Expert: Sally Wendkos Olds - 9/17/2009

Question
I have been breastfeeding my daughter for one week. My nipples are cracked, bleeding and incredibly sore. I can no longer breastfeed due to the pain. I tried to get through it, hoping it would get better, but it feels like she just chews on my nipple no matter how hard I try to get her in the proper position.
I am now pumping and bottle feeding. How often and how much should she be getting? Also, is there any hope that she will be able to go back to breast when my nipples heal? I feel extremely guilty and inadequate for not being able to exclusively breastfeed, but I don't know what else to do.

Answer
Dear Katie,

I'm sending you this additional point because I have been thinking about you and I realized that I didn't say this before. Your baby may not want two or three ounces at a single feeding, so start by putting about two ounces in the bottle to start. If your daughter consistently does not take all of it, you can scale back to 1 1/2 oz, if the baby easily finishes the 2 oz you can put 2 1/12 to 3 oz in the bottle.  It's somewhat of a trial and error process so that you won't waste your precious expressed breast milk. The rest of the answer is the same.

I am revising this answer because I gave you incorrect information earlier about how much milk your baby should be getting at every feeding. She should be getting two or three ounces at a feeding. The rest of this answer is the same as the earlier one.

I am so sorry to hear about the pain you're in. Please don't feel guilty or inadequate for not being able to breastfeed exclusively. You need to tell yourself that you're doing the best you can -- the important thing is that you're taking care of your baby, and by giving her your pumped breast milk you're providing her with important antibodies and nutrients.

Now you need to take care of yourself. If you have not already seen a lactation consultant, please do so right away! The cost of this care will be more than outweighed by your savings on formula over the long run. I am attaching an excerpt from my book (see below) about taking care of sore nipples, but you really need to have someone see you in person and help you heal. Yes, there is hope that you will be able to go back to breastfeeding. Many women undergo the kind of problems that you're having now, manage to resolve them, and go on to have a happy nursing experience.

For a one-week-old baby you should be pumping 8 to 12 times a day, even at night, to build and maintain your milk supply, and your baby should be getting two or three ounces at every feeding. She also should be seen by her pediatrician to be sure she's gaining enough weight.

If you can't find a lactation consultant through your hospital or pediatrician, contact the International Lactation Consultants Association at www.ilca.org to find someone near you.

Good luck!

Sally
--------------------------------
Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.
-------------------------
Sore Nipples
Many women experience a pulling sensation and a mild, temporary tenderness in the first few days after giving birth, and sometimes through the first week or two. If you’re not in real pain and if your discomfort is relieved when your milk comes in and lets down for your baby, you don’t need to do anything special. This initial tenderness usually goes away in a few days, as your milk begins to let down. But if your nipples look red and chapped or cracked or if you feel severe pain during or after nursing, call your doctor or lactation consultant right away. Don’t wait until the pain becomes unbearable, because that will make the problem much harder to clear up. Martyrs are not happy breastfeeders!
  It’s important for several reasons to resolve nipple problems early, in addition to removing the “ouch” factor and making breastfeeding a happier experience. A major medical reason lies in the fact that any break in the skin makes you more susceptible to infection. And a psychological reason for prompt treatment was brought out by research that – not surprisingly – found that women without nipple pain were much less likely to be depressed than were women whose nipples hurt. When nipple problems were cleared up, rates of depression decreased. What had looked like postpartum depression seemed in many cases to be the result of physical pain.
  Not all women experience nipple discomfort during early nursing. If you have positioned your baby properly from the start, and if he has latched on well, you can usually prevent sore nipples. Some infants, though, have more trouble than others learning how to latch on and to suckle; as a result, their mothers’ nipples begin to hurt.
  Proper positioning techniques almost always alleviate or completely eliminate sore nipples. So check the way you’re holding the baby. Is she in a position that lets  her get enough of your breast in her mouth without straining? If not, take another look at the pictures and text in Chapter 6 and reposition.
  Sometimes you may be doing everything right, but your baby may have a suckling problem. Some babies, for example, suck their tongues instead of the breast, or suck their lower lips along with the breast. Others thrust their tongues forward, or because of a tight frenulum (the membrane that attaches the tongue to the floor of the mouth) cannot grasp the nipple properly (see page 000). Ask your lactation consultant or a La Leche League leader to observe you and your baby while you’re nursing. She may be able to pick up any suckling problems and advise you.
  Even if some blood appears in cracks in your nipple, you can continue to nurse; your blood won’t harm your baby. You may even see this blood in your baby’s spit-up, and if it’s from your nipples, it won’t harm the baby. If you’re bleeding, take immediate measures to heal your nipples. Aside from the pain you’ll be feeling, cracks in the nipples can let in bacteria that can cause a breast infection (mastitis -- see page 000).

