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Milky Adventure
Cracks, engorgement, and mastitis: managing breastfeeding difficulties
In this episode 6, Lauriane Emond helps you recognize and treat cracked nipples, engorgement, and mastitis, and know when to seek urgent medical attention.
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Summary
🔊 This program is an information program by a trained professional. This is generic advice and is not a personalized diagnosis. In all cases, we recommend that you be followed by a gynecologist and/or a midwife for individualized follow-up.
What you will learn in this episode
In this episode, Lauriane Emond helps you recognize and treat the three most common breastfeeding difficulties: cracked nipples, engorgement, and mastitis. You'll learn the right techniques, mistakes to avoid, and most importantly, when to seek urgent medical attention.
- Understanding the true cause of cracked nipples and how to treat them without stopping breastfeeding
- Good and bad accessories (silverette cups vs. nursing shells, silicone nipple shields)
- Recognizing engorgement and treating it according to new recommendations (cold, not hot)
- How to differentiate between engorgement, mastitis, and abscess, and when to seek urgent medical attention
💡 Key figures
Up to one in four breastfeeding women develop mastitis within the first 26 weeks postpartum.
Source: Literature review cited in the analysis of ABM Clinical Protocol #36, 2022. Link
___
A randomized controlled study showed that the use of hot showers and antipyretics did not improve the course of mastitis, which prompted the shift from hot to cold in the 2022 recommendations.
Source: Mitchell KB, Johnson HM, et al., « ABM Clinical Protocol : The Mastitis Spectrum, Revised 2022 », Breastfeeding Medicine, 2022. Link to the full protocol
Cracked nipples: an injury caused by poor positioning
A cracked nipple is a small wound on the nipple, comparable to chapped skin on your fingers. It almost always results from improper positioning of the baby at the breast, which rubs the skin abnormally. You can continue breastfeeding with a nipple crack, even if infected (there are treatments compatible with breastfeeding), but the priority is to address the cause : readjust the positioning. If cracks persist despite good positioning, there might be an oral restriction (tongue tie) to be checked by a manual therapist trained in breastfeeding.
How to reposition baby rather than letting them latch poorly
Contrary to popular belief, you don't adjust the baby's mouth directly on the breast : you remove them and reposition them, unless the latch is almost good (just the lips to flange out or the mouth to open a bit more). The "sandwich" technique (pinching the breast to stabilize its shape while the baby takes the breast) also helps a lot, provided you only release once the baby has started swallowing.
Relieving pain: what works, what doesn't
The healing compresses (e.g., Multimam), to apply for a maximum of 1 hour twice a day, are what Lauriane calls "magic compresses." The silver nursing cups (thin and flat, not thick or hollow) are a good long-term investment to add to your baby registry. Conversely, pretty nursing shells are not recommended : they are too thick and hollow, overstimulating the nipple and potentially causing engorgement. The lanolin should be used very sparingly (risk of maceration, fungal infections, and recent studies indicate an allergenic risk even when purified).
Silicone Nipple Shields: Neither for nor against
They stabilize the baby's suckling but prevent proper hormonal signaling to the brain (prolactin, oxytocin), with a risk of decreased lactation or engorgement in the medium term. They are relevant for a premature baby who doesn't yet have the strength to suckle effectively without them. They are not a solution to mask a cracked nipple without treating the underlying cause.
Understanding Engorgement
Engorgement always results from a drainage imbalance : overstimulation (shells), understimulation (silicone nipple shields), poor positioning, or an insufficient breast pump. In stagnant milk, a protein accumulates that slows down production : hence the vicious cycle of engorgement → decreased lactation. It is recognized by sensations similar to milk let-down (hard, painful breast, sometimes a slight fever) but which appear at a time when they should no longer be present (several weeks after birth).
Treating engorgement: the new protocol
The latest recommendations from the Academy of Breastfeeding Medicine have changed the game: we use cold or lukewarm, never hot (which increases inflammation, contrary to what was previously advised). We effectively drain the breast with the baby (good positioning, breast compression, rapid alternation of breasts), we take an anti-inflammatory if needed, and if truly necessary, we use the warm water glass suction technique to relieve engorgement without over-stimulating. Massage is performed towards the back of the chest (lymphatic drainage), never towards the front.
Pain during breastfeeding is not normal. No matter where the pain is, you should never stay in this situation: seek support.
