Kwartalnik | Zeszyt 2 | Tom 22 | Rok 2025
ISSN: 1733-4101
eISSN: 1733-7607
MNiSW: 20 IC: 86,65
breastfeeding
Ekspozycja na materiał potencjalnie zakaźny i profilaktyka poekspozycyjna
ISSN: 1733-4101 | e-ISSN: 1733-7607
Redakcja
Redaktor naczelny
Arkadiusz Jawień 0000-0001-8380-9371
Katedra i Klinika Chirurgii Naczyniowej i Angiologii, Szpital Uniwersytecki Nr 1 im. dr. A. Jurasza w Bydgoszczy, e-mail: ajawien@ceti.com.pl
Zastępcy redaktora naczelnego
Maria T. Szewczyk 0000-0002-0511-0685
Katedra Pielęgniarstwa Zabiegowego, Collegium Medicum UMK, Szpital Uniwersytecki nr 1 im. dr. A. Jurasza w Bydgoszczy
Beata Mrozikiewicz-Rakowska 0000-0002-1160-9204
Klinika Diabetologii i Chorób Wewnętrznych, Warszawski Uniwersytet Medyczny
Maciej Sopata
Katedra i Klinika Medycyny Paliatywnej, Hospicjum Stacjonarne Uniwersytetu Medycznego im. Karola Marcinkowskiego w Poznaniu Mariusz Kózka
Oddział Kliniczny Chirurgii Naczyniowej, Szpital Uniwersytecki w Krakowie
Sekretarz Redakcji
Katarzyna Cierzniakowska 0000-0002-4657-8321
Katedra Pielęgniarstwa Zabiegowego, Collegium Medicum UMK, Szpital Uniwersytecki nr 2 im. dr. J. Biziela w Bydgoszczy, e-mail: katarzyna.cierzniakowska@biziel.pl
Konsultant ds. statystyki
Andrzej Tukiendorf
Pracownia Biostatystyki Klinicznej, Zakład Radioterapii, Narodowy Instytut im. Marii Skłodowskiej-Curie w Gliwicach
Redaktorzy językowi
Timothy Alexander Monika Ślusarska
Rada Naukowa
Magdalena Annersten Gershater 0000-0003-4395-2522
Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
Dariusz Bazaliński 0000-0003-1717-1319
Instytut Nauk o Zdrowiu, Kolegium Nauk Medycznych, Uniwersytet Rzeszowski, Rzeszów, Polska
Piotr Ciostek 0000-0001-7461-0221
Katedra i Klinika Chirurgii Ogólnej i Naczyniowej, Warszawski Uniwersytet Medyczny, Polska
Gaye Filinte 0000-0003-2583-2922
Plastic, Reconstructive and Aesthetic Surgery Department, Faculty of International Medicine, University of Health Sciences, Istanbul, Turkey Kartal Dr Lütfi Kırdar City Hospital, Kartal Burn and Wound Centre, Istanbul, Turkey
Eugenia Gospodarek 0000-0003-0334-7520
Katedra Mikrobiologii, Collegium Medicum w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, Polska
Wydawnictwo Moc Media
ul. Mokra 2/51
03-562 Warszawa, Polska e-mail: biuro@mocmedia.eu
na prośbę Polskiego Towarzystwa Leczenia Ran | Polish Wound Management Association
Finn Gottrup
University of Southern Denmark, Copenhagen Wound Healing Centre, Bispebjerg University Hospital, Copenhagen, Denmark
Tomasz Grzela 0000-0001-8519-4868
Katedra i Zakład Histologii i Embriologii, Centrum Biostruktury, Warszawski Uniwersytet Medyczny, Polska
Tomasz Karpiński 0000-0001-6599-9204
Katedra i Zakład Mikrobiologii Lekarskiej, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu, Polska
Anna Korzon-Burakowska 0000-0002-5655-1798
Katedra Nadciśnienia Tętniczego i Diabetologii, Gdański Uniwersytet Medyczny, Polska
Maria Kózka 0000-0002-5165-6929
Instytut Pielęgniarstwa i Położnictwa, Uniwersytet Jagielloński Collegium Medicum w Krakowie, Polska
Christine J. Moffatt 0000-0002-2436-0129
Centre for Research and Implementation of Clinical Practice, London, United Kingdom Nottingham University Hospitals, NHS Trust, Nottingham, United Kingdom
Paulina Mościcka 0000-0002-0128-5533
Katedra Pielęgniarstwa Zabiegowego, Wydział Nauk o Zdrowiu, Collegium Medicum w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, Polska
Harikrishna K.R. Nair
Wound Care Unit, Department of Internal Medicine, Specialist Complex and Ambulatory Care Centre (SCACC), Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
Andrea Pokorná 0000-0002-1305-6455
Department of Nursing and Midwifery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
