Dear Tricia,
I love your thoughtfulness in this post.
I work as a private practice IBCLC and nipple pain is a huge reason that 
people see me. These comments are based upon what I have read, to me the 
research is largely ambiguous and often contradicts itself, but more so, 
on my clinical experience.
As to your points:
1. Sense of smell. Absolutely. How about all the hand sanitizer as well? 
Mom are putting this on their hands all the time and then putting their 
hands near the baby's face while latching. I can't stand the smell 
either! I suggest good hand washing practices when possible instead. I 
had questioned peppermint oil use here due the strong smell.
2. Gut microbiome. Yes! I like the idea of organic coconut oil or olve 
oil because I feel this would at least not hurt the gut microbiome too 
much. These are good for grown human's guts. However, with pain the odds 
of reaching for the can of formula goes up and we know that that reeks 
havoc on the gut microbiome. Being able to take time in a consultation 
to assess where each mother is in her process is critical. I have had 
mothers say to me that if I can't get this pain under control they are 
switching to formula today. And they are serious. So using a thicker 
cream to keep things moist and hydrogel pads to lessen the pain seems 
important. See point 9 for more on this.
3. Agree
4. Agree. I never suggest APNO. It is expensive to get here in Michigan. 
I personally disagree with the notion that you need an antibiotic cream 
and an anti fungal cream. Figure out which it is if either! As to the 
steroid cream, if the pain is severe enough, using this may keep her in 
the game. Again, not something I usually suggest she talk to her health 
care provider about. I have actually had mothers come into me and been 
using APNO for months. They are still in pain due to the fact the 
steroid in the cream has thinned their skin down to paper. They 
discontinue the cream, the pain goes away! The cream says to not use 
more than 10 days but this is not emphasized. Moms use it for weeks or 
months.
5. Agree
6. I used to worry about this but in my practice my mothers are never 
(and I mean this) getting yeast or mastitis from moist wound healing. I 
do always suggest mothers with open wounds talk to their doctors about 
washing with mild soap and water twice a day to keep the odds of 
infection down along with an over the counter antibiotic cream if that 
seems appropriate. It seems to have worked, at least in my population.
7. Agree
8. Agree
9. Most important point. I respectfully disagree. Again, having helped 
mother's heal for 18 years, I have found moist wound healing works 
incredibly well, combined with (Point 10) better latching and 
positioning. I tell my mothers, "Think about if you had a cut on your 
arm (or finger) and someone was going to come and squeeze it hard for 
10-20 minutes every 2-3 hours. Would you want your wound to be moist and 
supple or have a hard scab that needs to be softened?" I believe, and 
this is my opinion, that the "recracking" of the dry, hard scab is the 
most excruciating part of when a baby latches when there is nipple pain. 
I envision that hard, dry scab being cracked open again. I believe this 
is incredibly painful AND can cause the wound to be worsen by the 
cracking, the wound often starts bleeding or ends up looking deeper 
after the feed. Again, these are my thoughts and observations. Even if a 
mother has no visible damage, she can have that initial, "Oh my 
goodness! This is so painful!", feeling for 10-30 seconds. And then the 
pain goes away or is greatly reduced. Is this that those tiny micro 
abrasions, tiny cracks on the nipple surface have softened up?
So, if we keep them soft, and clean (remember washing twice a day), and 
with a better latch, do we have better outcomes? In my world, yes. I 
think the problem with air drying is that nipples have to be squished 
again in a way that most cuts don't. I suggest they talk to their health 
care providers about washing with mild soap and water twice a day, 
perhaps using an over the counter antibiotic cream if the health care 
providers feel their is infection, and keeping the wound moist with ?, I 
give them a list of options that they can discuss with their health care 
provider, coconut oil, olive oil, food based organic creams, lanolin.
10. Completely agree. A cream will not give you a deeper latch. A cream 
will not help with vasospasms. Our careful help is critical.
Thank you! I look forward to hearing from others on this.

-- 

Barbara Robertson, MA, IBCLC, RLC
The Breastfeeding Center of Ann Arbor
bfcaa.com

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