A-Z

Breastfeeding

Medical conditions that could affect breastfeeding

Medication, medical conditions and breastfeeding
Some medications taken by the mother can pass into breastmilk, but for many women the benefits of taking certain medication outweigh the risks. Evidence indicates that the possible risks of medication used during breastfeeding are significantly lower than during pregnancy because a nursing baby receives a lower dose than the fetus during pregnancy (BMJ Clinical Review 2014).
 
There are, however, some situations where the potential risks of the medications or condition mean that it's safer and so not advisable to breastfeed for example women with HIV infection or those taking some cancer medications. The American Academy of Paediatrics suggests that radioactive compounds and anticancer drugs should be avoided during lactation (2013).
 
In the UK, the National Institute for Health and Care Excellence (NICE) Guidelines gives advice and information on particular medical conditions and breastfeeding. LactMed is another reliable source of information that is geared to the healthcare practitioner and nursing mother. It includes information on the levels of drugs and other chemicals in breastmilk and infant blood, and the possible adverse effects in the nursing infant.
 
All women who have a medical condition that requires medication, and are considering breastfeeding, are advised to speak to their midwife, health visitor, pharmacist, GP, obstetrician or consultant about their particular circumstances and concerns.
 
There are some medical conditions and treatments related to breastfeeding such as mastitis, poor infant attachment, nipple damage, and fungal infection. These breastfeeding difficulties are considered separately under the following headings: see The milk coming in, Sore nipples, Dealing with difficult times and When breastfeeding doesn’t work out. Below, we illustrate the experience of women who were unable to breastfeed due to two very different medical conditions: HIV and Raynaud’s.

HIV and breastfeeding
The World Health Organisation (WHO) guidelines on HIV and infant feeding recommends that HIV positive mothers with infants who are HIV negative (or whose status is unknown) should either avoid breastfeeding altogether, or breastfeed when on antiretroviral therapy (ART) to lower the risk of HIV transmission (2010). HIV positive mothers in resource rich countries like the UK are advised to abstain from breastfeeding and use formula feed instead.
 
We talked to Kate and Hana, two HIV positive women who did not breastfeed their children born after they were diagnosed with HIV. Both women knew that an HIV infected mother can pass the virus to an uninfected baby through breastmilk so they followed medical advice.
 
During their pregnancies both women were carefully monitored by their HIV specialist, obstetricians and their HIV clinic consultant. The use of antiretroviral therapy (ART) ensured that Hana and Kate’s children were born HIV uninfected and Hana was able to have her children by normal delivery. Kate was deeply disappointed when told she needed to have a C section. 
 

Hana says that breastfeeding was not an option but that at least she was able to have normal deliveries.

Hana says that breastfeeding was not an option but that at least she was able to have normal deliveries.

Age at interview: 44
Sex: Female
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Now tell me about breastfeeding. What did the doctor say about breastfeeding?
 
Breastfeeding is not even an option, no way, because everything it come from me it goes to them. So the best thing to do from start, I have to teach them how to use a bottle so I used to have, one was for three months I used to have a problem, you know, too much milk coming out and I have to, I can’t go out even unless I have to put on plastic, under the plastic I have to put protection otherwise, otherwise I’ll be wet.
 
Did they give you any medication to stop the milk?
 
No, no. They didn’t. They didn’t.
 
Okay.
 
So they said, he’s going to stop by himself.
 
How did you feel with the breast full of milk and unable to feed the kid?
 
I don’t feel anything because you know what, one thing is for the protection of my kids and I’m lucky enough, at least I could give them a natural birth, you know, so what else I could ask.
 
Okay, So breastfeeding wasn’t..
 
I was aware of it already. When, during pregnancy time I was already, I was already been told. Just completely I have to clear it out from my mind. This is not going to happen, so I knew it. So, if it’s for the protection of my kids, then I want, I just have to feed them milk.
The impact that having a diagnosis of HIV had on their options regarding breastfeeding affected Hana and Kate differently. Hana’s two children were both born after she was diagnosed HIV positive, so at the time of both her pregnancies, she had been on ART therapy for some time. She felt that to avoid the transmission of the HIV virus to her children was more important than breastfeeding. So, abstaining from breastfeeding was not a problem for her. Kate on the other hand, found out she was HIV positive during the pregnancy with her second child, and went through her pregnancy in what she described as a ‘state of emotional shock’. She found it very difficult to accept the consultant’s advice to avoid breastfeeding. She complied but she felt utterly miserable.
 