From engorgement to mastitis
Mastitis is untreated engorgement that worsens: fever lasting more than 48 hours, general condition deteriorating. It is essential to have milk from each breast sampled (culture + antibiogram) before taking antibiotics, to be treated with the correct treatment tailored to the specific germ. You can continue to breastfeed during bacterial mastitis: the baby has already been exposed to the causative germs, and the mother's treatment is compatible.
Abscess: a sometimes silent emergency
An abscess can manifest without fever : just pain, a red patch, or a mass in the breast, sometimes 10 to 15 days after poorly resolved engorgement. It is a relative emergency that requires prompt management (puncture or surgical intervention for drainage).
🔎 Useful definitions
Nipple Crack : a small injury or wound on the nipple, caused by incorrect baby positioning at the breast, comparable to chapped skin.
___
Engorgement : accumulation of milk in the breast linked to an imbalance of supply and demand, causing hardening, pain, and sometimes a slight fever.
___
Mastitis : worsening of untreated engorgement, with persistent fever lasting more than 48 hours, requiring a milk sample before any antibiotic treatment.
___
Breast Abscess : a pocket of pus in the breast, a complication of unresolved mastitis, which can occur without fever, requiring prompt medical drainage.
🎯 Practical actions
- In case of a nipple crack or suspected nipple crack:
- Readjust baby's positioning (remove and re-latch rather than correcting in place)
- Use the sandwich hold technique to stabilize the breast during feeding
- Apply healing compresses like Multimam for a maximum of 1 hour, twice a day.
- Opt for thin, flat silver cups rather than nursing shells to prevent fungal infections.
- Use lanolin sparingly, or avoid it if possible (though it is often recommended).
- Consult a manual therapist trained in lactation if cracks persist despite good positioning.
- In case of engorgement or suspected crack :
- Effectively drain the breast with baby: good positioning, breast compression, rapid alternation.
- Apply cold or lukewarm, never hot (recommendations changed in 2022, heat worsens engorgement).
- Take an anti-inflammatory if necessary.
- Use the warm water glass suction technique if engorgement is too painful.
- Perform a lymphatic drainage massage towards the back of the chest, never towards the front.
- In case of suspected mastitis (fever lasting more than 48 hours):
- Have milk from each breast sampled (culture + antibiogram) before taking any antibiotics.
- Continue breastfeeding, it is compatible and recommended.
- In case of suspected abscess (pain, red patch, mass, with or without fever):
- Seek urgent medical attention, do not wait.
.png)
Summary
🔊 This program is an information program by a trained professional. This is generic advice and is not a personalized diagnosis. In all cases, we recommend that you be followed by a gynecologist and/or a midwife for individualized follow-up.
_____
⭐ The Milky Adventure series is made possible thanks to the participation of Fizimed, a French company that develops innovative solutions for women's health, such as their Emy Pump portable breast pump.
What you will learn in this episode
In this episode, Lauriane Emond helps you recognize and treat the three most common breastfeeding difficulties: cracked nipples, engorgement, and mastitis. You'll learn the right techniques, mistakes to avoid, and most importantly, when to seek urgent medical attention.
- Understanding the true cause of cracked nipples and how to treat them without stopping breastfeeding
- Good and bad accessories (silverette cups vs. nursing shells, silicone nipple shields)
- Recognizing engorgement and treating it according to new recommendations (cold, not hot)
- How to differentiate between engorgement, mastitis, and abscess, and when to seek urgent medical attention
💡 Key figures
Up to one in four breastfeeding women develop mastitis within the first 26 weeks postpartum.
Source: Literature review cited in the analysis of ABM Clinical Protocol #36, 2022. Link
___
A randomized controlled study showed that the use of hot showers and antipyretics did not improve the course of mastitis, which prompted the shift from hot to cold in the 2022 recommendations.
Source: Mitchell KB, Johnson HM, et al., « ABM Clinical Protocol : The Mastitis Spectrum, Revised 2022 », Breastfeeding Medicine, 2022. Link to the full protocol
Cracked nipples: an injury caused by poor positioning
A cracked nipple is a small wound on the nipple, comparable to chapped skin on your fingers. It almost always results from improper positioning of the baby at the breast, which rubs the skin abnormally. You can continue breastfeeding with a nipple crack, even if infected (there are treatments compatible with breastfeeding), but the priority is to address the cause : readjust the positioning. If cracks persist despite good positioning, there might be an oral restriction (tongue tie) to be checked by a manual therapist trained in breastfeeding.
