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Sore nipples are not inevitable during the early days of breastfeeding. Painful feedings are a signal that something's not right and you need to make a change.

You can expect some tenderness in your nipples during the first days of breastfeeding. As baby grasps the nipple and stretches the breast tissue, you may feel a pulling sensation that is uncomfortable. However as baby begins to suck and your milk lets down, breastfeeding should become more comfortable. This initial soreness should improve within two to four days after birth, if baby is positioned well at the breast and latched-on properly. (See Signs of Efficient Latch-on and Sucking for tips on evaluating what your baby is doing at the breast.)

If baby is having difficulty learning to latch-on efficiently, you can expect that your nipples will be sore. Pain that lasts throughout the feeding or soreness that persists beyond one week postpartum indicates that something needs to be changed about the way that baby is latching-on or sucking. It's important to do something about nipple soreness before it gets worse and your nipples develop painful cracks. If you are dreading the next feeding because your nipples hurt, get some help from a lactation specialist.

Sore nipples in the first days and weeks postpartum are usually the result of poor latch-on or baby's sucking technique. Sore nipples that persist beyond the early weeks postpartum or that occur after weeks or months of pain-free breastfeeding may have other causes, such as a candida infection.

Careful attention to how your baby takes the breast will prevent, or at least minimize, problems with sore nipples. prevention is by far the best cure! See Latch-on basics to teach your baby to breastfeed correctly. If you have problems with positioning and latch-on, get hands-on help from a lactation consultant before your nipples get terribly sore and your baby develops poor nursing habits.

The first and most important thing to do if you have sore nipples is to check how baby is being positioned at the breast and how baby is latching on. When baby is positioned and latched-on correctly, the sucking pressure and the action of his tongue and gums is on the areola (the pigmented area around the nipple), rather than on the sensitive nipple itself.

If your nipples are very sore, baby is probably not getting enough breast tissue in his mouth. A horizontal red stripe across the tip of your nipple or a temporary indentation at the base of your nipple are signs that the nipple is not far enough back in the baby's mouth during sucking. The baby's tongue may be rubbing against the tip of the nipple (ouch!) or the baby's gums are chomping at the base of the nipple instead of on the areola over the milk sinuses. (See illustration.) This kind of sucking is painful for mom, and inefficient for baby. Baby will not get enough milk if he sucks only the tip of your nipple.

Here's how to work on the problem:

• Review Latch-on basics. Is your baby well-supported at the level of your nipple? Is she turned on her side and pulled close to the breast during feedings? Is she taking the breast with a wide-open mouth? Are both her top and bottom lips turned out like a fish? Are your back, shoulders and arms well-supported so that baby does not slip down onto the nipple as the feeding continues and you relax your hold on her? Are you supporting the breast with your fingers underneath, thumb on top and keeping the weight of the breast off baby's chin?

• Encourage baby to take more breast tissue into her mouth. At least one inch (2.5 cm) of breast beyond the nipple should disappear into baby's mouth. Wait for baby to open her mouth very wide before pulling her in close to take the breast. Be sure that baby is latched on far enough back on the areola.

• Try the "breast sandwich" to help you cram more breast into baby's mouth. Support your breast with fingers underneath, thumb on top, well behind the areola. Press in with your thumb and fingers to flatten the breast while at the same time pushing back toward your chest. This makes the areola longer and narrower and easier for baby to take into his mouth.

• Use the index finger on the hand supporting the breast to push down on baby's chin as she latches on. This will help keep her mouth open wide. You can continue putting gentle pressure on her chin throughout the feeding. Keeping her mouth open wide throughout the feeding should keep her from "tight-mouthing" the breast. This will make breastfeeding more comfortable for you.

• Check that baby's lips are turned out. Sucking in the lower lip will cause soreness underneath the nipple. It's often hard for a mother to see if baby's lower lip is turned out when he is latched on, so ask someone else to peek under the breast and check this for you. You can gently pull baby's lip into a more comfortable position while he is latched on. This is the lower lip flip described in Latch-on basics.

