Interventions which don't help lactation-related nipple pain and wounds

There's no evidence to show that silver caps help nipple wounds heal

The promoters of silver caps believe that silver ions are effective against common wound pathogens, including methicillin-resistant S aureus, because they adhere to bacterial cell membrane, penetrating cell wall and disabling enzymes. Those who promote the use of silver caps (or silverettes) claim they prevent entrance of microorganisms to wound site and protect against trauma, by creating an hypoxic, moist, protected microenvironment.

However, silver is known to have cytotoxic effects on both keratinocytes and fibroblasts and can result in significant delays in epithelialisation in vitro.3 Silver-containing dressings or topical agents have not been shown to improve skin wound healing or prevent infection.

In 2015, an Italian RCT randomised 40 women with nipple fissures to silver cap use or standard care. The latter included an unspecified fit and hold intervention by an International Board-Certified Lactation Consultant and topical application of expressed breast milk. No changes between groups were detected at day 2 but more rapid resolution of symptoms were reported with silver cap at days 7 and 15.4 This study is methodologically weak because one popularly applied fit and hold intervention has been demonstrated to worsen nipple pain fourfold and it is not clear what approach to fit and hold was used by the IBCLCs used. Also, application of expressed breast milk only in the control group, without careful education concerning prevention of adherence of the nipple wound to the breast pad, may have exacerbated epithelial damage and delayed healing.

Some women find use of the silverette cups soothing. They need to be informed of the risk of

• Over hydration and moisture-associated skin damage, making the nipples more likely to be damaged with microtrauma and mechanical pressures

• Pressure on the milk ducts, 60% of which lie in a three centimetre radius of the base of nipples. This may predispose to breast inflammation.

Once informed, women may decide to use the silverettes judiciously, for comfort on occasions when wearing a bra. Other women find their nipple is high enough to touch the top of the cup, even when using the largest, worsening discomfort or pain.

There's no evidence to show that breast shells help nipple wounds heal

The promoters of breast shells believe that they protects painful or damaged nipples and promote healing.

A 2004 study of 94 Latvian women with sore nipples, randomised into using breast shells combined with lanolin compared to usual care showed no benefit.9

Some women find use of the breast shells soothing. They need to be informed that the same risks as occur with silverettes, above, apply to breast shells. Once informed, women may decide to use the breast shells judiciously, for comfort on occasions when wearing a bra.

There is no evidence to show that All Purpose Nipple Ointment resolves nipple pain or damage

All Purpose Nipple Ointment (APNO) contains:

1. Mupirocin ointment 2%: 15 grams

2. Betamethasone ointment 0.1%: 15 grams

3. Miconazole powder to a concentration fo 2% miconazole.

Dr Jack Newman claims that APNO heals nipples, destroys bacteria and candida.

However, APNO

• Risks Moisture Associated Skin Damage

• Suppressing bacteria with mupirocin destabilises normal microbiome and may worsen dominance of certain resilient bacteria (such as S aureus) in the context of simultaneous steroid treatment

• Betamethasone suppresses inflammation, but inflammation is necessary for wound healing and for resolution of any microbial overgrowth.

• Miconazole treats Candida which has not been shown to cause nipple pain.

Canadian women with damage to one or both nipples were randomised into APNO and lanolin application groups. No significant difference were found in pain scores after one week. Women in lanolin group reported greater satisfaction with their infant feeding method.8

There's no evidence that other topical applications help

Lanolin, polymem and hydrogel

You can find out about lanolin, polymem and hydrogel, including when they may be useful and the risks associated with their use, here.

Honey

Honey has a antimicrobial, anti-inflammatory and antioxidant activity, and stimulates lymphocytic and phagocytic activity. However, honey applications risk overhydration and moisture-associated skin damage if applied to the nipples.

Manuka honey contains the chemical methylglyoxal, which is toxic to human cells, and may delay healing.2

Petroleum-based products e.g. vaseline

Petroleum-based products risk overhydration and moisture-associated skin damage.

Salt water

Salt water causes pain and stinging, without benefit.

Steroid cream or ointment e.g. betamethasone, mometasone, triamcinolone Reduces inflammation. Fails to address repetitive mechanical micro-trauma which results in inflammation; disrupts inflammatory processes and may disrupt skin microbiome homeostasis; may overhydrate and risk Moisture Associated Skin Damage (Appendix 2).

