SAY “NO” to APNO!

DON’T THROW THE KITCHEN SINK AT YOUR NIPPLES. SAY “NO” TO APNO!

It’s common to get some nipple discomfort at the start of breastfeeding. Babies and moms are learning how to do this new skill, and sometimes they just don’t get it right, and nipple damage can occur. If caught and adjusted early, this can clear up quickly, but in the meantime, women can have cracks, bleeding, and extreme sensitivity of their nipples.

All Purpose Nipple Ointment - otherwise known as APNO - has been prescribed by physicians for years for nipple pain. APNO must be compounded by a pharmacy (or made at home via many online recipes) and is a combination of an antibiotic (bacitracin), an antifungal (miconazole), and a steroid (hydrocortisone). This combination is prescribed and recommended as a panacea for any and all nipple pain that lactating women develop.

And lo and behold, APNO often helps. At least for a bit. You see, APNO is essentially a nipple ointment or nipple balm. Putting an ointment on the nipples can be very soothing, depending on the cause of the pain. Covering nipples and allowing them to remain moist is the mainstay of wound healing, and therefore APNO can serve this purpose when women have cracked nipples or sores on their nipples or areolae.

But APNO is like throwing the kitchen sink at nipple pain. This goes against my personal treatment method and decision-making as a physician. It is true - sometimes we aren’t sure what is causing a symptom. For example, rashes can be confusing at times. Many rashes can look fairly similar but have very different causes and treatments. We often make our best educated diagnosis based on our training and experience and treat the rash for that particular diagnosis. The response to treatment can give us additional information - if it responds and doesn’t come back, we were likely correct in our diagnosis (or lucky, and the rash just went away on its own, but it seems like we succeeded in treating it). Sometimes a rash doesn’t get better or even gets worse with our treatment. In those cases, we need to move on to the next most likely diagnosis and treat that. By following this method, it may take a bit longer to resolve the symptoms, but we will know that we are not treating with unnecessary medicines, and we will have an answer once we find the correct treatment (which is super helpful if the rash comes back a year later!). If we throw the kitchen sink at the rash and treat every possible diagnosis all at once, we may get better, but then we don’t really know which of the treatments helped. We also may get side effects but have no idea which of the treatments is causing the side effect. And boy is that annoying if we have a side effect (possibly a harmful one) from a treatment that wasn’t even the correct treatment. And finally, if the rash comes back later, we must use the kitchen sink again because we don’t know which treatment was effective last time.

Yes, there may be times when throwing on the kitchen sink makes sense. There are life-threatening infections when we need to start a wide variety of antibiotics while we wait for more information (and slowly discontinue the “wrong” ones as we get more information over time). Nipple pain while lactating may seem like one of those urgent times when the kitchen sink sounds like a good idea. Nipple pain can be toe-curling, and to anticipate that pain every time you feed your baby is excruciating physically and mentally. I know - I’ve been there. Many women give up on breastfeeding entirely because of the pain, and I don’t blame them.

But as a breastfeeding medicine physician, I have also seen the side effects of APNO. I have seen rashes because of allergic reactions to an ingredient, or simply from prolonged, unnecessary use of the ointment. Steroid ointments likely help pain because they treat the underlying inflammation, but they are not safe long-term, and ultimately the pain will come back if we do not treat the underlying cause of the inflammation. I have seen women who have been using APNO for an entire year of lactation when simply adjusting the latch or treating a completely different diagnosis (like nipple vasospasm - a common cause of nipple pain) would have been vastly more effective.

I write this because, firstly, I’d like to stop the unnecessary use of a treatment that is typically not necessary, and with the help of a medical professional we can make more evidence-based decisions about diagnosis and treatment. But also, to bring to light the many non-evidence-based diagnoses and treatments that are used in lactation due to a lack of training during medical school and residency. Treatments like APNO are unfortunately passed down during medical training and perpetuated time and time again but our lack of GOOD, comprehensive breastfeeding medicine education.

Thankfully, this is soon to change. The North American Board of Breastfeeding and Lactation Medicine was formed in 2021 and is positioned to certify its first cohort of Breastfeeding and Lactation Medicine Specialists in 2024. I am a founding member of this Board and I hope that its existence will serve many purposes. It will give credibility to this important field and increase medical education on lactation and make it an integrated and universal part of medical training. It will increase the visibility of the field so that other physicians and breastfeeding supporters know where they can find physician-level care for lactating women and will hopefully improve both patient access and insurance reimbursement for the services. As a recognized medical specialty, it will also increase research and provide us with a larger body of evidence to support and broaden our ability to treat lactation problems.

So please, say “NO” to APNO. And say yes to the art of using evidence-based medicine in the evaluation and treatment of breastfeeding and lactation. Say “yes” to the breast! It has been neglected for far too long in medicine.

P.S. If you are looking for a nipple balm that will provide moisture without the kitchen sink, I recommend straight-up olive oil, coconut oil, or my personal favorite is MotherLove Nipple Cream. Any of these organic options is great. Lanolin is an option, but I find it a bit too thick and sticky for my taste, and many have allergic reactions to it.

P.P.S. After writing and posting this article, I came across an eerily similar article (same title, too!) written by my Breastfeeding Medicine and 4th Tri colleague, Michelle Haggerty! I think this underscores how important it is to get the world out about this. Dr. Haggerty has all sorts of good stuff on her business’s webpage - you can find her blog HERE!