Moist Wound Healing for Cracked Nipples
  Moist wound healing involves putting a dressing on broken skin to increase the skin’s moisture content from within. For example, if you have dry, chapped lips, you put on a cream to restore their internal moisture and you avoid surface wetness by not licking your lips. The same principle applies to nipples. If your nipple cracks, “moist wound healing” can accelerate the healing process, eliminate scab formation, and provide pain relief. It restores internal moisture by increasing the moisture content of the skin. At the same time, you avoid surface wetness by not allowing milk to pool on your skin.
  If your nipples are not too sore, you can express a little bit of your breast milk and apply it to the affected areas. You will thus be taking advantage of the healing and antibacterial properties of human milk, as well as its moisturizing benefits. And of course, you don’t need to wipe it off your nipple before your baby nurses.
For more severely sore, cracked nipples, you can apply pure, medical-grade, anhydrous lanolin (Lansinoh), which is soothing and will also lubricate the skin and help it retain its internal moisture. Pure lanolin does not need to be wiped off before feedings because it won’t harm your baby. Or your doctor or lactation consultant may recommend a topical balm or antibiotic that they have had good results with. If the nipple cream you’re using has steroids in it, don’t use it more than two days.
   While some moisture is good, too much is not. Too moist an environment can promote bacterial growth, leading to an infection. Therefore you need to change your breast pads or your bra often enough so that your nipples don’t remain wet.

