Introduction

Nipple fissures are cracks or injuries on the nipple.¹ It can occur in breastfeeding women, patients with dry skin, from trauma or friction, and in the presence of skin diseases.² It commonly occurs during breastfeeding, causing pain in the nipple, thereby disturbing the joy and satisfaction that comes with breastfeeding. It makes the nipple painful or appear red, and it is the second most common reason why mothers stop breastfeeding their babies.³

It is essential to identify and treat these fissures early during breastfeeding. If left unaddressed, the pain and discomfort it causes can prevent the mother from breastfeeding, depriving the child of breast milk, which provides important nutrients for the baby during the growth or formative period of life. Furthermore, it can progress to infection, breast abscess, psychological burden for the mother, and loss of mother and child bonding if not promptly taken care of. 

The risk factors include incorrect positioning of baby during breastfeeding, dry nipples, infection of the nipple caused by organisms that cannot be seen without a microscope such as Staphylococcus or Candida albicans, weak or very strong suckling by the infant, short fre-nu-lum (a band that holds the tongue down to the floor of the mouth), use of pacifiers, use of improper breast pumps etc.⁴

Prevention is key to avoiding untoward effects and ensuring the baby can achieve adequate breastfeeding. 

Understanding nipple fissures

Nipple fissure is a condition whereby there is an opening on the skin of the nipple that appears in the form of a crack, skin loss, or tear. It leads to breast pain, redness, and occasionally bleeding in the nipple, especially with friction.^3,4 It is common in 80-90 % of breastfeeding mothers. It commonly occurs in the first 3-7 days after delivery, while for others, it occurs within 6 weeks of birth.³ It is the second most common cause of cessation of breastfeeding. 

Symptoms of nipple fissure include nipple pain, bleeding, redness, increased sensitivity for the mother, and discomfort during feeding. The nipple pain, which occurs as a result of the presence of the fissure, interferes with breastfeeding as it causes reduced production of breast milk. This is because maternal stress reduces the sensory connection to the brain that informs the brain of the need to produce breast milk by releasing a chemical called oxytocin. The role of oxytocin is to stimulate a part of the brain called the pituitary gland to cause the let-down of breast milk. On the other hand, the baby is furthermore affected in that vomiting results when the baby swallows blood in the breast milk, resulting from a bleeding in the nipple fissure.⁴

If untreated, nipple fissures can lead to mastitis or inflammation of the breast, pus collection in the breast, or breast abscess, all of which will further delay breastfeeding.³ Furthermore, it affects the bonding between the mother and child by causing psychological distress for the breastfeeding mother.⁴

The World Health Organization (WHO) recommends that breastfeeding is essential for babies; children should be exclusively breastfed for 6 months with supplementary breastfeeding continuing until the child is 2 years old. This is because breast milk provides essential nutrients, nourishment, and antibodies to the growing infant.⁵ Unfortunately, nipple fissures are one of the barriers that hinder effective breastfeeding. 

Prevention and prompt treatment will improve outcomes. 

Risk factors

There are numerous factors that increase the risk of a breastfeeding mother having nipple fissures. These include the following:^4,7

• Poor positioning of the baby and improper latch, which increases the risk of nipple trauma, leading to nipple fissure
• Use of harsh agents for nipple hygiene - these damage the gland around the nipple, making latching difficult 
• Excessive moisture around the nipple
• Prolonged and inappropriate use of breast pumps or nipple shields
• Tongue tie - although this may affect the ability of the tongue to move freely, causing a poor latch. Studies do not support its presence as a constant source of nipple fissure. 
• Oversupply of breast milk- increases the moisture around the nipple and breast; also increases the risk for fissuring
• Intervention for tongue tie can improve pain 
• Infections, such as bacterial, viral, or fungal infections, all increase the risk for nipple fissures
• Flat or inverted nipples
• Abnormal infant palatal anatomy, eg, high arched anatomy
• Strong infant suction
• First-time mothers

