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Join Cindy Rubin, a pediatrician and breastfeeding medicine specialist, as she discusses the common challenges of nipple discomfort during breastfeeding and the controversial use of all-purpose nipple ointment (APNO). Learn about evidence-based approaches to diagnose and treat lactation issues and the importance of comprehensive breastfeeding medicine education. Discover how the North American Board of Breastfeeding and Lactation Medicine is revolutionizing the field for improved patient care and outcomes. Say “yes” to the breast and explore evidence-based solutions in lactation management.

Cindy Rubin is a pediatrician and breastfeeding medicine specialist.

She discusses the KevinMD article, “Say ‘no’ to APNO and say ‘yes’ to breastfeeding medicine.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Cindy Rubin. She’s a pediatrician and breastfeeding medicine specialist. Her KevinMD article today is “Say ‘no’ to APNO and say ‘yes’ to breastfeeding medicine,” APNO being all-purpose nipple ointment. Cindy, welcome back to the show.

Cindy Rubin: Thank you for having me.

Kevin Pho: We’ll get into the article in a little bit, but for those who didn’t listen to our first episode together, just briefly share your story and journey.

Cindy Rubin: Sure. So I am a pediatrician and, as you said, a breastfeeding medicine specialist, and I am in the Chicago area. I was an academic outpatient general pediatrician for 13 years before I decided to venture out on my own. I opened a primary care pediatrics practice, but also a breastfeeding medicine and fourth-trimester care practice where I do home visits.

Kevin Pho: And as a breastfeeding medicine specialist, tell us some of the top things that you would see.

Cindy Rubin: So with breastfeeding medicine, I want to actually start by just making a distinction. A lot of people don’t really understand what that is in relation to breastfeeding care and how it differs from lactation consulting. Lactation consulting is amazing and is usually the first line for breastfeeding issues or preventative breastfeeding care. Lactation consultants can give counseling and education. Oftentimes, there are more complicated problems that require physician-level care.

So the things that I commonly see are pain, breast pain, nipple pain, persistent or recurrent plugged ducts, people who want to induce lactation, and, oh, simply low milk production. High milk production has its own problems, too. Oftentimes lactation consultants can help with these things, but sometimes they get to a point where they need somebody who can evaluate and do a workup and treatment.

And unfortunately, most physicians, even the physicians on the front line like OBs, pediatricians, and even breast surgeons, don’t get much training, or any training, in breastfeeding. So patients go to these people asking for help, and they don’t know how to help. Breastfeeding medicine is a new specialty that is offering a way for patients to access this kind of help.

Kevin Pho: All right, and we’re going to talk more about that in your KevinMD article, “Say ‘no’ to APNO and say ‘yes’ to breastfeeding medicine.” Before getting to your article, let’s bring everyone up to speed. What are some common reasons for nipple pain during breastfeeding? And where does APNO, or all-purpose nipple ointment, come into play?

Cindy Rubin: Probably the most common thing is simply a latch not being quite right. For breastfeeding to be effective and not painful for a mom, the nipple has to hit the right place in the baby’s mouth, which is at the junction of the hard and soft palate. If a baby’s not latching deeply enough or widely enough, or using their tongue correctly, then that may cause pain. And when there’s pain, there is sometimes nipple trauma following that.

Also pumping: No matter how advanced pumps are, and there are a lot of newer pumps that try to be as correct as possible, they’re always going to be artificial. So pumping can cause nipple trauma. Also, infections, dermatitis, or nipple trauma for some other reason can cause pain. Usually we go back to that latch. That’s the most common place that we need to work, and then potentially try to heal any trauma that has already happened.

Kevin Pho: And what is all-purpose nipple ointment, and when is it typically prescribed?

Cindy Rubin: So all-purpose nipple ointment is a combination of a steroid, an antifungal, and an antibacterial. This is usually obtained at a compounding pharmacy that can mix all of these together; some people just make it themselves. The purpose is to treat whatever it is that’s causing the pain. As we know in medicine, there often are multiple things leading to pain, but ideally, we can find a specific diagnosis to treat. We don’t seem to do that with breastfeeding and with nipple pain. All-purpose nipple ointment is kind of a catchall: “OK, there’s pain. It might be one of these three things, so let’s treat with the nipple ointment.”

