Nipple Death! Is this really a thing?

So I was recently interviewed by freelance writer Ronny Maye www.lifeofronny.com for a few global news publications, INSIDER & YAHOO! on the topic of Nipple Necrosis, which means nipple death. The article went live today, see below for link and full interview...

A woman on TikTok said her nipple fell off while she was breastfeeding. It's very rare, do not be scared. If you are working with a lactation consultant you shouldn't encounter this issue ever, but this woman I believe had some preexisting factors and conditions like untreated nipple damage and possibly and underlying health condition that contributed to this horrific story.

I gave them my opinion and expertise on the matter, you can read it here:

https://www.insider.com/woman-on-tiktok-says-her-nipple-fell-off-while-breastfeeding-2023-3

Here's my full take on it, the interview with the amazing author, Ronny Maye.

1. What can cause something like this to happen? Can it be prevented?

Bilateral nipple necrosis in a breastfeeding person is a rare occurrence. Unilateral nipple necrosis can happen but is also uncommon amongst lactating people. When the nipple and its tissue don’t get enough blood flow, some of the tissue can die. This tissue breakdown is known as “necrosis” which translates to tissue death. When this type of trauma happens with chest/breastfeeding it should be considered that there could be an intensified inflammatory response from a preexisting known or unknown condition. For instance, Behçet's disease, is a rare disorder or syndrome that causes blood vessel inflammation throughout your body or Pagets disease which is a disease of the nipple most associated with some breast cancer diagnosis’. In the latter mentions, nipple damage is not 100% preventable, but generally speaking, there are absolutely things that can be done to mitigate the risk of nipple trauma. Other well known causes of nipple damage can be from breast pump misuse or trauma from poorly fitting flanges, excessive high pressure or even too prolonged duration of pumping. Dermatosis, infection, vasospasm/Raynaud’s phenomenon, functional pain–due to a stimulus that does not normally provoke pain, are some potential causes of breast and nipple pain which can result in damage.

Some of the basics include:

• Going to a breastfeeding class to learn about what to expect and when to seek help with breastfeeding before things worsen.

• Practicing proper latching techniques can be the biggest game changer when it comes to prevention.

• Booking a lactation consultation with an IBCLC within the early days/weeks postpartum (1 - 4 weeks) to complete an evaluation which may include:

  • Oral assessment on the baby, weight check and weighted feed (to see how much your baby is transferring)

  • Visual inspection of your chest/breast

  • Observation of a feeding or pumping session

  • Medical history and birthing experience

  • Mental health evaluation (using a GAD-7 and/or EDPS)

  • General discussion of your goals and current situation to find problems and solutions

A special note on oral restrictions / tethered oral tissues (TOT) also known as Tongue Tie. This is a hot topic amongst medical providers, lactation professionals and parents. If you suspect your baby has a tongue tie, or just would like more information on it, I strongly recommend going to an IBCLC. They can do an assessment using a frenotomy or frenectomy tool, and send a report to your pediatrician. If necessary, provide you with a recommendation/referral to see a pediatric dentist or specialist who can diagnose and offer further treatment options. Tongue tie doesn’t mean your baby cannot breastfeed, it simply means you and your baby might need additional care and support in establishing and maintaining a successful and pain free chest/breastfeeding relationship. Tongue ties do not always cause pain, tongue tie ranges in degree of severity. It’s critical to discuss this with a skilled professional rather than self or “internet” diagnosing, Dr. Google is not always our friend. Do not panic if you are told your baby has a tongue tie because there are many options to resolve and/or manage it. Many times insurance may cover the cost of your visit to an IBCLC, so check your coverage!

2. Are there symptoms that mom can be looking out for that will indicate the risk of experiencing nipple trauma?

Many breastfeeding people complain of having breast pain, but it’s important to remember that breastfeeding shouldn’t cause pain or be painful. If it is, you should seek professional help as soon as possible. It can be particularly difficult for new parents in the early weeks to distinguish between pathological pain from discomfort, which the latter is common in the early days and weeks of beginning a chest/breastfeeding relationship. This due to the frequent stimulation that your chest was likely not receiving previously.

Poor latch is something any parent can be on the lookout for, since it’s one of the biggest indicators for nipple trauma. In order to avoid this risk of receiving nipple trauma due to poor latch, it’s critical to practice and learn proper positioning and deep latch techniques. If the baby is only latched onto the nipple they are causing lots of nipple trauma.

One of the best ways to get a deep asymmetrical latch is by bringing the breast up and over the baby’s nose and “dragging” or bringing the breast down into the baby’s mouth. Tickling the philtrum (the vertical space/groove between the base of the nose and the top “edge” of the upper lip) with the nipple or finger. This may help to elicit the rooting reflex that comes naturally to babies when that area is touched. Additionally, stroking the side of the cheek might also elicit a rooting reflex that will cause the baby to open nice and wide, like when we take a big bite of a sandwich or burger. This allows the baby to utilize the maximum space in their oral cavity reaching the hard and soft palate. It allows not just the nipple but also some areola and breast to go inside and fill that oral cavity for proper compression of the milk ducts, which run all the way from nipple up the sides of the breast/chest and branch out and around up to the armpit and wrap slightly around the sides our bodies.

The compression and release action that the baby does and/or a breast pump or even our hands, is what needs to happen in order for milk production to thrive. With consistent and frequent stimulation, the process of milk production continues. The more milk removed effectively and efficiently from the body, the more you will create. This is ultimately the only sure way of increasing milk supply, which is a common concern amongst lactating people.

