Very common, crevices are the main cause of breastfeeding pain. Their management is based on a correction of the position at the breast, care to accelerate their healing and, if necessary, an antibiotic or antifungal treatment in the event of bacterial infection or mycosis.

The crevice is an injury to the nipple. The skin involvement can be more or less advanced, ranging from simple erosion, with small red lines or small cracks, even real wounds that can bleed. The crevice may be accompanied by erythema (a congestive redness of the skin), slight edema, bruising, white or yellow blisters, or even a yellow discharge if there is a bacterial infection. Sometimes the whole nipple is red and raw. 

When do crevasses occur?

Cracks occur most often during the initiation of breastfeeding, during the 3 to 7 days after childbirth. They are the main cause of early weaning. The mother dreads the moment of breastfeeding, tenses up, the ejection of milk is less well, with the risk of engorgement which will worsen the condition of the nipple. It is a real vicious circle that we must quickly get out of. This pain, whether or not it is accompanied by visible lesions on the nipple, is a warning signal to be taken into account as soon as possible. Indeed, breastfeeding should not be painful.

There are two types of crevices:

The “mechanical” crevasse

It is caused by improper latch on the baby, which causes friction and abnormal stretching of the nipple. This poor latch can itself have different causes:

• the most common is poor positioning of the baby at the breast, due to an inadequate breastfeeding position or congenital stiff neck (the baby always turns his head to the same side) for example;
• Then comes a problem of sucking the baby, which can itself have different causes: a tight tongue frenulum, a short tongue, a hollow palate or a back chin;
• engorgement of the breast, making it difficult for the baby to latch on because the nipple is strained. This often happens at the time of the flow of milk;
• flat or retracted nipples, which make it difficult to grip the nipple.

Inadequate use of the breast pump (too strong suction, too small nipple, too long pumping sessions) can also weaken and damage the nipple. 

The crevasse of infectious origin

The nipple is a prolific area for the proliferation of infectious agents, especially when its skin surface is damaged. An untreated mechanical crevice can thus evolve into an infectious crevice, with small cracks and wounds being a gateway for pathogens. Thus, the crevasse may be the seat:

• bacterial infection, with Staphylococcus aureus being the most common germ. The pain, similar to that of a burn, is then intense, even outside of feedings;
• candidiasis, a fungal infection due to the proliferation of Candida Albicans, a yeast present physiologically in our body (in the intestinal, oral and vaginal flora), and which particularly appreciates hot and humid environments such as the nipple. The sharp, hot pain radiates to the armpits. The skin on the nipple is shiny and may flake. This candidiasis can also develop in the baby’s mouth. It is then a thrush, which manifests itself by whitish spots in the mouth, on the tongue, on the inside of the cheeks, sometimes even on the palate and the gums.

The management of cracks must integrate two axes: eliminate the cause of the crack and help the nipple to heal. 

To treat the cause of the crevice, it is first necessary to check the correct position of the baby at the breast and its sucking. 

In case of bacterial infection

It is important to treat as soon as possible in order to avoid the progression to mastitis. Local or oral antibiotic treatment will be prescribed. It must be continued throughout the duration of treatment, even in the event of improvement. 

In case of candidiasis

Antifungal treatment will be prescribed. The baby must also be treated at the level of the mouth, in order to avoid mutual recontamination.

To facilitate the healing of the crevice, it is no longer recommended, as was the case in the past, to dry the nipple. On the contrary, it is necessary to favor wound healing in a humid environment. By maintaining a constant moisture barrier, this healing method helps limit skin damage, better repair tissue and reduce pain.

Methods to facilitate the healing of crevices

Different methods can be tested to facilitate the healing of crevices. 

Breast milk 

It contains anti-inflammatory substances, epidermal growth factors (EGF) and anti-infectious factors (leukocytes, lysozyme, lactoferrin…) which promote healing of the nipple. The mother can use it in two ways: simply by expressing a few drops of milk after feeding, to apply to the nipple, or in the form of a breast milk bandage. All you need to do is soak a sterile compress with breast milk and hold it in place on the nipple (using cling film, for example) between each feeding. Change it every 2 hours. Note that these breast milk poultices should be avoided in case of candidiasis.

Lanolin

It is a natural substance extracted from the sebaceous glands of sheep, from which it protects the wool from rain and other bad weather. Endowed with emollient, soothing and moisturizing properties, it is applied to the nipple between feedings, at the rate of a small amount previously heated between the fingers. Safe for the baby, it is not necessary to remove it before feeding. Choose it purified and 100% lanolin. Note that there is a very low risk of allergy to an allergen present in the free alcohol portion of lanolin. 

Coconut oil

It has moisturizing, antibacterial and antifungal properties that can help heal light cracks. Make sure to choose extra virgin, organic and deodorized. 

Honey

It has antibacterial, anti-inflammatory and healing properties. It can be applied to the nipples as a poultice, under cling film. Make sure to choose it sterile, so that it is safe for the baby (risk of botulism).

Hydrogel compresses

They are composed of water, glycerol and polymers. They relieve pain and accelerate the healing of crevices. They are applied to the nipple between each feeding. There are different models on the market, reusable 24 hours or 3 to 7 days. 

The all-purpose ointment from Dr. Jack Newman (Canadian pediatrician and lactation consultant)

Dr Jack Newman is a clever blend of antifungal, antibacterial and anti-inflammatory substances that treat pathogenic bacteria, yeasts and inflammation. Delivered on medical prescription, it must be applied according to a specific protocol with gradual spacing until it is completely stopped.

Antibiotic treatments and antifungal treatments are compatible with breastfeeding. The baby is not at risk by drinking breast milk because it contains specific antibodies that protect it. 

In case of severe pain

If the pain is severe, an analgesic compatible with breastfeeding (paracatemol, ibuprofen) may be prescribed. 

In case of deep crevices

If the crevices are deep and very painful, silicone breast tips can be used during feeding, while the crevice heals. However, they should be handled with care over a short period. Because they induce less efficient sucking, they can indeed interfere with lactation.

The best prevention against crevices is to ensure a good latch on the baby. The help of a breastfeeding specialist (midwife or IBCLC lactation consultant) can be of great help in finding the right position. 

It is not necessary to wash or rinse the nipples before and after each feeding, such practices even seem to increase the incidence of nipple pain and crevice pain. A daily shower is enough.