University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• A recent mother presents with breast feeding pain and sore, cracked nipples.  Are oral antibiotics warranted when bacterial colonization with Staphylococccus aureus exists?

Clinical Bottom Lines

1. Oral antibiotics are the preferred choice in treating S. aureus colonized sore, cracked nipples.¹  Number Need to Treat (NNT) is 2 for oral antibiotics over positioning alone and 3 for oral antibiotics over positioning plus topical antibiotics.
2. Oral antibiotics are also highly effective in preventing mestitis (NNT=4).
3. Dose is cloxacillin or erythromycin 500mg qid x 10 days.¹

Summary of Key Evidence

1. Comparative, prospective study took 84 breastfeeding women who had sore, cracked nipples and a S. aureus positive nipple cultures and randomized them into 4 treatment groups: 

               1) Breastfeeding technique (BFT) education only, 2) BFT with topical mupirocin, 
               3) BFT with topical fusidic acid, 4) BFT with oral antibiotics.
 The women scored their initial and post-treatment pain.  The clinicians scored the clinical findings.
2. Oral antibiotics with basic breastfeeding advice was more effective at curing (79%) sore, cracked, and colonized nipples then basic breastfeeding technique alone (9%) or with topical mupirocin(16%) or with topical fusidic acid (36%).
3. Oral antibiotics with basic breastfeeding advice was more effective at preventing mastitis (95%) than basic breastfeeding technique alone (65%) or with topical muprocin (72%) or with topical fusidic acid (64%).

Additional Comments

• Nipple soreness is thought to be a combination of recurrent trauma, exposure to maternal and infant flora, exposure to wet/dry environment and clothing friction. One conventional treatment for nipple pain is massaging maternal milk onto the nipple after feeds and allowing it to air dry before applying Lanolin Cream with breast shields.
• Nipple pain is experienced by about 80%.²
• Pain is the most common reason mothers stop breastfeeding within the first 6 weeks.^1-4
• Proper technique significantly reduces nipple pain and irritation.^1-4
• Educating on proper technique can increase the percentage who remain breastfeeding at 6 weeks by 3 fold (88% vs. 28%)⁶
• If the proper technique is not used, the application of teabags, water compresses, or Lanolin does little to help reduce early nipple irritation and pain.^4,5
• Most pain subsides by the fifth breast-feeding day.⁴
• Mothers with infants younger than 1 month who complain of moderate to severe nipple pain with cracks, fissures, ulcers or exudates have a 54% chance of having S. aureus colonization.²
• Note:  Pain more than one week after initiating breastfeeding is abnormal.  If there are signs of infection or erythema the breast may very well be infected with S. aureus or candida and therapy should be used.

Citation

1. Livingstone V, Stringer LJ.  The Treatment of saphylococcus areus infected sore nipples: A randomized comparative study.  Journal of Human Lactation, 1999; 15(3):241-46.
2. Livingstone V, Willis CE, Berkowitz, J.  Staphylococcus aureus and sore nipples. Canadian Family Physician, 1996; 42:654-9.
3. Brent N, Rudy SJ, Redd B, Rudy TE, Roth LA.  Sore nipples in breast-feeding women.  A clinical trial of wound dressings vs. conventional care. Archives of Pediatrics and Adolescent Medicine, 1998; 152:1077-82.
4. Lavergne NA.  Does application of tea bags to sore nipples while breastfeeding provide effective relief?  Journal of  Obstetrics Gynecology and Neonatal Nurses, 1997; 26(1):53-58.
5. Pugh LC, Buchko BL, Bishop BA, Cochran JF, Smith LR, Lerew DJ. Comparison of topical agents to relieve nipple pain and enhance breastfeeding. Birth, 1996; 23(2):88-93.
6. Duffy EP, Percival P, Kershaw E.  Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates. Midwifery, 1997; 13(4):189-96.

CAT Author: Alan Barton, MD

CAT Appraisers: John G. Frohna, MD

Date appraised: February 14, 2000