I'm sure every breastfeeding mother has heard of the ubiquitous "APNO". Maybe it was recommended to you by an IBCLC, maybe you found it while trying to google solutions to your own sore nipples. All-purpose Nipple Ointment (or "APNO" as it is so endearingly abbreviated) is a mixture of various prescription creams, and was developed by Dr. Jack Newman. [1]
Mupirocin 2% ointment + Betamethasone 0.1% ointment + Miconazole powder to a final concentration of 2%
In laymen's terms, it's an Antibiotic + Steroid Cream + Anti-fungal.
Because those ingredients are prescription only, APNO has to be obtained via prescription from a compounding pharmacy. Despite this, I continue to see APNO recommended with near-reckless abandon to all breastfeeding women, regardless of the cause of their sore nipples. Some have even taken the liberty of developing over-the-counter substitutes for APNO, such as bacitracin, polysporin, lamasil, nystatin, hydrocortison, miconazole, and all sorts of combinations/variations.
Mupirocin/Antibiotic Ointment
Mothers with severe, persistent nipple pain are at a high risk of becoming infected with Staphylococcus aureus, a bacterial strain which can form biofilms, has methicillin-resistant strains, and has been isolated in cases of mastitis. [2],[3],[4] Staph. aureus has been found growing in the abrasions of severely damaged nipples, which has led to a strong correlation between cracked and bleeding nipples with Staph. aureus colonization. [5],[6]
However, colonization is not the same as infection. Colonization is just the presence of bacteria, but without any accompanying symptoms or illness. An infection, on the other hand, implies symptoms and illness. Colonization with Staph. aureus usually requires no treatment. In cases where severe nipple trauma is present, an antibiotic might be prescribed to prevent a Staph. aureus colonization from entering the bloodstream through the cuts and becoming an infection. The first ingredient in APNO, Mupirocin (trade name is bactroban), is known to be effective against strains of Staph. aureus, including MRSA.
That said, there are increasing reports of bacterial resistance to Mupirocin (used for nasal decolonization of MRSA), even being reported in up to 50% of community-acquired MRSA cases in some regions. [7],[8] Such resistance develops as a result of over-use of specific antibiotics, sometimes without cause. In accordance with Antibiotic Stewardship protocols, antibiotics should only be used when they are clinically indicated, in the lowest dose, for the shortest duration of time. [9] Recommending that women put Mupirocin on their nipples for cases of minor to moderate nipple pain with no accompanying abrasions is not good practice. Such practice may result in an increase in Mupirocin resistance, which may reduce the overall effectiveness of Mupirocin (or other antimicrobials) when treating true cases of Staph. aureus infection.
In some cases, oral antibiotics have even been found to be more effective than topical Mupirocin in treating Staph. aureus colonization [16],[17], suggesting that true cases of Staph. aureus nipple infections require treatment outside the scope of APNO.
Betamethasone/Other Cortisone Creams
The inclusion of Betamethasone in APNO is specifically to target nipple soreness that is caused by atopic dermatitis, eczema, or general inflammation. As a steroid cream, it may help reduce redness and swelling and irritation in the early days of breastfeeding.
That said, a double-blind study published in the Journal of Breastfeeding Medicine found no advantage to Betamethasone (in the form of APNO), versus pure lanolin. [10] When undergoing any treatment with medication, best practice indicates to always begin with the most basic treatment and work up. Therefore it stands to reason that mothers experiencing nipple soreness would be better off starting with pure lanolin rather than a prescription cortisone cream. Corticosteroid creams are not without risk, and their use needs to be monitored and kept within the shortest parameter's possible to prevent unwanted side effects. [11]
Another consideration with the use of Betamethasone ointment is the potential exposure of the infant to high levels of mineral paraffins. [12],[13] Most pharmaceutical ointment bases contain paraffin. Given that no significant benefit has been found for Betamethasone vs pure lanolin, most mothers would be better off using lanolin unless an actual case of atopic dermatitis has been identified.
Miconazole/Anti-Fungals
Some cases of nipple pain may be traced back to an overgrowth of Candida. Candida is a fungus that is present in all humans, but in some cases it may grow to high levels, causing a condition known colloquially as thrush. Thrush can be difficult to get rid of, and is very strongly associated with recent antibiotic use. Antibiotics kill many of the good bacteria that compete with Candida for food. Destruction of this good bacteria can allow Candida fungus to grow.
Miconazole is an anti-fungal and although it is not the first choice of many doctors for treating nipple thrush, it has nonetheless been found to be effective. When used in conjunction with a topical antibiotic it could potentially prevent thrush from developing. But, when it comes to APNO, Mupirocin already has anti-fungal properties and therefore is unlikely to result in thrush. [14],[15]
When it come to "all purpose" nipple ointments, I have to wonder if we really need to be treating ALL the potentials. A mother who has a known case of thrush is not going to need an antibiotic. A mother who needs a topical antibiotic probably doesn't need a steroid cream. Even. Dr. Newman acknowledges that when it comes to medicine, it is best to go with the single "right" treatment for the "right" problem. Any time a case of nipple pain can be isolated to its roots, treatment should be tailored to that specific problem.
