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ABM Clinical Protocol #26: Persistent Pain with Breastfeeding


Abstract

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Purpose

TO PROVIDE EVIDENCE-BASED GUIDANCE in the diagnosis, evaluation, and management of breastfeeding women with persistent nipple and breast pain.

Definitions

Among breastfeeding women, it can be challenging to distinguish pathologic pain from discomfort commonly reported in the first few weeks of breastfeeding. In this protocol, we define persistent pain as breastfeeding-associated pain lasting longer than 2 weeks. We are not addressing acute or recurrent mastitis as it is covered in ABM Protocol #4 Mastitis, Revised March 2014.

Background

Pain and discomfort associated with breastfeeding are common in the first few weeks postpartum. (II-2) (Quality of evidence [levels of evidence I, II-1, II-2, II-3, and III] is based on the U.S. Preventive Services Task Force Appendix A Task Force Ratings and is noted in parentheses.) Since this is a common cause for early breastfeeding cessation, the mother–baby dyad should be evaluated by a lactation specialist. Beyond this early period, reports of pain generally decline, but as many as one in five women report persistent pain at 2 months postpartum. While initial discomfort with early latch may be considered physiological, pain severe enough to cause premature weaning should not. In one study of 1323 mothers who stopped breastfeeding during the first month postpartum, 29.3% cited pain and 36.8% identified sore, cracked, or bleeding nipples as an important reason. Several authors have found a relationship between breastfeeding-associated pain and postpartum depression. (II-2, III)

These studies suggest that breastfeeding-associated pain is linked with significant psychological stress; thus, mothers presenting with pain should be evaluated for mood symptoms and followed closely for resolution or treatment as needed. Timely identification and appropriate management of persistent breastfeeding-associated pain are crucial to enable women to achieve their infant feeding goals.

Although the literature on persistent nipple and/or breast pain is limited and the differential diagnosis is extensive, a number of etiologies and management strategies are emerging, most of which are based on expert opinion ( Table 1 ). The highly individual nature of the breastfeeding relationship combined with the complexity of the lactating breast, including its anatomy, physiology, and dynamic microbiome, adds challenges to the clinicians’ efforts.

Table 1
Conditions, Symptoms, and Management of Persistent Nipple/Breast Pain
Condition Symptoms/signs Management
Infant ankyloglossia Ongoing nipple damage and an infant with restricted tongue movement due to a tight lingual frenulum

  • Frenulotomy/frenulectomy using scissors or laser by a trained health professional (I, II-2, 1).

Breast pump trauma/misuse Nipple or soft tissue injury/bruising

  • Observe a pumping session.

Eczematous conditions

  • Erythematous skin Acute episodes: blisters, erosions, weeping/oozing, and crust formation Chronic eruptions: dry, scaling, and lichenified (thickened) areas.

  • Lesions can be pruritic, painful, or even burning.

  • Reduce identifiable triggers.

  • Apply an emollient

  • Apply low/medium-strength steroid ointment twice daily for 2 weeks (immediately after a breastfeed to maximize contact time before the next breastfeed).

  • Use second-generation antihistamines for pruritus.

  • Consider a short course (less than 3 weeks) of oral prednisolone or prednisone in resistant cases.

Psoriasis

  • Erythematous plaques

  • Clearly demarcated borders

  • Fine silvery overlying scale

  • Apply an emollient. (I)

  • Apply low/medium-strength steroid ointment twice daily (immediately after a breastfeed) as first-line treatment.

  • Avoid prolonged topical steroid use to prevent thinning of the nipple epithelium and delayed healing.

  • Topical vitamin D creams or gels and phototherapy (UVB) are safe to use.

  • Immunomodulating agents should not be used on the nipple due to the risk of infant oral absorption.

