TITLE: Management of Cracked Nipples in Breastfeeding Women: Clinical Evidence and

Guidelines
DATE:

16 December 2010

RESEARCH QUESTIONS
1.

What is the clinical effectiveness of the available ointments and creams for the
management of cracked nipples in breastfeeding women?

2.

What are the evidence-based guidelines for the management of cracked nipples in
breastfeeding women?

KEY MESSAGE
The evidence identified regarding the effectiveness of topical treatments presented mixed
conclusions; guidelines suggest the application of expressed breast milk for the management of
cracked nipples in breastfeeding women.
METHODS
A limited literature search was conducted on key health technology assessment resources,
including PubMed, the Cochrane Library (Issue 12, 2010), University of York Centre for Reviews
and Dissemination (CRD) databases, ECRI (Health Devices Gold), EuroScan, international
health technology agencies, and a focused Internet search. The search was limited to English
language articles published between January 1, 2005 and December 7, 2010. For question #1,
no filters were applied to limit the retrieval by study type. For question #2, a filter was applied to
limit the retrieval by guidelines. Internet links were provided, where available.
The summary of findings was prepared from the abstracts of the relevant information. Please
note that data contained in abstracts may not always be an accurate reflection of the data
contained within the full article.

Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing
health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews.
The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts
within the time allowed. HTIS responses should be considered along with other types of information and health care considerations.
The information included in this response is not intended to replace professional medical advice, nor should it be construed as a
recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality
evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for
which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation
of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect.
CADTH is not liable for any loss or damages resulting from use of the information in the report.
Copyright: This report contains CADTH copyright material and may contain material in which a third party owns copyright. This
report may be used for the purposes of research or private study only. It may not be copied, posted on a web site,
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RESULTS
Rapid response reports are organized so that the higher quality evidence is presented first.
Therefore, health technology assessment reports, systematic reviews, and meta-analyses are
presented first. These are followed by randomized controlled trials, non-randomized studies,
and evidence-based guidelines.
OVERALL SUMMARY OF FINDINGS
One systematic review1 and four comparative studies2-5 were identified examining the
effectiveness of different topical preparations for the prevention and treatment of painful or
cracked nipples in breastfeeding women. The studies presented mixed results and are
summarized in Table 1. The included systematic review1 found none of the topical treatments to
be superior. Two studies2,3 found peppermint preparations to be helpful in preventing cracked
and sore nipples.
Two evidence-based guidelines6,7 were identified. Limited evidence was available to develop
recommendations regarding the use of topical preparations for the prevention and treatment of
painful or cracked nipples in breastfeeding women. Both guidelines recommend that expressed
breast milk be applied to the nipples to treat sore or cracked nipples.
Table 1: Topical treatments for nipple pain
Study type Indications Interventions
Results

Study
Morland-Schultz
1
(2005)

SR

Prevention
and
treatment

RCT

Prevention

Sayyah et al.
3
(2007)

RCT

Prevention

Peppermint water,
EBM

Mohammadzeadeh
4
et al. (2005)

RCT

Treatment

EBM, lanolin +
cleaning, no treatment

Abou-Dakn et al.
5
(2010)

NRS

Treatment

EBM, lanolin

Melli et al. (2007)

EBM, lanolin, vitamin

A, dexpanthenol,
hydrogel therapy,
glycerin gel therapy
Peppermint gel, lanolin
ointment, placebo gel

No single topical treatment

demonstrated superior ability
to relieve discomfort.
Fewer nipple cracks were
observed in patients using
peppermint gel.
Fewer nipple cracks and less
pain observed in patients
using peppermint water.
Healing time was longer for
patients in the lanolin group.
The authors suggested EBM
be used for treatment of sore
nipples
A statistically significant
difference was found in
healing rates and nipple pain
in favour of lanolin.

EBM = expressed breast milk; NRS = non-randomized study; RCT = randomized controlled trial; SR = systematic review

Management of Cracked Nipples in Breastfeeding Women

REFERENCES SUMMARIZED
Health technology assessments
No literature identified.
Systematic reviews and meta-analyses
1.

Morland-Schultz K, Hill PD. Prevention of and therapies for nipple pain: a systematic
review. J Obstet Gynecol Neonatal Nurs. 2005 Jul;34(4):428-37. PubMed: PM16020410

Randomized controlled trials

2.

