The NDC Clinical Guidelines for lactation-related nipple wounds align with international paradigm shifts in wound care, including minimised antimicrobial use

The NDC Clinical Guidelines for nipple wound care are aligned with a paradigm shift occuring internationally in the treatment of skin wounds

Clinical protocols for the management of lactation-related nipple damage commonly confuse the pathophysiology of acute and chronic wounds.

The Neuroprotective Developmental Care evolutionary and complex systems approach to prevention and management of inflammatory nipple pain and damage in breastfeeding mirrors a paradigm shift occurring in the treatment of skin wounds.

Traditional wound care from the 1960s has prescribed removal of necrotic and non-viable tissue. Exudate and eschar have been viewed as dirty or infected, needing to be cleansed or debrided. Moist wound care has become standard practice in dermatology and wound management more broadly. But moist wound care has been inappropriately extrapolated into the management of nipple wounds sustained during breastfeeding and lactation.

In wound care internationally, the pathogenic microorganism model which has resulted in overuse of antibiotic treatments and beliefs that the eschar and exudate are 'dirty' are increasingly replaced by multi-lateral interventions which aim to optimise the healthy function of the interacting biological systems which make up the host's immunity, including the skin microbiome.

The pathophysiology of chronic wounds

• A chronic wound, regardless of initial insult, is a wound that fails to heal because of an endogenous dysregulation of the immune response.2

• As a result, a chronic wound is characterised by excessive levels of pro-inflammatory macrophages and an overabundance of inflammatory mediators, as the inflammatory phase of wound healing fails to resolve.

• This environment then becomes difficult to control clinically due to formation of pathogenic bacterial biofilms, perpetuated by a dysregulated immune environment.

The chronic wounds of diabetic foot ulcers, vascular ulcers, and pressure ulcers feature

• Pathogenic biofilm formation

• Chronic exudation

• Tissue necrosis

• Defective re-epithelisation, and

• Decreased angiogenesis.3

For this reason, the research shows benefits to moist wound healing strategies and products for these chronic wounds.

The pathophysiology of acute wounds

In contrast, acute wounds occur in response to external insult and undergo a series of molecular events which result in restoration of structural integrity. You can read about the normal wound healing process of the nipple-areaolar complex skin during lactation here. Although lactation-related nipple pain and damage may be persistent, the injury remains acute.

Once the source of repeated mechanical insult ceases, damaged epidermis and dermis heal rapidly due to the unique features of the nipple-areolar complex. You can find out about these unique characteristics here.

The role of antimicrobials in wound healing

The pathogenic model of wound management assumes that a reduction in microbial load reduces wound infection, and that more or longer antibiotic or anti-fungal treatment is necessary if a wound does not heal.

But the pathogenic microbiota paradigm of skin wounds is vigorously contested, in the context of the global crisis of antimicrobial resistance and the urgent need for responsible antimicrobial use.1-4 As the Director General of the World Health Organisation stated in 2020: “Antimicrobial resistance is a slow tsunami that threatens to undo a century of medical progress.”1

Research elucidating biofilm development in chronic wounds (such as burns, diabetic or vascular ulcers) has been erroneously extrapolated to inform clinical protocols for management of nipple skin showing signs of lactation-related inflammation and damage.5 6

Clinical protocols advise that when a purulent exudate is visible on an area of nipple damage, bacterial infection is likely and topical mupirocin or oral antibiotics should be prescribed, citing research which shows that Staphylococcus aureus has been isolated from the nipple of about one-third of women with persistent nipple pain.7 8

But skin microbiomes commonly includes Staphylococcus aureus in the absence of pain or damage. Healthy skin biofilms are strong and dynamic ecological structures created by dense network associations of bacteria, fungi, protozoa, archaea, viruses and mites, and are integral to the host’s immune defence.9 Antibiotics have been shown to destabilise the skin microbiome without altering the diversity or relative abundance of specific targeted species.

Bacterial presence is required for wound regeneration and healing. The aim of treatment is not to eradicate them but to maintain or return control to the immune system, so the immune system can maintain or re-establish balance in the microbiome.

