Introduction 

Breastfeeding is the ideal method of feeding infants, especially from birth to six months of age.

This is even recommended by the World Health Organisation. It can then be complemented with other feeds till the baby is two years of age. It is safe and clean and provides all the nutrients needed for the child.

Not just for satisfying hunger, breastfeeding also contains antibodies that protect babies from common infections, is easy to digest, and helps build a strong bond between mother and child, especially during feeding.¹

Nipple fissures are one of the common complications that arise during breastfeeding.²

It can occur from either the child sucking directly from the breast or from the use of breast pumps.

In this article, we are going to have an in-depth look at nipple fissures, especially as a result of suctioning from breast pumps, and ways we can prevent them.

What are nipple fissures?

Nipple fissures are skin injuries that occur on the nipple or the surrounding darker area, known as the areola. They may appear as cracks, sores, or open wounds and can be red, swollen, or sometimes blistered. ⁴It is a common complication of breastfeeding, which causes pain for the mother and can hinder effective breastfeeding.

It might even lead to early stoppage of breastfeeding.

According to a study, on average 80% to 90% of breastfeeding women experience nipple pain and fissures. ³It means that to harness the full benefits of breastfeeding, the condition must be addressed fully.

Causes of nipple fissures 

The causes of nipple fissures are varied.  The causes, not related to pump use, include:

1. Improper positioning, which makes the nipple not fit well into the mouth of the baby, causing friction that can lead to skin tears
2. Dry or sensitive skin is more prone to cracking or irritation
3. Frequent or unnecessarily prolonged feeding
4. Infection with Staphylococcus aureus and Candida albicans can lead to cracks or soreness³
5. Weak sucking due to poor latch or mouth motor issues, like tongue tie, that causes the nipple to rub against the gums
6. Strong sucking can cause excessive friction and pressure on the nipple
7. A short frenulum or malformed nipple can lead to difficulties with latching, hence leading to trauma⁶
8. Nipple wash with soap or a sponge, which might cause irritation
9. Engorgement of the breast, which causes oedema, making the nipple distend, preventing proper latching⁵^,⁶
10. Nipple fissures themselves can lead to engorgement because mothers prolong the time between feeds or don't feed at all because of pain⁶
11. Use of feeding bottles makes milk flow easier, hence babies latch shallowly. However, on the breast, such a shallow latch puts pressure on the nipple instead of the areola, increasing the risk of fissures
12. First-time mothers,⁵ because they are new to breastfeeding, may not know the proper technique, increasing their chance of having nipple fissures and cracks

Breast pumps and suction-related causes of nipple fissures 

1. Improper flange size or fit

If the flange is too small, the nipple can rub against it, causing irritation and possibly leading to sores or skin damage at the base of the nipple. If the flange is too big, the skin may expand to fill the extra space. This can lead to cracking.

2. Prolonged or frequent pumping

Continuous or unnecessarily long suction sessions can put strain on the nipple skin, leading to skin breakdown that can develop into fissures.

3. Cracked, rough, or poorly shaped flanges can rub or pinch the nipple during pumping, directly causing abrasions and fissures
4. Strong suction can make the effects of a wrong flange worse. If the nipple is off-centre or rubbing against the tunnel, it increases friction and injury

5. Misalignment

If the parts shift during use, they may cause improper nipple positioning and uneven friction, irritating the skin and causing cracks.

6. Worn-out pumps, which can cause inconsistent or jerky suction, leading to irregular pressure and friction that traumatises the nipple skin
7. A damaged valve or membrane can reduce suction efficiency, leading users to increase suction or pump longer than necessary, both of which increase the risk of skin breakdown
8. Damaged or inferior materials can trap bacteria, raising the risk of infection that may lead to new fissures or aggravate existing ones on already injured nipple skin

Signs and symptoms of nipple fissures 

Some signs and symptoms of nipple fissures are:

• Redness and swelling around the skin surrounding the nipple
• Various spots on the nipple, which can be raised or discoloured areas
• Cracked skin on the nipple
• The breast may look pale suddenly
• Flake-like plaques can come off the skin
• A yellow, hardened crust or discharge lodged in the nipple(s)
• Pain during breastfeeding or pumping

Risk factors of nipple fissures 

Some factors that can put one at a higher risk of having nipple fissures include:

1. First-time mothers: 

Due to a lack of experience with breastfeeding and pumping techniques, increases an increased risk of poor latch and nipple injury.

2. Engorged breasts: 

This makes it harder for the baby to latch properly, leading to increased friction and skin damage.

3. Pre-existing nipple damage: 

Already irritated or cracked nipples are more vulnerable to further injury during breastfeeding.

4. Misuse or insufficient guidance: 

Inadequate training in breast pump usage can lead to uncorrected poor positioning or latch, resulting in persistent nipple damage.

Treatment for nipple fissures 

• Stop or reduce pumping frequency temporarily so that the nipples can heal
• Apply nipple cream or ointment, which can soothe and protect the area
• Express a few drops of breast milk and let them air dry on the nipples. Breast milk has natural healing properties
• Always keep nipples clean and dry
• A warm compress can be used after pumping to reduce pain, or pain relievers can be used too

Prevention of pump-related nipple fissures

1. Choose the right breast pump. Ensure it has an adjustable setting for gentle and effective milk expression without damaging nipple tissue
2. Ensure proper flange fit: Correct flange size reduces friction on your nipples, prevents pinching, and supports comfortable, safe pumping
3. Using appropriate suction settings: Moderate suction mimics natural nursing and prevents excessive pulling that can cause skin trauma
4. Regular pump maintenance and hygiene: Clean the parts thoroughly to prevent irritation and reduce infection risk in the nipple, since it's vulnerable skin
5. Applying nipple balm or hydrogel, which moisturises and maintains skin elasticity, and protects against cracking from dryness or friction
6. Taking breaks between pumping helps with healing and also prevents worsening of minor damage

Other prevention strategies include

• Ensuring proper latch and positioning
• Avoid prolonged moisture and irritation of the nipple
• Practise nipple care
• Treat skin condition
• Manage engorgement and milk flow
• Use correct breastfeeding aids
• Regularly inspect for anomalies

Best practices for pump use

Some best practices for pump use are:

1. Choose the right flange Size. The manufacturers most time provide size guards
2. Always start on the lowest suction and gradually increase to a comfortable level that mimics your baby’s natural suck.
3. Use a pump that is clean, functioning well and has parts intact
4. Sit in a relaxed, upright position with good back support
5. Apply a warm compress or gently massage the breasts before pumping to stimulate let-down and reduce the need for aggressive suction
6. You can apply nipple-safe balm after pumping to maintain skin integrity
7. Stick to a consistent schedule to avoid engorgement and over-pumping
8. Allow your nipples time to recover between sessions
9. Monitor for signs of damage like redness, cracking, or unusual sensitivity
10. Stay hydrated and nourished to keep your body functioning well and producing enough milk
11. If need be, reach out to a lactation consultant or healthcare practitioner for care or counselling

Summary 

Breastfeeding is the optimal method for infant nutrition, especially during the first six months of life. While it supports immunity, bonding, and development, it can also present challenges, and one being nipple fissures.

Nipple fissures are painful to the mothers and hinder the baby from being fed efficiently due to problems associated with expressing breast milk. Improper breast pump use is one of the associated causes.

It is very important to practice strategies to prevent this condition and visit the health care provider if needed to avoid complications.