Kate didn’t breastfeed her second son and felt that she missed out on the bonding experience that she felt she has had with her first child.

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Kate didn’t breastfeed her second son and felt that she missed out on the bonding experience that she felt she has had with her first child.

Age at interview: 39
Sex: Female
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But then they told me I had to do caesarean and all that, and not breastfeed, which was hard for me because…
 
Which one?
 
Knowing, knowing that I have to do caesarean, go for caesarean and not breastfeed my baby because I had my first one, child, and I breastfed him. Had a normal birth and everything so it was like everything is just changing.
 
Yeah, so how did you feel about the idea of not being able to breastfeed?
 
That hurts.
 
Hurts?
 
Yep and I just, I just, I don’t know even anything that is worse to me than that and because you know I felt like no breastfeeding to me is just a way of bonding with a child and it’s something that a mother should do. And I felt like, okay, the disease has robbed me of that opportunity to breastfeed my child, to be that close to him you know because it’s not the same as some men.
 
I can tell you that with my first child we are really, really that close, he’s a boy as well, we’re very close. But the other one, I felt like whether I’m there or not there, it doesn’t really bother him and sometimes I, I think about it that is it because of that  I didn’t breastfeed him because he felt a bit distant than other one. I don’t know if it’s just me honestly beating myself about it, knowing that, oh, well I didn’t do this or may be it shouldn’t have any effects on him, I don’t know. But…
 
Carry on, carry on.
 
I still wish there was a way that I could have breastfed him but anyway if it was for his own good then.
But Kate’s attitude changed when she became pregnant with her third child. By then, she had accepted being HIV positive, and was more prepared to accept the limitations imposed by HIV on the experience of motherhood: the possibility of a C section and the used of baby formula instead of breastfeeding.
 
Both women appreciated the specialist medical care and the help they received from medical teams and HIV support workers during and after their pregnancies. Both found HIV support workers were an important source of support and information. Hana commented that during her pregnancies, she had come to rely a lot on her obstetrician consultant, in whom she had absolute trust. 
 

Kate talks about the kinds of help she got from her HIV support worker.

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Kate talks about the kinds of help she got from her HIV support worker.

Age at interview: 39
Sex: Female
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I think, you know, when you are a mother, they are, I’m, I’m the kind of person, maybe, they, they do a lot things like… like they’ll provide us with all the milk and appointments and maybe they can even make appointments for us. And they remind me because I’m, I think I was at the point where I was really stressed, couldn’t even remember sometimes what day it was and I wouldn’t even remember my appointments but you know. Or sometimes when I don’t have transport available they would even come, offer to come pick me and take me to the hospital and they would go sometimes with you to the hospital if you don’t want to be, go there on your own, they, they support and they know all of it. There is things that they can explain things to you if there’s things you don’t understand. They do a lot, I don’t want to…, they do, I mean and also if you want to meet up with other people they can organise it if you need someone else to talk to whose going through similar issues with you, so.
 
And did you meet other expecting mothers when you were pregnant with her or no?
 
Yes, I have. I have met a couple of ladies who were expecting about the same time as me.
 
Okay, so that was, kind of, was that reassuring, was that sort of, kind of supportive?
How did you feel about it?
 
Yes, this time round, like I say, I was, I was okay with it, you know. The first time I think that was a…. When you’re first time is when it’s harder because then you do not want to talk to people. You don’t want, even though there are people who are, you don’t want people to know that you are, I would say that you don’t want to be painted with the same brush as others, you just, even though you know that you’re HIV positive actually, it’s like I don’t want to be like them. It’s just, I don’t know if it makes sense.
 
Yeah, it does make sense, yeah.
 
Because I, it’ll be like, oh shall I talk to those people, or accepting them, accepting what, who, what you are, and I think it’s just sort of hard at the times like okay now I fe... now I feel like I belong to a second group of people who are like this and that and I didn’t want, I wasn’t ready to accept it. But this time, I just don’t mind honestly. I meet people there, we talk.
 
