1. Session 11BREAST AND NIPPLE
CONDITIONS

2. Session Objectives:
1. List the points to look for when examining a
mother’s breasts and nipples.
2. Describe causes, prevention and management
of engorgement and mastitis.
3. Describe causes, prevention and management
of sore nipples.
4. Demonstrate through role-play assisting a
mother with breast or nipple conditions.

3. Flat & Inverted Nipples
Mothers can breastfeed with flat and inverted
nipples.
Nipple exercises and breast shells have not
been shown to be effective in correcting
nipples during pregnancy. During the third
trimester, nipple exercises may stimulate
contractions and are therefore discouraged.

4. Strategies for Inverted Nipples
Pumping on low setting with soft flange kit will
evert many nipples.
Check to be sure any devices sold specifically to
evert nipples have evidence-based safety and
efficacy studies to include with your protocol.
Frequent post-discharge weight checks are
strongly recommended.
Nipple shields reduce milk supply and are rarely
indicated for any nipple problems.

5. Sore and Cracked Nipples
Correct positioning and latch-on is critical to nipple
comfort.
Nipple sucking is associated with sore, cracked nipples.
This is an example of incorrect latch-on.
An infant with a tight labial or lingual frenulum may
cause nipple pain or soreness.
Nipple irritants may include creams and ointments,
plastic-backed breast pads, nipple shields, etc.
Stabbing pain in nipple and breast may be due to a
bacterial or other infection, and may be multifactoral.

6. Strategies for Nipple Pain
First, identify and correct the cause(s) of sore
and cracked nipples
Individual assessment leads to an appropriate
treatment plan, which includes correcting
latch-on and
Changing the latch or nursing position
healing plan
nursing on the unaffected breast first
Consider pain relief medications if necessary
(aspirin or acetaminophen). Use short-acting
preparations taken just before nursing.

7. Nipple Ointments
Creams or ointments that should NOT be used
include any preparation that the manufacture
states is not for ingestion these usually include:
any substance that must be removed before feedings
Vitamin E
Topical antibiotic cream
Astringents
Steroids
preparations containing bismuth subnitrate,
petrolatum or benzalkonium chloride

8. Engorgement
Fullness in the breasts in the early postpartum
period is due to increased vascularity as well as
increased milk production.
Drainage is important for optimal milk
production.
Frequent breastfeeding is the most effective
way to assure drainage.

9. Engorgement, cont.
If mother and baby are separated for medical
reasons, hand express or pump to promote
drainage.
Comfort measures such as warm or cold packs
should be determined in consultation with the
mother. There is no research to support
superiority of either warm or cold applications.
Engorgement has been associated with nipple
discomfort.

10. Plugged Ducts
A benign lump in the breast.
Also called “caked” breasts.
Caused by
infrequent breastfeeding and milk stasis
inadequate removal of milk from one area of the
breast
local pressure on one area of the breast creating a
blockage (e.g., from a tight bra)

11. Managing Plugged Ducts
Continue nursing. Feed frequently on affected side.
Gently massage affected area, trying to move lump
toward nipple to assure drainage. This can be done
before and during feedings.
Try warm moist compresses as a comfort measure
Try nursing infant in different positions to ensure
drainage of affected area.
Is clothing restricting milk flow?

12. Mastitis
An inflammation of the breast that produces flu-
like symptoms and is characterized by extreme
tenderness, swelling, redness and heat in a
section of the breast
It may be infective or non-infective
Usually unilateral, but may occur in both breasts

13. Mastitis II
May be caused by bacterial infiltration through
cracked or fissured nipple. Usually
Staphylococcus aureus or Escherichia coli;
occasionally Streptococcus.
Untreated plugged ducts or unresolved
engorgement may lead to milk stasis and
inflammation or infection.

14. Contributors to Mastitis
Contributing factors include:
lowered resistance to infection (stress, exhaustion,
anemia)
insufficient drainage of the area or obstruction of
ducts
missed feedings
sudden changes to feeding schedule (e.g., infant
begins to sleep through the night)

15. Management of Mastitis
Antibiotic treatment is usually prescribed in
the United States
Treat with an antibiotic that is appropriate to
the causal organism, and which is tolerated
well by the infant

16. Management of Mastitis II
Antibiotics, if prescribed, should continue for at
least 10-14 days. Tell mother to complete entire
course of medication.
Continue to breastfeed on both sides, starting
infant on unaffected side. Additional expression
or feeding may be necessary to adequately drain
the affected breast.

17. Management of Mastitis III
Mother should consider bed rest, keeping the
baby in close proximity to assure frequent
nursing.
Apply ice packs or warm packs to the breast,
depending on mother’s comfort.
Drink plenty of fluids
Consider a mild analgesic especially one with
anti-inflammatory properties
Assure that the bra or other clothing does not
restrict flow or apply painful pressure

18. Preventing Mastitis
Practice early, frequent feeding
Avoid supplementation
Alternate feeding positions for optimal drainage
Identify and treat sore nipples and plugged ducts
proactively

19. Mastitis for Woman is HIV-positive
If a woman is HIV-positive, mastitis or nipple
fissure may increase the risk of HIV transmission
If an HIV-positive woman develops mastitis, an
abscess or a nipple fissure, she should avoid
breastfeeding from the affected breast while the
condition persists. She must express milk from the
affected breast, by hand or pump, to ensure
adequate removal of milk.
If only one breast is affected, the infant can feed
from the unaffected side, feeding more often and
for longer to increase milk production.

20. Breast Abscess
A deep-seated localized infection
Mother feels ill
Causes include inadequate or delayed
treatment of mastitis
Management:
Drainage is usually required. Older techniques such
as surgical lancing and drain insertion are being
replaced by ultrasound visualization and needle
drainage.
Bacterial cultures of purulent matter help the
prescriber to select appropriate antibiotic.

22. Management of Abscess
Nurse or express breast every few hours
If location of surgery/drain would not interfere
with infant attachment to the breast, baby may
continue to breastfeed on the infected side.

23. Management of Abscess II
Milk will remain clean unless the abscess ruptures
into the ductal system. Abscesses usually rupture to
the outside.
If the location of the surgery/drain is incompatible
with breastfeeding, mother should hand express or
pump to promote drainage.

24. Candida Infections
Candida albicans is a fungal organism that may
affect the surface of the nipple and areola.
Candida has not been found to penetrate the
breast.
The appearance of shiny or flaky on the
nipple/areola was predictive of Candidiasis when
combined with burning pain (Francis-Morrill,
2004).

25. Candida Infections II
Predisposing factors:
lowered immune response
bacterial and viral infection, anemia, diabetes
trauma to nipple
damp breast pads, damp bras or occlusive clothing
previous use of antibiotics
poor hygiene (especially of hand washing)
repeated exposure through intimate contact with
infected family members

26. Management of Candida
Infection
Both mother and baby need to be treated
simultaneously. Other members of family should
be treated in recurrent infections.
Infant Rx: nystatin mouthwash for 14 days
Mother Rx:
vaginal infection: miconazole for 10-14 days
nipple infection: mycolog for 14 days or nystatin
cream after every feeding
Recalcitrant cases: ketoconazole, fluconazole