No Pain- No Gain? The Nipples Article

For this article we interviewed Catherine “Cat” Halek. Our favorite IBCLC whose mission it is to remove barriers and help mothers have the most relaxed breastfeeding [feeding] experience possible. Mother’s and their nipples across the country thank you Cat, for the valuable information you have provided for this article.

Too often the internal dialog that accompanies nursing pain is shocking and wrings at the heart when it is said out loud. But so many mothers do not put volume to these words. Or worse, when they do they are let down by our medical community who are meant to help. Here are real quotes from women who wanted to nurse their babies and experienced pain:

“I don’t think that it’s uncomfortable enough to be considered pain.”

“I am just weak or oversensitive.”

“If I just push through it will get better.”

“Breast is best. Ouch (cry). Breast is best.”

“I can suck it up because this is best for my baby.”

“Is this normal?”

“I gave birth unmedicated and I thought that was tough…this is tougher.” 

“Maybe this is the last time it will hurt and my nipples are just getting used to this.”

“Maybe I should have roughed up my nipples during pregnancy like my mother 

suggested.”

“Maybe I’m a millennial snowflake because my mom nursed 4 babies and only mentioned how great it was.”

“I am failing at the one thing that is supposed to come naturally.”

“I  want so badly to quit but feel like I would be failing my son and my feeding goal, if I do.”

“Is this what others call discomfort? Maybe I’m just a crier.”

“I would give birth over and over again if I could avoid the first month of breastfeeding.”

“I will not show on my face how badly it hurts because I don’t want my baby to get a complex, so I will smile as he piranha chomps. Even as my eyes stream with silent tears.”

No doubt at some point these mother’s spoke to another mother, perhaps a close friend. When good intentioned friends offer support it can often be in the form of cheerleading to push on or to stop breastfeeding all together. While we do need our cheerleaders and those who give us permission to let something go, these are not always helpful for the mother who wants to breastfeed but is in pain. When I shared these examples with Cat, she comically pointed out that, “Those are two really crappy options. That you need to give up on breastfeeding or have to suffer.” Cat expanded further, “It is a misconception that pain with breastfeeding is normal. Pain is common with breastfeeding, but it’s not normal.” She goes on to say that if there is pain, then something is wrong and getting help on how to fix it is both important and time sensitive.

Dearest mothers,

If you can relate to any of these real examples. Please find a lactation consultant- one you trust. It may mean firing and hiring a new one if you do not feel the right fit. The end of this article includes some resources for finding nursing support after hospital discharge. Many inpatient lactation consultants are not available to provide the post hospital support that mother’s need and deserve.

With Sincere Concern,

Barbara

If you are feeling determined to maintain the mantra of “No Pain, No Gain”- Let us try to convince you otherwise

I believe Cat’s quote is worth repeating. “Pain is common, but not normal.” The no pain-no gain mentality is damaging. With this mentality, mothers are trying to tough it out and push their way through breastfeeding. This is not only depleting your motherhood experience, but breastfeeding pain can have a negative impact on you, your milk supply, and even your baby. Cat explained that, “Another reason that [breastfeeding] pain is bad, is that pain communicates via nerves to the rest of the body. So instead of your body saying ‘hey let’s make all these great hormones to make plenty of milk and help you and your baby relax’, you are having an increase in cortisol. For some, repeated pain can even inhibit the hormones that assist in the milk ejection reflex.” She also passed along some helpful advice that she learned from one of her colleagues, “What’s good for baby, is good for mama. What’s good for mama, is good for baby.” To me, this advice reaches beyond the breastfeeding experience. But for this article we will keep our focus to nipple care.

How to determine normal sensation from pain

We are told many times over that nipple pain with breastfeeding is not “normal” and that breastfeeding “shouldn't hurt”. But in the hazy days (months) post birth it’s easy to get hung up on sensation, versus discomfort, versus pain. And who knows what’s normal now that the world has a tiny new human in it? Because pain is subjective, and varies between people, it can feel difficult to label. So when I say you should not have any pain with nursing what-so-ever, it doesn’t feel as clear cut as it sounds.

I asked Cat what the difference was between pain and discomfort. “Discomfort with breastfeeding sounds like: I wish this was more comfortable. I feel it, my attention is drawn to what’s happening. It doesn’t hurt, but I wish it was more comfortable.” She says with discomfort you are not dreading the next feed, but when baby latches on you’re like, “ooh that could be better.” She goes on to share that discomfort in the first 2-3 weeks of breastfeeding is normal especially if you have extra fluid in your breasts from a medicalized birth.

