Hi Francine,

You ask difficult questions. There is little research on nipple fissures.
(One wonders WHY, but that's another matter.) Here's my experience:

Nipple fissures often start with poor technique and/or poor suck on the part
of the baby. A poor suck and/or tongue tie should be the first thing ruled
out, because unless it's corrected, the problem will persist. A tongue-tied
baby will very often cause such fissures, sometimes in the first few feeds;
if so, the solution is to clip the frenulum.  I've seen many fissures from
tongue-tie, from babies with a strong tongue thrust due to mom's overactive
let-down and high supply, and from all sorts of birth injuries and insults.
Vacuum extraction is a strong risk factor. Fissures from mechanical trauma
from the baby's suck are usually on the tip of the nipple.

Any infection, especially yeast, makes the nipple skin more fragile which
(1) cracks easily, and (2) does not heal. Once the skin is infected,
ordinary baby behavior at breast can cause fissures, especially at the base
of the nipple (nipple/areolar junction). I see these in the 4-month and
older crowd when they squirm around while nursing. If I see a fissure at the
base of the nipple, I have to assume the skin is infected unless proven
otherwise. Healthy nipple skin just does not crack under normal use. Yeast
is far more common than bacteria, especially in warm weather and
high-mold-count areas.

You know the symptoms of yeast: burning, stinging, and/or itching. Close
visual inspection may help - yeast looks shiny and reddened especially as it
gets more entrenched. Bacterial infections look wetter and oozy, often with
yellow crusts. Think of what these infections look like elsewhere on the
body. Kathleen Huggins had a good article on "20 cases of sore nipples" in
the JHL some time ago.

My recommendation would be to look for signs of infection from yeast,
bacteria, or both. Or try treating the moms as if the skin is infected with
yeast, bacteria, or both. This has worked very quickly in my clients.  Jack
Newman MD recommends treatment with a dual-purpose ointment - you may want
to contact him at [log in to unmask]

If you dig up more research on this, please post it!

Linda J. Smith, BSE, FACCE, IBCLC
Bright Future Lactation Resource Centre
Dayton, OH USA
http://www.bflrc.com