Persistent Pain with Breastfeeding

Publication Date: January 1, 2016
Last Updated: March 14, 2022


Nipple damage

Abnormal latch/suck dynamic

Suboptimal positioning
Often cited as the most common cause of sore nipples, suboptimal positioning of the infant during a breastfeed can lead to a shallow latch and abnormal compression of the nipple between the tongue and palate. (, )
(II-2, III, III)
Disorganized or dysfunctional latch/suck
The ability of an infant to properly latch and breastfeed is dependent, among other factors, on prematurity, oral and mandibular anatomy, muscle tone, neurological maturity, and reflux or congenital abnormities, as well as maternal issues such as milk flow, breast/ nipple size, and engorgement. Infants who are premature, have low oral tone, and reflux/aspiration or congenital anomalies that may be at risk for disorganized suckling. (III)
Evaluation of the infant for difficulty coordinating sucking and swallowing may be indicated.
Ankyloglossia (tongue-tie)
Ankyloglossia, recognized in 0.02– 10.7% of newborns, involves the restriction of tongue movement (projection) beyond the lower gum due to an abnormally short or thickened lingual frenulum. Poor tongue movement may lead to difficulty attaining a deep latch and is frequently associated with maternal nipple pain. (, )
Factors such as breast fullness, milk flow, nipple size and elasticity, infant palate shape, and height affect the impact of ankyloglossia on the mother’s nipples. Not all infants with ankyloglossia cause problems for the breastfeeding dyad.
(II-3, I)
Infant biting or jaw clenching at the breast
Infants who bite or clench their jaws while breastfeeding may cause nipple damage and breast pain. Conditions that may lead to this behavior include clavicle fractures, torticollis, head/neck or facial trauma, mandibular asymmetry, oral defensiveness or aversion (e.g., infants force-fed with ridged nipples [teats]), tonic bite reflex, nasal congestion, a response to an overactive milk ejection reflex, and teething. (III)
Breast pump trauma/misuse
Because of the widespread use of breast pumps in many countries and the variability of consumer education, literacy, and support, there is significant potential for harm from breast pump use. In a survey in the United States, 14.6% of 1844 mothers reported injuries related to pump use. (II-2)
Injury may be either a direct result of pump misuse or failure or an exacerbation of pre-existing nipple damage or pathology. Observing the mother while using the breast pump may clarify the cause(s) of trauma (i.e., improper flange fit, excessive high-pressure suction, or prolonged duration).


Breast dermatoses such as eczematous conditions or, less commonly, psoriasis and mammary Paget’s disease may be responsible for nipple and/or breast pain in lactating women. Any of these conditions may be secondarily infected with Staphylococcus aureus, causing impetiginous changes such as weeping, yellow crusting, and blisters. (III)

Eczematous conditions

These conditions can affect any skin, but are commonly seen on and around the areola in breastfeeding women. Attention to the distribution of skin irritation and lesions may help identify the underlying cause/ trigger. Eczematous rashes vary considerably.
  • Atopic dermatitis (eczema): This condition occurs in women with an atopic tendency and may be triggered by skin irritants and other factors such as weather and temperature change.
  • Irritant contact dermatitis: Common offending agents include friction, infant (oral) medications, solid foods (consumed by the infant), breast pads, laundry detergents, dryer sheets, fabric softeners, fragrances, and creams used for nipple soreness.
  • Allergic contact dermatitis: Common offending agents include lanolin, antibiotics (topical), chamomile, vitamins A and E, and fragrances.


Flares can occur during lactation sporadically (usually 4–6 weeks after the birth or as a response to skin injury (koebnerization) from latch, suckling, or biting. (III)

Mammary Paget’s disease (Paget’s disease of the nipple)

More common in postmenopausal women (60–80% of cases), but observed in younger women, this slow growing intraductal carcinoma mimics eczema of the nipple. A unilateral, slowly advancing nipple eczema that begins on the face of the nipple is unresponsive to usual treatment, persists longer than 3 weeks, or is associated with a palpable mass should increase suspicion for Paget’s disease. Other findings consistent with the diagnosis are ulceration, moist erythema, vesicles, and/or granular erosions. (II-2)
Skin biopsy and referral for specialist treatment are necessary.