And oftentimes it does improve, which has probably facilitated the fact that this gets used again and again, because sometimes just a barrier, a moisturizer, or just a moist environment for healing is all the nipple actually really needs. This ointment can provide that, though it’s providing it with a lot of extra things that aren’t needed and that can potentially cause problems. So it is very commonly recommended and prescribed, because people don’t have the additional training and knowledge to know how to make those diagnoses and what treatments might work.

Kevin Pho: So you wrote in your article, just echoing what you said, that APNO is like throwing the kitchen sink at nipple pain, and it goes against your personal treatment method and decision-making as a physician, partly because, as you said before, sometimes the true cause can be elucidated with a proper evaluation and treatment plan. So in your ideal scenario, what would that look like? What would the ideal plan be if a mom came to a breastfeeding specialist like yourself? What would the ideal situation look like?

Cindy Rubin: Ideally I would be able to see them in person. Sometimes that’s not possible, and I do virtual visits, but ideally I would want to see them in person and be able not only to physically examine their nipples and their breasts, but also to watch their baby nurse or watch them pump, so that I can troubleshoot those mechanical, physical things that might be contributing to the problem. And then of course, as we always do in medicine, actually before I do the exam, I would take a good history to see if I can get any clues to what is happening based on the timeline and all the other factors that are going into the breastfeeding.

I think about how sometimes I’m diagnosing just a rash in a child, and it’s like, “Well, it kind of seems like it could be this, and it could be this. It might be fungal, but it might be eczema.” And I don’t like to throw that kitchen sink. So I go with what is most likely based on the exam and the history and all of that: “Let’s try this first, touch base in a few days, and see whether we’re making progress.” And if we’re not, or if things are getting worse, then maybe we need to go to plan B. And if there are ways to actually help facilitate a diagnosis, then you do that, so a culture or something like that to help guide your management. So I really like to provide that personalized care, with as much information as I can get in order to make, hopefully, the right decision, and close follow-up to make sure that we change gears if we need to.

Kevin Pho: Now, how common is it that you’re able to diagnose the true cause of nipple pain without resorting to something like APNO?

Cindy Rubin: Fairly common. Again, sometimes with that latch, just making a few little adjustments, moms will be like, “Oh my gosh, this is so much better.” If the latch is better, then usually the pain diminishes, there isn’t any additional trauma, and whatever trauma was there is allowed to heal. So that’s relatively common. By the time people get to me, sometimes it’s been a while, and so the pain might not go away immediately. But when there’s trauma to the nipple, using basic wound care techniques is really what it’s all about. For some reason, we have come up with these different ways of treating that are different from just the wound care that we would do for other parts of the body. But the nipple is a part of the body, and we treat it the same way. We need moist, closed wound healing, and that will often do the trick if you’re patient and fix whatever that trigger was.

And I actually didn’t mention this before: Vasospasm is another cause, kind of like Raynaud’s of the nipple, similar to that. It is often a cause of nipple pain, and it’s usually triggered by something else that’s going on, like the latch not being right, or a pumping technique triggering a problem. So if you’re able to put all of these things together, I find that maybe 90 percent of the time I can find the one or two diagnoses that are going on, get to the root of it, and get people feeling much more comfortable.

Kevin Pho: You mentioned earlier that repeated use of APNO can be problematic. What are some of the issues with it? What are some of the side effects from repeated use?

Cindy Rubin: I mean, it depends. The formulation is a little bit different depending on who’s preparing it. There are antibacterials that people can have allergies to, and so APNO itself can create more of a rash or a problem. We see that frequently. And also, if you’re using it and you’re feeling a little bit better, but it’s really not getting to the root cause, that root cause may just get worse and worse, and you don’t really realize that you’re not treating it correctly. And why treat something for longer than you need to? Sometimes people will start APNO, feel better, and use it for about a year when they don’t really need to do that. And with the antibacterial component, they may be breeding resistance. So there are definitely ways that it can be problematic.

Kevin Pho: So how about in the primary care setting, where sometimes primary care clinicians may not have access to a breastfeeding medicine specialist like yourself? What kind of advice can you share with them when it comes to nipple pain?

