individualized counseling for managing breastfeeding pain
needs to include
A. assessment of skin integrity, history of onset and symp-
toms, characterization of the pain, treatment of pain
with antibiotics, analgesics, and/or antifungals
B. assessment of skin integrity, history of onset, pain
intensity, other symptoms that accompany the pain, dis-
cussion of “normal” versus “abnormal” pain
C. assessment, history of onset and symptoms, apprecia-
tion of the mother’s perception of her pain, understand-
ing of strategies already tried by the mother, and
acknowledgment of maternal competence
D. history of onset and symptoms, characterization of the
pain, discussion about seeing the lactation specialist
4. Interventions for infection should include
A. analgesics prescribed along with antibiotics
B. after 24 hours of antibiotic therapy, resume breastfeeding
C. use of breastmilk on the nipples after feedings to
increase immune function
D. resume breastfeeding only after infection clears
5. Antenatal breastfeeding education significantly decreases
breastfeeding pain by providing
A. strategies to maintain nipple integrity
B. instruction on proper infant positioning and latch
C. management of lactogenesis II
D. medications to increase or decrease the milk supply
12
October 2016
certificate immediately. Please note: Lippincott CME Institute, Inc., will
not mail certificates to online participants. Online quizzes expire on the
due date.
To earn nursing CNE credit, you must take the quiz online. Go to
www.nursingcenter.com, click on CE Connection on the toolbar at the
top, and select Browse by Journal. On the next page, select Topics in
Pain Management.
Log-in (upper right hand corner) to enter your username and
password. First-time users must register. After log-in, locate and click
on the CE activity you are interested in. There is only one correct
answer for each question. A passing score for this test is 7 correct
answers. If you pass, you can print your certificate of earned contact
hours and access the answer key. If you fail, you have the option of tak-
ing the test again at no additional cost. For questions, contact Lippincott
Williams & Wilkins: 1-800-787-8985. The registration deadline for
CNE credit is October 31, 2018.
6. Which of the following topical interventions for treatment
of nipple pain are supported by Oxford Center for
Evidence-Based Medicine level 2 evidence?
A. Peppermint and purified lanolin
B. Trilaminate silver and warm compresses
C. Purified lanolin and expressed breast milk
D. Petroleum jelly and shea butter
7. The Breastfeeding Pain Reasoning Model proposes that
maternal pain during breastfeeding is affected by
A. maternal social, emotional, and cognitive state
B. maternal nipple shape
C. positioning during breastfeeding
D. maternal age, race, and ethnicity
8. Although all mothers are at risk for nipple pain and trauma
during the first week of the infant’s life, which one of the
following indicates increased risk?
A. First-time mothers
B. History of preexisting dermatologic conditions
C. History of antibiotic use
D. History of diabetes
9. Engorgement occurs within 72 hours after delivery and is
characterized as
A. severe pain
B. neurohormonal pathway regulation of milk supply
C. filling of milk sinuses
D. an abnormal physiologic process
10. Mothers who persist with severe pain during breastfeeding
after treatment with antifungals and antibiotics should be
evaluated for
A. Reynaud syndrome
B. eczema
C. mastitis
D. fibromyalgia
©2016 Wolters Kluwer Health, Inc. All rights reserved.