The justification for prescribing APNO is that mothers who are suffering from sore nipples "without known cause" may not have time to play a juggling game with treatments, trying to figure out which one works. Therefore prescribing an ointment designed to knock out all of the potentials may be prudent, particularly if weaning is being considered. That is where APNO has carved out a very valuable place in breastfeeding management.
But it needs to be said that anytime a mother is experiencing such severe pain and trauma that she is considering weaning, she needs to be seen by an IBCLC. Such problems do not arise out of nothing, and it is critical to prolonged and sustained relief that the root cause be identified and corrected. I see many times where those in the breastfeeding community treat APNO as a substitute for proper lactation management, or they recommend it for mild to moderate transient pain, where pure lanolin would work just fine.
Also concerning is the upsurge in "over-the counter" APNO's, made by mixing various store-bought topical creams together. The proportions of these creams may vary, and over the counter antibacterial ointments have also been increasingly linked to antibiotic resistance in the community. Antibiotics in particular need to be used very judiciously, and there is no scientific basis for applying antibiotic cream or ointment to nipples for just transient pain. Antibiotic ointments themselves do not get rid of pain; they inhibit bacterial growth. Therefore they only need to be used in cases where the pain is either a direct result of an infection, or else the mother has nipple wounds and is at risk of developing an infection.
Whenever those in the breastfeeding community are dealing with sore nipples, start with the most effective treatment that also carries the fewest side effects. Unless a mother has sustained, severe pain and/or open nipple wounds, pure lanolin is most certainly the safest and best choice.
References:
1. International Breastfeeding Centre. 2009. "All Purpose Nipple Ointment (APNO)"http://www.nbci.ca/index.php?option=com_content&id=76:all-purpose-nipple-ointment-apno&Itemid=17
2. Journal of Emerging Infectious Diseases. 2007. "Postpartum Mastitis and Community-acquired Methicillin-resistant Staphylococcus aureus."
http://wwwnc.cdc.gov/eid/article/13/2/06-0989_article.htm
3. Journal of Obstetrics and Gynecology. 2008. "Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization."
http://www.ncbi.nlm.nih.gov/pubmed/18757649
4. International Breastfeeding Journal. 2008. "The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment"
http://www.internationalbreastfeedingjournal.com/content/3/1/6
5. Journal of Human Lactation. 1999. "The treatment of Staphylococcus Aureus Infected Sore Nipples: A Randomized Comparative Study." http://www.breastfeedingclinic.com/ckfinder/userfiles/files/TreatmentofStaphyloccocus.pdf
6. American Family Physician. 2008. "Management of Mastitis in Breastfeeding Women" http://www.aafp.org/afp/2008/0915/p727.html
7. Journal of Antimicrobial Agents and Chemotherapy. 2007. "Mupirocin-Resistant, Methicillin-Resistant Staphylococcus aureusStrains in Canadian Hospitals"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2151460/
8. Journal of Clinical Infectious Diseases. 2009. "Mupirocin Resistance"
http://cid.oxfordjournals.org/content/49/6/935.long
9. The Nebraska Medical Center. "Antimicrobial Stewardship Program"
http://www.nebraskamed.com/careers/education-programs/asp
10. Journal of Breastfeeding Medicine. 2012. "An All-Purpose Nipple Ointment Versus Lanolin in Treating
Painful Damaged Nipples in Breastfeeding Women: A Randomized Controlled Trial"
http://online.liebertpub.com/doi/pdf/10.1089/bfm.2011.0121
11. Journal of Cutaneous Medicine and Surgery. 2004. "Nipple and Areolar Eczema in the
Breastfeeding Woman"
http://dermatologycentral.typepad.com/files/nipple-and-areolar-eczema-i.pdf
12. Journal of Regulatory Toxicology and Pharmacology. 2003. "Exposure of babies to C15-C45 mineral paraffins from human milk and breast salves."
http://www.ncbi.nlm.nih.gov/pubmed/14623482?dopt=Abstract
13. Drugs and Lactation Database
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~S8ICbU:2
14. The Journal of Antimicrobial Chemotherapy. 1999. "The antifungal activity of mupirocin."
http://www.ncbi.nlm.nih.gov/pubmed/10350391
15. International Journal of Dermatology. 1999. "Perianal candidosis--a comparative study with mupirocin and nystatin."
http://www.ncbi.nlm.nih.gov/pubmed/10487455
16. University of Michegan: Department of Pediatrics. 2003. "Oral Antibiotics and Positioning Are Effective in Decreasing Morbidity in Breastfeeding Mothers"
http://www.med.umich.edu/pediatrics/ebm/cats/bfeed.htm
17. Journal of Human Lactation. 1999. "The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study."
http://www.ncbi.nlm.nih.gov/pubmed/10578803
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