Most (not all!!) mammals have nipples as they feed their live young milk from their bodies made in mammary tissue. Marsupials and eutherian mammals typically have an even number of nipples arranged in pairs on both sides of their bodies, from as few as two to as many as 19 pairs. Some 5,600-6,000 species of mammals feed their young milk, and thus have mammary glands, but not all mammals have breasts (or nipples!!). In humans, the areola surrounds the nipple in a round shape and comes in varying sizes, on average 3 to 6 centimeters. The little bumps around the areola (called Montgomery glands) secrete an oil that smells like amniotic fluid to help baby use smell to find the nipple to latch on. In the center of the areola is the nipple, again in a wide variety of sizes shapes and lengths, and can be 10 to 27 millimeters (mm) wide by 1 to 10 mm in height. Its skin is similar to the areola, but has no oil glands. It has 4 to 20 pores where milk can come out. The skin of the nipple rests on a thin layer of smooth muscle, called areolar muscle fibers which are distributed in two directions: radial and circular. The muscle of Sappey responsible for circular fibers and the muscle of Meyerholz, formed by the radial fibers. Contraction of these muscles is responsible for the erecting of the nipples during stimulation and breastfeeding as well as the ejection of milk from the breast. How tight or loose these nipple muscles are may contribute to why some of us leak more than others and some don’t leak at all, but there is no way to exercise these nipple muscles!
Cracked. Painful. Damaged. Nipples. Ouch!!! Did you know the nipple shield you were given at the hospital may be the culprit for your persistent nipple pain? Most hospitals will give out a 24mm cone shaped shield (Medela brand). While this may work for some, for many it will be too big or the wrong shape, causing baby to still bite your nipple through the shield. Those with elastic nipples may have their nipple sucked too far and poke out the holes. Ouch!!! Nipple shield now come in many shapes, sizes, lengths and materials to individualize the shield to get an optimal latch. Not happy with your current shield? Schedule an appointment to find out what other options may work better for you.
If you have cracked, bleeding nipples there is always a reason. Reasons for cracked nipples:
🗡Very short or flat nipples where baby is not yet proficient at taking a big mouthful of breast
🗡Baby is tongue tied
🗡Pumping with the suction too hard
🗡Wrong size pumping flanges causing friction on the nipple
🗡Wrong size nipple shield
🗡Baby was in an odd position in utero and has tension in the head/neck/shoulders
🗡Baby has torticolis (they prefer to turn their head toward one shoulder and they pull the head in this direction while nursing, twisting the nipple)
To treat cracked nipples:
🧸Get a deep latch every time
🧸Breast milk on the nipple after every feeding
🧸Coconut oil, EVOO, nipple balms, butters or creams
🧸Breast shells or Lacticups keep the nipple from touching clothing when damage is severe but should be limited in use
🧸Dr Jack Newman’s All Purpose Nipple Ointment
Has your nipple looked waxy or dull white after feeding or pumping? That’s because the blood vessels have gone into spasm and are not letting blood through. Vasospasm occurs when there is exposure to cold, an abrupt temperature drop, vibration, or repetitive motion in the affected area. The arteries go into spasm and stop letting blood through. There is a disorder called Reynauds that make peoples experience this in their fingers and toes on a more routine basis. When it happens in the nipple it really HURTS. Some say it feels like fire or ice. Others describe it as a pinchy, slicing feeling, or pins and needles. The nipple often turns pale and become painful right after the baby unlatches. It often gets misdiagnosed as thrush but will not respond to medications. So if you’ve been on multiple rounds of medications for thrush and it’s not working, you may actually be having vasospasm.
It can simply be caused by a bad latch, but can have several other culprits. For people prone to vasospasm, the repetitive action of feeding or pumping in combination with the abrupt drop in temperature when baby unlatches or the pump stops is enough to trigger the spasm.
The two main ways to help: massage and heat.
🤲🏼Gently massaging, rubbing, or pinching the nipple helps. Immediately cover your nipples with your shirt/bra/nursing pad, then gently rub or massage them through the fabric.
🌞Heat is important because of science: evaporation is a cooling process. When liquid turns to gas, it uses heat energy from its surroundings to transition. When milk and saliva evaporate off your nipple, the skin and surface tissue cool rapidly, causing the vasospasm.
