Raynaud's phenomenon and Nipple vasospasm pain

Nipple pain and breast pain are common reasons for seeking help with breastfeeding. The pain may feel burning, stabbing, throbbing or tingling, and it can occur during a feed, immediately afterwards or between feeds.

If nipple pain is particularly strong after feeding, when the nipple is exposed to cold air, or when the nipple changes colour, you may come across the term nipple vasospasm. Raynaud’s phenomenon is one possible cause of nipple vasospasm, but it is not the only one.

Understanding the difference can help identify what may be contributing to the pain and what support may be useful.

For more about some of the reasons breastfeeding can become uncomfortable, see When Breastfeeding Doesn’t Feel Right.

What is Raynaud’s phenomenon?

Raynaud’s phenomenon is a condition in which small blood vessels temporarily constrict, reducing blood flow to the affected area. It most commonly affects the fingers and toes, but the nipples can also be affected (The Breastfeeding Network, 2019).

Cold is a common trigger. During breastfeeding, the nipple can be particularly exposed to changes in temperature because it may be uncovered and wet immediately after a feed. Moving from the warmth of the breast or baby’s mouth into cooler air can trigger blood-vessel constriction in some people.

The nipple may become white or pale as blood flow reduces, followed by blue or purple colouring as oxygen levels in the tissue change, and then red or pink as blood flow returns. These colour changes are sometimes described as a triphasic response, although not everyone experiences all three stages.

Pain can be severe and may be described as burning, throbbing, stabbing or shooting. It may occur immediately after a feed or continue for some time afterwards. Symptoms can affect one or both nipples.

A history of Raynaud’s phenomenon elsewhere in the body, circulation problems or migraines may provide additional clues, although these are not required for nipple symptoms to occur (The Breastfeeding Network, 2019; GP Infant Feeding Network, n.d.).

What is nipple vasospasm?

Nipple vasospasm describes temporary constriction of the blood vessels supplying the nipple. It can cause significant pain and may be associated with visible changes in nipple colour.

Nipple vasospasm does not necessarily mean that someone has Raynaud’s phenomenon.

A nipple can become compressed during breastfeeding, particularly when attachment is shallow or the nipple is being squashed between the baby’s tongue and the roof of the mouth. The resulting vascular response can cause the nipple to blanch and become painful after the feed. In this situation, vasospasm can be a response to mechanical compression rather than Raynaud’s phenomenon (The Breastfeeding Network, n.d.).

Improving positioning and attachment may resolve compression-related nipple vasospasm, whereas Raynaud’s phenomenon may continue despite comfortable attachment.

For more information about attachment, see Latching Your Baby.

Raynaud’s phenomenon and nipple vasospasm: what is the difference?

The terms are sometimes used interchangeably, but they describe different things.

Nipple vasospasm describes what is happening to the blood vessels: they temporarily constrict, reducing blood flow to the nipple.

Raynaud’s phenomenon describes a vascular condition in which blood vessels constrict in response to triggers such as cold or emotional stress. When Raynaud’s affects the nipple, it can cause nipple vasospasm.

Nipple vasospasm can therefore occur without Raynaud’s phenomenon. It can be a normal vascular response to nipple compression caused by a poor or shallow latch.

A white nipple immediately after a feed can be a useful clinical clue towards vasospasm, but it does not confirm a diagnosis of Raynaud’s phenomenon.

Recognising a possible pattern

The timing of the pain can provide useful information.

Raynaud’s-related nipple vasospasm may be more likely when:

• pain begins or becomes significantly worse immediately after feeding

• the nipple is exposed to cold air after a feed

• the nipple is still wet after feeding when exposed to the cooler environment

• the nipple changes colour, particularly becoming white, purple or red

• warmth relieves the pain

• symptoms are triggered by cold at other times

• symptoms occur even when positioning and attachment appear comfortable

• there is a personal history of Raynaud’s phenomenon or other circulation problems.

However, colour changes are not always obvious. In a study of 22 breastfeeding women diagnosed with Raynaud’s phenomenon of the nipple, only 14 had notable nipple colour changes recorded (Barrett et al., 2013).

Colour changes may also be more difficult to recognise on some skin tones. The absence of an obvious colour change therefore does not necessarily exclude nipple vasospasm.

Nipple compression as a cause of vasospasm

Mechanical compression is an important cause of nipple vasospasm.

If the nipple is being compressed during breastfeeding, blood flow through the small vessels can temporarily reduce. The nipple may then appear white and become painful when the baby comes off the breast.

Suboptimal positioning or attachment, or a baby repeatedly compressing the nipple during feeding, can contribute to this pattern (GP Infant Feeding Network, n.d.; The Breastfeeding Network, n.d.).

If the latch feels pinchy or painful, changing position or attachment may help. Your baby’s body position, the way they approach the breast and the depth of attachment can all influence how much pressure is placed on the nipple.