Angelo Scuderi
Sao Paulo, Brasil
Anna Sobieszek-Kundro 0000-0002-8938-5263
Oddział Dermatologiczny, Wojewódzki Szpital Zespolony w Elblągu, Polska
Anna Spannbauer 0000-0002-7745-5754
Klinika Chirurgii, Wydział Nauk o Zdrowiu, Instytut Fizjoterapii, Uniwersytet Jagielloński Collegium Medicum w Krakowie, Polska
Elżbieta Tomaszewska
Oddział Opieki Paliatywnej, Hospicjum Palium w Poznaniu, Polska
Hakan Uncu
Division of Vascular Surgery, Department of General Surgery, Ankara University School of Medicine, Ankara, Turkey
Tomasz Urbanek 0000-0002-5044-9186
Katedra i Klinika Chirurgii Ogólnej, Naczyń, Angiologii i Flebologii, Śląski Uniwersytet
Medyczny w Katowicach, Polska
Peter Vowden 0000-0002-7068-6859
Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Bradford, United Kingdom
Oficjalne czasopismo naukowe Polskiego Towarzystwa Leczenia Ran członka Europejskiego Towarzystwa Leczenia Ran www.pjwm.mocmedia.eu
Dostęp do artykułów publikowanych w czasopiśmie jest otwarty Wersja papierowa czasopisma jest wersją referencyjną
CEO Moc Media
Sylwia Chrabałowska
e-mail: s.chrabalowska@mocmedia.eu
Sekretarz Redakcji Moc Media
Monika Szymor
e-mail: m.szymor@mocmedia.eu
Dział Prenumerat Czasopism journals@mocmedia.eu
Dyrektor Biura Reklamy Crockett Media
Marta Orzełowska
e-mail: morzelowska@crockettmedia.pl
GUIDELINES
46 Treatment of nipple wounds during breastfeeding. Position of the Center for Lactation Science and the Polish Wound Management Association
Monika Żukowska-Rubik, Magdalena Nehring-Gugulska, Beata Mrozikiewicz-Rakowska, Monika Aleksy-Polipowska, Natalia Żółtowska, Roksana Kulińska, Debora Barbay
Annex 1. General principles of wound assessment
Annex 2. List of lavaseptics, antiseptics, and specialized dressings
ARTYKUŁ ORYGINALNY | ORIGINAL PAPER
80 Ekspozycja na materiał potencjalnie zakaźny i profilaktyka poekspozycyjna
Exposure to potentially infectious material and post-exposure prophylaxis
Katarzyna Cierzniakowska, Daria Kaniewska, Elżbieta Kozłowska, Aleksandra Popow
SPRAWOZDANIE | REPORT
88 Sprawozdanie z Warsztatów „Rozwój zaawansowanych kompetencji w leczeniu ran” realizowanych podczas II Międzynarodowej Konferencji Naukowo-Szkoleniowej
Beata Wieczorek-Wójcik, Paulina Mościcka, Katarzyna Kowalska, Katarzyna Cierzniakowska
Od Redakcji
tegoroczny drugi numer „Leczenia Ran” ma dla mnie szczególne znaczenie.
Po pierwsze, na dorocznym zjeździe EWMA w Barcelonie, w którym uczestniczyło ponad 5ooo osób, dr hab. n. med. Justyna Cwajda-Białasik z Bydgoszczy, po pięknej prezentacji zatytułowaniej Results of a pilot study of diabetes-related foot disease (DFD) screening in an AT-risk group, otrzymała nagrodę za najlepszy abstrakt roku (Best Abstract of the Year Prize). Praca ta powstała przy współudziale dr hab. n. med. Pauliny Mościckiej i pod kierownictwem prof. Marii Szewczyk w Katedrze Pielęgniarstwa Zabiegowego Collegium Medicum im. L. Rydygiera UMK i Poradni Leczenia Ran Przewlekłych Szpitala Uniwersyteckiego nr 1 w Bydgoszczy. To ogromne wyróżnienie i ukoronowanie wieloletniej pracy naukowej całego zespołu prof. Marii Szewczyk, która w 2000 r. rozpoczęła piękną przygodę z leczeniem ran przewlekłych, tworząc bardzo dobry ośrodek i wychowując kolejne pokolenie osób zainteresowanych tą dziedziną medycyny. Niedawno zatwierdzone dwa tytuły doktora habilitowanego dla dr Pauliny Mościckiej i dr Justyny Cwajda-Białasik są nie tylko potwierdzeniem właściwego procesu kształcenia i prowadzenia badań naukowych, lecz także znakomitym przykładem dla innych szybko rozwijających się ośrodków leczenia ran w Polsce, w jaki sposób łączyć i rozwijać te wszystkie elementy dla dobra chorego z raną przewleką.