3. Is there a best practice for reattachment?

As a lactation consultant, I wouldn’t reattach a nipple myself, this would be outside of my scope of practice. For nipple/areola fissure treatment, I’d highly recommend using first aid techniques such as using clean hands or gloves, cleanse the nipple, blot the nipple with sterile gauze after irrigation, and allow it to dry. Apply a bandage or cover to the area and seek medical attention at the nearest emergency health location for proper reattachment and assessment and observation for additional trauma and/or nerve damage. You can also ask them about pain-relieving medication. Over the counter pain medications might be helpful as well.

The nipple and areola can be very delicate for some, so I always encourage my clients to keep that area moisturized from the friction of constant feeding or pumping. Edible food grade coconut oil (if no allergy), lanolin, nipple butter/cream (preferably organic), APNO (all purpose nipple ointment), and even breastmilk are all acceptable choices. You can also use these to lubricate your flanges when you pump to prevent friction. Lubrication can be applied as often as after every feed or a little as once a day or as needed. When there is extreme nipple damage, for faster healing, I sometimes recommend a product called Medi-honey which is a medical grade Manuka honey ointment that is sterilized to kill bacterial spores and is considered safe for you and baby. However, real honey is not recommended for babies under 12 months old.

4. How does this affect milk supply? Will mom’s experience engorged breasts? Can the milk from that breast become infected?

With nipple damage, depending on the severity and parent’s pain level, I sometimes recommend taking a break from nursing on the affected side. This doesn’t mean we would stop removing milk from that side completely, but it would mean maybe nursing less or not nursing at all on that side until it is more or less healed. Instead doing gentle hand expression or using a hand pump on that side only for maybe 24 to 48 hours while we allow the skin to recover may be advisable and then you can gradually reintroduce when you are ready. By continuing to remove milk from the breast frequently to avoid plugged ducts, engorgement and prevent supply from reducing. If the milk sits too long and collects in the affected side, it can become an infection of the breast known as mastitis, that comes with flu like symptoms. The milk is safe to drink with mastitis. Pumping and dumping is not necessary.

The best way to manage mastitis is to continue to remove milk from the breast frequently, effectively and efficiently, every 2 - 3 hours is recommended. Booking a lactation consult with an IBCLC would be a great idea, and if the symptoms worsen or stay the same rather than improve over the next 2 - 3 days. You should also contact your primary care health provider or other licensed medical doctor. They can provide you with additional support which may include antibiotics to treat the infection. If you are ever unsure of whether a medication is safe to take while breastfeeding or pregnant, you can visit reputable sources like infantrisk.com, lactmed.com or mothertobaby.org

5. How does nipple trauma impact breastfeeding long term?

In the long term, nipple trauma and pain can impact the breastfeeding relationship in a few ways. Persistent nipple pain is the most common cause of ceasing a chest/breastfeeding relationship. Pain is the result and the chest/breastfeeding person will respond to pain with tension. I know from clinical experience and recent studies that almost all of the complaints of breast pain (and/or nipple pain) are due to how the baby latches. Latching difficulties include:

• Suboptimal positioning

• Disorganized/dysfunctional suck or latch

• Ankyloglossia (tongue tie)

• Infant biting or jaw clenching–due to fast flowing milk

• Tightness in the jaw and oral cavity due to malpositioning in utero, long/traumatic labor

• Structural abnormalities / physical impairment

This can all lead to a secondary problem of vasoconstriction, including vasospasm. Vasoconstriction is the tightening of blood vessels, and this can cause a lack of blood flow and oxygen. For example, the person experiencing a painful latching may tighten the shoulders, clench the teeth and buttocks etc. This response can cause tightening of the chest muscles, shoulders and neck which leads to squeezing those blood vessels that go to the nipples and breast. The feeling is usually described as deep, sharp, shooting, or dull pain. The pain may also feel like throbbing or constant, itchy, tingling, aching, daggers, burning and/or freezing or a combination of any of these feelings. It can also cause the nipples to change white, black, blue or purple. This collection of symptoms is also known as mammary constriction syndrome and can make some people want to quit breastfeeding right away not knowing this is not “normal” or that help exists to correct it.

Long term nipple trauma could be harmful to overall breastfeeding goals, duration and mental health. If left untreated or becomes a recurrent issue, it could lead to recurrent plugged ducts or mastitis from less or incomplete emptying of the breasts. Severely damaged nipples that are left untreated can lead to other serious medical issues or conditions. It’s advisable to seek treatment from a skilled professional if you experience bloody, cracked, compressed/misshapen or detached nipples. It is safe to feed a baby from a bloody nipple, you may notice “blood” tinged milk if you pump or in your baby’s diaper output if you have a bloody nipple. Lastly, many authors have determined a relationship between breastfeeding pain and postpartum depression. PMADs (postpartum mood and anxiety disorders) are very common within the first year and even longer after birth. It’s important that we remember to check in on our mood and mental health as we embark on our parenting journey. Reevaluate your chest/breastfeeding goals every so often, and know that it's OK to change your goals as you go. Doing what you think is best for you and your baby is what matters most. Try not to compare yourself to other breastfeeding experiences. It’s never has to be all or nothing with breastfeeding, any amount of breastmilk is helpful. It’s all about finding a balance for you and your baby to both be comfortable and happy.