Topical antiseptic

Topical antiseptic applications have cytotoxic properties which kill human cells, including newly formed tissue generated on periphery of and within wound, impeding wound healing. These should be avoided.

Zinc oxide

Examples of products which contain zinc oxide are desitin and sudacrem. Zinc oxide is sometimes mixed with cod liver oil. Promoters of zinc oxide propose that it will debride the nipple wound and protect epithelium. However, attempts to remove zinc oxide from nipple may exacerbate nipple damage and it's safety has not been established if ingested by infant.

‘Natural’ nipple care products

Examples of natural nipple care products promoted for nipple pain and damage include calendula, kamillosan, juba, aloe vera, guaiazulene ointment, and p.oleracea. These risk epidermal overhydration and Moisture Associated Skin Damage, with no evidence of benefit.

Tea bag or hot water compress

Proponents of tea bag or hot water compresses claim this will increase blood flow, oxygen and nutrients. The Niazi et al systematic review claimed benefit of warm water compresses for nipple pain but the analysis is methodologically weak.5 Tea bag or hot water compresses should be avoided.

There's no evidence to suggest that sunlight or hairdryer air help nipple wounds heal

Too much direct sunlight can have an irritating and inflammatory effect on skin. It's best not to advise direct sunlight exposure on nipples, though modest incidental exposure is unlikely to harm. There's no reason to think that blowing air from a hairdryer on a nipple wound helps healing.

Interventions for central sensitisation don't help with persistent nipple pain

Persistent pain that hasn’t resolved with IBCLC intervention is often treated with a range of pharmaceutical interventions, despite absence of evidence or sound physiological rationale. These treatments include non-steroidal anti-inflammatories, gabapentin, serotonin reuptake inhibitors (eg. Zoloft), beta-blockers (e.g. propranolol 20 mg tds), and antihistamines (e.g. Zyrtec, cetirizine 10 mg qid).

Yet there is no evidence of benefit for pharmaceutical, psychological, or multi-disciplinary pain clinic treatments, and reasons to be concerned about unintended consequences of these treatments, including patient disempowerment and medication side-effects.

You can read here why the theories of central sensitation, including the Breastfeeding Pain Reasoning Model, diagnoses of allodynia, hyperalgesia, functional pain, and neuropathic pain, fail to align with international definitions of chronic pain and lack convincing pathophysiological rationale or evidence.12 13

There's no convincing evidence that infant bodywork therapy helps more than the passage of time

The promoters of bodywork therapy for breastfeeding problems claim that cranial nerve dysfunctions, fascial restrictions, musculoskeletal misalignments, and dysfunctional neural habits impact on tongue function, causing maternal nipple pain.

However, intra-oral bodywork exercises do not address the biomechanical problems which result in lactation-related nipple pain. The effects of repeated intra-oral bodywork exercises on the infant oral mucosal immune system and microbiome are unknown, but possibly disruptive, introducing a range of environmental microorganisms in abnormal volume loads due to repeated digital insertion, also intermittently drying out protective mucosa.

• In 2017 Herzhaft-Le Roy & Xhignesse conducted a trial in which 97 mother-baby pairs with infants younger than 6 weeks diagnosed with biomechanical sucking dysfunctions were randomised to 30 minute sham or real osteopathic treatment by an osteopath treatment combined with unspecified one hour intervention by an IBCLC. No improvement in nipple pain with osteopathic treatment relative to IBCLC intervention was found.10

• A 2024 systematic review by Chowdhury et cal of chiropractic care, myofunctional therapy and osteopathy in improving breastfeeding for infants diagnosed with anklyglossia found four studies which met the inclusion criteria, showing inconclusive evidence to support these interventions.

Selected references

Numbered citations found in Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health. 2022;18:17455057221087865.

Chowdhury R, Khoury S, Leroux J. Alternative therapies for ankyloglossia-associated breastfeeding challenges: a systematic review. Breastfeeding Medicine. 2024:DOI: 10.1089/bfm.2024.0072.

Herzhaft-Le Roy J, Xhignesse M, Gaboury I. Efficacy of an osteopathic treatment coupled with lactation consultants for infants' biomechanical sucking difficulties: a randomized controlled trial. Journal of Human Lactation. 2017;33(1):165-172.