Hi,

It's taken me some time to lay hands on the article, which explains why it took
me so long to react. So, now I've read the article and the exerpt (thank you
Catherine) and am ready for my thoughts to come out and be written down.
First, I must admit I do not see many infected cracked nipples. I do see lots of
all kinds of soreness and cracks, but they usualy are cured by management
improvement, which now makes me to conclude that they probable weren't infected.
But, I do hear from lots of moms -afterwards- that had stopped brestfeeding
because of persistent sore nipples. Since they did not consult me before
weaning, I can't tell wether these were due to mismanagement and failure to
adjust management (which may -given the overall status of lactation management
knowledge in hcp's around here- may well be the case) or to infection or a
combination of both.
That all to explain that in first instance this article sounded to me as a kind
of ''far from my bed show'', but reading on, I got really interested and started
asking myself some questions.
1. it has always been my understanding that it is kind of hard to get a
lactating breast/nipple/areola infected from the outside, because of the active
anti-infective agents in fresh breastmilk and the activity of the Montgomery
glands. A collegue and me used to joke: ''You'll have to rub your nipples around
at your bottom to get them infected.'' (Well, not to clients in those words,
ofcourse!) Meaning that with normal bathroom-hygiene it should be rather hard
for staphs and streps to come from the gut to the nipple. That made me be
surprised to read that over 50% of women with cracked nipples are positively
diagnosed with S. aureus colonisation.
2. About some other interesting points the autors found (5 women with deep,
radiating, burning breast pain and episodic vasospasm of the nipples, 17% of the
moms with S. aureus infections had poorly graspable nipples, 10% of their
infants had tongue tie, and 12% had significant retrognathia) I wonder how these
relate to normal occurrence of these conditions in mothers and newborns. Is this
more than usual? How much more? If so, that could indicate a increased risk for
developping nipplesoreness and, if not treated well, to nipple cracks and
infection. But that would rather be a secundairy connection between these
conditions and the risk of S. aureus infected cracked nipples.
3. Breast hygiene. Washing the breasts with soapy water will kill bacteria and
thus lower the risk for infection, but it will also increase the vulnarability
(?spelling?) of the skin to injuries and thus increase the risk for infection. I
don't see a solution for this dilemma, other than trying to prevent nipple
trauma by teaching both hcp's and mothers good breastfeeding management
techniques. But that is beyond the purpose of this study.
4. I wondered if the women given antibiotics were screened for or preventively
treated for yeasts? The authors do recognise that antibiotic treatment can
include risks, but did not mention what risks they meant or what they recommend
to rule these out as far as possible.

I was glad to read this study as it gave me new insights in the reason why some
nippleproblems are hard or not te be resolved by improvement of technique. Thank
you Verity Livingstone and Judy Stringer for sharing this information with us
collegues.

Gonneke van Veldhuizen, IBCLC, Maaseik, Belgium
http://www.users.skynet.be/eurolac
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