Sore nipples, engorgement, mastitis and low milk supply

Some nipple tenderness in the first days is common, and for most mothers it eases to a mild level within 7 to 10 days.¹ Pain that lasts, cracked nipples, or a baby who is never satisfied usually point to a latch problem, which can be fixed. Mastitis and true low supply are treatable too, and you rarely need to stop breastfeeding.

Why does breastfeeding hurt?

Mild tenderness when your baby first latches is normal in the first week. Pain that lasts through the whole feed, or after the first week, is usually caused by a shallow latch.

Across trials, nipple pain dropped to a mild level by about 7 to 10 days after birth for most women, whatever treatment they used.¹ Knowing this helps many mothers keep going.

If your baby takes only the nipple into her mouth, the nipple rubs against her hard palate. That pinches and cracks it. Other causes include tongue-tie (a tight band under the tongue), thrush (a yeast infection), and engorged breasts that are too firm to latch on to. If pain is sharp, burning, or getting worse, ask for help early.

What does a good latch look like?

With a good latch, your baby's mouth is wide open, her lips are turned out, and she takes in a large mouthful of breast, not just the nipple.

• Her chin presses into the breast and her nose is free.
• You see more of the dark area (areola) above her top lip than below the bottom lip.
• Her cheeks look full and round, not sucked in.
• You hear slow, rhythmic swallows after the first few quick sucks.
• The feed may feel like a strong tug, but it should not pinch.

When she comes off, your nipple should look round, not flattened like a new lipstick.

How do I fix a poor latch?

Break the suction with a clean finger, take her off, and start again. Bring your baby to the breast rather than leaning your breast to her.

1. Hold her close, tummy to your tummy, so her head and body face you without twisting.
2. Start with her nose opposite your nipple.
3. Let her head tip back slightly. Touch her top lip with your nipple.
4. Wait for a wide-open mouth, like a yawn.
5. Bring her quickly onto the breast, chin first.

Pillows or a folded bedsheet under your baby help, so you are not bending forward. If latching keeps hurting after a few tries, see a lactation counsellor or your paediatrician to check for tongue-tie.

What are the best breastfeeding positions?

The best position is the one where you are comfortable and your baby latches deeply. Most mothers use a mix of cradle, cross-cradle, football and side-lying holds.

• Cross-cradle: support your baby's neck with the hand on the far side from the feeding breast. This gives good control in the early weeks.
• Cradle: her head rests in the crook of your arm on the same side. Good once feeding is settled.
• Football (rugby) hold: she lies along your side, under your arm. Useful after a caesarean, with large breasts, or for twins.
• Side-lying: you both lie on your sides, facing each other. Restful for night feeds, but move her back to her own safe sleep space if you feel sleepy.

Changing positions also changes which part of the breast drains best, which can help prevent blocked areas.

What helps sore or cracked nipples?

Fixing the latch helps most. For the skin itself, a few drops of your own milk left to dry on the nipple may work as well as costly creams.

A Cochrane review (a careful summary of trials) found no clear proof that lanolin, gel pads or nipple ointments relieved pain. Applying nothing, or just expressed breast milk, was as good or better in the short term.¹

Other tips: start feeds on the less sore side, air-dry after feeds, and wear a soft cotton bra. Avoid soap on the nipples. If a crack is deep, oozing or not healing in a few days, see a doctor, as it may be infected.

What is breast engorgement?

Engorgement is when the breasts become very full, hard, swollen and painful, usually in the first week when the milk comes in, or later when feeds are missed.

It happens because of extra milk plus extra blood and fluid in the breast tissue. The skin may look tight and shiny, and the nipple can flatten, making it hard for your baby to latch. A mild fever can occur. Engorgement is common and usually settles in a day or two with frequent feeding.

How do I relieve engorgement?

Feed your baby often, 8 to 12 times a day.² Cold packs between feeds may ease the swelling.³

A Cochrane review found that cold gel packs, cabbage leaves, herbal compresses and gentle massage look promising, though the evidence is weak.³ They are cheap and safe, so they are worth trying.

• Hand express a little milk before a feed to soften the dark area so your baby can latch.
• Gently press around the nipple with your fingertips for a minute to push the swelling back (reverse pressure softening).
• Use a cold pack or chilled cabbage leaves for a short while after feeds.
• Do not pump to empty the breasts fully; that tells them to make even more.

What is mastitis?

Mastitis is inflammation of the breast, often with a painful, red or darker, hot area, plus fever, chills and body aches like the flu.

About 1 in 10 breastfeeding women get it, most often in the first 3 months.⁴ Doctors diagnose it by examining you; tests are not usually needed.⁴ Most cases are caused by swelling and inflammation, not by a true infection.⁴

Risk goes up with a poor latch, missed feeds, and oversupply. Overstimulating the breasts and rough breast massage are now known to make it more likely.⁴

Can I keep breastfeeding with mastitis?