Pain on the other hand, shows itself more visibly. “I can usually see pain on someone. It can be breath holding, tight lifted shoulders, or a squished face.” Cat shared that even when these are overt, many clients still deny they are in pain. This is especially common if they identify as a tough person or have the expectation that nursing will be uncomfortable. “If you can’t speak or have to grab onto something to bear the breastfeeding, you are for sure in pain. And probably at an 8-9-10 on the pain scale.” Gritting your teeth, wincing, or crying- also all signs of severe pain and that you need help ASAP.

Then there's the middle of the road pain. “You can experience what I call middle of the road pain if you’ve had prior poor latching and nipple trauma that is in the healing process.” This brief discomfort or pain can also be due to a history of repetitive painful nursing or recurrent nipple trauma. Cat described that what can happen is really intense pain at the beginning of the feed which dissipates quickly as the feed goes on. “When I say dissipates, I mean if you count to five the pain should be gone and you should feel comfortable again.”

Normal comfortable breastfeeding without any curveballs, does not include pain. It’s expected that after the first 2-3 weeks of settling into breastfeeding it should feel comfortable and pretty routine. Cat went on to clarify, “So when I’m talking about comfortable; I mean that most women, not all, but most women don’t even feel it.” It’s not that you can’t feel the rhythmic tug, but there is no discomfort and your attention could easily go elsewhere. If we don’t feel comfortable, that’s when we need to assess the situation to find the underlying cause. And, just a little side note: if the latch “looks good” to a professional but still feels bad- we need to keep digging. Sometimes it’s a very simple position and latch adjustment, other times it takes getting to the right person for the answer. But the answer is never that if it looks good but feels painful it’s fine.

Give it a number

Another helpful tool Cat suggests is giving it a number. This can be helpful when trying to determine where you land more objectively. Here is a helpful guide for self rating on a scale of 1-10 according to Cat:

0:   You don’t even feel much, but baby is eating and growing. You could multitask and go get that Amazon package on the front porch without breaking the latch.

1:   You feel it, and oh that’s what everyone says about the gentle tug.

2:   Ya feel it, and it’s kind of uncomfortable.

3:   This is discomfort. Meaning it’s uncomfortable, but you could do it all day long  if you had to.

4:   Four or greater has crossed into pain territory. In Cat’s experience anything four or above is frequently correlated with recurring nipple trauma or insufficient  milk transfer.

5:   Pain

6:   More Pain

7:   Worse Pain

8:   Now we are in the severe pain zone- if you haven’t already please get help

      ASAP.

9:   Severe Pain

10: Ten is the most severe. Cat said at this level, “You consider tossing the baby across the room and cutting off your breasts because you can’t live life with this pain. It’s really extreme.”

This article is specially about nipple pain, but Cat reminded me that there are also breast pain issues that can arise. Examples would be mastitis or plugged ducts. In Cat’s experience, “Plugged ducts, poor latch, and painful nipples tend to travel all together.” It’s a domino effect in which poor latch causes nipple trauma and insufficient milk removal, which can set the stage for plugged ducts and/or mastitis.

Pain with pumping

No. Just no. Cat stressed, “Pain with pumping is bad. Not good. Need Help. It is a red flashing light in your face telling you to call a lactation consultant right now”.  We forget that breast pumps are medical devices because they are readily given out to everyone without proper fitting, instruction, or lactation support. When it comes to personal pumps, “First, there’s a lot of people pumping with the wrong flange size which causes either rubbing or sucking too much of the areola into the flange. And that can be painful. Second, too strong of a suction can cause nothing to come out.” This is because pain can be a barrier to milk let-down. She also shared that many pumping mothers are trying to breastfeed and pump. “Your nipples are not ever getting a break or feeling better for a second.” Finding the right flange size is its own topic, but I do think it’s important to share that if your nipples are inflamed from pain or damage, they may require a different flange size than a healed nipple.

How to treat your ladies (AKA your nipples)

For those experiencing pain and especially those with visible nipple damage there are some options for soothing them until you get help. And please do get help as soon as possible. Soothing wounded nipples will not target the root cause of why your nipples became damaged in the first place. No amount of nipple care products will fix the underlying culprit and you will likely be caught in a vicious cycle of pain, damage, band-aid solutions. Okay now, on with the nipple care!

Cat, who has seen over 1,000 nipples in her practice, shared with us her top nipple care recommendations. In her experience, “Some mother’s, usually those with more melanin in their skin or who have darker nipples, need to moisturize their nipples to avoid dry, chapped, or flakey nipples.” If you are experiencing dryness, a nipple balm or quality edible oil, such as coconut oil or olive oil can help. “I’m not a fan of Lanolin”, Cat said. Partially because she has seen a handful of Lanolin allergies in babies, “and also because things that coat the nipple [sitting on top of the skin without absorbing] have the potential to trap bacteria and yeast.” Mohammadzadeh, Farhat, and Esmaeily (2005) also note the history for potential allergenic response to lanolin in their research article on postpartum sore nipple intervention. 

