Treatment of Cracked Nipples During Breastfeeding
For most breastfeeding mothers with cracked nipples, highly purified anhydrous (HPA) lanolin is the most effective topical treatment, combined with proper breastfeeding technique education, as it demonstrates superior healing rates and pain reduction compared to expressed breastmilk alone. 1
Initial Assessment and Management
Rule Out Infection First
- If nipples are cracked AND painful with burning/stinging pain radiating into the breast, suspect Staphylococcus aureus infection or candidiasis 2, 3
- S. aureus-infected cracked nipples require systemic oral antibiotics (not topical antibiotics alone), as topical mupiricin showed only 16% improvement versus 79% with oral antibiotics 3
- Untreated bacterial infections progress to mastitis in 12-35% of cases versus only 5% when treated with systemic antibiotics 3
- Candidal nipple infections may require fluconazole 200 mg loading dose followed by 100 mg daily for 15-45 days if topical antifungals fail 2
Standard Treatment for Non-Infected Cracked Nipples
Primary recommendation:
- Apply HPA lanolin after each feeding - this reduces nipple pain (absolute risk reduction 0.61 by day 3) and accelerates healing (absolute risk reduction 0.43) compared to expressed breastmilk 1
Alternative option:
- Peppermint gel is more effective than lanolin (RR of nipple crack 1.85 vs 2.41 for lanolin), though less widely available 4
Critical Technique Modifications
- Optimize positioning and latch - this is more effective than any ointment alone for preventing and treating nipple trauma 5
- Avoid pacifiers and feeding bottles in the hospital - both are significantly associated with sore nipples (p=0.02 and p=0.03 respectively) 5
- Discontinue test-weighing at each breastfeed - associated with shorter breastfeeding duration 5
Special Consideration: Hepatitis C-Positive Mothers
If the mother has hepatitis C AND cracked/bleeding nipples, temporarily stop breastfeeding until nipples heal - this is recommended by the CDC and Society for Maternal-Fetal Medicine to minimize theoretical transmission risk 6, 7
- The mother should express and discard milk during the healing period 7
- Resume breastfeeding once nipples are healed and no longer bleeding 6
- Standard HCV status alone does NOT contraindicate breastfeeding - only the combination of HCV plus cracked/bleeding nipples requires temporary cessation 6
Pain Management
- For severe pain, hydrocodone/acetaminophen (10/650 mg) may be necessary to allow continued breastfeeding when standard analgesics fail 2
- Standard acetaminophen or ibuprofen should be tried first 2
What NOT to Do
- Do not rely on routine nipple ointments without addressing technique - no difference in outcomes between mothers using ointments versus those avoiding all nipple products when proper technique is not addressed 5
- Do not use topical antibiotics alone for infected nipples - only 16-29% improvement versus 79% with oral antibiotics 3
- Do not continue breastfeeding with cracked nipples if HCV-positive without temporary cessation and specialist consultation 7