Although a number of studies have attempted to identify what, if any, microbe may cause persistent nipple/breast pain during lactation, the roles of bacteria and yeast remain unclear.
  • Both Staphylococcus sp and Candida can be found on nipples and in breast milk of women with no symptoms.
  • Additional theories suggest a role for virulence traits that make detection and elimination of potentially causative microbes extremely difficult. These include biofilm formation, consisting of bacteria alone.
(, )
(III, III animal/ in vitro studies)
  • or mixed species of Staphylococcus sp and Candida,
(III, III animal/in vitro studies)
  • as well as intracellular infection by small colony variants.
(animal/ in vitro studies)


Superficial bacterial infection in setting of skin trauma
Infection secondary to damaged skin, especially around the nipple–areolar complex, is a common occurrence. Impetigo and cellulitis may occur alone or concurrent with an underlying dermatitis. (, )
Bacterial dysbiosis and lactiferous duct infection
Bacterial overgrowth combined with biofilm formed by bacteria (possibly in conjunction with Candida sp) may lead to narrowed lactiferous ducts and inflamed epithelium. (III)
A relatively constant, dull, deep aching pain in both breasts is characteristic of this inflammation as well as tenderness to palpation on breast examination. (II-3)
Milk flow and ejection cause increased pressure and sharp shooting pain during milk ejection and breastfeeding. Recurrent blocked ducts, engorgement and oversupply, and nipple cracks and fissures may also be associated with this condition. (III)
Factors that are thought to predispose a woman to developing dysbiosis and ductal infection include the following:
  • History of similar symptoms during prior lactations
  • Previous episodes of acute mastitis
  • Nipple cracks or lesions
  • Recent treatment with antifungals and/or antibiotics
Judicious use of antibiotics is encouraged and so the workup should include the following:
  • Nipple and breast milk cultures
  • Wound culture if crack/fissure present
(, )

Candida infection

The association of Candida with nipple/breast pain remains controversial.
  • Human milk does not inhibit growth of Candida in fungal cultures.
  • Some authors have not found a correlation between symptoms and Candida sp identification,
(II-2, II-2)
  • while others have,
(, )
(II2, II-2)
  • including one study using PCR technology.
Factors that are thought to predispose a woman to develop Candida infection include the following:
  • A predisposition to Candida infections
  • Thrush in the infant’s mouth or in the diaper (nappy) area (monilial rash)
  • Recent use of antibiotics in mother or child
(, )

Viral infection

Herpes simplex
  • Herpes simplex infection (HSV) that either predates lactation or is acquired from a breastfeeding child can infect the breast or nipples. HSV infection of the breast or nipple skin can result in neonatal transmission during breastfeeding, putting the infant at significant risk for morbidity and mortality.
  • Culturing the blisters to confirm the diagnosis is optimal. Mothers should not breastfeed on the affected side and expressed milk should be discarded until the lesions have healed.
Herpes zoster
Herpes zoster may erupt along a dermatome that involves the breast. The rash often starts close to the spinal column on the posterior thorax and migrates peripherally along the dermatome toward the breast. Exposure to these lesions can result in chicken pox (varicella zoster) in unimmunized infants. In most situations, it should be treated similarly to a Herpes simplex infection and women should not breastfeed or use expressed breast milk from an affected breast until the lesions have healed. Infants may be given Zoster immunoglobulin if appropriate. (, )


Vasospasm presents with blanching or purple color changes of the nipple accompanied by sharp, shooting, or burning pain.
Women may report pain after breastfeeding, on getting out of a warm shower, or in the setting of cold temperatures, such as in the frozen food section of the grocery store. Symptoms may be bilateral or unilateral in the setting of current or past nipple trauma. Some mothers report a history of cold hands and feet, such as needing to wear socks to sleep or gloves in mild weather, or a formal diagnosis of Raynaud’s syndrome. Women with a history of connective tissue disorders such as rheumatoid arthritis or prior diagnosis of Raynaud’s phenomenon are at risk for vasospasm of the nipple.
(II-3, II-3)

Allodynia/functional pain

Allodynia is defined as sensation of pain in response to a stimulus, such as light touch, which would not normally elicit pain. Breast allodynia can occur in isolation or in the context of other pain disorders, such as irritable bowel syndrome, fibromyalgia, interstitial cystitis, migraines, temporomandibular joint disorders (TMJ), and pain with intercourse. Taking a careful history to assess for other pain disorders is important for informing treatment.
  • In the chronic pain literature, pain disorders are associated with catastrophization, reduced psychological acceptance, depression, and anxiety, and these psychological factors are associated with diminished treatment response.
  • This literature suggests that mothers who present with breast allodynia, particularly in the setting of other chronic pain syndromes, may benefit from psychological therapy designed to treat chronic pain, given findings from studies of other chronic pain conditions.