When choosing what to put on your nipples, it’s important to keep in mind that your baby will be ingesting some amount of it.  “I find that coconut oil absorbs into the skin fairly quickly compared to other options which is not only practical but also results in less nipple residue by the next feed.”

Now, “if I am just having sensitive, tender nipples; then covering them with a breast pad, being gentle with yourself, not wearing too tight of a bra [etc.] can manage it on its own.” Cat said gentle handling can go a long way for those mildly uncomfortable. 

On the other hand, if there’s nipple damage, treatment should be managed by a professional. “In the meantime, I really like a hydrogel. It’s usually my go-to. That’s what I would use if I had nipple damage until I could get to see a lactation consultant.” In her practice, Cat has used and recommended both the Medela hydrogels or Lansinoh Soothies Gel Pads. “I see the quickest healing for nipple damage when somebody uses one of those products consistently between nursing or pumping. It usually only takes about 2-3 days to heal when using one of these products if you’ve managed whatever was causing the damage.” Dodd and Chalmers (2003) compared hydrogel to lanolin and found hydrogel to be more effective for pain management and without side effects.  As an added bonus, those participants were able to stop treatment faster. To use a hydrogel, follow the brand specific directions.

Mohammadzadeh et al. (2005) compared sore nipple care using lanolin versus breast milk and found that sore nipples had better healing time with breast milk compared to lanolin. But, they did not find a significant difference between breast milk and nothing at all. Most importantly, mother’s in all three groups received proper positioning and latch support during the study. “This study shows the breast-feeding technique correction is the basis of sore nipple treatment” (p.1234).  The researchers suggest that if you are going to put something on your nipples, “breast milk has the advantage of being convenient, inexpensive, and nonpharmacologic (p.1234). They also point out that use of breast milk eliminates additional trauma from having to wash your nipples before nursing your baby. If you want to give breast milk a try, put a few drops of your expressed breast milk on your nipples after the feed, and allow them to air dry before covering them with clothing.

Nippple shields are best used as a short term tool under the guidance of a professional. Cat says she’s a fan of nipple shields if it helps a mom continue to feed their baby at the breast until the issue can be resolved. However, “I wouldn’t buy a nipple shield without a lactation consultant’s guidance. They can show you what size to get, what type to get, and how to use it properly.” Remember that normal nipple stimulation is part of the cycle that builds and stimulates milk supply, so wearing a barrier such as a shield over your nipples should only be introduced with a plan that includes weaning off of the nipple shield. Additionally, a nipple shield changes the sensory input and latch for a baby. It goes without saying that there are outliers to the norm, that require longer term use of certain feeding tools for medical reasons. These are not included in this article, which is focused on nipple pain specifically.

Face-to-face evaluations are ideal for nipple pain

Cat and I both agree that for nipple pain evaluations, in person consults are ideal. Otherwise you just can’t see as much or help in a hands-on way. In Cat’s opinion, “There are certain topics that are great for virtual consults. Nipple pain is not one of them.” She says it’s very helpful from a diagnostic standpoint to see things in person. “Sometimes I need to be able to touch or see something at a certain angle or in a certain light to know what we are dealing with; and you just can’t do that virtually.”

Standard health insurance should cover lactation consultant visits. Finding a consultant with clinical experience for post hospital discharge is where asking friends, family, or medical professionals for a referral may prove efficient. The Lactation Network is an online resource that will check your insurance coverage and link you to a local lactation consultant (unfortunately they don’t work with all insurances). The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federally funded program that employs lactation consultants (WIC is available to those below certain income levels only). And of course, there is also the internet search (to me this is the most daunting option when sleep deprived but choose your own adventure).

If after reading this you are still not quite sure, then you would likely benefit from a consultation to gain support or peace of mind. You and your nipples deserve the best, with less stress:)

Interviewed specialist:

Catherine “Cat” Halek, IBCLC. CatHalekIBCLC.com

References:

Dodd, V., & Chalmers, C. (2003). Comparing the use of hydrogel dressings to lanolin ointment with lactating mothers. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN, 32(4), 486–494. https://doi.org/10.1177/0884217503255098

Mohammadzadeh A, Farhat A, Esmaeily H. The effect of breast milk and lanolin on sore nipples. Saudi Med J. 2005 Aug;26(8):1231-4. PMID: 16127520.

Written by: Barbara Nelson, MA, CCC-SLP, CLC, a shorter version was originally posted on BabyBoldly.com