🌞To slow evaporation, place heat on your nipple as soon as baby unlatches. Use dry heat like a lavender pillow, microwaveable rice/barley/flax pack, hand warmer/Hot Hands (like you use in snowy climates for skiing), or a heating pad can help. Leave heat on for a few minutes until the pain subsides.
🌚Avoid anything wet on the nipple as this promotes evaporation.
🌝Wear wool nursing pads between feedings
Unfortunately, there isn’t a lot of good quality research about treating breastfeeding nipple vasospasm no. Much of what we know is taken from other vasospasm research, or applied from anecdotal evidence. You should always consult your primary health care provider before making any changes to your health, such as adding a supplement, taking medications, or making big lifestyle changes. At a basic level:
🌻Watch for a deep latch every time
🌻Have baby assessed for tongue tie
🌻Check your flange size. If you’re maxing our the suction on the pump, your flange is too big. When too much areola is drawn into the tunnel, the areola swells shut around the nipple and causes the spasm. Using too small a flange does the same: cuts off blood flow to the nipple tip.
Other tips to reducing vasospasm:
🌸Avoid nicotine and medications that cause vasoconstriction (such as pseudoephedrine, beta blockers).
🌸Limit or avoid caffeine
🌸Some research indicates hormonal birth control pills increase the risk of vasospasm.
🌸The main supplement that seems to help with vasospasm is vitamin B6. Dr Jack Newman suggests 100 mg of B6 twice day, as part of a B vitamin complex. If your B vitamin contains 50 mg of B6, you’d take two of them, twice a day. If it contains 25 mg of B6, you’d take four of them twice a day.
🌸Calcium plays an important role in blood vessel dilation. Magnesium helps in calcium regulation. Supplementing with cal/mag often helps with vasospasm.
🌸Being active helps prevent their vasospasm. An active lifestyle can keeps blood circulating through your body.
🌸The internet is full of conflicting opinions on if ibuprofen is a vasoconstrictor or vasodilator. Regardless, it sometimes turns up to treat/prevent vasospasm. If you have regular vasospasm, the risks of longterm ibuprofen use most likely outweigh the potential decrease in vasospasm. It may be OK for occasional vasospasm. Discuss regular ibuprofen use with a healthcare provider.
🌸For chronic, painful vasospasm that does not respond to breast-feeding help, some doctors may prescribe a short course of a blood medication called Nifedipine.
Will nipple piercings impact breastfeeding? Every body is different in how it reacts to taking out the jewelry out prior to breastfeeding. Just like with pierced ears, some of us will have the hole scar closed, the scar may partially close, or it could stay open for years and never have a problem sticking jewelry in and out at whim. Often the longer the time since the piercings were initially placed the better the outcome as the nipple has had time to properly heal. Common concerns may include nerve damage that impacts milk let down or scarring that prevents the milk from leaving the nipple. On the other hand, the extra holes created by the piercings could lead to a faster milk flow! (which some infants struggle to manage while others do just fine with). If the nipple pores have scarred shut, the breast may be able to make milk but it may not be able to exit from the nipple. This can lead to plugged ducts and mastitis. If the nerves have been damaged, the breast may make milk in the early days or weeks after delivery, but without the nerve impulse the breast will make less and less milk with time, even with all the herbs and quality pumping and efficient baby. Because our bodies are not perfectly symmetrical, some may have a problem on one side and not both. Some have no problem at all. We don’t know what your body is going to do and it cannot be predicted prior to birth. If your
Breastfeeding with the nipple jewelry in place is never recommended as it can make it difficult for the infant to latch-on correctly, increases the risk of choking on loose or dislodged jewelry, and can damage the inside of the baby’s mouth. If you are going to take your jewelry in and out every feeding, make sure you are being extremely careful with hand washing and jewelry sanitizing to reduce the risk of infection. Best practice says take the piercings out for the entirety of your breastfeeding journey. Many go on to successfully with pierced nipples, but if you’re having any problems or concerns, see a lactation consultant such as myself. For more of my thoughts on nipple piercings and breastfeeding, click here to check out my YouTube video
Not all nipple shields are created equal. Nipple shields are a great tool that can be used to help baby latch and stay latched, help you heal from nipple damage or trauma, or transition baby back to breast from using a bottle. Nipple shields are a great tool and can be used as long as needed. There are risks to long term use, the biggest one is a decrease in milk supply if baby isn’t able to trigger let downs or remove milk efficiently. If you weren’t given a plan for transitioning off the shield, a qualified lactation consultant can help!
