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Jack Newman, a Toronto pediatrician and breastfeeding expert, created a prescription for APNO, and it remains the most commonly prescribed treatment for pain at the start of breastfeeding. APNO contains an antibiotic ointment called mupirocin, a corticosteroid ointment called betamethasone, and an antifungal powder called miconazole:

  • Mupirocin (Bactroban is the trade name) is an antibiotic that is effective against many bacteria, particularly Staphylococcus aureus. Staphylococcus aureus is commonly found growing in abrasions or cracks in the nipples and probably makes worse whatever the initial cause of sore nipples is. Treatment of sore nipples with an antibiotic alone sometimes seems to work, but  the antibiotic works best in combination with the other ingredients discussed below. Although mupirocin is absorbed when taken by mouth, it is so quickly metabolized in the body that it is destroyed before blood levels can be measured. Moreover most of it gets stuck to the skin so that very little is taken in by the baby. Thus it is safe to swallow if indeed the baby gets any.

  • Betamethasone is a corticosteroid, which decreases inflammation. A large part of the pain mothers experience when they have sore nipples is due to inflammation. The redness of the nipples and areolas is another sign of inflammation. By decreasing the inflammation, the ointment also decreases the pain the mother feels. Most of the betamethasone is absorbed into the skin by the mother so that the baby takes in very little.

  • Miconazole is an antifungal agent. It is very effective against Candida albicans.

How do I use the ointment?

Apply it sparingly after each feeding. “Sparingly” means that you apply just enough to make the nipples and areola glossy or shiny. Do not wash it off or wipe it off, even if the baby comes back to the breast earlier than expected.

How long can I use the ointment?

Somehow the “word” has gotten around to use the ointment for only two weeks. This is based on the belief that the steroid in the ointment will cause “thinning” of the skin. While this is a concern with any steroid that one puts on their skin, in our experience, this has not occurred with APNO as several mothers have used it for months.

Any drug should be used for the shortest period of time necessary, whether it’s taken by mouth or put on the skin. There is no problem using the ointment for 2 or 3 or even more weeks, but if you still need the ointment after two or three weeks, or you pain returns after you have stopped it, you should get “hands-on” help again to find out why and fix the way the baby is taking the breast. The most important feature of decreasing nipple pain is getting the “best latch possible”.

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