Diagnosis of nipple pain/soreness

The most common cause of nipple pain or soreness is due to poor attachment of the infant. This should be ruled out fist before considering other causes of breast pain (1).

Enquire:

• about onset of the nipple pain
  • pain present during the first few weeks of feeding - poor positioning and attachment is the likely cause
  • pain after the first few weeks - candida infection of the nipples (except if the mother had vaginal thrush at delivery or had deep breast thrush at the end of the previous lactation where pain presents within the first few weeks of starting breast feeding)
    
    
• when the pain is at its worst o before a feed or during the night - over distended duct, unresolved breast engorgement
  • during a feed - if pain is present for more than 5 seconds it is likely to be a problem with the position and attachment
  • after every feed - lasting up to an hour usually indicates thrush
    
    
• character and severity of pain
  • severe pain - thrush
  • pinpoint nipple pain - due to white spot or bleb in the nipple
    
    
• whether one or both breasts are affected
  • if both breasts are affected - candidial infection (except in very early stages)
  • if only one breast is affected and the pain is experienced during the feed - poor attachment
    
    
• about the colour of the nipple or areola
  • reddening of the nipple and loss of colour in the areola - candidal infection
  • loss of colour (temporary) which becomes normal within a couple of seconds - incorrect positioning or Reynaud's syndrome
    
    
• about the change in the shape of the nipple after breastfeeding
  • any flattening of the nipple from top to bottom or side to side with a white pressure line across the tip - consider poor positioning (2)
  • in cases where skilled advice does not improve the nipple shape - consider tongue tie

Notes:

• white spot at the end of the nipple (3)
  • is usually about 1 mm in diameter
  • overgrowth of epithelium (which forms a blister), or an accumulation of fatty or particulate material is considered to be the cause
  • can be very painful during suckling
  • removal of the white spot by use of a sterile needle or rubbing with a towel results in quick relief of the obstruction (1)

Reference:

• 1. The Breastfeeding Network (BFN) 2009. Differential diagnosis of nipple pain
• 2. World Health Organization (WHO) 2009. Infant and young child feeding. Model chapter for textbooks for medical students and allied health professionals
• 3. World Health Organisation (WHO) 2000. Mastitis. Causes and management