Serdeczne gratulacje! Po drugie, numer ten jest ostatnim dla mnie w roli redaktora naczelnego. Podjąłem decyzję o zakończeniu współpracy z czasopismem „Leczenie Ran”. Chciałbym tym ciekawym, drugim tegorocznym, numerem podziękować wszystkim Państwu za miłą współpracę przez ostatnich blisko 18 lat. Stanowisko redaktora naczelnego przez te wszystkie lata było dla mnie ogromnym wyzwaniem polegającym nie tylko na kompletowaniu poszczególnych numerów, zapraszaniu do współpracy i pisania ciekawych artykułów,
ale i do odpowiednich relacji z wydawcami, których w czasie mojej kadencji aż czterokrotnie musieliśmy zmieniać.
Chciałbym serdecznie podziękować wszystkim członkom Rady Naukowej „Leczenia Ran” za wsparcie i pomoc w pozyskiwaniu prac oraz redagowaniu naszego czasopisma. Szczególne podziękowania kieruję do dr n. med. Katarzyny Cierzniakowskiej, sekretarz Redakcji, która nie tylko wykazywała się ogromną cierpliwością i wytrwałością w poprawianiu prac przychodzących do druku, ale i w kontaktowaniu się z autorami prac i mobilizowaniu recenzentów do dotrzymywania terminów ich recenzji.
Osobne podziękowania składam wydawnictwu
Moc Media i osobiście red. Sylwii Chrabałowskiej, której pomysł umiędzynarodowienia czasopisma zyskał moją aprobatę i okazał się przysłowiowym „strzałem w dziesiątkę”. Udało się nam pozyskać autorów z innych krajów i spowodować, że język angielski publikacji zagościł na łamach „Leczenia Ran” już na stałe, co pozwoliło na większą rozpoznawalność czasopisma na świecie.
Kończąc swoją, jakże ciekawą i zarazem wymagającą wiele wysiłku kadencję, chciałbym następnemu redaktorowi naczelnemu „Leczenia Ran” życzyć, aby zapoczątkowane zmiany udało się kontynuować, w tym działania o wprowadzenie czasopisma do nowych baz indeksacyjnych.
Wszystkim czytelnikom dziękuję za zainteresowanie naszym czasopismem i życzę, aby zawsze przekazywało ono najlepszą i najbardziej aktualną wiedzę o leczeniu ran w naszym kraju i na świecie.
To była wielka przyjemność służyć Państwu.
W imieniu Komitetu Redakcyjnego i Rady Naukowej „Leczenia Ran | Polish Journal of Wound Management” prof. Arkadiusz Jawień redaktor naczelny
From the Editor
This year’s second “Leczenie Ran” issue is significant to me.
Firstly, at the annual EWMA conference in Barcelona, attended by over 5,000 people, Dr. Justyna Cwajda-Białasik from Bydgoszcz, after a beautiful presentation entitled Results of a pilot study of diabetes-related foot disease (DFD) screening in an AT-risk group, received the Justyna Cwajda-Białasik from Bydgoszcz, after a beautiful presentation entitled Results of a pilot study of diabetes-related foot disease (DFD) screening in an AT-risk group, received the award for the best abstract of the year (Best Abstract of the Year Prize). This work was done in collaboration with Dr Paulina Mościcka, MD, PhD, and under the supervision of Prof. Maria Szewczyk at the Department of Surgical Nursing of the L. Rydygier Collegium Medicum of the Nicolaus Copernicus University and the Chronic Wound Treatment Clinic of University Hospital No. 1 in Bydgoszcz. This is a huge distinction and the crowning achievement of many years of scientific work by the entire team of Prof. Maria Szewczyk, who began her excellent adventure with chronic wound treatment in 2000, creating an outstanding centre and educating the next generation of people interested in this field of medicine. The recently approved two habilitation degrees for Dr Paulina Mościcka and Dr Justyna Cwajda-Białasik are not only a confirmation of the proper process of education and scientific research but also an excellent example for other rapidly developing wound treatment centres in Poland of how to combine and create all these elements for the benefit of patients with chronic wounds.
Congratulations!
Secondly, this issue is my last as Editor-in-Chief. I have decided to end my collaboration with the journal “Leczenie Ran” | “Polish Journal of Wound Management”.
