Nipple solutions 1: doing nothing

creamMy nipple fissures weren’t showing any signs of improving, so after a day of deliberation, I phoned the National Childbirth Trust. I was starting to realise that the fact that there were helplines (and whole charities, in the case of La Leche League) dedicated to solving breastfeeding problems should probably have served as a warning that it might not be that easy. The counsellor who answered the phone was helpful, if a little abrupt. She asked me which direction my nipples pointed (!) and when I said it was slightly outwards, rather than directly forwards, she said that they were probably getting bent backwards in C’s mouth when I was holding her in the cradle feeding position. She suggested using a different position to feed her (such as the rugby/football hold, where C’s mouth would approach the nipple from the opposite direction) while I waited for them to heal. This seemed sensible advice, and after a few goes, C and I managed to perfect some new feeding positions. Although I can’t say it was definitely less painful, the knowledge that C’s mouth probably wasn’t putting pressure on my nipples in the same way seemed to help at least psychologically.

The NCT counsellor, like every midwife I spoke to, also recommended I use Lansinoh cream – ‘absolutely loads of it, as a barrier’ – to protect my nipples. I had been religiously applying it since the bleeding had started, and following advice, continued to do so as the state of my nipples got worse. After a few more days, I stopped to think about this: the state of my nipples was getting worse…

Up to now, still in a post-birth haze, I’d been relying on the NHS resources, reading the leaflets and speaking to midwives and health visitors. They’d been very understanding and sympathetic, but things weren’t really improving, and I was getting desperate. I decided to start Googling in earnest, searching for things like ‘nipple fissures’, and going beyond the first page – sometimes even as far as the fifth! What I ended up with was quite a lot of hits for ‘anal fissures’ (not terribly useful), but in amongst these and the general parenting advice sites, was a scientific paper looking at treatments for cracked nipples1.

The study compared using lanolin cream (like Lansinoh) with using breast milk, and leaving nipples untreated. A short summary of the results goes as follows: the women who used breast milk on their nipples, or who did nothing at all, recovered significantly faster than the ones using lanolin (for a longer discussion see the is lanolin cream a waste of money? post).

Armed with this knowledge, I dumped the Lansinoh, and within only a few hours, things seemed to improve. I can’t be sure whether this was as a direct consequence of not applying the cream, but it seemed to be working, and I decided to stick with it.

  1. Saudi Med J. 2005 Aug; 26(8):1231-4

Is lanolin cream a waste of money?

ointments_photoGiven the high incidence of nipple pain (it seems most women experience it when they start breastfeeding1), it would be reassuring to know that something can be done to relieve it. At the breastfeeding antenatal class the midwife told us that there is no evidence for the effectiveness of most nipple creams, although there have been studies showing that Lansinoh (commercially available purified lanolin) helps, and this is the one to go for if you have a problem. This view was echoed by two other midwives (one of whom gave me some sachets) and an NCT breastfeeding counsellor. You can read about my experience of using this preparation in the nipple solutions 1 journal post, but suffice to say that it didn’t work for me.

So, what is the scientific evidence for the effectiveness of lanolin? Probably the first thing to mention is that most of the big brand off-the-shelf nipple creams are simply moisturizers, and as the midwife said, there aren’t any published clinical trials supporting their effectiveness. On top of this, most of them aren’t even safe to go in babies’ mouths, so have you have to clean them off first – not ideal. This isn’t the case for Lansinoh – as it is simply purified lanolin, it isn’t a problem if babies swallow it (although this in itself doesn’t mean it’s worth using, of course).

An article looking at various topical treatments for nipple pain reviews several studies testing the effectiveness of lanolin1. When compared with hydrogel dressings (designed to maintain a moist wound healing environment), lanolin does well. In one study, women treated with lanolin reported significantly less nipple pain and were less likely to suffer from infection than those using the dressings. In another, there was no difference in pain relief, but there were still fewer infections in the lanolin group. Evidence that lanolin is a useful treatment? Not necessarily. As neither of these studies had a control group where no treatment was given, all we can tell is that hydrogel dressings are a bad idea. A study looking at the effect of heat treatment (sunshine or heat lamps) suffers from a similar problem. Using lanolin with the heat treatment offered greater pain relief than using the heat treatment alone, but unfortunately there is no way of telling whether this is better than not using any treatment at all.

In fact, the three studies in the review that compared lanolin with a ‘no treatment’ baseline showed it to be no more effective than leaving the nipples alone. There is also evidence that lanolin offers no improvement over rubbing on expressed milk (which is also reported as being pretty useless at reducing pain). The article also reports some preliminary research indicating that glycerin gel is a better treatment for sore nipples than lanolin (although a later study has found no difference between the two2.

Two further studies also deserve a mention. One provides evidence that peppermint gel is better at preventing nipple cracks and pain than lanolin or a placebo gel3. Another shows that in certain circumstances applying lanolin not only offers no improvement, but might actually make things worse4. The study compared using lanolin cream or breast milk with not using a treatment. The results showed that the appearance of nipple wounds (cracks and fissures) was the same in each group. However, the women who applied breast milk or used no topical treatment recovered significantly faster than those using lanolin.

So, it seems you may be better off ignoring the health professionals’ advice to use a lanolin cream. If you want to keep your nipples trauma-free you may want to think about using peppermint gel, or alternatively go for the inexpensive option of not bothering to treat them at all.