Treating Sore Nipples
• Since so many nipple problems are caused by incorrect latch-on, go back to the positioning advice in Chapter 6, and make sure your baby is properly positioned for nursing. Her chest should be facing yours, her face and nose facing your breast, and her mouth covering all or part of your areola. Be sure that your nipple is well into your baby’s mouth and that her gums are compressing the milk ducts under the areola. If she is not properly positioned, carefully take her off the breast (breaking the suction with your finger in the corner of her mouth) and bring her back to it. If you are in any doubt about your nursing technique, consult a lactation specialist.
* Some babies latch on well but then slip down on the breast during the feeding, getting out of position and causing nipple pain. Keep checking the distance between your baby’s nose and your breast during the feeding, and if it increases, take him off and have him latch on again.
• Never let your baby chew on your nipple. If you feel this happening, carefully take him off the breast as above and bring him back. If he keeps doing it, end this feeding session.
• Express a little milk manually before putting your baby to the breast; this will start your milk flowing, help your let-down reflex operate more quickly, and lubricate your nipple.
• Practice a relaxation technique just before nursing (see the box on page tk, Chapter 7).
• Nurse your baby more frequently, but for shorter periods of time. Your breasts are less likely to overfill and your baby is more likely to suckle gently, since she’ll be less hungry.
* Apply an ice pack to your sore breast briefly just before you bring your baby to the breast. This will help to make the breast numb.
• Offer the less sore breast first most of the time. This will give your milk a chance to let down from the sore nipple, and your baby won’t be suckling as hard by the time he gets around to his second course.
• Change your position at each feeding. Lie down, sit up, hold your baby in different positions so that you can change the position of your baby’s jaws on your breast. If you have a crack in your nipple, it’s especially important to position your baby so his mouth clamps down elsewhere.
• If a scab forms on your nipple during early nursing, leave it alone.
• Avoid all irritating and drying substances. Never use soap, alcohol, tincture of benzoin, or witch hazel on your nipples.
• Don’t wipe away milk left on your breast after a nursing. In fact, you can express a few drops of your milk and rub that gently onto your nipples. As we said earlier, mothers around the world treat their children’s irritations and infections with human milk. Your milk’s curative powers can help you, too.
• Soothe the soreness with a cream prescribed by your doctor or with pure lanolin. Lansinoh for Breastfeeding Mothers® can be purchased from your local pharmacy or supermarket, or online. It’s hypoallergenic and thus safe even for people who are allergic to wool, and it does not need to be wiped off before your baby nurses. Be very cautious about using other over-the-counter nipple creams; one widely marketed cream was recently taken off the market after the FDA determined that it had ingredients that could harm babies.
* Wear hydrogel pads (made up of water, moisturizer, and polyurethane) inside your bra, and keep them in refrigerator or freezer when not in use. These pads provide cool, soothing relief. Prices vary considerably for the different brands, as do the amounts of time they can be worn. Popular brands include Ameda ComfortGels, Medela Tender Care, Soothies Gel Pads, LilyPadz, and Blossumz. Pads with adhesive backing next to the skin should be used only for special occasions and only for a short time, since longer wear can irritate your skin.
• Ask a lactation consultant about the advisability of wearing an ultrathin silicone breast shield to help your baby latch on better, and use it only under her direction.
• If only one nipple is sore, breastfeed only on the other side and pump (with an electric pump) from the sore side. If nipples on both breasts are sore, consult with your lactation specialist. You may need to stop nursing completely for a couple of days, during which time you can pump or express your milk. (Using an electric pump is usually less irritating than your baby’s suckling might be.)
* Be careful of excessive suction or vigor from the breast pump. An electric pump is the most nipple-friendly. Meanwhile, check for a good fit at the flange of the pump, the cup or funnel that is centered over the breast. Usually, pumping will not hurt, but if your nipple soreness seems related to pumping, call the pump’s manufacturer for help (see Resource Appendix). You can also hand-express your milk from the sore side. For instructions on how to do this, see page 000.
• Keep your nipples free of surface wetness (except for a few drops of expressed milk) to prevent skin breakdown or infection:
--If you wear breast pads to catch leaking milk, change them when they get wet. Don’t use the kind with plastic liners.
--Wear an all-cotton bra, not one made of a synthetic fabric. Change it every day.
--If you wear breast shells (milk cups) to bring out inverted nipples, empty them often.
--Walk around the house with your nipples uncovered when you can. If the air in your home is very dry (as in an overheated apartment), use a humidifier or keep a pan of water on the radiator.
--If it’s too painful to have clothing touch your nipples, apply a light coating of lanolin, and insert into your bra small mesh tea strainers from the hardware store, from which you have removed the handles. Or you can use plastic breast shells that have holes in them to allow for air circulation.
• If your nipples are tender after showering, apply a coating of lanolin before you take your shower.
* Try seashells. Seashells? Yes, Scandinavian mothers have worn them over their nipples between feedings for thousands of years. If you can’t go beach-combing yourself, you can buy them online. Air-dry your nipple area before you put seashells over your nipples, and boil them between uses. One  mom said, “I liked the notion of having this potent feminine energy from the ocean and the tides at my breasts.” We have no direct experience with these, but if you search online you can find enthusiastic testimonials.
• Occasionally take a mild pain reliever to ease your discomfort. See Chapter 10.
• Sore nipples are sometimes caused by thrush, a fungus infection, which may be affecting both you and your baby. See the next section.
• If, as happens in rare cases, your soreness worsens until your nipple cracks and bleeds and is absolutely too painful to nurse from, take your baby off the affected nipple for twenty-four to forty-eight hours. Nurse him often on the other breast. If necessary, give him expressed milk or formula. Pump your milk from the affected breast every three hours, or every time you would ordinarily be nursing. If pumping is painful, hand-express.
  Gradually resume nursing on the breast with the sore nipple, starting twice a day. Continue to pump milk from the sore breast at other feeding times until your nipple is healed enough to work up to the full nursing schedule. Apply pure lanolin to heal the nipple fissures. If the nipples on both breasts are sore, stop nursing temporarily and express as much milk as you can, either by pump or by hand, until your nipples are healed enough to resume nursing. Many women have been able to resolve their nipple problems and have not needed to wean their babies.
• If you have a persistent rash around your nipples that does not clear up, see your own doctor to rule out any underlying problem.