Prevention strategies

• Proper positioning technique- taught by midwives, lactation specialists, or doctors. A baby properly latches or is positioned for feeding when the mouth is wide open during sucking, with a dark segment around the nipple called areola is visible more above the lip than below, the chin of the baby is touching the breast, and the lower lip is turned outwards^3,4,7
• A position for breastfeeding is said to be good when both the head and body of the baby are along the same arbitrary line, the baby's whole body is supported on the back by a hand to lie close to the body. Finally, the baby’s nose first hits the nipple before adjusting to put the nipple in the mouth, as advised by the United Nations International Children's Emergency Fund (UNICEF)
• Mothers should adopt comfortable positions during breastfeeding. Examples of some breastfeeding positions include the cradle hold and cross cradle hold. The optimum position, however, ensures that the baby’s mouth approaches the breast with the nose to the nipple such that the baby's mouth comes for the nipple from beneath it³

Cradle hold Cross-cradle hold

Football hold or Rugby hold Side lying position

https://www.unicef.org/eap/common-breastfeeding-positions

Early identification and treatment of nipple infection

• Proper skin care and hygiene of the nipple, including the use of moisturizing agents such as lanolin, avoiding harsh soaps, and overwashing of the nipple.
• Release of tongue tie called frenectomy for children with tongue tie- Although not all children with tongue tie have breastfeeding related difficulties leading to fissures; the release of the tongue tie or frenectomy can improve breast pain due to improved sucking habits. 
• Breastfeeding support and education - by staff and support group.
• Correct use of breast pumps, including the placement and sizing.
• Use nipple shields only when necessary and avoid prolonged use. 
• Self-care for mothers- adequate hydration and nutrition, rest, and emotional support.

When to seek medical help

Because improper positioning or latching is the most common cause of nipple fissure, seek help from your doctor or lactation nurses when you are having difficulty positioning your baby. Other things that way warrant medical help include; 

• The presence of redness and pain in the nipple is suggestive of nipple infection 
• When a part of the breast appears red or warm, it may indicate an infection of the breast, also known as mastitis 
• When there is pus draining from the nipple, it is suggestive of a breast abscess 
• Maternal distress due to breast pain 
• Cessation of breastfeeding due to pain 
• Lack of improvement despite preventive measures

FAQs

What causes a fissure in the nipple? 

A fissure in the nipple is caused by a variety of agents. It is a mix of external forces, baby-related, and mother-related causes. It includes injury to the nipple by poor baby latching and positioning, high suction pressure of the baby, infection around the nipple, short tongue stalk limiting the ease of sucking the nipple, poor hygiene by the mother, use of harsh chemicals for cleaning the nipple, presence of other skin disease in the mother can also predispose them to infection of the nipple and fissuring. 

How do you prevent nipple fissures? 

Nipple fissures can be prevented by proper positioning and latching techniques of the baby as supported by the mother, good nipple hygiene, use of mild agents for nipple cleansing, avoiding excessive moisture around the nipple; use breast pads when there is milk overflow and change when soaked to prevent excessive moisture, allowing the nipple to air at intervals; having periods of bra breaks; prompt detection and treatment of nipple infection, correcting deformities in the mouth such as frenectomy for tongue tie, high arched palate. 

How do you stop your nipple from cracking when you breastfeed? 

Moisturise the nipple adequately, and keep it as dry as possible. Rest from wearing a bra at intervals and during this period, expose the nipple to room temperature. Do not use nipple shields at all times; use them only when necessary. Use breast pumps appropriately by properly positioning the nipple in the middle to prevent excessive suction and injury from pressure. 

Summary 

Nipple fissure is a crack in the nipple that commonly occurs during breastfeeding. It is the second most common cause of early cessation of breastfeeding, with poor consequences for the infant and mother. The risk factors include improper latching and positioning, anatomical deformities such as a short frenulum, and improper use of breastfeeding-assisted devices such as nipple shields and breast pumps. Although there are numerous risk factors, it is a preventable condition. Breastfeeding mothers should have a high index of suspicion for it and institute preventive strategies to prevent its occurrence. 

Early detection by mothers, seeking care early, and the institution of care plans will prevent complications from it. Mothers should seek help early and not give up on breastfeeding.