Cindy Rubin: Learn how to assess a latch. I think it’s really important if you’re going to be working with people who are breastfeeding. If they’re there in your office, and that baby is there and the mom is there, watch them breastfeed, and become more comfortable with watching them, assessing them, and seeing what a good latch looks like. Now, sometimes good latches can still be painful, so there are a lot of things going on.

There’s education out there through lactation organizations, and there’s some that is geared much more towards physicians: the Academy of Breastfeeding Medicine, and IABLE, which is the Institute for the Advancement of Breastfeeding and Lactation Education. I always have to think about that one. There is physician-geared education with videos, in-person conferences, and all sorts of ways to learn to better assess that. And if you can better assess it, then you can find the resources. If you’re not a specialist, you may not have the time to always sit there for an hour and watch a baby feed, but you would also know what resources are available in your community to be able to send people to. We breastfeeding medicine doctors want to help, and so we can be contacted to give advice over the phone as well to other physicians out there who need some help.

There are a lot of ways to make yourself better educated. It really is something that just has not been the focus in medical education and training, and so we need to take it upon ourselves to find that education. Now, hopefully we will have an upcoming board certification for lactation medicine, and that will hopefully increase access to education through academic programs, but it will also lead to better access for patients and more places that people can go to get educated, to be able to pass on the information and education to the next generation of physicians, too.

Kevin Pho: One of the points that you bring up in your article is that breastfeeding medicine, like you said, is a relatively new specialty. What’s the current status when it comes to evidence-based treatments in this field?

Cindy Rubin: That’s a really good question. There is a decent amount of evidence out there, but it is sorely lacking, especially in humans, because with anything breastfeeding-, newborn-, baby-, or pregnancy-related, it’s really hard to get IRB approval for the best kind of studies, the randomized double-blind studies. So we don’t have that much of that, and people are working at improving the bulk of research on that. Right now, honestly, a lot of the research and the evidence that we have is through the dairy industry, because that is where the bulk of our focus has gone as a country, in terms of getting milk from animals. So we do have a lot of information there, but it’s not all applicable to humans, obviously. So we do need a lot more good research and good evidence. And again, I hope that with this becoming a newer specialty, and a better-recognized specialty, there will be more money, support, and people to get this research done.

Kevin Pho: We’re talking with Cindy Rubin. She’s a pediatrician and breastfeeding medicine specialist. Her KevinMD article is titled “Say ‘no’ to APNO,” that’s all-purpose nipple ointment, “and say ‘yes’ to breastfeeding medicine.” Cindy, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Cindy Rubin: Well, say no to APNO, obviously. But really, the whole point of that article was that it was just an example of how there’s a lot of misinformation out there about breastfeeding. We’re recording this during World Breastfeeding Week, and one of the things that World Breastfeeding Week tries to encourage is just more education about the challenges that people have, in our country as well as our world, that revolve around breastfeeding.

So educate yourself, and find out where you can learn about breastfeeding to support your patients. If you have personal experience with breastfeeding and breastfeeding challenges, that is helpful in terms of being a practitioner, but it does go deeper, and there are ways to get more certification. And even if you’re not interested in certification, there are ways to get better education, to be able to provide the care that I think is deserved and necessary for patients.

And there really is a lot of pushback in the breastfeeding, infant feeding, pediatrics, and physician community, even towards, “Just don’t breastfeed. Breastfeeding isn’t that important. Your mental health is more important.” Well, your mental health is absolutely important, and I don’t think that there’s any amount of breastfeeding or breast milk that is worth a mother’s mental or physical health. But a lot of the time, people kind of have this default: “Just stop. It’s not worth it, it’s not worth it. It’s OK. Formula’s OK.” That may be the case, but nobody should feel like they didn’t receive the support that they should be able to get, to at least optimize their chances of reaching their goals if their goal is to breastfeed. So we need to improve that for patients, and the more primary care doctors, and frontline doctors really, who understand breastfeeding and start to learn what evidence is out there, the better chance people will have of succeeding in those breastfeeding goals.

Kevin Pho: Cindy, thank you so much for sharing your time and insight, and thanks again for being on the show.

Cindy Rubin: Thank you. Thanks for having me. Have a great day.