Raynaud's of the nipple is the name given when women are affected by nipple vasospasms. Vasospasm is the constriction of blood vessels, cutting off the blood supply. During this phase the nipple turns white. The nipple then typically turns purple and then pink as blood low in oxygen, and then high in oxygen enters the nipple. As different blood vessels can constrict for different lengths of time, it can be possible to see all three colours in the nipple at once. Pain typically occurs as blood re-enters the nipple, at the end of the event, with the pain lasting up to several minutes.
I have found that damage to the nipple can occur if a child latches onto a constricted nipple during a vasospasm event. The constricted nipple does not stretch well, and the internal, and sometimes external, damage can cause high levels of pain during latching and sometimes also with milk let down. Any such internal damage can take a week or so to heal and become pain free. Raynaud's can also cause a mild, continuous pain, or breast sensitivity, which sometimes starts a few days before the vasospasm events start to occur.
After the first vasospasm event, vasospasm is likely to continue to occur with each feeding or exposure to the cold, with treatment typically taking a week or two for the events to subside. Vasospasm events may last from a few minutes to continuously if the nipple is not warmed. Pain can be described as being in either the nipple or the whole breast.
Vasospasm most commonly occurs on both nipples, but I have found that it may be limited to one, and which nipple is affected may change over time. It can be triggered solely by the cold, extreme changes in temperature (such as going outside on a cold day), high emotions, leaving nipples to air-dry after breastfeeding, damage to the nipple caused by poor latch or similar, or a combination of factors. Raynaud's can recur with subsequent pregnancies and breastfeeding. Some medications have been associated with vasospasm including oral contraceptives. "Fibromyalgia, rheumatologic diseases (eg, systemic lupus erythematosus or rheumatoid arthritis), endocrine diseases (eg, hypothyroidism or carcinoid), and prior breast surgery have also been associated with Raynaud's phenomenon." (kellymom webpage).
Raynaud's is often misdiagnosed as poor latch, as pain can occur when feeding, external damage may be present, and it may not hurt every time you breastfeed. This can be a very frustrating diagnosis for the mother, as trying to repeatedly latch the baby to get the 'perfect latch' can result in intense pain every time. Raynaud's is sometimes also misdiagnosed as thrush, and I have had nipple damage misdiagnosed as a milk bleb. Broken capillaries and ducts due to Raynaud's can bleed into the surrounding tissue. When a milk duct is damaged a white ring can form around the duct, looking like a milk bleb. These "bleb's" do not need to be opened up or cleared, but can be left to heal.
Raynaud's of the nipple most commonly affects breastfeeding women, with onset typically occurring sometime in the first month, or during the first winter of breastfeeding. However, Raynaud's also occurs in pregnant women, and may also affect women who have never been pregnant. It is more common in cold climates, and can be hereditary. Women who have Raynaud's of the fingers and toes will often develop Raynaud's of the nipple when they start to breastfeed. Raynaud's occurs in up to 22% of women (Olsen and Nielson, 1978).
If the vasospasms are due to the cold only the term Raynaud's disease is used, and if they are secondary to another condition then the term Raynaud's phenomenon is used. If the vasospasms are due to poor latch only then the condition is not Raynaud's, but is just described as nipple vasospasm or blanching.
Management of Raynaud's
Raynaud's disease is a condition that is typically managed, not cured. I've listed all sensible management options that I am aware of below. No single option will work for every woman. Many women will use a range of management options, with methods used changing with the season, how badly they are being affected, pregnancy, and breastfeeding of a newborn or an older child.
The number of supplements and medications suggested to help with Raynaud's is significant, and I've only included the options that studies have shown to work for some women, or are widely accepted to help some women. Even this reduced list is extensive, mothers should try options that they consider appropriate for themselves, and not everything at once. All women should discuss all medical, herbal, and supplement management options with their health provider first.
Keeping Warm
- To prevent vasospasms occurring, dress warmly, especially when going outside in winter. Breastwarmers, which insulate the breast, or woollen breastpads can be used to keep the breasts warm.
