Re: saline soaks for open skin (nipple) healing:  I am a great supporter
of saline soaks for a variety of wound needs. I'd like to add to the
discussion. As always, proper latch-on, and also proper nutrition. Skin
integrity and healing is very reflective of underlying nutritional
status: of prime importance is protein (albumin) and zinc.

I have been reading the responses with interest; I am slightly (but
probably unnecessarily) concerned about the wide variation in "recipes"
posted for preparing saline solutions.

The easiest, most fool-proof way to acquire normal saline solution - and
sterile, at that - is to simply buy sterile saline sold for contact lens
wearers. It can (and should) be purchased for nipple care *without*
preservatives. In this case, it comes packaged in saline "bombs" - or
little plastic vials - which are perfect in size and quantity for nipple
soaks (10 ml/bomb). What could be easier? and one less thing for mom to
"do". Plus, the recipe is exactly right.

Saline solutions used for dressing soaks by nurses are always "Normal
Saline" solutions - in this case, "normal" has the distinct chemistry
definition of  9 percent  sodium in one (1) Liter of water (1/4 teaspoon
in a small cup is way too much). "Normal" is important because "normal"
is physiologic (friendly) for body tissues, especially moist ones where
body serum is present. To use an overly salty solution (the recipes I
saw posted *are* hypernatremic - ie, use too much salt) is to cause a
shriveling and death of moist tissue cells which can only make the sore
nipple worse, IMO. If there is a greater presence of salt outside the
cell wall, the water inside the cell will exit in order to equalize the
salt/water balance in the local environment. This can not be good for
mom's exposed mammary tissue cells. (This is not to be confused with
salt water rinses recommended in dentistry when the goal is to kill
bacteria (by shriveling them up) and where the salt-water gargle is only
in brief contact with the mucous membranes, as opposed to leaving it
soak against skin.)

Mature skin has a normal pH of 4.2 to 5.6, a slightly acidic mantle that
protects against microbial invasion. Alkaline soaps, then, (like Ivory)
can encourage the risk for skin injury and breakdown, so any advice
needs to reinforce the teaching *not* to use soap on the nipples, but
just water during mom's bath.

A brief review of wound healing in general reveals 3 phases: the
Inflammatory (exudative) phase lasting about 4 days from onset and
characterized by localized edema, erythema  (redness), and tenderness;
the Fibroblastic phase lasting from 4 to 20 days when there is both new
cell proliferation ("beefy red" with the creation of new capillary  beds
and *very fragile*, extermely prone to reinjury) and epithelialization
(actual covering of the serous tissue by new skin); and Maturation phase
from 20 days after injury to as long as 1 year (depending on the
location, depth of the wound, and whether it was infected ).

Wound management research supports maintaining a moist wound surface
while protecting the healing wound from trauma and bacterial invasion.
Moist wound surfaces heal faster and less painfully and avoid scabbing
or turning into necrotic tissue. In general, drying nipples *before* the
skin integrity is broken is a good approach. However, if the epidermis
is breached to the underlying moist mammary tissue, then perhaps, a
moist environment would be preferable. (Potential research topic in
nipple care)

Normal saline soaks are well-known and often used for decubitous care in
other realms of healthcare. Cracked nipples are, after all,
mini-decubitous ulcers (Stage II - patrial thickness/epidermal
stripping). I would recommend wet-dressing care after a  feeding is
completed. The standard procedure is to clean the area gently (normal
saline is all that is needed to clean). Protect the surrounding healthy
skin (that will nevertheless be exposed to the moist dressing) from
breakdown by applying a thick barrier of zinc oxide (petroleum jelly
with zinc added to it) or petrolatum. Then moisten a gauze pad with the
normal saline solution (it should be wet but not dripping, and moist
enough to still be moist at the next dressing change - or
breastfeeding), and place on the open area. Cover with a dry dressing. A
clean disposable breast pad works great, held in place by the bra. At
this point, there is no "standard" approach (for saline soaks in nipple
care), but I think, in our LC cases, at the next feeding, any remaining
zinc oxide could be massaged into the healthy skin. Gently rinse the
area with more saline and pat dry before breastfeeding.

This works well for really nasty diaper rashes, too, but I suspect that
is "off-topic"  :-)

Katharine West, BSN, MPH
Sherman Oaks, CA