Help! My nipples! (a list of topical treatments for sore nipples)

Which nipple cream is best?

An overview of topical nipple applications:

1. Breastmilk can be rubbed into a nipple that is sore or cracked. It has antimicrobial and anti-inflammatory properties.

2. Lanolin is soothing on chapped nipples, but not as great for cracked or scabbed nipples, because it can trap bacteria in the wound. It is tolerated well by most people, but is contraindicated in anyone with a wool allergy. Lanolin is good for short term use such as a hospital stay, but I don’t recommend it long term, because it may feed yeast. It can be used to lubricate nipples prior to pumping, but coconut oil is preferred.

3. Coconut oil is antimicrobial so it’s a great choice for longer term use. It is not thick or goopy like lanolin so it spreads easily. It’s a great choice for application prior to pumping. Coconut oil is mildly antifungal, so it is recommended for those who have had IV antibiotics with their delivery, because they are at an increased risk for a nipple yeast infection.

4. Nipple balms and butters that are commercially available, can be helpful too. A very popular one is Earth Mama's Organic Nipple Butter. It contains no lanolin, which may be a benefit for some, but it doesn't have coconut oil either, which is often desired for its antifungal properties.

5. APNO, or All Purpose Nipple Ointment, is a prescription ointment for nipples that are cracked, bleeding or scabbed. It contains an antibiotic, antifungal, and anti-inflammatory (steroid).  I usually suggest alternating its use with coconut oil, after feedings. Because of the steroid, which can make skin more fragile if it is used long term, I recommend just five days of use, and then discontinuing, or at least taking a holiday from it. Sometimes the bottle or tube of APNO does not contain much guidance on its use, so patients are unclear on these details. Prescription APNO is a compounded ointment that is expensive and often not covered by insurance. Only a compounding pharmacy will prepare it. The good news? You can make your own, with three simple ingredients from the drug store. (search Jack Newman's APNO cream) APNO does not need to be wiped off before baby breastfeeds. In fact, no nipple preparations that I know of are unsafe for baby. (except for gentian violet, but that is no longer recommended)

Of course, it's critical to have someone educated check your baby's latch and ensure that it's as wide and deep as it can be. Those baby lips should be flipped out like a fish. Positioning and alignment are important too, and sometimes experienced moms are the worst about achieving good positioning and alignment! I have seen moms who have breastfed five previous babies complain of nipple pain, who have forgotten all the basics. Baby #6 is latched, but his body is facing the ceiling and his neck is hyperextended so that it would be nearly impossible for him to swallow. And mom is breastfeeding while eating lunch, on her cell phone, and telling her 7 yr old not to touch that. These moms need a refresher course on positioning, "baby's body facing you, chin over his chest, arms open and hugging the breast," and alignment, "baby's ear, shoulder, hip, all in a line."

When baby's latch is textbook perfect and still isn't comfortable, it could be the normal nipple soreness that will alleviate with time. It's almost universal that baby's initial latch makes mom cringe. If it then becomes tolerable as baby establishes a rhythm of sucking, you may be experiencing the typical nipple soreness that gets better in a couple of weeks. The pain with initial latch has been nicknamed the "Sixty Second Sizzle." Cute, huh? Try varying positions when you nurse your baby to alternate the pressure points around your areola from baby's latch. I call this "distributing the abuse." Another option is to forgo topical applications all together, and wear silverettes or breast shells, that simply cover your nipple, and keep clothing from touching them.

However, if you are in pain throughout the entire feeding, and resisting the urge to push your baby off you to make it stop, then you likely need to make an adjustment in his latch or positioning, and you should also have baby checked for a tongue tie. Damaged nipples can heal even if you keep putting baby to breast, but if the pain is too extreme, you can take a "breast rest" for 24 hours by pumping and bottle feeding. However, sometimes this causes more problmes than it solves. More on that in another blog post!

*For the science enthusiasts who appreciate specifics: APNO contains mupirocin, betamethasone, and miconazole.