Nipple pain predisposes to other four conditions

Nipple pain and damage is common in breastfeeding women. Nipple pain is one of the most common reasons why women stop breastfeeding.

1. Nipple pain predisposes to postnatal depression

Nipple pain is a distressing sensory and emotional experience which interferes with maternal mood, activity, and sleep, whether or not there is visible damage. It predisposes to postnatal depression.1-3

2. Nipple pain predisposes to inflammation of breast stroma (or mastitis)

Nipple pain is linked with an increased risk of breast inflammation (for example, engorgement and mastitis).4

The NDC model hypothesises that the conflicting intra-oral vectors of force which result in nipple pain and inflammation also compress lactiferous ducts, resulting in elevated intra-luminal backpressures and increased risk of breast inflammation. That is, the link between nipple pain and breast inflammation is associative, not causative. You can find out about the mechanobiological model of nipple and areolar complex inflammation and pain here.5

3. Nipple pain predisposes to low supply

Even without visible trauma, nipple pain is associated with low supply.6 7

Some hypothesise that this is because nipple pain disrupts sensory nerve signals from the nipple to the hypothalamus, impairing oxytocin release and milk ejection.8 However, there is no evidence that pain is causally linked to decreased oxytocin levels, or to less effective and less frequent milk ejections.

Instead, NDC proposes that two factors explain the association between low milk production and nipple pain.

1. Women experiencing pain with breastfeeds are more likely to restrict breastfeeding frequency, which downregulates milk production.

2. The same conflicting intra-oral vectors of force which result in nipple inflammation and pain also compress lactiferous ducts and impair milk transfer, downregulating milk production.5,9-12

This hypothesis is corroborated by the finding that infants whose mothers have nipple pain transfer less milk.13 14 You can read more about the research here.

4. Nipple pain often results in pumping, which worsens occupational fatigue

Nipple pain and damage is a common reason for women to engage in mechanical milk removal rather than direct breastfeeding. However, mechanical milk removal in order to predominantly feed an infant with expressed breast milk is a work intensive practice which increases occupational fatigue.

References

1. McClellan HL, Hepworth AR, Garbin CP, et al. Nipple pain during breastfeeding with or without visible trauma. Journal of Human Lactation 2012;28(4):511-21.
2. Watkins S, Meltzer-Brody S, Zolnoun D. Early breastfeeding experiences and postpartum depression. Obstetrics and Gynecology 2011;118:214-21.
3. Brown A, Rance J, Bennett P. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing 2016;72(2):273-82.
4. Cullinane M, Amir LH, Donath SM, et al. Determinants of mastitis in women in the CASTLE study: a cohort study. BMC Family Practice 2015;16:181.
5. Douglas PS. Re-thinking benign inflammation of the lactating breast: a mechanobiological model. Women's Health. 2022;18: doi:10.1177/17455065221075907.
6. Kent JC, Ashton E, Hardwick C, et al. Nipple pain in breastfeeding mothers: incidence, causes and treatments. International Journal of Environmental Research and Public Health 2015;12:12247-63.
7. Geddes DT, Gridneva Z, Perrella SL, et al. 25 years of research in human lactation: from discovery to translation. Nutrients 2021;13:1307.
8. Newton M, Newton N. The let-down reflex in human lactation. Pediatrcis 1948;33:698-704.
9. Douglas PS. Re-thinking benign inflammation of the lactating breast: classification, prevention, and management. Women's Health 2021:Under review.
10. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery 2018;58:145–55.
11. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation 2017;33(3):509–18.
12. Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy Childbirth. 2022;22:94. doi:10.1186/s12884-021-04363-7.
13. McClellan HI, Geddes DT, Kent JC, et al. Infants of mothers with persistent nipple pain exert strong sucking vacuums. Acta Paediatrica 2008;97(9):1205-09.
14. McClellan HL, Kent JC, Hepworth AR, et al. Persistent nipple pain in breastfeeding mothers associated with abnormal infant tongue movement. International Journal of Environmental Research and Public Health 2015;12:10833-45.