How to reposition baby rather than letting them latch poorly
Contrary to popular belief, you don't adjust the baby's mouth directly on the breast : you remove them and reposition them, unless the latch is almost good (just the lips to flange out or the mouth to open a bit more). The "sandwich" technique (pinching the breast to stabilize its shape while the baby takes the breast) also helps a lot, provided you only release once the baby has started swallowing.
Relieving pain: what works, what doesn't
The healing compresses (e.g., Multimam), to apply for a maximum of 1 hour twice a day, are what Lauriane calls "magic compresses." The silver nursing cups (thin and flat, not thick or hollow) are a good long-term investment to add to your baby registry. Conversely, pretty nursing shells are not recommended : they are too thick and hollow, overstimulating the nipple and potentially causing engorgement. The lanolin should be used very sparingly (risk of maceration, fungal infections, and recent studies indicate an allergenic risk even when purified).
Silicone Nipple Shields: Neither for nor against
They stabilize the baby's suckling but prevent proper hormonal signaling to the brain (prolactin, oxytocin), with a risk of decreased lactation or engorgement in the medium term. They are relevant for a premature baby who doesn't yet have the strength to suckle effectively without them. They are not a solution to mask a cracked nipple without treating the underlying cause.
Understanding Engorgement
Engorgement always results from a drainage imbalance : overstimulation (shells), understimulation (silicone nipple shields), poor positioning, or an insufficient breast pump. In stagnant milk, a protein accumulates that slows down production : hence the vicious cycle of engorgement → decreased lactation. It is recognized by sensations similar to milk let-down (hard, painful breast, sometimes a slight fever) but which appear at a time when they should no longer be present (several weeks after birth).
Treating engorgement: the new protocol
The latest recommendations from the Academy of Breastfeeding Medicine have changed the game: we use cold or lukewarm, never hot (which increases inflammation, contrary to what was previously advised). We effectively drain the breast with the baby (good positioning, breast compression, rapid alternation of breasts), we take an anti-inflammatory if needed, and if truly necessary, we use the warm water glass suction technique to relieve engorgement without over-stimulating. Massage is performed towards the back of the chest (lymphatic drainage), never towards the front.
Pain during breastfeeding is not normal. No matter where the pain is, you should never stay in this situation: seek support.
From engorgement to mastitis
Mastitis is untreated engorgement that worsens: fever lasting more than 48 hours, general condition deteriorating. It is essential to have milk from each breast sampled (culture + antibiogram) before taking antibiotics, to be treated with the correct treatment tailored to the specific germ. You can continue to breastfeed during bacterial mastitis: the baby has already been exposed to the causative germs, and the mother's treatment is compatible.
Abscess: a sometimes silent emergency
An abscess can manifest without fever : just pain, a red patch, or a mass in the breast, sometimes 10 to 15 days after poorly resolved engorgement. It is a relative emergency that requires prompt management (puncture or surgical intervention for drainage).
🎯 Concrete actions
- In case of a nipple crack or suspected nipple crack:
- Readjust baby's positioning (remove and re-latch rather than correcting in place)
- Use the sandwich hold technique to stabilize the breast during feeding
- Apply healing compresses like Multimam for a maximum of 1 hour, twice a day.
- Opt for thin, flat silver cups rather than nursing shells to prevent fungal infections.
- Use lanolin sparingly, or avoid it if possible (though it is often recommended).
- Consult a manual therapist trained in lactation if cracks persist despite good positioning.
- In case of engorgement or suspected crack :
- Effectively drain the breast with baby: good positioning, breast compression, rapid alternation.
- Apply cold or lukewarm, never hot (recommendations changed in 2022, heat worsens engorgement).
- Take an anti-inflammatory if necessary.
- Use the warm water glass suction technique if engorgement is too painful.
- Perform a lymphatic drainage massage towards the back of the chest, never towards the front.
- In case of suspected mastitis (fever lasting more than 48 hours):
- Have milk from each breast sampled (culture + antibiogram) before taking any antibiotics.
- Continue breastfeeding, it is compatible and recommended.
- In case of suspected abscess (pain, red patch, mass, with or without fever):
- Seek urgent medical attention, do not wait.
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