Nipple Pain/Nipple Trauma Lactation Note

Date/Time: [Date and time of encounter]

Visit Type: [initial / follow-up]; [clinic / hospital / telehealth]

Clinician: [Name and credentials]

Patient of Record: [lactating parent / infant / dyad] ([how charted in system])

Dyad Snapshot: Parent: [postpartum timing]; [stated feeding goals]. Infant: [age in days/weeks]; [gestational age if preterm / term]; [current weight status if known]. Infant present: [yes / no]. (If infant not present, note that latch and oral exam findings cannot be assessed.)

Chief Concern

[Primary complaint in one sentence]

History of Present Illness

[Onset and trajectory relative to postpartum timing]; [laterality: left / right / bilateral]; [timing pattern: pain at latch / during feed / after feed / between feeds / with letdown / with pumping / cold-triggered]; [character: burning / shooting / sharp / itching / deep ache]; [numeric pain severity at latch X/10, during feed Y/10, after feed Z/10]; [visible trauma described by patient: cracks / bleeding / blisters / scabbing / ulceration]; [functional impact: shortened feeds / avoidance of direct breastfeeding / pumping instead / other]. Red flags if present: [fever / spreading redness / systemic symptoms / purulent discharge / vesicular lesions / pain out of proportion to visible findings]. [Patient's suspected cause]. [Most limiting issue today].

Feeding and Pumping History

• Feeding pattern: [frequency and intervals], [typical feed duration], [one vs both breasts per feed], [infant behavior at breast: clicking / slipping / chomping / pulling off / prolonged feeds / sleepiness].
• Swallowing and satiation cues: [perceived swallowing], [satiety signs].
• Elimination: [wet diapers/day], [stools/day].
• Supplementation: [expressed milk / donor milk / formula / none], [method], [volume], [frequency].
• Pumping/hand expression: [indication], [device type], [flange size if known], [frequency], [duration], [symptoms linked to pumping: ring marks / blanching / edema / rubbing / new trauma].
• Prior lactation support: [who and when], [key techniques taught], [patient-reported response].

Relevant History

• Lactating parent: [prior nipple sensitivity or breast surgery], [history of eczema / dermatitis / psoriasis], [Raynaud phenomenon or cold sensitivity], [chronic pain syndromes], [recent antibiotic or antifungal use], [history of HSV or zoster involving breast or nipple].
• Infant: [prematurity], [NICU course affecting feeding], [nasal congestion], [reflux], [hypotonia], [craniofacial anomalies], [torticollis], [prior tongue-tie evaluation or frenotomy and outcomes]. (Include only elements affecting suck–swallow–breathe coordination or differential.)

Psychosocial and Goals

[Patient feeding goals and acceptable trade-offs: exclusive direct breastfeeding / pumping / combination feeding]. [Brief mood screen or concern level]. [Support at home], [barriers to follow-up]. (Include when pain is moderate–severe, persistent, or threatens early weaning; may abbreviate for straightforward mechanical issues.)

Physical Examination

Vitals: [vital signs] (Include only when infection suspected or pain is severe.)

Lactating parent—breast and nipple exam: [Laterality: left / right / bilateral]. Nipple/areola appearance: [erythema / edema / fissures / cracks / bleeding / scabbing / blisters / ulcerations / shiny or flaky skin / weeping or yellow crusting / purulence / normal]. Nipple color: [normal / blanching / purple-red transitions]. Palpation: [tenderness: none / superficial / deep]; [masses / focal firmness / ductal cord / blebs / none]. Manual expression: [performed / not performed]; [tolerance]; [milk appearance if relevant]. (If exam declined, document and note assessment limitations.)

Infant examination: [Head/face symmetry], [jaw excursion], [neck ROM], [palate shape], [tongue mobility and function], [frenulum appearance and functional restriction], [oral lesions], [latch seal issues], [tone and alertness], [nasal congestion]. (If infant not present, state: "Infant not present; oral and latch findings not assessed.")

Observed Breastfeeding Session

(Include whenever feasible. If not performed, state reason and how plan accounts for this limitation.)