- Never allow the nipples to air dry. The evaporation of milk and saliva causes the nipple to quickly cool, causing vasospasm. As soon as the baby comes off the breast the breast should be covered. If the baby is repeatedly coming off, then just covering the nipple with your hand will suffice. If feeding is finished then cover the breast up immediately. Ensure that all bras and breastpads have either a wool or synthetic fabric against the skin - cotton must be avoided, as it feels cold when wet. If you have cotton bras then use breastpads with a synthetic or wool liner. I note that during vasospasm phases some women find their nipples become sensitive to some fabrics such as wool, in this case synthetic, stay-dry, fabrics, such as microfibre should be used against the skin. Breastpads should be changed as soon as they become wet. Lanolin barrier cream or olive oil can help stop the nipple from air-drying, the cream or oil should be warmed in your hands before being applied.
- When vasospasm occurs, repeatedly squeezing the nipple will help blood flow back into this area. Doing this immediately will limit damage to the nipple caused by a lack of blood, and will improve recovery times. Gently squeezing the nipple to ensure it is not constricted prior to latching will help ensure that secondary damage to the nipple does not occur. The Nbci website recommends massage of the chest muscles, these are below the collar bone and above the breast.If the nipple is constricted then the breast should be warmed before the baby is latched on.
- For serious vasospasm problems increased heat can be provided from heated wheat packs or oxidising packs. Large wheat packs keep warm for longer, however smaller, shaped, wheat packs will stay in place better. Oxidising packs provide up to eight hours of heat. If these products are not available, then a sock filled with rice and heated in the microwave, or a hot wet flannel in a zip lock bag can provide some help. Great care needs to be taken in using any heat source near babies or while sleeping. Heat sources should be encapsulated to ensure they are well insulated from both mother and baby's skin to prevent burns, and the disposable hand warmer systems should be protected from leaking milk.
- Use of breastwarmers and heating systems can increase milk supply, and may also help mothers who suffer from mastitis or blocked ducts. However, an increase in milk supply can lead to engorgement and a milk oversupply problem for some women. Mothers who experience engorgement may need to pump for comfort, and mothers with an oversupply problem should be informed how to treat this. Some women with Raynaud's also suffer from Erythromelalgia, where sensitivity to heat occurs, heat treatments will be inappropriate for these women.
General Suggestions
- Keep all rooms you are using, including the hallway, warm in winter. At night, having baby in the same room, and keeping this room heated can help.
- Pumping your milk may help reduce pain, or give you a break to help get Raynaud's under control. Pumping doesn't stretch the nipple as much as breastfeeding, and so reduces any latching pain, and there is no sharp change in temperature after feeding, making vasospasm after pumping less likely. For some women a day's break every now and then helps, with some women having to pump for longer periods. Methods to feed your baby expressed breastmilk without creating nipple confusion that bottles may cause include using a spoon, syringe, feeding tube, or cup.
- Exercise will improve your circulation and helps some women.
- 'Training' of the blood vessels to constrict and relax by turning the shower from warm to not so warm may help.
- Avoid all products that contain caffeine, nicotine or other vasoconstrictive drugs.
Remedies
B6 vitamin supplements help some women. There are no studies supporting this, but it does appear to help (DrJackNewman website). The recommended dosage is 150-200 mg/day for four days, reducing to 25 mg/day until the mother has been pain free for several weeks. Any improvements generally occur within the first few days of taking this supplement. Vitamin B6 can affect milk supply in some women, making this option most suitable for women with an established milk supply (baby older than three months) or an oversupply of milk. Women with a young baby or a low milk supply should feed their baby on demand and monitor wet and dirty nappies for the first week or so after starting these supplements.
If vitamin B6 does not work then nifedipine tablets, a prescription drug, may be considered (Kahan 1982). Nifedipine is typically used to treat raised blood pressure, and prevents vasospasm occurring by reducing smooth muscle tone in arteries. Treatment is usually a two-week dose of 15 to 30 mg per day, either taken over the day or using slow release tablets once a day. Future attacks can be treated with an additional course of tablets. Some women who suffer from regular repeat attacks may wish to take a continuous low dose treatment. Treatment can be unsuitable for women with low blood pressure, and side effects can include headaches. Women may need to reduce the dosage to avoid headaches, or increase it to treat the Raynaud's. Nifedipine does cross into breastmilk, however no harmful effects to the infant are known.
