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1.
“All purpose nipple ointment”
(APNO)
This combination of 3 ingredients
seems to help for many causes of sore nipples,
including poor latch, Candida (yeast), dermatologic
conditions, infections of the nipple with
bacteria and possibly other causes as well.
It is always good, however, to try to assure
the best latch possible, because improving
the latch helps with any cause of pain.
mupirocin 2% ointment
(not cream): 15 grams
betamethasone 0.1% ointment (not
cream): 15 grams. If betamethasone ointment
is unavailable, mometasone ointment (15
grams) can be used instead. It is better
not to mix creams and ointments.
To which is added miconazole
powder so that the final concentration
is 2% miconazole. Sometimes it is helpful
to add ibuprofen powder as well,
so that the final concentration of ibuprofen
is 2%.
This combination gives
a total volume of approximately 30 grams.
Clotrimazole powder to a final concentration
of 2% may be substituted if miconazole powder
is unavailable, but both exist (the pharmacist
may have to order it in). I believe clotrimazole
is not as good as miconazole, but I have
no proof of that. Using powder gives a better
concentration of antifungal agent (miconazole
or clotrimazole) and the concentrations
of the mupirocin and betamethasone remain
higher.
The combination is applied
sparingly after each feeding (except the
feeding when the mother uses gentian violet).
Do not wash or wipe it off, even if the
pharmacist asks you to. In Canada, Kenacomb
(easier to find) or Viaderm KC (less expensive)
ointments (not cream) can be substituted
for the above combination, but are distinctly
inferior. I used to use nystatin ointment
or miconazole cream (15 grams) as part of
the mixture, and these work well, but I
believe the use of powdered miconazole (or
clotrimazole powder) gives better results.
Any pharmacist should be
able to make up this ointment, but not all
want to. Not all pharmacies carry all the
ingredients. If you are having difficulties,
ask the pharmacist for the nearest compounding
pharmacy.
2.
Gentian violet for treating Candida
is discussed in handout
#6. See also Candida
Protocol.
3. Grapefruit seed
extract (See Candida
Protocol)
Grapefruit seed extract
can also be used for treating Candida as
well. It can be used directly on the nipples
and/or orally. If used directly on the nipples,
it should be diluted (5 to 15 drops, occasionally
up to 25 drops, in 30 ml or 1 ounce of water),
applied on the nipples with a Q-tip or cotton
ball, allowed to dry, and then covered,
sparingly, with the all purpose nipple ointment.
By mouth, grapefruit seed extract can be
taken as a pill, 250 mg three times a day.
4. Treatments for Raynaud’s
phenomenon (blanching of the nipple)
Raynaud’s phenomenon
is due to spasm of blood vessels preventing
blood from getting to a particular area
of the body. It occurs in response to a
drop in temperature. Most commonly, Raynaud’s
phenomenon will occur in the fingers, typically
when someone goes outside from a warm house
on a cool day. The fingers will turn white
and the lack of blood getting to the tips
of the fingers will cause pain. Raynaud’s
phenomenon occurs more commonly in women
than men, and is often associated with illnesses
such as rheumatoid arthritis.
Raynaud’s phenomenon
can also occur in nipples. In fact, it is
much more common than generally believed.
It can occur along with any cause of sore
nipples, is, in fact, probably a result
of damage, but it may also, on occasion,
occur without any other kind of nipple pain
at all.
Typically, Raynaud’s
phenomenon occurs after the feeding is over,
once the baby is already off the breast.
Presumably, the outside air is cooler than
the inside of the baby’s mouth. When
the baby comes off the breast, the nipple
is its usual colour, but soon, within minutes
or even seconds, the nipple will start to
turn white. Mothers generally describe a
burning pain when the nipple turns white.
After turning white for a while, the nipple
may actually turn back to its normal colour
(as blood starts to flow back to the nipple),
and the mother will notice a throbbing pain.
The nipple may go back and forth between
colours (and types of pain) for several
minutes or even an hour or two.
The treatment for Raynaud’s
phenomenon is to fix the original cause
of the pain (poor latch, Candida etc). Almost
always, as the nipple soreness from another
cause is getting better, so will the pain
from Raynaud’s phenomenon, but more
slowly. Fixing the original cause of the
pain (improving the latch, treating Candida
etc) should be the focus of treatment. However,
some mothers no longer have pain during
the feeding, or never had it at all. Indeed,
some start having Raynaud’s phenomenon
during the pregnancy. If the pain is mild,
there may be no reason to treat, and reassurance
is all that is necessary. However, in some
cases it is worth treating, especially if
severe, and especially if the pain during
the feeding does not improve, as severe
restriction of blood supply to the nipple
may delay healing.
The first choice for treatment
is:
- Vitamin B6. This
has shown to work by trial and error,
but it does seem to work. There is no
scientific evidence that it works, but
it does nevertheless. It is safe and will
do no harm. The dose is 150-200 mg once
a day for four days, followed by 25 mg/day
once a day. The mother continues it until
she is pain free for a few weeks. It can
be restarted if necessary. If the pain
resolves with the larger dose but returns
with the smaller dose, you can go back
to the higher dose. If you have been pain
free for a week or two, try going off
the vitamin B6. If vitamin B6 does not
work within a few days, it probably won’t.
It is then useful to try:
- Nifedipine. This
is a drug used for hypertension. One 30
mg tablet of the slow release formulation
once a day often takes away the pain of
Raynaud’s phenomenon. After two weeks,
stop the medication. If pain returns (about
10% of mothers), start it again. After
two weeks, stop the medication. If pain
returns (a very small number of mothers),
start it again. No mothers I am aware
of took more than three, two week courses.
Side effects are uncommon, but headache
may occur. It is a prescription drug.
The dose can be increased if 1 tablet
is insufficient.
- Nitroglycerin paste.
We no longer recommend it, as severe headache
associated with its use is fairly common.
It also does not work more than about
50% of the time.
5. Fluconazole
for treating Candida is covered in its own
handout #20.
Questions? (416) 813-5757
(option 3) or drjacknewman@sympatico.ca
or my book Dr. Jack Newman’s Guide
to Breastfeeding (called The Ultimate Breastfeeding
Book of Answers in the USA)
Handout #3b. Treatments
for Sore Nipples and Sore Breasts. January
2005
Written by Jack Newman, MD, FRCPC. ©
2005
This handout may be
copied and distributed without further permission,
on the condition that it is not used in
any context in which the WHO code on the
marketing of breastmilk substitutes is violated
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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