Latching Your Baby and When Breastfeeding Doesn’t Feel Right may be useful alongside individual breastfeeding support.

Skilled breastfeeding support, including support from an IBCLC, can be useful when the cause is unclear or when changes to positioning and attachment have not resolved the symptoms. You can read more about the role of an IBCLC in What is an IBCLC?.

Other factors that may contribute

Cold is particularly relevant to Raynaud’s phenomenon, but other factors can also influence vascular constriction.

Caffeine and nicotine can contribute to vasoconstriction and may make symptoms worse for some people. The Breastfeeding Network recommends reducing caffeine and stopping smoking as part of managing Raynaud’s symptoms (The Breastfeeding Network, 2019).

Stress may also affect vascular responses and can contribute to symptoms, although it is not necessary for Raynaud’s phenomenon to occur.

Pumping can also produce nipple pain and vascular symptoms. Excessive suction, an unsuitable flange size or prolonged pumping can cause nipple compression or trauma. If symptoms occur primarily following pumping, the pump settings and flange fit may therefore be worth reviewing.

What can help at home?

Keeping the nipple and breast warm is one of the simplest measures that may help reduce vasospasm.

You could try:

• keeping the breasts covered and warm after feeds

• avoiding sudden exposure to cold air immediately after feeding

• covering the nipple as soon as the feed finishes

• adding an extra layer of clothing around the breasts

• using sheepskin inserts or another insulating layer inside the bra

• applying a warm compress or other heat-retaining product after feeding

• reducing caffeine if it appears to worsen symptoms

• avoiding smoking or nicotine.

The Breastfeeding Network also recommends gently applying warm oil to the nipple after feeding. If using oil for warmth or comfort, it should be comfortably warm rather than hot, and care should be taken to avoid burns to already painful or sensitive skin (The Breastfeeding Network, 2019).

Warmth should be soothing rather than intense. Heating pads, reusable heat packs and similar products can cause burns if they are too hot or left against the skin for too long.

When should you speak to a breastfeeding specialist?

If nipple pain continues despite comfortable positioning and attachment, or if there is a recurring pattern of pain after feeds with colour changes or cold sensitivity, further clinical assessment may be useful.

An IBCLC or other appropriately trained breastfeeding professional can assess feeding position, attachment, nipple compression and the circumstances in which the pain occurs. This can help distinguish mechanical causes of nipple vasospasm from a pattern that may be consistent with Raynaud’s phenomenon.

It can also be helpful to describe exactly when the pain starts, how long it lasts, whether warmth helps and whether the nipple changes colour. Taking a photograph of the nipple colour change, if it occurs and you are comfortable doing so, may also provide useful information during an assessment.

Could medication help?

If symptoms are persistent or severe and Raynaud’s phenomenon is suspected, a GP may consider medication to reduce vascular constriction.

Nifedipine is a calcium-channel blocker that has been used to treat Raynaud’s phenomenon affecting the nipple. Research involving breastfeeding women has reported improvement or resolution of nipple pain in many of those who were able to tolerate nifedipine treatment (Barrett et al., 2013).

A GP may consider a slow-release or modified-release nifedipine preparation. Modified-release preparations are available with different dosing schedules, including preparations that are taken twice daily, so the exact formulation and dose need to be determined by the prescriber.

Information about medicines and breastfeeding is available through the Breastfeeding Network Drugs in Breastmilk service, which provides evidence-based information about medication use during breastfeeding (The Breastfeeding Network, n.d.).

The GP Infant Feeding Network information on pain when breastfeeding also includes information about assessment and management of nipple vasospasm and Raynaud’s phenomenon.

References

Barrett, M.E., Heller, M.M., Fullerton Stone, H., Murase, J.E. and Mancini, A.J. (2013) ‘Raynaud phenomenon of the nipple in breastfeeding mothers: an underrecognized cause of nipple pain’, JAMA Dermatology, 149(3), pp. 300–306. Available at: https://jamanetwork.com/journals/jamadermatology/fullarticle/1485351

GP Infant Feeding Network (n.d.) ‘Pain when breastfeeding’. Available at: https://gpifn.org.uk/pain-when-breastfeeding/

The Breastfeeding Network (2019) ‘Raynaud’s Phenomenon in Breastfeeding Mothers’. Available at: https://www.breastfeedingnetwork.org.uk/factsheet/raynauds/

The Breastfeeding Network (n.d.) ‘Drugs in Breastmilk’. Available at: https://www.breastfeedingnetwork.org.uk/drugs-in-breastmilk/

The Breastfeeding Network (n.d.) ‘Pain: If breastfeeding hurts’. Available at: https://www.breastfeedingnetwork.org.uk/breastfeeding-information/problems-with-breastfeeding/pain-if-breastfeeding-hurts/