from Gonneke:
 <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. >
You're right about the anti-infective agents in breastmilk, but anywhere the
skin is broken it is not difficult for infection to develop. Staph aureus
tends to grow in these situations, and it doesn't have to travel from the
gut. Many people carry it, eg in the nose. When I was doing a study a few
years ago, I was swabbing everyone's nipples (well, lactating women with
nipple pain, lactating women without pain, and some non-lactating women too)
trying to grow candida. But I found that many of the cracked nipples grew S.
aureus. Of 59 women with nipple pain: only 19% grew candida, and 34% grew
S.aureus. Of the 21 women with cracked nipples: 62% grew S.aureus.
(see Gynecol Obstet Invest 1996; 41: 30-34). By the end of the study, I was
able to have a good idea when a nipple would grow staph: yellowish exudate
or scabby looking.

from Catherine:
<However, a major weakness here is that there was no follow-up of the
mothers with negative nipple staph cultures, so we can't take for
granted that every cracked nipple has staph as the authors seem to
conclude, or that every cracked nipple is going to progress to
mastitis.  >
I agree, this was my point a couple of days ago. The article starts off
saying that cracked nipples were cultured for staph, but doesn't clarify how
or when women were randomised and given treatment.
The authors called a halt to the study early, which is a serious decision to
make. I wonder with a study like this that hasn't been done before whether
it would have been better to continue longer to reach the sample size they
were aiming for. I don't know, I'm just wondering.

<Finally, I would be interested to know where these women delivered.
Staph aureus is a common pathogen in hospitals.  >
yes, I have heard hospital midwives talk about having clusters of breast
abscesses occurring in women after leaving hospital, and wondering if the
hospital was the source of the staph. Cost-cutting has meant that hospitals
aren't as clean as they used to be (here in Australia anyway).

And from Sharon:
<Are all the women who present with cracked=
nipples at the Vancouver Breastfeeding Centre now being given systemic=
treatment?  >
I wonder this too. I did meet Verity in San Diego in October last year but I
had only had a quick look at the Sept JHL so couldn't discuss it with her.
She did wonder what people would think about recommending soap.
In my practice, I am prescribing a topical antibiotic earlier when I see a
cracked nipple starting to exudate or looking scabby. But I hesitate to
prescribe oral antibiotics on the basis of one study.
I am enjoying this journal club discussion!
Lisa Amir
MBBS, MMed, IBCLC in Melbourne, Australia

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