Nipples and penises have a lot in common. From an anatomical, cellular level, they are both made of the same elastic, erectile tissue. They erect and evert with stimulation. They can crack, bleed, and blister, but they can never toughen up or callous. And neither one should ever crack or bleed.
Babies mouths have two areas: the hard, bony palate up front and the soft palate at the back, just in front of where that little hangy downy uvula is. One of the reasons a nipple erects, everts, and stretches is to help to get it in the safe zone where the palate is soft.
When a baby is latched correctly, the nipple tip stretches back to where the palate is soft, then the tongue massages the nipple to express milk. If baby has a shallow latch, the tongue pinches the nipple tip against the hard roof of the mouth and causes damage. This also happens when there is a tongue tie where the tongue is restricted in its movement. Instead of the middle of the tongue massaging the nipple, the the tongue is anchored to the floor of the mouth and it flicks the nipple, or the middle of the tongue where the restriction is pinches the nipple against the bony palate.
Nipples are perfectly designed to withstand breastfeeding. Other than temporary tenderness in the first few days, there should be no pain or damage. If you do get damage, they should heal quickly (within 24-48 hours) if you can get a consistent deep latch.
Moist wound healing is most effective to heal a nipple. Tips to heal a damaged nipple:
💡Keep breast milk on the nipple. Using a washable breast pad can help keep milk on the nipple
💡Nipple balms/butters, coconut oil and lanolin can help keep the nipple from sticking to clothing and feel soothing
💡A 20 second saline rinse once or twice a day
💡Soak the nipple in an Epsom salt bath, either in a bowl or Haakaa filled with warm water
💡A prescription for Dr Jack Newman’s All Purpose Nipple Ointment for severely damaged nipples
💡Silverette cups for persistent damage
💡Temporarily use a nipple
💡Schedule a lactation consultation time get to the root of the damage
Tongue tie, technically known as ankyloglossia, is a condition present at birth that affects an estimated 2-5% of all babies born. It is characterized by a short, thickened, or abnormally tight lingual frenulum, which is the tissue that connects the tongue to the floor of the mouth. Depending on the severity of the tongue tie, range of motion of the tongue can be restricted. In very severe cases, the tip of the tongue can appear to be heart shaped. Because of this anatomical difference, sometimes tongue tied babies can’t maintain a latch for long enough to take in a full feeding. Others may appear to breastfeed for long periods of time without actually be effectively transferring milk. Some tongue tied babies will successfully breastfeed only during “let-down”, when the milk flows on its own from the breast into the babies’ mouths, but won’t be able to actively express milk out of the breast on their own. Many babies with tongue tie also have a lip tie, an abnormally tight membrane attaching their upper lip to their upper gums. This can be seen by rolling the upper lip upward. Babies with lip tie often have difficulty flanging their lips properly to feed which impacts their ability to latch well. This can cause them to take in excess air during breastfeeding which often makes these babies gassy and fussy.
While many pediatricians do not see tongue tie as an issue, current research and literature suggests that it can have a significant impact on breastfeeding. However, the American Academy of Pediatrics, among others, have documented the negative effects of tongue tie on breastfeeding. The most common complaint of mothers with tongue tied babies is sore nipples, which is due to poor latch and inefficient sucking. Other breastfeeding problems for the mother can include recurrent plugged ducts, mastitis or thrush, vasospasm, and supply difficulties. Babies with tongue ties typically have difficulty latching, make click sounds while nursing, may be gassy and fussy during feedings, and have slow weight gain despite having mothers who use correct positioning and nurse frequently.