If you go to see your doctor to talk about Nifedipine, it may pay to go prepared, as many doctors are unaware of this condition, and its treatment, and are reluctant to prescribe it to breastfeeding mothers. I recommend you take a printout of this page with you: http://www.ncbi.nlm.nih.gov/pubmed/15060268 Which is the research that supports the use of nifedipine. The prescription for nifedipine is usually subsidided in New Zealand.
Calcium (2000mg per day) and magnesium (1000mg per day) supplements can help some women if they are deficient in these minerals (Belch et al, 1985).Pain relief tablets such as Ibuprofen may help, however they should not be taken continuously over long periods of time.
Half a glass of red wine a day can help some women, however it should be noted that heavy alcohol use is associated with an increase in Raynaud's. The link to this research is here: http://www.arthritis.org/smoking-raynauds.php Women wanting to try this treatment should try half a glass of red wine, once a day, just after feeding your baby, at a time when you know you won’t need to feed your baby for half an hour at a minimum, or one hour if you are smaller than average. This delay will allow your body to process the alcohol.Given that moderate consumption is the key, the benefit may be derived from giving the blood vessels a rest. Some mothers find that their nipples seem to progressively constrict, with each episode getting worse, as it builds on the last vasospasm. Having a rest, a chance to relax and heal, is just what they need.
For pregnant women, the current recommended safe limit of alcohol is no alcohol at all. If a pregnant woman wanted to try this remedy, I would strongly suggest they consult with their Doctor first. This remedy may not be suitable for women whose babies feed very frequently, women with a history of alcohol abuse, or women suffering postnatal depression.
Some herbs help stimulate circulation; these include ginger, cayenne pepper, and cinnamon. Herbal preparations such as "winter warmth", tablets, or simply including these ingredients in your cooking helps some women. Ginkgo Biloba may also be of help (Muir et al 2002). The suggested dosage of ginkgo as a tea is one tablespoon per cup, and 2-3 cups a day. You should check with your Doctor before taking ginkgo, as it may reduce clotting, so isn't recommended if there is any potential bleeding for mother or baby, and it should never be combined with blood thinners, aspirin, ibuprofen, coumadin or arthritis medications. I also note that ginkgo may prevent ovulation.
Recommended websites:
http://www.kellymom.com/bf/concerns/mom/nipple-blanching.html
http://www.breastfeedingonline.com/articles.shtml
Your midwife, lactation consultant, or a la leche league leader can provide further help for women with Raynaud’s.
If you have suffered from Raynaud's I would love to hear from you as to what treatment methods you have tried, and what has worked for you, so this article can be added to over time. I can be contacted at tara@summerwarmth.co.nz.
References
Drjacknewman webpage (2009): http://www.drjacknewman.com/help/Vasospasm%20and%20Raynaud%E2%80%99s%20Phenomenon.asp
Kellymom webpage (2009): http://www.kellymom.com/bf/concerns/mom/nipple-blanching.html
Nbci webpage (2009): http://www.nbci.ca/index.php?option=com_content&view=article&id=52:vasospasm-and-raynauds-phenomenon&catid=5:information&Itemid=17
Belch JJF, Shaw B, O'Dowd A, Saniabadi P, Lieberman P, Sturrock Rd. et al. (1985) Evening Primrose Oil (Efamol) in the Treatment of Raynaud's Phenomenon : A Double Blind Study. Thrombosis and Haemostasis. 54(2): 490-494
Kahan A, Weber S, Amor B, Saporta L, Hodara M, Degeorges M (1982). [Controlled study of nifedipine in the treatment of Raynaud's phenomenon] (in French). Rev Rhum Mal Osteoartic 49 (5): 337-43.
Olsen N, Nielson SL. (1978) Prevalence of Primary Raynaud's Phenomenon in Young Females. Scand J Clin Lab Invest; 37:761-76
Suter LG, Murabito JM, Felson DT, Fraenkel L (2005) The incidence and natural history of Raynaud's phenomenon in the community. Arthritis and Rheumatism 52 (4): 1259-63.
Muir AH, Robb R, McLaren M, Daly F, Belch JJ (2002) The use of Ginkgo biloba in Raynaud's disease: a double-blind placebo-controlled trial. Vasc Med 7 (4): 265-7.
This information was adapted from an article written by Tara Hills for Mosaic, April 2010.