• Check baby's tongue while breastfeeding. If you gently pull down on baby's lower lip, you should be able to see the front of the tongue extended over the lower gum between the baby's lower lip and your areola. The tongue is cupped under the breast to help draw the milk from the reservoirs and channel it to the back of the mouth for swallowing. The tongue also protects the nipple from vigorous sucking. If you don't see baby's tongue under the breast during sucking, it may be pulled back and up in baby's mouth, where it will rub on the nipple causing soreness.

• To correct the position of the tongue, be sure that baby is taking the breast with a wide open mouth and the tongue forward and down. To encourage baby to bring her tongue forward and down, use the index finger of the hand supporting the breast to press down gently on baby's chin during latch-on. Opening the jaw wider naturally causes the tongue to protrude further. Tucking baby's chin down before latch-on will also help to bring the tongue down when baby latches on. Breastfeeding in the clutch hold may also be helpful.

• If it seems as if baby's tongue can't protrude over the lower gum or if it seems to curl downward rather than cupping under the breast, consider the possibility of tongue-tie. If baby's tongue seems to push the breast out of baby's mouth, he may have a tongue thrust. (See nipple confusion for suggestions.)

• Always break the suction before taking baby off the breast. "Popping" baby off the breast hurts--and leaves your nipples hurting for a surprisingly long time. Slip a clean finger into the corner of baby's mouth to release the suction before taking baby off the breast. Or, try pressing down gently on the breast near baby's mouth.

• Avoid artifical nipples during the time that your baby is learning to breastfeed. Getting milk from bottles requires a different technique than breastfeeding. Using the bottle technique at the breast leads to latch-on and sucking problems. Babies who get both the bottle and breast in the early days are likely to have problems with nipple confusion. Avoid pacifiers as well as artificial nipples on feeding bottles.

In the early days of breastfeeding, you'll have to keep working at getting your baby latched-on properly, even if it means taking the baby off the breast and starting over several times at the beginning of feedings. If you do this, you'll soon be rewarded with pain-free breastfeeding. If you are struggling with latch-on or your nipples have gone beyond the mildly-sore stage to the painfully, cracked or bleeding stage, get help. The sooner you get help, the easier it will be to fix the problem. Call a lactation consultant or a La Leche League Leader.

Improving your baby's latch-on and sucking techniques will make breastfeeding more comfortable in the days to come. Realize this soreness won't last forever - in a few days the pain should begin to lessen. To make breastfeeding less painful right now, try these suggestions:

• Use different breastfeeding positions, including the cradle hold, the clutch hold, and the side-lying position. Varying positions from one feeding to the next changes the distribution of pressure on your areola and nipple during sucking.

• Feed baby on the side that is least sore first. Start the feeding on the less tender breast. If you need to empty the sore breast, switch baby to that side after you have had a milk-ejection reflex. The pain from sore nipples is usually less intense after the milk is flowing.

• Feed baby before he is desperately hungry, so his sucking is less vigorous and he can cooperate better with your latch-on lessons. Shorter, more frequent feedings are easier on your nipples than longer nursing sessions spaced farther apart.

• Pad your nipple. As you're putting baby to the breast, use your thumb and index finger to slide the skin of the areola forward with gentle compression. This forms a wrinkle at the base of the nipple, which adds extra padding to protect the sore nipple.

• If baby needs to suck for comfort and your nipples are wearing out, let him suck on your index finger instead of a pacifier. Long periods of comfort sucking at the end of feedings may be hard to endure. Dads, use a well-scrubbed "pinky" finger. When baby sucks on an artificial pacifier, he learns sucking habits that will make it more difficult for him to learn to latch-on and suck correctly at the breast. Sucking on an adult finger that extends well into baby's mouth is a better alternative in the early weeks of life.

• Avoid engorgement. It is more difficult for a baby to latch-on to a breast that is swollen and engorged. Frequent feedings will help prevent this. While you may want to limit the amount of comfort sucking your baby does when your nipples are very sore, be sure that you breastfeed often enough and long enough for baby to get the milk out of your breasts. Engorgement can make problems with latch-on and sore nipples worse.

• Numb your nipples. If your nipples are exquisitely tender, try numbing your nipples before breastfeeding by applying ice wrapped in a damp cloth.

