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 after a feeding, and the hospital might give you a small tube for free! However, lanolin is not ideal for cracked or scabbed nipples, because it can trap bacteria in the wound. It is tolerated well by most people, but avoid it if you have 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. One more downside is that lanolin doesn't taste great, but luckily, most babies don't seem to care if their colostrum meal comes with a side of lanolin. Lanolin is safe if your baby happens to ingest some.

3. Coconut oil is overall my favorite nipple preparation because it's hostile to yeast, and a great choice for lubricating nipples prior to pumping. It is not thick or goopy like lanolin so it spreads easily. Coconut oil is mildly antifungal, which is helpful in any environment that tends to breed yeast. It is recommended for those who have had IV antibiotics with their delivery, because their gut and breast floras have been disrupted, putting them at an increased risk for a nipple yeast infection. Coconut oil is also safe for baby and does not need to be wiped off prior to offering the breast. (unless you just applied it and your nipple is slippery with it - let's not make staying latched harder than it already is!)

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 those who are allergic, but it doesn't have coconut oil either, which is often desired for its antifungal properties. Earth Mama is safe for baby as well.

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).  The antibiotic will combat any bacteria in the wound, while the antifungal will kill yeast. The steroid calms inflammation. If a nipple yeast infection is suspected, which is usually bilateral and can cause sharp, shooting, stabbing pains in your nipples, APNO cream is often prescribed. (sometimes yeast has invaded the ducts of the breast, so oral antifungals are also necessary) I usually suggest alternating APNO 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 APNO. 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. In my area, 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, although it's best to apply it after baby nurses. In fact, no nipple preparations that I know of are unsafe for baby. (except for gentian violet, but that is no longer recommended)

6. Silverettes are making a comeback! These little shallow domes that are made by Italian silversmiths, are comprised of pure silver, which has antimicrobial factors. They're hostile to bacteria and yeast as they sit on top of your nipples, protecting them from chafing in between feedings. They're all-natural and meant to be worn without creams or lotions, and quite expensive at $60/pair. But because they're sterling silver, they'll last through several babies, and then the company will turn them into silver charms, if you wish. A word of warning though - you may have to stop wearing them once your milk comes in, if the silverettes are filling up with milk and trapping the leakage such that your nipples are swimming in milk all day. This nipple environment could cause a yeast infection. You might be better off wearing absorbent breast pads if you are leaking that much.

7. Breast shells are great for sensitive nipples. These 2-piece plastic domes are larger than silverettes, but a similar concept, and a lot cheaper. Medela makes a good set. They fit over nipples and protect them from touching anything, such as clothing that causes painful friction. They can also collect leakage, but usually the milk pools inside the channel in the back of the shell, so nipples stay dry. Like the silverettes, they need to be loosely held in place with a bra or stretchy, fitted camisole top. Unlike the silverettes, you can wear them while lathered up with your choice of cream/lotion, so you're doubling up the therapy for your poor nipples.

Of course, when you're experiencing nipple pain, 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 three previous babies complain of nipple pain, who have forgotten all the newborn basics. Baby #4 is latched, but his body is facing the ceiling and his head is flexed so that it's 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. In the early days, it's common for baby's initial latch to make mom cringe. If it then becomes tolerable as baby establishes a rhythm of sucking, you may be experiencing the mild, 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 lips and suction. I call this "distributing the abuse."

What do you do if you've improved baby's positioning and alignment, achieved a deeper latch, applied topical treatments, but you're still in pain throughout the entire feeding, and resisting the urge to push your baby off to get some relief? You should have baby checked for a lingual tongue tie. If your baby's tongue extension is restricted, he may be using his bottom gumline to strip milk out of the breast, and this will really hurt! Furthermore, if there is damage to your nipples like cracks, scabs, blisters, or open sores, this can heal once you've improved the latch, even if you keep putting baby to breast. But if the pain of latching is unbearable, you can take a "breast rest" for 24 hours, by pumping and bottle feeding. This path does have some risk, however, so the interruption of direct breastfeeding should be as brief as possible. Baby's latch and breastfeeding skill might regress while he bottle feeds, making reintroduction to the breast a challenge. Another option, one that doesn't disrupt breastfeeding, is using a nipple shield while nursing. The shield is worn over the nipple and areola, so baby does not make direct contact with his mouth or lips, but can still access milk. For some people, this is a lot more comfortable and gives nipples time to heal. Of course it also comes with a cost, so if you try it, see my blog post about nipple shields!

Regardless of what methods you employ, keeping your nipples healthy is important, because cracks and breakdown can put you at risk for clogged ducts and mastitis. So don't just fight through the pain - bring in some reinforcements, and get some professional help if you're suffering!

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