It was 3:00 pm when Karen (a grandmother, mother, nurse, lactation consultant, and friend) telephoned to see if I could add any strategies to those she had already tried in an effort to ease the breastfeeding pain of her daughter, Jenny.

A delightful, twenty-something, first time mom, Jenny had given birth to a healthy, seven-pound baby girl. Like many moms-to-be, Jenny had read numerous books on breastfeeding and was confident that breastfeeding would be easy.

“After all,” she told her mom, “breastfeeding is natural.”  

By day five Jenny was beginning to wonder if generations of breastfeeding mothers had all lied. “Women have been breastfeeding for years,” cried Jenny. “Why doesn’t anyone tell you that it hurts?”

Many health care providers avoid discussing even the remote possibility of pain.

“We don’t want to discourage new moms from breastfeeding.”

“Breastfeeding shouldn’t be painful if a mother and her baby are doing everything right.”

“A little bit of pain is a small price to pay for giving your baby the best.”

“Mothers just need to get accustomed to the sensation that breastfeeding provides.”

Given Jenny’s experience, perhaps it’s time for a candid discussion of breastfeeding and pain.

Examining the evidence
Pain while breastfeeding has been the focus of numerous studies. In 1950, Newton and Newton reported that more than 80 percent of breastfeeding women experienced nipple pain in the early postpartum period, citing skin health, dietary deficiencies, estrogen deficiencies, and changes in temperature and sunlight as possible causes. Others have suggested that nipple pain may be associated with improper positioning, flat or inverted nipples, frequency or duration of feedings, use of nipple shields, and improper use of breast pumps. DeCarvalho and colleagues found no correlation between the frequency or duration of feedings and nipple soreness during the first 10 days of breastfeeding. Esperance found that only three of sixteen variables (flat and inverted nipples and frequency of breastfeeding) were negatively associated with nipple pain. Prenatal breast and nipple preparation was among the 13 factors unrelated to soreness. Morland-Schultz and Hill conducted a systematic review of the literature in 2004 and concluded:  

• Knowledge of correct positioning and latch was the most effective strategy for decreasing the incidence of nipple pain.
• No one topical agent yielded better results than another in relieving nipple pain.
• Women would benefit from anticipatory guidance regarding the high incidence of early postpartum nipple pain.

Pain happens
According to Google, there are nearly 100,000 websites with information on breastfeeding and nipple pain. Pain is among the most common reasons mothers give for stopping breastfeeding (not enough milk tops the list). Is Jenny right. Is breastfeeding natural? If the answer is yes, then why is it painful?

Nipple sensitivity may play a role. Nipples are less sensitive if they are consistently exposed to air, sunlight, and friction. In cultures where women are more inclined to cover their breasts, it may take several days or weeks for mothers to become accustomed to the tugging, pulling, or stretching sensation that inevitably occurs with breastfeeding.

Data suggest that poor position or latch is the most common cause of breast or nipple pain. But even when babies are positioned well, mothers can experience soreness, tenderness, or discomfort (pain by any other name is still painful) when the baby latches on to the breast. Usually the pain associated with latch-on lasts only a few seconds. If it persists, it is best to remove the baby from the breast and try again. If the pain continues despite an effective latch, you need to consider other causes such as flat or inverted nipples, breast infection, misuse of a breast pump, or tongue-tie.  

You can measure the quality of your baby’s position and latch by asking yourself the following questions:

• Is your baby facing the breast?  

• Is your baby well supported? 

• Is your baby’s mouth open wide?

• Is your baby’s mouth filled with breast? 

• Is breastfeeding comfortable?

• Can you hear your baby swallow?

If you can answer yes to each of these questions you can be sure your baby is positioned well.

What to expect when you’re breastfeeding
The popularity of “What to Expect When You’re Expecting” shows that many parents want to know before it happens, what might happen, especially if what might happen is likely to happen. When mothers seemingly do everything right, they need to know that breastfeeding can still hurt, nipple damage can still occur, and treatment may be necessary in the form of creams, ointments, antibiotics, nipple shields, or peppermint water. (Note: A study of a group of Iranian women found that the use of peppermint water on the nipples reduced the incidence of pain.) 

In situations like Jenny’s, where the pain is so severe that stopping breastfeeding seems like a good option, you can always interrupt breastfeeding for 24 hours and remove milk from the breasts either by hand or with a breast pump. This will give the nipples a chance to heal and the mom a chance to regroup. The expressed milk can be fed to the baby with a teaspoon, eye dropper, cup, or bottle, whichever the mom prefers. Some mothers worry that using a bottle will create nipple confusion. While there is no clear evidence for nipple confusion, it is best to avoid bottle nipples and pacifiers until you and your baby have learned to breastfeed well. 

Is breastfeeding natural?
You’ll recall that Jenny told her mother that, “breastfeeding is natural.”

Not exactly. Making milk is natural. Breastfeeding (getting it into the baby) is a learned skill that requires patience, practice, and sometimes persistence!

Fortunately the tenderness, soreness, and pain that many mothers experience during the early days and weeks is short-lived. But the benefits of breastfeeding last a lifetime.

Post Script: By day 14 Jenny was on the road to recovery. While it’s true that nearly all babies will learn to breastfeed on their mother’s breasts, sometimes they need to grow into them!