This is a late draft of a chapter from my new, completely revised 2014 version of Dr Jack Newman’s Guide to breastfeeding,now on sale at Canadian bookstores and also via www.amazon.ca

The “all-purpose nipple ointment” or APNO

We call our nipple ointment “all purpose” since it contains ingredients that help deal with multiple causes or aggravating factors of sore nipples. Mothers with sore nipples don’t have time to try out different treatments that may or may not work, so we have combined various treatments in one ointment. Of course, preventing sore nipples in the first place is the best treatment and adjusting how the baby takes the breast can do more than anything to decrease and eliminate the mother’s nipple soreness.

The APNO contains:

1.Mupirocin 2% ointment. Mupirocin (Bactroban is the trade name) is an antibiotic that is effective against many bacteria, including Staphylococcus aureus including MRSA (methicillin resistantStaphylococcus aureus). Staphylococcus aureus is commonly found growing in abrasions or cracks in the nipples. Mupirocin apparently has some effect against Candida albicans(commonly, called “thrush” or “yeast”). Treatment of sore nipples with an antibiotic alone sometimes seems to work, but we feel that the antibiotic works best in combination with the other ingredients discussed below. Although some mupirocin is absorbed from the gut when taken by mouth, it is so quickly metabolized in the body that it is destroyed before blood levels can be measured. Most of it gets stuck to the skin so that very little is taken in by the baby.

2.Betamethasone 0.1% ointment. Betamethasone is a corticosteroid which decreases inflammation. By decreasing the inflammation, the APNO also decreases the pain the mother feels. Most of the betamethasone in the ointment is absorbed into the skin by the mother, so that the baby takes in very little.

3.Miconazole powder to a final concentration of 2%. Miconazole is an antifungal agent, very effective against Candida albicans. Because it is added as a powder, the concentration of miconazole can be increased to 3% or even 4% or decreased to less than 2%. We feel 2% is the best concentration for most situations. Fluconazole powder to 2% may be substituted for miconazole and so can clotrimazole powder to 2%, but I believe that clotrimazole (Canesten) irritates more than the other drugs in the same family. Miconazole cream or gel cannot be substituted for miconazole powder as the compound will usually separate. Where miconazole or any of the above mentioned drugs (fluconazole, clotrimazole) are not easily available as powders, it is better to use only the mupirocin and betamethasone ointments mixed together than add a cream or gel or nystatin ointment for example.By using a powder, the concentration of the other two ingredients is not as decreased as they would be if another ointment were used for the anti-fungal agent (for example, nystatin ointment). Thus, in the above preparation the concentration of the betamethasone becomes 0.05% (due to combination withthe mupirocin) and the mupirocin concentration is decreased to 1%.

Note that nystatin ointment, which we used to use and which decreases the concentration of the other ingredients, is far inferior to miconazole and also tastes bad.

I write the prescription this way.

1. Mupirocin ointment 2%: 15 grams

2. Betamethasone ointment 0.1%: 15 grams

3. To which is added miconazole powder to a concentration of 2% miconazole
Total: about 30 grams combinedApply sparingly after each feeding. Do not wash or wipe off.

NO SUBSTITUTIONS

If possible, it is best to get the prescription filled at a compounding pharmacy. A list of compounding pharmacies in Canada and the US and maybe some other countries can be found at the website www.iacprx.org. Click “For Patients, Pet Owners” in the red box on the left side of the page, then click “Finding a Compounding Pharmacist Near You”.

The mother will need to sign in and then find the nearest compounding pharmacy. Canadians should make sure to leave a space between the two sets of 3 letters in the postal code: M2K 2E1, not M2K2E1.

How to use the ointment:

1. Apply sparingly after each feeding. “Sparingly” means that the quantity of the ointment used is just enough to make the nipples and areola glossy or shiny.

2. Do not wash it off or wipe it off, even if the baby comes back to the breast earlier than expected.

How long should the ointment be used?

Any drug should be used for the shortest period of time necessary and the same is true for our ointment. If the mother still needs the ointment after two or three weeks, or the pain returns after the mother has stopped the ointment, the mother should get “hands on” help again to find out why the ointment is still necessary. The most important step for decreasing nipple pain is still getting the “best latch possible.” Sometimes a tongue tie has not been noticed and is a reason for continued pain. Some pharmacists have told mothers that the steroid in the ointment will cause thinning of the skin if she takes for too long. While this is a concern with any steroid applied to the skin, we have not seen this happen even when mothers have used it for months.