I would like to use this interesting second issue of the year to thank you all for your kind cooperation
over the past nearly 18 years. The position of editor-in-chief has been a massive challenge for me over the years, involving putting together individual issues, inviting contributors, writing interesting articles, and maintaining good relations with publishers, which we had to change four times during my tenure.
I would like to sincerely thank all members of the Scientific Council of “Leczenie Ran” | “Polish Journal of Wound Management” for their support and assistance in obtaining articles and editing our journal. Special thanks are due to Dr. Katarzyna Cierzniakowska, MD, Editorial Secretary, who demonstrated great patience and perseverance in proofreading the submitted articles for publication, contacting the authors, and motivating the reviewers to meet their deadlines.
I would also like to thank the publishing house Moc Media and personal editor Sylwia Chrabałowska, whose idea of internationalizing the journal won my approval and proved a proverbial “bull’s eye”. We have attracted authors from other countries and made English a permanent feature of “Leczenie Ran” | “Polish Journal of Wound Management”, dramatically increasing the journal’s international recognition.
As I conclude my interesting and demanding term of office, I wish the next Editor-in-Chief of Leczenie Ran every success in continuing the changes that have been initiated, including efforts to introduce the journal to new indexing databases.
I would like to thank all readers for their interest in our journal and hope it will always provide the best and most up-to-date knowledge on wound treatment in our country and worldwide.
It has been a great pleasure to serve you.
On behalf of the Editorial Committee and Scientific Council of the “Leczenie Ran | Polish Journal of Wound Management” Prof. Arkadiusz Jawień Editor-in-Chief
GRUDZIEŃ
18.01.2025 | Łódź
Warsztaty PTLR
Cukrzycowe
owrzodzenia stópprofilaktyka i leczenie
8.03.2025 | Bydgoszcz
Warsztaty PTLR
Rany w praktyce dermatologicznej
12.04.2025 | Kraków
Warsztaty PTLR
Rany w ginekologii, położnictwie i neonatologii
5-7.06.2025 | Łochów k. Warszawy Kongres
Naukowo-Szkoleniowy Polskiego Towarzystwa Leczenia Ran
13.09.2025 | Poznań
Warsztaty PTLR
Leczenie ran w opiece paliatywnej i opiece długoterminowej
25.10.2025 | Katowice
Warsztaty PTLR Owrzodzenia goleni
15.11.2025 | Gdynia
Warsztaty PTLR Rany w POZ
6.12.2025 | Warszawa
Międzywojewódzka Konferencja Polskiego Towarzystwa Leczenia Ran
oczyszczanie nawilżanie dezynfekcja ran hipoalergiczny od 1. dnia życia
Guidelines
LECZENIE RAN 2025; 22 (2): 46–79
DOI: 10.60075/lr.v22i2.103
Monika Żukowska-Rubik1,2, Magdalena Nehring-Gugulska1,3, Beata Mrozikiewicz-Rakowska4, Monika Aleksy-Polipowska5,6, Natalia Żółtowska7, Roksana Kulińska8, Debora Barbay1,9
1 Center for Lactation Science, Poland
2 Lactation Clinic, Żelazna Medical Center, Poland
3 Lactation Disorders Clinic, Medical University of Warsaw Medical Center, Poland
4 Endocrinology Clinic, Postgraduate Medical Education Center, Warsaw, Poland
5 Medical Entity of the Order of Camillians, Palliative Medicine Department, St. Camillus Hospital, Tarnowskie Góry, Poland
Abstract
Nipple soreness and wounds are a common problem during lactation, especially in the first weeks after birth. These issues are associated with an increased risk of mastitis, poor weight gain in the newborn, formula supplementation, and premature cessation of breastfeeding. Prevention and early diagnosis are fundamental tasks for medical staff caring for both the mother and infant. The most common cause is the baby latching onto the breast too shallowly.
Therefore, improving the feeding technique is essential to prevent and treat nipple damage. With appropriate care, healing occurs quickly. However, in cases of hard-to-heal or infected nipple wounds, diagnostic and therapeutic measures should be taken immediately.
The position paper from the Center for Lactation Science (CLS) and the Polish Wound Management Association (PWMA) outlines practical guidelines for treating nipple wounds during lactation, considering their specific differences compared to wounds of other etiologies and in different locations. This study discusses issues related to wound
6 The Rotmistrz Witold Pilecki Małopolska State University, Institute of Health Sciences, Oswiecim, Poland
7 “Lekarz Rodziny” NZOZ, Aneta Wojno, Mariusz Wojno s.c., Sanniki, Poland
8 “Saska Skin” Healthy Skin Center, Poland
9 Department of Neonatal and Infant Pathology, Prof. J. Bogdanowicz Children’s Hospital, Independent Public Healthcare Institution, Poland
Correspondence address Monika Żukowska-Rubik, FTK/Centrum Nauki o Laktacji
9 Bobrowiecka St., 00-728 Warsaw, Poland, e-mail: mzr@kobiety.med.pl
Received: 15.05.2025; Accepted: 24.05.2025
infection development, the TIMERS strategy, and detailed guidelines for lactation care, essential for optimal healing.
