Question
We have an African American mother pumping for her preterm baby. The nursery nurse noticed black flecks in the milk. The nursery nurse was concerned so she did not give the mother’s milk to infant. I thought maybe it was her skin flaking off while pumping. I suggested the mother use a larger breast flange while pumping. What are you thoughts on this?
Carlotta RN,IBCLC
Answer
Some new mothers have what appears to be a build-up of very dry skin on their nipples. Occasionally in the early days of breastfeeding the skin will flake and “pepper” the milk. Kay and I do not think this is an issue exclusive to African American women; perhaps it is merely more visible when the skin being shed is darker in color.
Sometimes the mothers we have encountered were warned to not ever put soap on their nipples. Sometimes women interpret this advice to mean they should even guard the nipples from normal bathing activity. Throughout the pregnancy the woman may also have been applying moisturizing creams to her nipples. Nearer the birth, if she oozed colostrum, she may have been instructed to massage that fluid back into her nipples. Consequently, fluids and dry skin may accumulate, causing a crust to form on the nipple tips. When the crust inevitably begins to slough off, it can appear that the woman is losing considerable amount of actual nipple. The skin underneath has been deprived of normal air/light exposure, and it can feel tender and raw when abruptly exposed to pumping or the infant’s sucking.
Because some women experience dry skin issues, prenatal nipple care instruction should reassure women about normal bathing as a part of nipple care and address treatment for dry skin.
Postpartum women with nipple crusting can be instructed to gently and gradually remove the layers of dried skin that have formed over the nipples. While showering, or while suspending her breasts in a clean basin of warm water to soften the skin, she should VERY GENTLY massage the nipples with a wet washcloth. The gentle action will help remove the accumulated layers of flakey skin. Afterwards, the mom can gently lubricate with purified lanolin or Aquaphor (an inert, mineral oil/lanolin/glycerin based lubricant dermatologists often use to help heal nipple skin fissures.) The woman should be reassured that she does not need to protect her breasts from reasonable exposure to mild soap and water during showering or bathing.
When presenting the information, the mom should never be told to scrub the nipple vigorously. Remember: The skin under the crust will be tender! Respectful counseling must be employed so that caregivers simply explain how this has happened and what to do about it. This is an issue of having received incomplete skin care information and it is not about poor hygiene. Health care providers must also distinguish between what is merely accumulation of crusted dry skin and other conditions (e.g. staph infections which create golden, crystallized crusts, etc).
Finally, while the aesthetics of the dry skin shedding into the milk are not pleasing, we doubt the milk becomes harmful to the infant. Surely it would not justify discarding the milk or withholding it from the infant. Exceptions would be large chunks of shed debris that might (rarely) present a choking hazard. It would not hurt to ask what kind of nipple cream the woman has previously used (in case there is any risk of toxic exposure). The greatest risk in our opinion is that sucking and pumping will expose friable nipple tissue that is vulnerable to cracking, causing pain for the mother.
