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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.
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