Okay and you go to the meetings organised by THT?
 
Yeah, yeah I do go to the meetings and meet other people. 
In close-knit communities, people become suspicious that a woman is HIV positive if she becomes a mother, but doesn't breastfeed. Hana and Kate felt under the scrutiny of others; friends and even family members who wanted to know why they were not breastfeeding.
 

Hana didn’t tell friends or family the reason why she couldn’t breastfeed her children. If asked, she said her milk had dried up.

Hana didn’t tell friends or family the reason why she couldn’t breastfeed her children. If asked, she said her milk had dried up.

Age at interview: 44
Sex: Female
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I never feed my kids in front of them because you know why I don’t want all that question. I’ve been through, through, you know all that kind of things. I don’t want someone to remind me and then, and then ask me, “Why didn’t you feed them because you breast.” And I have to go in to the bedroom. It’s feeding time, I have to go. My bottle’s ready, my husband he makes a bottle. It’s ready before, you know when people are sitting and playing and talking and then that’s the time, either me or him he has to, so I have to take them in the bedroom and come back, yeah. And when my breast is dry I say to them, “No, I have to feed them bottle because I don’t have no milk no more.” That’s how I have to give some.
 
Okay, so people did ask?
 
Yeah, they ask and then my answer is always just something. I’m not going to give them, you know, why and how.
 

Kate says that in her community people suspect the mother is HIV positive if she has had a Caesarean section and does not breastfeed.

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Kate says that in her community people suspect the mother is HIV positive if she has had a Caesarean section and does not breastfeed.

Age at interview: 39
Sex: Female
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To be quite honest, the thing is like a lot of people, once you tell them your baby was a caesarean and you’re not breastfeeding, that’s it, they conclude the person must be HIV Positive. That’s just something that most people, like every, like most people that’s what they think and I mean, it’s not like I had very good like, natural birth. I had a very hard natural birth with my son because he was quite big and I really suffered. Maybe anything [laughs] I would have done to relieve that would have been nice but you know just the thought now of, ‘Okay, I just had, oh I could get away maybe with saying that I had a caesarean because of whatever but then I’m not breastfeeding either.’ And then I don’t know if you know but a lot of people, those two things, if you’ve had a caesarean and you’re not breastfeeding, that’s it, they, they conclude that you are HIV Positive, and…
 
What, did people ask why you are not breastfeeding?
 
Yeah, but I always had to make up stories isn’t it. Oh hey, de,de,de,da
 
What? You had cracked nipples or not milk or something like that?
 
Yeah, you say whatever or maybe say, “Oh, yeah.”
Raynaud’s phenomenon of the nipple
Raynaud’s is a condition that affects the blood vessels primarily in the fingers and toes. Raynaud’s is characterised by episodic attacks called vasospastic attacks that cause the blood vessels to constrict. Vasospasm can also occur in the nipples of lactating mothers. When a vasospastic attack occurs in the nipples, the nipple goes white or blue and is painful. Nipple vasospasm pain can range from minor discomfort to severe pain and so may or may not affect breastfeeding. Known triggers for vasospasm attacks include poor attachment, nipple damage (e.g. cracked nipple) or an infection (e.g. nipple thrush); and exposing the nipples to cold air (see notes 2,3,4,5).

Most people tend to develop this condition before the age of 25 and women are more likely than men to be affected by the condition – and so it commonly affects women of childbearing age. Some researchers estimate as many as 20% of all women in their childbearing years have Raynaud’s (The Raynaud’s Association 2018).
 
We talked with Jessy who has recently discovered that she was affected by Raynaud’s disease. She was only able to breastfeed both her children for a short period because of severe pain that she described as ‘burning and throbbing’ and damaged nipples. Jessy was able to breastfeed her first child for ten days, and her second child for fifteen days.
 

The GP diagnosed Jessy’s cracked and bleeding nipples as ‘thrush’. By chance Jessy found out she suffers from Raynaud’s and that it could affect the nipples of lactating mothers.

