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

NDC Clinical Guidelines for lactation-related nipple wounds

The same principles #1-6 for management of nipple pain (without visible breaks in the epidermis), found here, are also foundational to nipple care when a lactating woman has developed a wound of her nipple epidermis, or of her epidermis and dermis. These six principles include the two most important management principles, elimination of mechanical microtrauma and elimination of overhydration and moisture-associated skin damage.

In addition to principles #1-6, NDC Clinical Guidelines for nipple wound management include the following.

Nipple wound management principle #7: prevent the nipple wound from adhering to the breast pad

When the lactating woman wears a bra, it is important that the exudate or scab from her wound does not stick to her breast pad.

• For this reason, it's protective to apply some lanolin, or a hydrogel or polymembranous dressing. You can find out about these here. She may alternate between different applications or dressing (or discs).

• Remove breast pads carefully or soak off if adherent.

In the NDC Clinical Guidelines, moist wound healing products are used for comfort in the short-term to avoid the wound adhering to breast pads, on the understanding that breastfeeding women are appropriately educated about the risks associated with their use and how to minimise these - and women are not given false information that these products will help healing.

Nipple wound management principle #8: exudate is a normal part of healing

The patient is educated that exudate, which may be grey, yellow, green or cream in colour (illustrated in the photo at the top of this page), and which may have a malodour, is a normal part of the healing process and is not 'dirty', but healthy and protective. It is rich in immune cells, bioactive immune factors, and growth hormone.

• The exudate will be washed away when the woman showers, which is best occuring twice a day when she has nipple wounds.

• If the woman is not showering twice daily, she can carefully wash over her nipples with cotton wool that is sodden with clean water. Saline water stings, irritates the wound, and is not helpful.

Nipple wound management principle #9: the eschar (or scab) is a normal part of healing

The woman is educated that the scab is a normal part of the healing process and is not 'dirty', but healthy and protective.

• If the wound remains small, there is no need to remove a scab. Direct breastfeeding or mechanical milk removal will debride the wound through mechanical contact and vacuum application. The infant mouth is an ideal cleansing and debriding application due to antimicrobial and immunoprotective effects of infant saliva, human milk, and milk and oral microbiomes.

• If the wound is large enough for the clinician or breastfeeding woman to be concerned that the scab is too large for the baby to remove, and a nipple shields is not appropriate, she could soak her nipple in milk and remove the scab prior to breastfeeding. However, if the scab is this large, the NDC guidelines recommend a complete break from breastfeeding, and depending on the circumstances, possibly also mechanical milk removal, for healing.

Nipple wound management principle #10: mechanical milk removal (pumping)

Women's nipples have variable resilience to mechanical milk removal (pumping). The clinician assesses the effects of pumping with the woman, ensuring that the pump is on the lowest workable setting, and the flange is properly fitted. Most often, mechanical milk removal also perpetuates mechanical microtrauma, and needs to be ceased to support the most rapid possible nipple wound healing. Olive oil may help eliminate friction during mechanical milk removal (lanolin may become adherent).

Nipple wound management principle #11: rest the nipple from mechanical pressures (either direct breastfeeding or pumping)

The nipple rest may need to last anywhere between 3-7 or more days, depending on the extent of damage. The NDC Clinical Guidelines continue to recommend dry wound healing as much as possible, promoting hyperosmolar wound granulation and re-epithelialisation under the dessicating scab.

• When the nipple is being rested, active removal of the scab is avoided. Contact with water in the shower twice daily is adequate cleansing (and may also inadvertently remove a scab once healing is advanced, which isn't a problem). If she is not showering twice daily, the woman can carefully wash over her nipples with cotton wool that is sodden with clean water. Salt water irritates the wound and is not helpful.

• Hand expression protects the breast from mastitis. It is unlikely that a woman can hand express enough from both breasts to maintain her supply over the days of rest if both breasts are damaged, and unrealistic to suggest that she try to maintain her milk supply to meet her baby's needs.

• The lactating woman with nipple pain or wounds which need to heal with complete nipple rest is educated about the downregulation of milk supply that will occur. Even if she is using the other breast because that side doesn't have pain or damage, it is unlikely (though not impossible) that she will be able to increase her supply in the one healthy breast to exclusively meet the baby's needs.

• Women are likely to need to introduce breast milk supplementation if they are completely resting both their nipples (either donor milk or formula).

• As the clinician works collaboratively with the breastfeeding woman with severe nipple pain or damage, you may explain that breastfeeding is more likely to be saved in the medium to long term by complete nipple rest and wound healing in the short term.

• Complete nipple rest, though associated with grief for many breastfeeding women, because of the uncertainty about long-term impact on her breast milk supply, is most likely to save either exclusive or predominant breastfeeding, compared to persisting on through severe pain and damage - which often culminates in despair about the breastfeeding, severe fatigue, chronic stress and distress, and the decision that she really can't continue on and needs to completely wean. If the baby is older and supply is established, production is likely to quickly build again back to exclusive breastfeeding, if a woman needs to completely rest her nipples until the wound or wounds are healed.

• Direct breastfeeding is recommenced, if at all possible, in the presence of a clincian who is able to deliver the gestalt method and ensure elimination of nipple and breast tissue drag when breastfeeding recommences. If the can't recommence in a F2F consultation with an NDC practitioner, the woman requires careful education about the gestalt intervention so that she is empowered to address her underlying fit and hold problems.

• It is important to only gradually increase the frequency of direct breastfeeding once re-introduced, so that pain and wounds don't occur again. If a woman is educated about this risk, she will calibrate the frequency of direct breastfeeding in a way that is safe and protects her breasts.

Indications for antibiotic use in lactation-related nipple-areolar-complex wound

Indications for topical or oral antibiotic use when a lactating woman has a nipple wound are found here.