This may explain why antimicrobial approaches which have proven so effective for internal infections have minimal efficacy against skin wound infections. Several topical formulations of antibiotics have been shown to be ineffective in chronic skin wounds, yet risk bacterial resistance, contact dermatitis, and MASD.5 A number of studies conclude that most existing approaches to skin wound care are ineffective, and some interfere with healing.10

Extract from Data Sheet 2 Sams-Dodd et al 2024:

Many microbes, including the commensals, are intrinsically resistant to antimicrobials and many already possess “intrinsic” or have “acquired” a high degree of clinical tolerance and resistance to both antibiotics (Ciofu & Tolker-Nielsen 2019; Antimicrobial Resistance Collaborators 2022) and antiseptics (Wassenaar et al. 2015; Wand et al. 2016; Ignak et al. 2017; Hassan et al. 2019; McCarlie et al. 2020; McCarlie 2021; van Dijk et al. 2022; Wicaksono et al. 2022).

When an antibiotic is administered or an antimicrobial is applied to the wound, some of the microbes will survive while the rest are eliminated. The antimicrobial therefore does not act as a reset button, but actively favours the resistant microbial species to spread in the now non-occupied territory and take over control. As antimicrobial resistance is usually linked to increased microbial virulence (Bengoechea and Sa Pessoa 2019), the wound infection has become even more challenging and the required efforts by the immune system to fight the infection, i.e. regain control of the area, have actually increased (Fig. 2.) (Wang et al. 2021)

You can find out when antibiotics are indicated here.

Recommended resources

Nipple wounds in lactation: management, including exudate, scabs, and nipple rest

The NDC Clinical Guidelines for lactation-related nipple wounds align with a paradigm shift occuring in wound care internationally, including minimising the use of antibiotics

When are moist applications helpful for nipple pain and what is moisture associated skin damage?

Why moist wound healing is likely to increase the risk of nipple epithelium pain, inflammation and damage during breastfeeding

Research studies and systematic reviews show NO CONVINCING BENEFIT for moist wounding healing of lactation-related nipple wounds

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

References

Sams-Dodd J, Belci U, Bandi S, Smith D, Sams-Dodd F. Stable closure of acute and chronic wounds and pressure ulcers and control of draining fistulas from osteomyelitis in persons with spinal cord injuries: non-interventional study of MPPT passive immunotherapy delivered via telemedicine in community care. Frontiers in Medicine. 2024;10(1279100):doi: 10.3389/fmed.2023.1279100. Data Sheet 2

1. World Health Organisation. Addressing the crisis in antibiotic development, 2020:https://www.who.int/news/item/09-07-2020-addressing-the-crisis-in-antibiotic-development#:~:text=Today%2C%20more%20than%20%20leading,treatments%20to%20patients%20by%202030.
2. Editorial. The antimicrobial crisis: enough advocacy, more action. The Lancet 2020;395(10220):247.
3. Durham P. Why antibiotic resistance really is a tragedy. The Medical Republic 2019:https://medicalrepublic.com.au/antibiotic-resistance-really-tragedy/21127.
4. Lesho EP, Laguio-Vila M. The slow-motion catastrophe of antimicrobial resistance and practical interventions for all prescribers. Mayo Clinic Proceedings 2019;94(6):1040-47.
5. Drago F, Gariazzo L, Cioni M. The microbiome and its relevance in complex wounds. European Journal of Dermatology 2019;29(1):6-13.
6. Raziyeva K, Kim Y, Zharkinbekov Z. Immunology of acute and chronic wound healing. Biomolecules 2021;11(5):700.
7. Dennis C, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014(12):doi:101.1002/14651858.CD007366.pub2.
8. Amir LH, Bearzatto A. Overcoming challenges faced by breastfeeding mothers. Australian Family Physician 2016;45:552-56.
9. Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health 2021;17:DOI: 10.1177/17455065211031480.
10. Sams-Dodd J, Sams-Dodd F. Time to abandon antimicrobial approaches in wound healing: a paradigm shift. Wounds: a compendium of clinical research and practice 2018;30(11):345-52.