Disclaimer:
Information provided by Summer Warmth is not meant as a substitute for professional help from your health care professional. Please seek advice from your health care professional if you are having problems with breastfeeding or if you have continuing concerns.Mother’s Stories
If you would like to write your story for this page I’d love for you to send it to me.
Tara’s Story
My experience with Raynaud’s started when my son, Olly, was just a few weeks old. I quickly noticed my white nipples, googled "white nipples breastfeeding", and found out that it was probably Raynauds of the nipple. My midwife agreed, and I made a booking to see my doctor to see if I could take nifedipine. Meanwhile I started using a large heated wheat pack after each feed. My doctor considered nifedipine to be unsuitable for me due to my low blood pressure, and advised me to keep warm. My large wheat pack obviously wasn’t a practical long-term solution, I brought a herbal tonic that I couldn’t drink, and had such low milk supply that I was supplementing, so didn’t want to take vitamin B6. So I went back to the internet where I found out about breastwarmers and ordered some from Australia. These made a huge difference for me.
However the breastwarmers I had were very large, and not that practical, therefore I never used them as much as I should, and would eventually end up with vasospasms again when they weren’t being used during times of cold weather. I had particular trouble with my left side, which once every three or so months, would get damaged with what appeared to be a leak from one of the milk ducts, causing intense pain with latching.
Olly was weaned when he was two years old and I was three months pregnant. Soon after this I began having trouble with vasospasms again. They would always be heralded a few days beforehand by very sensitive ‘tingly’ nipples. I really didn’t want to use my existing breastwarmers all the time due to their bulk, so I figured out how to make some myself that were smaller and more discrete, and found them to be very effective at getting rid of the ‘tingly’ feeling. They never really felt like they were doing anything, but whenever I stopped using them the sensitive nipples came back, and this is a comment that some of my testers also made.
After having my second child, Emma, I was so sure that I had my Raynaud’s under control that I never even bothered to tell my midwife about it. I was sure that if I was extra careful, never let my nipples air-dry and always used my breastwarmers, I would be fine. I guess I forgot about how with a newborn you are regularly waving your nipple in front of them for minutes at a time, in the middle of the night, trying to latch them. This scenario was no match for my current management of Raynaud’s. I started having vasospasms about a week after Emma was born. These were particularly bad on my right side, and I also started having had intense latching pain on this side, moderate pain during feeding, and some external damage. My midwife and I both figured this was all due to poor latching on this side, and I watched all the latching video clips I could, and reread the latching information I had. Nothing I did would guarantee a pain free latch though. I felt like such a failure that I couldn't latch properly and feed pain free.
With every latch words like "bitch", and "how could you do this to me", would spring into my mind. I was horrified that these words could be associated with my beautiful, loved, daughter. Emma had had a beautiful birth, followed by days of continuous skin-on-skin contact, and demand breastfed. We were strongly bonded to each other, yet these awful words somehow found their way into our lives. Latching was torture. Way worse than childbirth. However, I was completely determined to breastfeed, knowing the huge benefits that it had given Olly and I. I was also completely sure that whatever was causing my pain was something that I could work through.
The vasospasms and painful latching lasted for a few weeks. I used my breastwarmers all the time, and tried many ways of keeping my wheat packs warm at night so I didn't have to go to the kitchen to heat them up.
I had a second bout of Raynaud's a few months later, during fine weather in December. I had vasospasms as well as excruciating pain during latching. The pain during latching had a distinct starting point, after I had latched while my nipple was constricted, and this had caused me internal and external damage, causing me ongoing pain with each latch. My constricted nipple wouldn't stretch, and a baby’s suck is very strong, and something had to give. After realising this, with every latch I would gently squeeze the nipple to check it wasn't constricted. If it was, I would squeeze/massage it for a few moments was all it usually needed to become stretchy again. If a vasospasm occurred I would also squeeze and massage to make sure the blood returned to the nipple as soon as possible to stop the pain and prevent tissue damage.
I knew that latching trauma to the nipple was believed to be associated with Raynaud's. But it damage due to latching of a constricted nipple seems to me to be a better fit to women's description of an "intense pain regardless of perfect latching". Usually when the problem is poor latch, if the latch is corrected then the latch will be pain free, leading to the advice that "breastfeeding shouldn't hurt, if it does, take the baby off the breast and try relatching". For a woman who is going to have intense pain with every latch, advice like this is terrible information. I remember latching Emma again and again, trying to obtain pain free breastfeeding. In hindsight I think I was probably doing more damage than good, as really I knew Emma was well latched.