Melli MS, Rashidi MR, Nokhoodchi A, Tagavi S, Farzadi L, Sadaghat K, et al. A

randomized trial of peppermint gel, lanolin ointment, and placebo gel to prevent nipple
crack in primiparous breastfeeding women. Med Sci Monit. 2007 Sep;13(9). PubMed:
PM17767120

3.

Sayyah MM, Rashidi MR, Delazar A, Madarek E, Kargar Maher MH, Ghasemzadeh A, et
al. Effect of peppermint water on prevention of nipple cracks in lactating primiparous
women: a randomized controlled trial. Int Breastfeed J. 2007;2:7 [cited 2010 Dec 15].
PubMed: PM17442122
Full-text available from:
http://www.internationalbreastfeedingjournal.com/content/pdf/1746-4358-2-7.pdf

4.

Mohammadzadeh A, Farhat A, Esmaeily H. The effect of breast milk and lanolin on sore
nipples. Saudi Med J. 2005 Aug;26(8):1231-4. PubMed: PM16127520

Non-randomized studies
5.

Abou-Dakn M, Fluhr JW, Gensch M, Wockel A. Positive Effect of HPA Lanolin versus
Expressed Breastmilk on Painful and Damaged Nipples during Lactation. Skin Pharmacol
Physiol. 2010 Aug 18;24(1):27-35 [cited 2010 Dec 15]. PubMed: PM20720454
Full-text available from:
http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=000318
228&Ausgabe=254379&ProduktNr=224194&filename=000318228.pdf

Guidelines and recommendations

6.

National Guideline Clearinghouse [Internet]. Rockville (MD): National Guideline

Clearinghouse; c2010-. Model breastfeeding policy (revision 2010); 2010 [cited 2010 Dec
15]. Summary available from: http://www.guideline.gov/content.aspx?id=24013
Note: see recommendation #18

Management of Cracked Nipples in Breastfeeding Women

7.

Toronto Public Health. Breastfeeding protocols for health care providers [Internet]. Toronto
(ON): City of Toronto; 2007 [cited 2010 Dec 15]. Available from:
http://www.toronto.ca/health/breastfeeding/pdf/protocols.pdf
Note: see Nipple creams, gels and ointments, page 33

PREPARED BY:
Canadian Agency for Drugs and Technologies in Health
Tel: 1-866-898-8439
www.cadth.ca

Management of Cracked Nipples in Breastfeeding Women

APPENDIX FURTHER INFORMATION:

Guidance documents
8.

Maternity guidelines, protocols, policies and pamphlets [Internet]. Victoria, Australia:

Grampians Region Health Collaborative. Breastfeeding challenges: nipple problems; 2009
[cited 2010 Dec 15].
Full-text available under Breastfeeding and Infant Feeding section:
http://www.grampianshealth.org.au/index.php?option=com_content&view=article&id=66&It
emid=65
Note: see Treatment for Nipples, page 2

9.

Guidelines on the treatment, management and prevention of mastitis [Internet]. Belfast,

Ireland: Guidelines and Audit Implementation Network (GAIN); 2009 [cited 2010 Dec 15].
Available from: http://www.gainni.org/Library/Guidelines/GAIN%20Mastitis%20Guidelines.pdf
Note: see Cracked Nipples, page 14

10.

Committee on Health Care for Underserved Women, American College of Obstetricians

and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and
infant aspects. Obstet Gynecol. 2007 Feb;109(2 Pt 1):479-80 [cited 2010 Dec 15].
PubMed: PM17267864
Full-text available from:
http://www.acog.org/departments/underserved/clinicalReviewv12i1s.pdf
Note: see Nipple Pain, page 10s

Review articles
11.

Lochner JE, Livingston CJ, Judkins DZ. Clinical inquiries: Which interventions are best for
alleviating nipple pain in nursing mothers? J Fam Pract. 2009 Nov;58(11):612a-c.
PubMed: PM19891933

12.

Joanna Briggs Institute. The Management of nipple pain and/or trauma associated with
breastfeeding: best practice. [Internet]. South Australia: Joanna Briggs Institute;
2009;13(4) [cited 2010 Dec 15]. Available from:
http://www.joannabriggs.edu.au/pdf/BPISEng_13_4.pdf

Additional references
13.

Breastfeeding: sore breasts and nipples [Internet]. Children, Youth and Womens Health
Service, Government of South Australia; Adelaide, South Australia; 2010 [cited 2010 Dec
15]. Available from:
http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=302&id=2140

Management of Cracked Nipples in Breastfeeding Women