Sue Huml, LLLL, IBCLC
Lansinoh Laboratories Inc.,

Linda Moore's Mom with sore nipples has my sympathy and commiserations as she
deals with the excruciating pain that must be involved in the kind of nipple
trauma Linda describes.   I agree with Chris Hafner-Eaton that the cause should
be determined and looking at the frenulum and palate would be good places to
start.

Linda mentioned that she was recommending warm moist heat or soaking each nipple
to soften the scabs.  I can guarantee that by softening the scabs with external
wetness like this they will loosen or be removed with each subsequent nursing
and healing will be delayed.

There is a great  deal of misinformation now in lactation circles regarding
moist wound healing and the main misunderstanding is that this means keeping the
skin wet or using saline soaks or using moist heat.  These methods, though they
will provide some very temporary immediate relief for the mother with
traumatized nipples will only make matters worse  and delay healing in the long
run.

When skin is wet for a long period of time it imbibes moisture and the stratum
corneum (outer layer of skin) swells.  When this skin is left to dry in the air
(or worse, dried rapidly or left to dry in areas of low humidity)  the stratum
corneum will dry unevenly, and, as it shrinks, it will lose even more moisture
and the resulting tension on the skin can cause it to crack and break......the
very thing we are trying to prevent.

This phenomenon is easy to understand if you think of how your lips feel when
they are dry and cracked.  If you lick the chapped lips, they will temporarily
feel good for the moment they are wet, however, as soon as they dry in the air
you need to lick them again to keep them feeling hydrated.  This only depletes
more internal moisture from your lips and they will eventually crack.  If you
would continue this practice until the lips bleed and scab, as long as you keep
licking (wetting) and allowing to dry you will be removing some of the scab and
encouraging more moisture depletion- a vicious cycle that will only be relieved
when you apply a moisture barrier (i.e. chap stick) to stop moisture loss and
cease licking the lips.

It is important to distinguish between surface wetness and internal moisture.
External/surface wetness is to be avoided as it causes further skin moisture
depletion and can also cause maceration.
By soaking the nipple/areola and softening the scabs then allowing them to air
dry, the mother will be losing part of the scab at each nursing then skin
regeneration will have to begin anew.  You can all relate to how long it takes
to heal a cut finger that has a wet band aid placed over it, the injured finger
under the band aid  gets all soggy and healing is delayed.  When air drying is
employed following soaking even more moisture will  be depleted from the damaged
skin causing even more dryness and cracking.

Creating the moist healing environment means creating a moisture barrier at the
injured skin site to retain the moisture (not oil) that is already present in
the skin.  By placing a moisture barrier at the injured skin site the
evaporation of internal moisture is slowed and  the internal moisture is
retained in the skin. Healing will be speeded up, NO scab will form and, mother
will usually get some degree of relief from her pain.

Commercial moist healing dressings are not appropriate for the nipple/areola
because of the size and shape of the area in need of treatment and need for
frequent access to the breast by the breastfeeding baby.  USP modified lanolin
was created specifically for use by breastfeeding mothers because it creates the
moist healing environment at the injured nipple site and does not need to be
removed before baby nurses.

If there is one thing that I have noticed it is  when LCs  complain that they
don't see the rapid healing and relief using this method it is that mothers are
not using the modified lanolin in large enough quantity or often enough.  To
make sure that the moisture barrier is adequately applied I will quote from the
new "Are Your Nipples Sore?" information sheet from La Leche League
International.
        " Moist wound healing speeds healing without scab/crust formation.
Gently pat nipple dry, take a small pea sized portion of modified lanolin,
soften between clean fingers, and gently pat it on; do not rub it in.  This will
help ease pain and retain the natural moisture present in your skin."

This process should be followed for each nipple after each feeding and, if there
are open cracks they should be filled with the modified lanolin.  Breast pads
can also be coated with the modified lanolin so that the pad does not stick to
the nipple, and, coverage with the lanolin is assured.

LLL's sheet goes on to say,
         " If the pressure of your clothing or your bra causes further discomfort
for your nipples, apply L...... (modified lanolin) after feedings to help
soothe, protect, and heal nipples, then use breast shells with large openings.

The reason so many women remark on the pain relief is that the modified lanolin
places the broken free nerve endings in a more normal environment and instead of
abrading against each other in a scabby ( dry) environment, they gently glide
against each other therefore reducing the sensation of pain.  Again, you can
test this phenomenom next time you have a paper cut.  If you keep the cut filled
and covered with modified lanolin you will forget you even have one!  Leave it
dry and you will feel it every time your skin moves.

The process of moist wound healing is also explained very well in the New
Breastfeeding Answer Book (LLLI 1996).

If any of you would like to receive one of the articles I have authored on the
topic of Moist Healing and Cracked Nipples, e mail me your snail mail address
and (provided its not too many of you) I'll be happy to send one of them  to
you.

Hope this helps your poor Mom

Sue Huml, IBCLC
Illinois