Some babies with very short or thick lingual frenulums are able to compensate well and breastfeed without difficulty. Tongue tie needs to be diagnosed by function and not just appearance, so what the baby’s tongue looks like is not as important than what it can do. According to one study, simple inspection of a tongue-tie is not enough to determine which infants will need medical intervention. However skilled professionals will complete a clinical assessment which includes observation and measurement of the effectiveness of feeding to help determine appropriate action to improve breastfeeding skills. This is not a comprehensive list for tongue function, but it may give you an idea for why your baby is having breastfeeding difficulties:
- Does the tongue elevate? When the baby cries the front edge of the tongue should come up at least as high as the corners of the baby’s mouth.
- Does the tongue extend? The baby’s tongue should be able to protrude or stick out at least past the lower gum if not to the border of the lower lip
- Does the tongue lateralize, or move side to side? Tracing the baby’s bottom gums triggers a reflex for the tongue to follow the finger..
- The baby’s tongue should be able to lift towards the roof of the mouth and touch behind where the upper teeth will come in. Is there a membrane there that prevents the tongue from lifting? When very tight from tension, the membrane may appear white.
If it is determined that the tongue tie is indeed the culprit for breastfeeding difficulties, some pediatricians, ENTs and dentists can perform a frenotomy or frenectomy. This is a quick procedure to cut the frenulum which returns the full range of motion of the tongue and upper lip. Specialized scissors may be use to simply cut the tongue or lip tie. Some prefer to use lasers, which have the benefit of minimizing the amount of bleeding during and after the procedure and decrease the chance that the frenulum will grow back. Many practitioners use a local topical anesthetic to numb the area before the procedure and some use an injection of anesthetic as well. Babies can breastfeed as soon as the procedure is done. Post-procedure care should be done to minimize the frenulum from growing back. Current research shows this is a safe, easy procedure with minimal risk to the baby. The majority of mothers notice an immediate difference in breastfeeding effectiveness and a significant reduction in nipple pain.
When should the frenotomy be done? Current research shown between 2-6 days after birth to establish proper breastfeeding patterns. This same study showed that waiting more than four weeks for frenotomy drastically increased the likelihood that mothers would abandon breastfeeding all together.
If you suspect your baby has a tongue or lip tie, set up a consultation for a full assessment of your baby’s oral motor skills.
For more resources and articles, see Breastfeeding a Baby with Tongue-Tie or Lip-Tie at kellymom.com
- Lalakea, M. Lauren; Messner, Anna H. (2002). “Frenotomy and frenuloplasty: If, when, and how”. Operative Techniques in Otolaryngology-Head and Neck Surgery. 13: 93. doi:10.1053/otot.2002.32157.
- Wallace, Helen; Clarke, Susan (2006). “Tongue tie division in infants with breast feeding difficulties”. International journal of pediatric otorhinolaryngology. 70 (7): 1257–61. doi:10.1016/j.ijporl.2006.01.004. PMID 16527363.
- Emond A1, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, Sutcliffe A. “Randomized controlled trial of early frenotomy in breastfed infants with mild to moderate tongue-tie.” Arch Dis Child Fetal Neonatal Ed. 2014 May;99(3):F189-95.
- Jack Donati-Bourne, Zainab Batool, Charles Hendrickse, Douglas Bowley “Tongue-Tie Assessment and Division: A Time-Critical Intervention to Optimise Breastfeeding/” Journal of Neonatal Surgery 2015; 4(1):3
Jain E. Tongue-tie: its impact on breastfeeding. AARN News Lett.1995;51 :18
- Huggins K. Ankyloglossia: one lactation consultant’s personal experience. J Hum Lact.1990;6 :123– 124
- Messner, Anna H.; Lalakea, M. Lauren; Aby, Janelle; Macmahon, James; Bair, Ellen (2000). “Ankyloglossia: Incidence and associated feeding difficulties”. Archives of otolaryngology—head & neck surgery. 126 (1): 36–9. doi:10.1001/archotol.126.1.36. PMID 10628708.
- Tongue Tie – What Do Parents Need To Know? Submitted by jessicabarton on
Rosegger H, Rollett HR, Arrunategui M. [Routine examination of the mature newborn infant. Incidence of frequent “minor findings”]. Wien Klin Wochenschr.1990;102 :294– 299