Yes. Keep breastfeeding from the affected side. Your milk is safe for your baby, and stopping suddenly can make mastitis worse.

The World Health Organization notes that health workers often wrongly advise women to stop breastfeeding when they have mastitis.⁵ Current advice is to feed your baby directly from the breast as usual, rather than pumping extra.⁴ The milk from that side may taste a little salty, and some babies fuss, but it does them no harm.

How is mastitis treated, and do I need antibiotics?

A 1 to 2 day trial of simple care is often enough: an anti-inflammatory painkiller such as ibuprofen, ice packs, feeding your baby directly from the breast, and pumping as little as possible.⁴ Antibiotics are added if you do not improve.⁴

Older advice to use heat, deep massage and pumping to "empty" the breast is no longer recommended, because these can make things worse.⁴ If there is no improvement after a day or two, your doctor may prescribe an antibiotic that covers common skin germs.⁴ Go to hospital if you feel very unwell, have a high fever that will not settle, or a lump that keeps growing. This can mean an abscess (a pocket of pus). An ultrasound scan is advised when symptoms get worse or keep coming back.⁴

How do I know if my milk supply is low?

The best signs are your baby's nappies and weight. By 5 to 7 days old, a well-fed baby has 6 or more wet nappies and at least 3 to 4 yellow stools a day.²

A baby may lose up to 8 to 10 percent of birth weight in the first few days before gaining again.² After that, steady weight gain at check-ups is the most reliable proof of enough milk.

Many mothers worry their milk is not enough. In studies, about a third of women who stopped breastfeeding early gave "not enough milk" as the main reason, often judged only from a fussy baby.⁶ Soft breasts, short feeds, cluster feeding in the evening, and not leaking are not signs of low supply. Babies fuss for many reasons.

How can I increase my breast milk supply?

Feed more often and make sure each breast is drained well. Milk is made on demand, so more removal means more milk.⁷

• Breastfeed at least 8 to 12 times in 24 hours, including at night.²
• Offer both breasts at each feed. Switch sides when sucking slows.
• Use breast compression: gently squeeze the breast while your baby sucks to keep milk flowing.
• Express after some feeds. Warmth, relaxation and breast massage increase the amount collected.⁸
• Hold your baby skin to skin, and avoid unneeded formula top-ups, which reduce demand on the breast.

Eat and drink normally. Forcing extra glasses of milk or ghee does not make more milk.

Do methi, shatavari or domperidone increase breast milk?

The evidence for all of them is weak. Medicines may increase milk volume a little, and herbs such as fenugreek (methi) might help some mothers, but no one can say how much.⁹

A Cochrane review of oral galactagogues (substances taken to increase milk) found low-certainty evidence that drug galactagogues such as domperidone may increase milk volume. For natural products, including fenugreek and other herbal mixes, the studies were too varied to measure the effect reliably.⁹ Side effects reported were mostly minor, but data were limited.⁹

My advice: methi in food is fine. Before any pill, powder or prescription, fix the latch and feed more often. That is where most supply problems lie. Domperidone is a prescription medicine; take it only after a doctor has assessed you.

Can I breastfeed when I am sick?

For most common illnesses, such as colds, flu, a sore throat or loose motions, yes. Keep breastfeeding, wash your hands well, and wear a mask if you are coughing.

By the time you feel ill, your baby has usually already been exposed. Your milk carries antibodies (germ-fighting proteins) that help protect her. Drink enough water, especially in the Kolkata heat, because dehydration and fever can make you feel your supply has dipped. A few serious conditions do need special advice, so tell your doctor you are breastfeeding.

Can I breastfeed while taking medicines?

Usually yes. Only a small number of medicines are unsafe during breastfeeding, and many mothers are wrongly told to stop.¹⁰

The American Academy of Pediatrics advises doctors to check each drug in LactMed, a free US government database on medicines in breast milk.¹⁰ Radioactive tests are one clear case where a short pause is needed.¹⁰ Always tell every doctor, and your chemist, that you are breastfeeding before you start anything new, including herbal products.

When should I see a doctor about breastfeeding problems?

Get help the same day if you or your baby shows any of these signs:

• Your baby has fewer than 6 wet nappies a day after day 5, or dark urine.²
• Your baby lost more than 10 percent of birth weight, or is not gaining.²
• Your baby is very sleepy, yellow, or not waking for feeds.
• A red, hot, painful area on the breast with fever that is not better in 24 to 48 hours.⁴
• A breast lump that is growing, or pus from the nipple.
• Nipple pain that is getting worse, or cracks that will not heal.
• You feel very low, anxious or unable to cope.

Go to hospital at once if you have a high fever with shivering, feel faint, or your baby is floppy or not feeding.