Other etiologies

Recurrent plugged (blocked) ducts

Plugged (blocked) ducts are very common among breastfeeding women and can be associated with persistent pain. Reducing an excessive milk supply is paramount in reducing plugged ducts. Reliance on expressing rather than breastfeeding can increase the risk of blockages due to insufficient breast drainage. If there is redness, an infection should be ruled out, while an abscess should be ruled out if symptoms persist for more than 3 days. (, )

Maternal oversupply

Oversupply of milk can cause persistent breast and nipple pain. Mothers will typically complain of sharp breast pain or dull breast aching and breast tenderness when their breasts are quite full. Oversupply is very common in the first few weeks postpartum as the body adapts to the infant’s milk supply needs. Milk expression should be minimized because it can lead to continued oversupply issues.

Recommendation Grading




Persistent Pain with Breastfeeding

Authoring Organization

Publication Month/Year

January 1, 2016

Last Updated Month/Year

June 9, 2022

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

To provide evidence-based guidance in the diagnosis, evaluation, and management of breastfeeding women with persistent nipple and breast pain.

Target Patient Population

Breastfeeding women experiencing pain

Inclusion Criteria

Female, Adult

Health Care Settings

Ambulatory, Emergency care, Home health, Hospital, Outpatient

Intended Users

Nurse midwife, nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management

Diseases/Conditions (MeSH)

D001942 - Breast Feeding, D017443 - Skin Diseases, Eczematous, D011565 - Psoriasis


lactation, Breastfeeding, Lactation, painful breastfeeding

Supplemental Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
January 1, 1986
Literature Search End Date
December 31, 2016
Description of External Review Process
Yes. The draft protocol is peer reviewed by individuals outside of contributing author/expert panel, including specific review for international applicability. The Protocol Committee's sub-group of international experts recommends appropriate international reviewers. The Chair and/or protocol resource person institutes and facilitates this process. Reviews are submitted to the committee Chair and resource person. The contributing author/expert panel and/or designated members of protocol committee work to amend the protocol as needed. The draft protocol is submitted to the Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. The Chair, resource person and protocol contributor(s) amend the protocol as needed. Following all revisions, the protocol has the final review by original contributor(s) to make final suggestions and ascertain whether to maintain contributing authorship. The final protocol is submitted to the Board of Directors of ABM for approval. A two-thirds majority of Board members' positive vote is required for final approval.
Specialties Involved
Family Medicine, Obstetrics And Gynecology, Pediatrics, Neonatology And Perinatology, Pediatrics
Description of Systematic Review
Yes. Expert Consensus from systematic reviews with evidence tables.
List of Questions
Yes. To provide evidence on the diagnosis, evaluation and management of breastfeeding women with persistent nipple and breast pain.
Description of Study Criteria
Yes. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English. Exclusion: acute mastitis, recurrent mastitis
Description of Search Strategy
Yes. See methods below.
Description of Study Selection
Yes. Consensus-based. Led by Chair.
Description of Evidence Analysis Methods
General Methods An initial search of relevant published articles written in English in the past 75 years in the fields of medicine, psychiatry, psychology, and basic biological science is undertaken for a particular topic. Once the articles are gathered, the papers are evaluated for scientific accuracy and significance. Specific Methods The search was conducted using PubMed. In addition, a search of the original references and literature searches (from the previous version) were used to look for additional supportive articles. The time frame for the literature search was January 1986 to December 2016. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English. The specific search terms used were: breastfeeding, primary care, physician, pediatrician, obstetrician, family physician.
Description of Evidence Grading
U.S. Preventative Services Taskforce Recommendations. An expert panel is identified and appointed to develop a draft protocol using evidence-based methodology. An annotated bibliography (literature review), including salient gaps in the literature, is submitted by the expert panel to the Protocol Committee.