The following is part of a paper I will be presenting at the NMAA conference in October. It summarises the treatment of Raynaud's phenomenon affecting the nipples of breastfeeding women. I hope you find it of use. The management of Raynaud's phenomenon in the lactating woman is limited by the need to ensure the safety of any treatment not only for herself but also for her breastfeeding infant. Avoiding cold stress is the mainstay of treatment of Raynaud's phenomenon. It is of interest that not only the affected part but the whole body needs to be kept warm to avoid reflex sympathetic vasoconstriction (Coffman 1990). Patients should therefore be advised to breastfeed in a warm environment, to wear warm clothing and to avoid cold exposure at all times. Once painful vasospasm has occurred warming the nipples (for example by using warm compresses) may be helpful. Smoking should be avoided in patients with Raynaud's phenomenon. Smoking as little as two cigarettes per day has been shown to increase vascular resistance by 100% and decrease cutaneous blood flow by 40% (Cardelli and Kleinsmith 1989). Smoking may therefore potentiate Raynaud's phenomenon. Caffeine may exacerbate Raynaud's phenomenon in some patients and should therefore be avoided. Although it is a vasodilator, its use may be associated with rebound vasoconstriction through central mechanisms thereby precipitating symptoms of Raynaud's phenomenon (Adee 1993). Moderate aerobic exercise has been shown to be of benefit in Raynaud's phenomenon and may be worth a trial in the breastfeeding patient (Cardelli and Kleinsmith 1989). The use of calcium (2000mg per day) and magnesium (1000mg per day) has been reported anecdotally as a treatment for nipple vasospasm (Maher 1988). There is no scientific evidence to date however to support the efficacy of this regimen. Evening primrose oil (Belch et al 1985) and fish oil (Digiacomo et al 1989) have individually been found to be of benefit to patients with primary Raynaud's phenomenon. Both agents are certainly safe for the lactating woman and her baby. However large doses of these agents are required to improve symptoms - 12 capsules per day of evening primrose oil equivalent to 540mgs of gamma linoleic acid or 12 fish oil capsules per day equivalent to 3.96gms of eicosapentanoic acid and 2.64gms of docosahexanoic acid. Furthermore it takes 6 weeks to get any significant clinical response with either of these agents and they are therefore not useful in the short term. A lactating woman presenting with acute nipple pain secondary to vasospasm is therefore likely to require more immediate relief at least in the interim. Of all drugs investigated thus far for the treatment of Raynaud's phenomenon, nifedipine, a calcium channel blocker of the dihydropyridine group has been the most effective (Wollersheim and Van Zweiten 1993). In primary Raynaud's' phenomenon nifedipine is associated with reductions in attack frequency between 50 and 91% ( Rodheffer et al 1983, Corbin et al 1986 and Kahan et al 1983). When given to a lactating woman less than 5% of the total dose of nifedipine appears in her breast milk (Ehrenkranz et al 1989). The administration of nifedipine does not alter breast milk composition (Ehrenkranz et al 1989). Treating a breastfeeding woman with nifedipine therefore appears to pose no risk to her infant. Nifedipine appears therefore to be a safe and rational choice for the treatment of Raynaud's phenomenon affecting the nipples of lactating women. The successful use of nifedipine in treating this condition has recently been described in five breastfeeding patients (Lawlor-Smith and Lawlor-Smith 1997). Side effects to nifedipine are said to occur in approximately one third of patients and are usually secondary to peripheral vasodilatation. These may include headache, flushing, dizziness, reflex tachycardia and peripheral oedema (Cooke and Nicolaides 1990). Side effects may be minimised by either starting at a small dose such as 5mg three times per day and slowly increasing until an optimal clinical response is achieved (Cooke and Nicolaides 1990) or by using a slow release preparation to avoid the peak blood levels associated with standard therapy (Belch 1991). Side effects occurred in three of five breastfeeding patients treated for nipple vasospasm. Side effects settled in one patient spontaneously and in the remaining two with a change in dose (Lawlor-Smith and Lawlor-Smith 1997). The reference for the use of nifedipine to treat affected nipples is Lawlor-Smith LS, Lawlor-Smith CL. Raynaud's Phenomenon of the Nipple: A preventable cause of breastfeeding failure? MJA 1997;166:448. I would start this patient on 30mg of slow-release nifedipine as a single daily dose and then assess response. Laureen Lawlor-Smith South Australia