• Position: [cradle / cross-cradle / football / laid-back / side-lying]; [breast side: left / right].
• Alignment and stability: [infant body proximity], [ear–shoulder–hip alignment], [support adequacy].
• Latch sequence: [gape adequacy], [asymmetry], [lip flanging], [chin contact], [seal quality].
• Suck pattern and transfer cues: [nutritive vs non-nutritive], [audible/visible swallowing], [clicking], [rhythm], [de-latching or sliding shallow], [identified triggers].
• Pain scores: Pre-adjustment [X/10] → Post-adjustment [Y/10].
• Nipple post-feed: Shape: [rounded / creased / lipstick-shaped]; Color: [normal / blanching line / color change].
• Milk transfer estimation: [clinical signs / test weight], [results]. (Include if performed.)

Pumping Observation

(Include if pump-related trauma suspected.)

• Device and setup: [pump type], [flange size], [centering and seal].
• Nipple movement: [smooth glide / rubbing], [areolar drag], [blanching / edema / ring marks].
• Settings: [suction level], [cycle rate], [duration], [comfort level].
• Post-pump findings: [visible trauma], [color change], [pain].

Tests Ordered

[Specimen source], [laterality], [indication], [disposition]. (Include only if cultures or other tests obtained.)

Assessment

Summary: [One-sentence synthesis: postpartum timing, pain severity/timing, salient trauma/exam findings, observed mechanics, presence/absence of systemic signs.]

Problem List

• [Problem 1]: [Supporting evidence from history, exam, and observed feeding]; [differential considerations]; [working diagnosis]; [risk considerations]. (Document ankyloglossia and thrush as "suspected" with functional findings rather than definitive diagnoses based on appearance alone. Note if key mechanism was not directly observed and adjust diagnostic certainty accordingly.)
• [Problem 2]: [Supporting evidence]; [differential]; [working diagnosis]; [risk considerations]. (Add problems in descending clinical priority.)

Plan

In-Visit Interventions

• Techniques trialed: [position changes and rationale], [latch adjustments: asymmetric latch / lip eversion / chin support / re-latch strategy], [teach-back confirmed].
• Observed response: [pain score change: X/10 → Y/10], [nipple shape/color improvement], [transfer cues: swallowing, infant calmness].
• Nipple shield: [size/type], [placement technique taught], [observed transfer]. (Include if used.)
• Other: [analgesia provided], [topical therapy applied], [test weights], [referrals initiated].

Home Plan

First 24–48 hours: [Feeding approach: continue direct breastfeeding as tolerated / temporary pumping to allow healing]; [threshold for switching to pumping]; [nipple wound protection]; [analgesia with lactation safety counseling if applicable].

Next 3–7 days: [Daily positioning/latch practice with specific cues]; [nipple shield monitoring and weaning plan if used: output/weight checks, supply protection]; [pumping optimization if applicable: flange sizing, suction/duration].

1–2 week checkpoint: [Escalation criteria: cultures, targeted medical therapy, specialist referral if pain/trauma persists despite optimized mechanics].

Condition-Specific Management

(Include relevant conditions only.)

• Vasospasm: [warmth application], [cold trigger avoidance], [medication discussion if needed].
• Dermatitis/contact allergy: [trigger avoidance], [topical therapy], [follow-up plan].
• Bacterial infection: [topical vs systemic therapy], [culture plan].
• Suspected candidiasis-like syndrome: [supporting signs and risk factors], [shared decision-making: empiric therapy vs further evaluation].
• Suspected HSV or zoster: [feeding restriction for affected breast if applicable], [urgent treatment/referral pathway].
• Suspected ankyloglossia: [full assessment documented], [conservative measures attempted and response], [referral criteria], [follow-up access].
• Milk flow/supply contributors: [oversupply / forceful letdown / engorgement / plugged duct management].
• Pump-related trauma: [flange fit adjustments], [settings changes], [duration limits], [healing measures].

Follow-Up

[Interval: 48 hours / 5–7 days / other] with [IBCLC / breastfeeding medicine / OB / pediatrics / ENT / dermatology]. Success markers: [pain reduction target], [healing trajectory], [infant weight and output adequacy], [latch mechanics improvement].

Return Precautions

• Fever or systemic illness
• Rapidly spreading breast redness, worsening focal tenderness, or new mass
• Purulent drainage
• Vesicular lesions on nipple or areola
• Infant dehydration or poor intake concerns (reduced wet diapers, lethargy, poor weight gain)
• Pain escalating or not improving by defined checkpoint

Patient Education

[Feeding goals reviewed and patient preference]; [options discussed: direct breastfeeding / pumping / supplementation]; [lactation safety counseling for medications and resources consulted]; [teach-back confirmed for latch technique and devices].