The GP diagnosed Jessy’s cracked and bleeding nipples as ‘thrush’. By chance Jessy found out she suffers from Raynaud’s and that it could affect the nipples of lactating mothers.

Age at interview: 39
Sex: Female
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No it took a while to heal actually. Like, even after when I, with the mastitis, the mastitis last two weeks. The nipples I have to put these, the doctor look at them and say, “You might have thrush”. So he gave me a cream for thrush. But then in, it was still the blood in the like, you know - it was all, it was all broken, completely broken. I didn’t even, I could see it from above, I just promised myself not to look at it in the mirror because that would make me really freaked out [laughs].
 
The second time or both times?
 
Both times, but the first time I didn’t see, the first time I thought I was going to lose my nipple because the nipple was really coming apart of the breast and the second time it was just the skin was just completely broken and it was blood in my shirts like, I was literally dripping blood…
 
So I only recently discovered - I have problems with my tissue. My tissue doesn’t heal as quick as it should. My blood doesn’t flow, I have a circulatory problems and then it affects, as much as it affects my hands it affects my breast tissue which makes it really painful. 
At the time her first child was born, Jessy’s command of English was poor and she was unsure whether she had understood all the information given to her about breastfeeding. She also experienced different attitudes regarding support and understanding from health professionals. She felt hassled to continue breastfeeding despite the agonising pain.
 

Jessy felt under pressure from one midwife to carry on breastfeeding her baby but the health visitor was more understanding.

Jessy felt under pressure from one midwife to carry on breastfeeding her baby but the health visitor was more understanding.

Age at interview: 39
Sex: Female
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I thought that maybe because my English wasn’t good enough, I didn’t understand the instructions. So this time and I went - and that time it didn’t work at all. It was painful. It was horrible. And I asked for help, I’ve, I was - I felt I was bullied into you must breastfeed even when you are, I was in agony. I was just having the worst time of my life…
 
…and their target was that I was a mum that must, mum must breastfeed, no matter what. Her nipples were bleeding, it doesn’t matter. She was in pain? It doesn’t matter. She was almost getting post-natal depression from all the stress? It doesn’t matter. She must breastfeed. And that’s what, what I felt like it was really terrible. In, in fact I got, they got like, they were turning up at my house, they were calling me, like every so often to check that I was breastfeeding. Then, the last thing it was, the last straw was that they make me pay to a woman to come and give me a personal lesson in breastfeeding.
 
So I was just like and then and my husband at that time, he stepped up and then he, he basically kicked them out and said, and sat with me and said, “What are you doing? You should stop, this is not good for you”. And then it was lucky when the midwife hand me over to the health visitor, one of the health visitor was really still like pushing me, pushing me, “You must breastfeed, you must breastfeed, you must breastfeed”. But then the second health visitor came to me and say, “Listen, the most important thing is a mummy’s OK. If the mum is not OK, how are you going to look after your baby? So don’t worry, my children grew up in, on formula, OK? And, don’t tell anyone I said it, I said so”. And then it was all, OK so she makes me feel better. 
When Jessy became pregnant with her second child, she felt better prepared: her understanding of English was greatly improved and she attended workshops, watched videos and read lots of information in preparation for breastfeeding.  But her second experience was much the same as her first. She had mastitis and experienced severe pain every time she nursed her baby. She persisted for two weeks but the pain caused her to wean the baby earlier than she would have chosen. This time, she did not seek support from health professionals.
 

When pregnant with her second child, Jessy made careful preparations to ensure breastfeeding was successful, but sadly, she had the same experience as with her first baby. She felt devastated that she was unable to breastfeed.

When pregnant with her second child, Jessy made careful preparations to ensure breastfeeding was successful, but sadly, she had the same experience as with her first baby. She felt devastated that she was unable to breastfeed.

Age at interview: 39
Sex: Female
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This time I kind of like worked it out with a different strategy. So I gave the chance to myself, I really want, I really, really wanted to breastfeed it was in my birth plan and everything. And then I went into the workshop again. This time I understood everything. I understood the theory. I watched videos. I read books. I talked to people. I practiced with dollies. I did everything possible. So by the time he was born my birth was a bit complicated. So I ended up having what I think was too much epidural so my breasts were numb for a good 24 to 40 hours.
 