Superficial bacterial infection associated with skin trauma

  • Persistent cracks, fissures

  • Weeping, yellow crusted lesions especially in conjunction with other skin conditions

  • Cellulitis

  • Topical mupirocin or bacitracin ointment

  • Oral antibiotics such as a cephalosporin or penicillinase-resistant penicillin (I)

Bacterial dysbiosis

  • Bilateral dull, deep aching bilateral breast pain±burning

  • Pain during and after breastfeeds

  • Breast tenderness (especially lower quadrants)

  • Consider oral antibiotics such as a cephalosporin, amoxicillin/clavulanate, dicloxacillin, or erythromycin for 2–6 weeks.

  • Indirect evidence to support that breast probiotics may assist the restoration of normal breast flora.

Candida infection

  • Pink nipple/areola area

  • Shiny or flaky appearance of the nipple

  • Nipple pain out of proportion to the clinical findings

  • Burning nipple pain and pain radiating into the breast

  • Topical azole antifungal ointment or cream (miconazole and clotrimazole also inhibit the growth of Staphylococcus sp ) on nipples.

  • Nystatin suspension or miconazole oral gel for infant’s mouth.

  • Gentian violet (less than 0.5% aqueous solution) may be used daily for no more than 7 days. Longer durations and higher concentrations may cause ulcerations and skin necrosis.

  • Oral fluconazole (200 mg once, then 100 mg daily for 7–10 days) may be used for resistant cases.

  • Before prescribing fluconazole, review all maternal medications and assess for drug interactions. Do not use fluconazole in combination with domperidone or erythromycin due to concern of prolonged QT intervals.

Herpes simplex

  • Small, clustered exquisitely tender vesicles with an erythematous, edematous base

  • Solitary small ulcer

  • Axillary lymphadenopathy

  • Oral antiviral therapy such as acyclovir or valacyclovir should be used in doses recommended for treating primary or recurrent Herpes simplex infections.

  • Prevent contact between lesions and the infant.

  • Avoid breastfeeding or feeding expressed breast milk to infants from an affected breast/nipple until the lesions are healed to prevent neonatal herpes infection.

Herpes zoster Pain and vesicular rash following a dermatome

  • Oral antiviral therapy such as acyclovir or valacyclovir should be used in doses recommended for treating Herpes zoster

  • Avoid breastfeeding or feeding expressed breast milk to infants from an affected breast/nipple until the lesions are healed

Vasospasm Shooting or burning breast pain with blanching and other color changes (purple or red) of the nipple associated with pain

  • Warmth (compresses, heat pads) following a breastfeed or whenever the mother experiences pain.

  • Avoid cold on the breasts and nipples.

  • Nifedipine 30–60 mg sustained release daily or immediate release 10–20 mg thrice a day for 2 weeks initially if pain persists. (I) Longer treatment may be necessary for some women.

Allodynia/functional pain

  • Pain to light touch

  • Clothing brushing against the nipple causes excruciating pain, or that drying their breasts with a towel is painful

  • History of other pain disorders

  • Round-the-clock nonsteroidal anti-inflammatory medications.

  • Propranolol starting at 20 mg thrice a day if not responding. (I based on treatment of TMJ pain)

  • Antidepressants may also be effective (see ABM Protocol #18 Use of Antidepressants in Breastfeeding Mothers).

  • Consider evaluation for trigger points and treatment with massage therapy.

Recurrent plugged (blocked) ducts Localized tender cord of tissue, usually a few centimeters in size, which is usually reversible with expression

  • Heat, direct pressure, and milk expression usually offer relief

Oversupply Breast fullness, milk leakage

  • Stop any overstimulation by not pumping or hand expressing between breastfeeds. Only hand express or pump in lieu of breastfeeding or if breasts are overfull before bedtime.

  • Block feeding is a strategy that many lactation consultants endorse, but is controversial with limited evidence. This involves feeding from one breast for a block of time, typically 3 hours. The other breast rests, allowing the fullness to provide feedback to the breast to reduce milk supply.

  • Medication such as pseudoephedrine and sage extract have been used to reduce milk supply as has the oral contraceptive pill containing estrogen.

Data to support management of persistent breastfeeding-associated pain are limited and based largely on expert opinion. Recommendations below are therefore based on Level III evidence, unless otherwise indicated. TMJ , temporomandibular joint pain.

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