  1. J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37.
  2. J Perinat Educ. 2004 Winter;13(1):29-35.
  3. Med Sci Monit. 2007 Sep;13(9):CR406-411
  4. Saudi Med J. 2005 Aug; 26(8):1231-4.

Nipple nightmares 2: fissures

mother holding babyHaving been told that my initial breastfeeding difficulties – cracked, bleeding, excruciatingly painful nipples – were quite normal (despite what the official literature said), I was looking forward to the three week deadline after which everything would be functioning as it should. I was, however, slightly perturbed by the fact that as he deadline approached, no improvement was evident. In fact, my nipples were getting much, much worse. My husband expressed genuine concern that C was going to chew one of them off! By this stage, the bleeding had stopped, but it had been replaced by deep, ulcerated gashes on the outside edge of each nipple. I dreaded feeding, and as C wanted to do so 10-12 times a day, I spent all 24 hours either in pain, or anticipating its imminent start.

‘A mother’s guide to breastfeeding’, provided by my health visitor, wasn’t particularly reassuring. The only place it mentioned what I had finally come to recognize as fissures was in the ‘problem solving chart’ on the back cover. Apparently, this meant that C had tongue tie! I thought this was unlikely, as we’d seen her sticking her tongue right out of her mouth. Nevertheless, the information sent me into another panicked state, and I was on the phone yet again to the maternity unit.

On the next visit, the midwife assured me that C didn’t have tongue-tie. In fact, she seemed remarkably unperturbed by what I felt was the pretty horrifying sight of my nipples. Although she didn’t know quite what the problem was, she acknowledged that some mothers have these difficulties, and that many of them give up as a result. She was confident that things would improve, and said that I should consider getting a nipple shield to make things more bearable in the short term. She also suggested I call a breastfeeding helpline. I was sceptical they would be able to tell me anything I didn’t already know, but by this point anything was worth a try.

Nipple nightmares 1: bleeding

mother breastfeedingThe first couple of days at home were pretty breezy. Before I left hospital I was assured by two midwives that C was latching on properly – cheeks puffed out, chin pumping, ears wiggling – so I was confident we had the technique sorted. Family visited and I assured them everything was going well, demonstrating our successful feeding on several occasions. By the time I got to day four, however, things weren’t quite so easy. Accompanying the hormone-induced plunge into despair inadequately named ‘the baby blues’ (that coincides with the start of proper milk production) was a serious deterioration of my nipples.

The ‘initial soreness’ quietly mentioned in some of the leaflets just didn’t cover it. Not only did feeding result in agony extending minutes beyond the approved first 10-15 seconds, but I was starting to display serious war wounds. The first time that C vomited blood I was frantic with worry, and straight on the phone to the maternity unit. But, as the midwife reassured me (!), the blood was my own, swallowed by C while she fed. Bleeding!? No one had told me about this. Well, no one except for my friend Zara… Surely it couldn’t be normal? It certainly wasn’t according to the copious NHS breastfeeding resources.

And this was a major part of the problem. Everywhere I looked I was told that nipple soreness, cracks and bleeding were caused by the baby failing to latch on correctly: these problems were my own fault, caused by a poor technique. The thing is, when I talked to the health professionals, I was told I was doing it right, and fortunately, C seemed to be getting plenty of milk.

When the midwife next visited, I voiced my concerns. She checked my attachment – again, it seemed fine – and then admitted that she had had the same problem. Apparently, people with fair skin have a much harder time of it when it comes to breastfeeding. My nipples hadn’t darkened at all during pregnancy, so I could be particularly susceptible to problems. Hearing this was a massive relief. Ironically, being told that I might find it more difficult because of my inferior nipples made it easier to carry on (see the post on skin colour and nipple pain for more info on this). The midwife suggested I grit my teeth, and within two to three weeks it would be ‘a piece of cake’.

Does pale skin mean problem nipples?

test tubes and tape measureOne of the anecdotes you may have heard (particularly if you are pale) is that women with fair skin are more likely to experience sore or damaged nipples. If you have very light skin and painful nipples (as I did), it may be strangely reassuring to be able to attribute at least some of the difficulties you’re experiencing to your colouring. On the other hand, if you have dark skin and sore nipples, you may simply view this kind of statement as irritating nonsense.

Is there any evidence that skin colour is associated with nipple problems when breastfeeding? There don’t seem to be any studies looking solely at the relationship between the two, but there are some studies that have included it as a factor, and the results they report are mixed. Whilst one study looking at breastfeeding in the first few days after birth found an association between nipple damage and skin colour1, another found that there was no link between the two2.

To confuse matters further, some research looking at the effect of ‘conditioning’ nipples prior to breastfeeding (by rubbing them with a rough towel – ouch!) found that women with fair skin reported significantly more pain when feeding on the unconditioned nipple, and olive skinned women reported significantly more pain when feeding on the conditioned nipple3. (I should mention that this research was carried out in 1979 – actively damaging you nipples whilst pregnant to ‘toughen them up’ for breastfeeding is no longer recommended.)

So, it seems the jury’s still out on this one. I suppose the most important thing to remember is that whilst there may be some link between fair skin and nipple pain or damage when breastfeeding, there certainly isn’t conclusive evidence for this, and there definitely are reports from women of all skin types that breastfeeding can be very painful!

  1. Rev Bras Enferm. 2005 Sep-Oct;58(5):529-34
  2. Birth. 1987 Mar;14(1):41-5.
  3. Nurs Res. 1979 Sep-Oct;28(5):267-71