After the birth?
 
After the birth. So I was breastfeeding fine no problem. He was having no troubles at all. I, he was latching perfectly. Everything was fine. As soon as I came back from hospital the painkillers started wearing, wearing off. Then every time I have to breastfeed him even when he was latched properly, it was just like - I just talk to myself and I say, “Sharp pain”. So I started doing breathing and I was like ok it might go. I started talking to people and they kept telling me, “No it will be, it will go, it will, it will go away”. I showed people the - well like a friend, I had a friend who’s a doula and she was [hush] helping me with the breastfeeding.
 
So she was telling me, “He’s latching properly”. And I said, “Yes but the pain is getting unbearable”. And after ten days like my breasts were completely raw, bleeding and swollen. And every time he cried I was, I was really tense. My hands sweat. And I was trying, I was getting angry at people every time he wake, I felt that they weren’t, you know because he wanted to be fed. And I just - I was terrified…
 
I had everything I could possibly have, I had nipple cream, I had the training, I watched the video, I read the books, I have a doula with me, a friend, a friend I could trust. I have, I even bought nipple shields and I used everything I could, I did everything I could possibly do. But then I was still obsessed with the, “I’ve got to do it, this, my boobies are not going to win, I’m going to win, I’m going to be able…
 
I was using nipple shields, made of silicon - well, I used them a week after, after seven days just to give it a try because my, at the beginning, my aim was to be able to get him to latch and then I managed to get him to latch properly and then tried different, different position, the rugby ball, the front facing, sideways, every position possible until I found the one, the one that suitable for me that was the rugby ball. But then, I noticed that, that no matter what, how many massages I did, I gave to my breasts they were so sore. My nipples start, start cracking even when I, my, when I was continually keeping them with nipple cream, like Lanolin cream. I then, I noticed that they start bleeding and they would not stop bleeding the milk was,  I tried to press the milk just to carry it, be, to carry on giving him milk [sighs] and the milk looked like strawberry milkshake, there was so much blood in that, I wasn’t able to give him that neither. Then I try to just use the breast that was less damaged for a while and tried to let the other one heal It, it seemed I was never, ever healing. And then it was that, that feeling of the fire, they were on fire, it was horrible. He felt like, every time they were out, I put him near my breast he felt like he was like a little shark or like a piranha [laughs] like just biting your breast, it was just oh. It was agony, agony, completely agony.
 
And during this time you were trying to do everything on your own? Trying to, trying to cope with this on your own. You didn’t want the health visitor or the midwife involved?
 
Yeah, no, I try, I was just like I got my friend, the wonderful doula to come and look at me. As soon as she came, “Oh yeah you’re latching fine, that’s the right way, that’s the right position”. I just went, “OK”, and I didn’t tell her, I didn’t seek her help anymore. I didn’t tell the midwife when they came, I just say yeah, “You’re breastfeeding?” “Yeah, yeah, I’m fine”. And I was just like hoping that, that he wouldn’t cry for a feed while she was there in my house. Then I just was trying to cope on my own, I didn’t, my partner wasn’t, he noticed, because he knows me, he noticed my change every time I have to do the breastfeeding and then, and then he start noticing that I was getting sadder and sadder, and sadder, and then, until, until I got to a point that every time I was breastfeeding he knew I was crying. He said, “You can’t carry on like that. This is, this is not right. This is not right. Just stop it please”. Off he went, got the formula, got the bottles, made the bottle, and then he just went, “It’s fine, and then you could, you will be able to sleep at night. Come on”. And then he made it look like it was great, but to me it was just, I was devastated. I felt like, really like the end of the world like oh, like I failed, like a failure. 
 

When Jessy experienced painful breastfeeding with her second child, she didn’t ask for help from her midwife or health visitor.

When Jessy experienced painful breastfeeding with her second child, she didn’t ask for help from her midwife or health visitor.

