Persistent nipple pain is one of the leading reported by mothers for ceasing exclusive breastfeeding.1 An evaluation of the prevalence and factors associated with the occurrence of cracked nipples in the first month postpartum revealed that the factors significantly associated with the occurrence of cracked nipples included poor breastfeeding technique; breast engorgement; cesarean section; use of a feeding bottle; and higher maternal education level.2 In an assessment of breastfeeding problems in the 1st postnatal week, their predictors and impact on exclusive breastfeeding rate at 6 months, nearly 89% of the mother-newborn dyads had one or more breastfeeding problems before discharge. Positioning and attaching the infant to the breast was the leading factor (88.5%). During follow-up, the most common breastfeeding problem was poor positioning and attachment (70.3%).3 Improper latch to the breast has been shown to be associated with sore as well as macerated/traumatized nipples.4

A study evaluated the relationship between various aspects of optimal breastfeeding such as the positioning of the baby at the mothers breast, the positioning of the babys head and mouth, the breastfeeding dynamic and the latching process. In all, 95 healthy postpartum breastfeeding mothers who sequentially reported sore nipples within ten days of giving birth to healthy, term babies were recruited in the study. More optimal latching process behavior of the baby (rooting, gaping, sealing, and sucking behaviour) appeared to be related to lower levels of reported pain.5

Correct positioning and latch are therefore one of the key treatment options advised for dry, cracked, sore and painful nipples. Improvement is often seen by the simple improvement of the infant’s latch.4 Correction of positioning and attachment represents the most common experience-based recommendation for treatment of nipple pain. When performed within the first week of birth, it is associated with a longer duration of breastfeeding and fewer breastfeeding problems (including sore nipples).1

A healthcare professional must assess the needs of each individual mother and encourage and educate mothers to correctly and safely position and attach their baby to the breast. Appropriate positioning and attachment can significantly reduce the challenges of reduced milk supply and soreness. Often, achieving an optimal attachment at the breast is the only treatment required for many breastfeeding challenges.6

There are several different positions that mothers can use to breastfeed their babies, including laid back breastfeeding or biological nurturing, cross cradle hold, cradle hold, rugby or football hold and side lying position. A healthcare professional should assist a mother in finding a comfortable breastfeeding position. There is no ‘one size fits all’ approach to positioning and attachment of baby to the breast.6

Correct positioning and attachment^6,7

Mother – Mother should be relaxed and comfortable and her back, neck, arms and feet should be well supported.

Baby - The baby should be aligned close to his mother, and baby’s hips and feet should be supported; mother should hold her baby close, supported and facing the breast, and should support the baby’s neck, back and shoulder thus allowing the baby to be free to tilt his head back easily.

Attachment – An angle of ‘nose to nipple’ helps the baby get to the breast. When the nipple is between his upper lip and nose, the baby feels the nipple and smells the breast milk. As the baby’s chin touches the breast first, he tilts his head back and opens his mouth wide to attach on to the breast. The baby should come closely onto the breast and the mother’s nipple and areola should be deep in the baby’s mouth ideally at the junction of the hard and soft palate or the comfort zone with his nose free to breathe. So, the baby’s mouth has to be wide open; an angle of nose to nipple with head slightly tilted back; chin first; shoulders, hips, legs and feet pulled in close; a gentle push on baby’s shoulders at latch to move the nipple into the comfort zone. The baby’s lower lip should be turned out; top lip should cover nearly all of the areola; more areola should be visible above rather than below the baby’s mouth.

References

1. Kent JC, Ashton E, Hardwick CM, et al. Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments. Int J Environ Res Public Health. 2015 Oct; 12(10): 12247–12263.
2. da Silva Santos KJ, Santana GS, de Oliveira Vieira T, et al. Prevalence and factors associated with cracked nipples in the first month postpartum. BMC Pregnancy Childbirth. 2016; 16: 209.
3. Suresh S, Sharma KK, Saksena M, Thukral A, et al. Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: experience in a tertiary care centre in Northern India. Indian J Public Health 2014;58:270-3.
4. Walker M. Are There Any Cures for Sore Nipples? Clinical Lactation 2013;4(3), http://dx.doi.org/10.1891/2158-0782.4.3.106.
5. Blair A, Cadwell K, Turner-Maffei C, Brimdyr K. The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples. Breastfeed Rev. 2003 Jul;11(2):5-10.
6. Positioning and Attachment of Baby to the Breast - Fact sheet for Health Care Professionals. Available from: https://www.breastfeeding.ie/Uploads/Positioning-and-attachment-of-baby-to-the-breast.pdf.
7. Breastfeeding - the best start for your baby. Available from: https://www.unicef.org/pacificislands/Breastfeeding_BEST_START_FOR_YOU_BABY_web.pdf.