You'll want to do everything you can to help your nipples feel better and heal quickly. Here are some time-tested tips for soothing tender nipple skin:

• After each feeding, manually express a few drops of milk and massage this natural skin-soother into the skin of your nipples. This stimulates circulation and promotes healing. Colostrum is an ideal nipple "cream."

• Be sure the surface of your nipple is free of moisture when not "in use." Pat your nipples dry with a soft cotton cloth after feedings. If patting hurts, let your nipples air-dry. Leave your bra flaps down and your shirt open, if practical, until the nipple is no longer moist. Or, go without a bra, especially at night. You can sleep on a towel to absorb any leaking milk. Use fresh, dry breast pads after feedings, without plastic liners, to be sure no moisture stays in contact with your tender skin.

• Don't use quick drying methods, such as a hair dryer (even on a low setting), to dry your nipples. While some nipples tolerate this technique, it can cause more delicate nipples to crack because it dries the skin itself, not just the surface of the skin.

• Try exposing your nipples to a few minutes of sunshine during the day. Only two or three minutes--sunburned nipples would be a disaster!

• To soothe and help heal sore nipples, use a modified lanolin ointment, such as Lansinoh. Massage a small amount into your nipples after nursing. Don't use oils or creams that are not safe for baby and would need to be washed off before breastfeeding. Medical-grade, modified lanolin works on the principle of moist wound healing, allowing the skin of the areola and nipple to retain its natural moisture. This prevents cracking and speeds up the process of healing.

• Avoid using soap on your nipples. The little bumps on the areola around your nipples are glands that secrete a natural cleansing and lubricating oil. Soaps remove these natural oils, causing dryness and cracking.

• Check your bra. Be sure your bra is not so tight that it compresses your nipples or so rough that it irritates them. Your nipples may feel better if you go without a bra and wear a soft t-shirt instead.

• If your nipples are too tender to touch, try wearing breast shells in your bra. These will hold the bra fabric away from your sore nipples and allow nothing but air to touch them. You can obtain breast shells through a lactation consultant, who will also help you determine the cause of your sore nipples and help resolve the problem.

If your nipples are still very sore after using the above measures, you may need to take more drastic action. If you haven't seen a lactation consultant yet, now is the time. You need expert help in fixing the cause of the soreness. A lactation consultant can show you how to teach your baby to suck better so that he will not traumatize your nipples. If your nipples really need a rest, try the following suggestions:

• Try a nipple shield. This is a soft, flexible silicon artificial nipple that fits over your nipple and areola. The baby sucks on the shield to get milk out of the breast. Nipple shields can ease the pain during vigorous sucking and can also provide a temporary solution to some latch-on difficulties. Nipple shields, however, should be used with a great deal of caution. Studies show that babies get twenty to fifty percent less milk during sucking with a shield because they are unable to compress the milk sinuses beneath the areola very well. To lessen this problem, use only the new thin, soft, silicon shields, and be sure baby's lips are turned out and positioned high on the part of the shield that covers the areola - and not just on the nipple. Try to use the nipple shield only temporarily, since some babies develop problems with latch-on if these shields are overused. Also, long-term use of a nipple shield can lead to problems with your milk supply, since the breasts don't receive as much stimulation. To wean your baby from the shield, try using it only at the beginning of feedings. Once the baby is latched on and nursing, quickly slip the shield off and get baby attached directly to the breast. Eventually, baby will take the breast without the shield at the start of the feeding. You can obtain a nipple shield from a lactation consultant, who will also help you resolve the problems that have made the nipple shield necessary.

• Rest the breast with a pump. Let baby suck on the nipple that is less sore while you pump the sore side for a day or so. But be careful. Pumping can irritate the nipples if you use too much suction, pump for too long, or if the nipple rubs against the flange of the pump. Offer the milk that you pump to your baby using a cup, a feeding syringe, or a spoon. Avoid giving supplements with artificial nipples. Feeding pumped milk with an artificial nipple will often make it more difficult to solve the latch-on problems that caused the sore nipples in the first place.

• Consider other causes. If after trying all the above measures your nipples remain exquisitely tender, suspect a yeast infection, called candida. Sore nipples that appear after weeks or months of comfortable breastfeeding are almost always caused by yeast. Other causes of persistent sore nipples include eczema or Reynaud's syndrome.