Age at interview: 39
Sex: Female
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So because of my past experience I decided not to tell too much to the mid, to the health visitor or the midwife because I didn’t want to feel any of that pressure I had before, that I felt bullied into “You must breastfeed, it’s the best for your child”. Because when they tell that, I felt like well I felt like - first I wasn’t doing good enough. I wasn’t doing the best for my child. I was - I didn’t feel like a good mother. I felt like a good bad mother instead. And I felt useless because I wasn’t able to breastfeed. So this time I tried to avoid that so I didn’t tell much to the midwife. But when I went to weight him on the- I think it was in - the last time I saw the midwife I mentioned to her that, “Oh no I stopped breastfeeding”. And she sort of mentioned, “Are you sure, why don’t you pump it? Are you sure you don’t want to?” And I felt like oh here we go, here we go, here we go and I avoided the subject completely because I, I just felt like I can’t.
The experience of painful breastfeeding seems to affect women in Jessy’s family - her mother was unable to breastfeed and her sister has managed, but with the use of nipple shields and painkiller injections. But despite her family history, she felt sad and experienced a deep sense of ‘being a failure’.
 
Jessy believes that health professionals should make expectant mothers aware that in some cases breastfeeding is not possible.  
 

A doctor at her place of work noticed Jessy’s hands and asked her about breastfeeding. It was the first time Jessy heard about Raynaud’s phenomenon of the nipple.

A doctor at her place of work noticed Jessy’s hands and asked her about breastfeeding. It was the first time Jessy heard about Raynaud’s phenomenon of the nipple.

Age at interview: 39
Sex: Female
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I was in this place and he comes along and he said, “Hi, how are you?” And I said, “Oh, yeah, look, I have my baby”. And he say, “Oh very good”. And then he looks at my hands and then he said, “Did you, were you able to breastfeed?” Like that. And I said, “Hm, hm, no, not really, I had problems, it was really painful”. He say, “Hmm, so during the winter your hands get really cold and painful?” And I said, “Yeah, yeah, my fingers, I can’t move them and they get really purple”. He was like, “Hmm. That’s called Raynaud’s”. And I say, “OK”. And yeah, it’s a circulatory problem - and it affects the tissue. And what happens is the blocked vessels don’t get enough blood and that causes pain. And that also happens, may happens, may be the reason why your breastfeeding was so painful to you. And it’s actually, he, the, it’s very, very painful. And I said, and he said, “Unfortunately, it’s, it’s something that’s not been researched enough and not many people know and it would be wonderful if GPs knew more about it because there is some medicine that they can prescribe that you can, you can take while you’re breastfeeding that will help your circulatory issues and then it will make the experience more - less painful or bearable”. Because my, and I could see the benefits completely because as much as there is people out there that choose not to breastfeed - my choice was to breastfeed but I was physically unable to do it. 
 
And then I think it will be really, really helpful if future generations or, or the next generations of mums that go, who are suffering from the same as I do, can benefit from these information, or if the GPs know more about it. And then when a woman goes to see them they can say what it is, or if the midwives, the midwife are aware of these and they can help the mum if the choice, if the mum chooses to breastfeed.  
She said that neither midwives or health visitors; nor the workshops she attended and all the information she read, mentioned vasospasm of the nipple as a possible cause of painful breastfeeding. Jessy said that such knowledge would have meant appropriate diagnosis, treatment, relief from pain and perhaps a more successful and fulfilled breastfeeding experience.
 
In severe cases of nipple pain, health professionals can prescribe calcium channel blockers (Nifedipine). (See notes 3 4 5)

Notes
1. Committee on Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Hale TW, Pediatrics 2013,132:e796-809
2. Managing common breastfeeding problems in the community. Lisa H Amir. BMJ 2014;g2954 doi:10.1136/bmj.g2954 (Published 12 May 2014)
3. Guidelines on HIV and infant feeding 2010 Principles and recommendations for infant feeding in the context of HIV and a summary of evidence
4. The Royal Hospital Women’s Hospital Fact Sheet
5. Raynaud’s Phenomenon of the Nipple: A treatable cause of painful breastfeeding Jane E. Anderson et, al. Pediatrics 2004;113;e360
6. Vasospasm of the nipple - a manifestation of Raynaud’s phenomenon. Lawlor-Smith L et, al. British Medical Journal 1997, 314:644-45

Topic added: September 2015
Last reviewed November 2018.
Last updated November 2018.
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