I started using disposable hand warmers during this episode of Raynaud's. I put these inside a cover to keep me and the warmers dry, and to make sure neither Emma or I could come into direct contact with them and get too hot. I had finally found the solution that worked for me - the bliss of having eight hours continuous heat at night. Emma slept with me, so this solution meant I didn't have to get out of bed at all at night. It only took a few nights for me to have my vasospasms under control, and the pain at latching took a week or so to go. Using the warmers gave me lots of milk in my right breast, but this was a problem that I could easily manage by block feeding, or expressing when I needed to. Using cold cabbage leaves to reduce engorgement was one solution I was happy to leave to those without Raynaud's.
Breastfeeding is now going great. Emma is currently at that incredibly cute stage where she comes off the breast every few minutes to look at me, smile, and then bury her head into me again. I so look forward to all the other breastfeeding stages we will be able to go through together, and consider myself so lucky to have been able to manage this condition and to be able to breastfeed my children.
Tracey’s Story
Hi - just wanted to let you know how great your site is, which I found via Trademe. I'm excited to be 20 weeks pregnant with my second baby (due May - a winter baby), my daughter was born in spring and is now 15 months old. I fed her for a year, and am a strong advocate for breastfeeding.
I have had Raynauds since I was a teenager, suffering from symptoms in my hands and feet. Red-purple-white symptoms fluctuated with my level of fitness and health, and were terrible when I was a smoker in my teens and early 20s. Go figure. But I especially learned over the years the true value of wool, to keep fit, and to keep-warm-stay-warm, rather than try to overcome an episode or sometimes nurse chillblains or horrible finger joint-lump lesion things. It didn't seem right to take the offered circulation drugs, and I tried lots of natural supplements, ginger, cayenne etc, none of which I stuck with. I wasn't actually given the Raynauds tag until my late 20s, by a GP then subsequently a hand therapist, when I was having trouble healing a badly broken finger. I thought they said "Reynolds" and had no luck with Google...
At 32, I was determined to breastfeed my daughter, and sought help from many sources - all excellent - when I found it challenging. I was vaguely aware that Raynauds (I worked out how to spell it) could affect nipples, but had often noticed mine being white and/or purple (but not particularly sore) and thought that was fairly standard. The intense pain I experienced when latching and at other non-feeding times was queried as thrush, but mostly poor latch, before a lactation consultant I saw at a small-town maternity unit suggested and then decided for sure it was Raynauds. I had plenty of milk, and very fast flow which required some other tactics for my daughter's comfort. I was managing the pain, however, by that point on instinct with a wheat pack, was using wool or microfibre breast pads by chance and only having success with expressing in a hot shower. Unlike you, I found air-drying really beneficial, although I only did this in full, hot, spring sunlight (inside my secluded house in front of the window, with towels to deal with the resulting let down - it was bliss). My blanching symptoms lasted for about 4 months, and while I had some on-off pain through the winter, I believe I was mostly pain-free because I had mastered the art and, basically, there was no mucking around with my nipples exposed at feeding times.
It's worth mentioning that my daughter was born with purple (dark purple) feet, alarming enough for my midwife to call in a pediatrician, who questioned me, then diagnosed... Raynauds! It's definitely hereditary. I'm preparing now for a winter newborn, really conscious that things could be different this time, and so came looking for affordable wool breast-pads (will purchase in a few months, thanks). I totally forgot you could buy contoured breastwarmers, so will get some of yours, too. Wish I'd found your site the first time round, there is some great advice, and I hope readers appreciate your information is well-sourced and legitimate.
Kind regards, Tracey
PS - Hand therapists use really warm wax to heat up hands and fingers in preparation for treatment - it's in a little slow cooker thing like you'd expect at a beauty therapist's, only the wax is wonderful, it stays warm for long enough to heat your fingers up after you dip your hand in then you just peel it off when it dries, and it doesn't adhere to your skin. At the time, my hand therapist invited me to drop by any time my hands were really cold for a dip! Just occurred to me that it could be an out-there therapy for Raynauds nipples??? You could do the whole breast...!