The study proposes a classification of wounds into four categories: uninfected, at risk of infection, infected, and spreading infection from the wound to surrounding tissues. Each wound category includes appropriate therapeutic agents such as lavaseptics, antiseptics, and specialized dressings. The document also addresses indications for antibiotic therapy, the technique for taking a swab from the wound, and the most common errors in treating nipple wounds.
The described principles of treating nipple wounds are based on global and Polish consensuses in wound treatment and the many years of unique experience of Polish lactation consultants.
Key words: breastfeeding, sore nipples, nipple pain, nipple wound, nipple injury, damaged nipples, wound infection, antiseptics.
This document is intended exclusively for healthcare professionals, particularly physicians, midwives, and nurses who care for women and their infants during lactation. It will be particularly useful for lactation specialists.
Nipple soreness and wounds are common issues among breastfeeding mothers. Studies from various countries show that 62–95% of women report such symptoms shortly after childbirth [1]. Pain occurs most frequently during the first week postpartum, with most women experiencing a reduction to mild discomfort within 7–10 days [2]. More than half of mothers with nipple pain also have visible nipple wounds or other skin changes [3]. Based on the number of births in 2024 (252,000) and the fact that 97% of women in Poland start breastfeeding [4], with 30% of them having nipple wounds, it can be estimated that over 73,000 breastfeeding mothers struggled with nipple wound problems.
In the study by Coca et al. [5], women with damaged nipples rated their pain intensity at an average of 6.2 points during the first week and 5.8 points later on, while women without visible damage rated it at an average of 2.7 points (on a numerical pain rating scale NRS or another scale ranging from 0 to 10 points, where mild pain is scored 1–3, moderate 4–6, and severe 7–10 points).
Nipple pain is one of the main reasons for formula feeding and premature breastfeeding cessation. In the USA, among mothers who stopped breastfeeding within the first month, one third cited nipple pain or wounds as the reason [3]. Nipple wounds are also a risk factor for mastitis [6]. The discomfort mothers experience multiple times a day when breastfeeding affects feeding quality, activity, mood, sleep, and increases the risk of depression. Disrupting the oxytocin reflex can reduce milk intake by the newborn [7].
Due to all the serious consequences of these issues, prevention is needed through educating mothers after childbirth about breastfeeding techniques, early detection of injuries, and implementing proper treatment. This responsibility lies with all healthcare professionals involved in maternal and child care, including midwives, nurses, doctors, and lactation consultants.
Distinctive features of nipple wounds compared to commonly occurring hard-to-heal wounds
A wound is a break in the continuity of the skin or the skin and the tissues beneath it. A wound of the nipple or areola usually occurs as a result of mechanical injury (pinching, pulling, rubbing, suction) caused by improper sucking technique or incorrect use of a breast pump.
Bite wounds occur as a result of being bitten by a teething infant.
Nipple wounds have several distinctive features compared to wounds of different etiology and locations. They occur in young, generally healthy women, in a well-vascularized and innervated area. Despite their usually small size of a few to several millimeters, they cause significant pain, and their healing is hindered by regular breastfeeding or expressing milk from the injured breast. Dressings must be removed every few hours before feeding, and medicinal agents must be wiped off the skin surface to ensure breastfeeding is safe for the baby. Sticky substances that are hard to wash off are not recommended.
The environment of a nipple wound is unique because it is shaped by the microbiome of the nipple skin, the milk ducts, the properties of breast milk, as well as the infant’s oral microbiome and contact with saliva. A relationship has also been discovered between the mother’s gut microbiota and her milk (the gut-breast pathway) [8].
The flora of the nipple skin is primarily composed of bacteria (commensal, symbiotic, probiotic), to a lesser extent fungi and viruses, and is integrated with the host’s immune defense. Interestingly, this flora differs from the flora of the milk and the infant’s stool. Dominant bacteria include Staphylococcus and Streptococcus species, as well as Enterobacteriaceae, Corynebacterium, Propionibacterium, Bacteroides, and others [9].
Any damage to the epidermis or dermis of the nipple (including micro-injuries) causes unfavorable changes in the microbiota composition, weakening the skin barrier and creating conditions for colonization by microorganisms of varying severity.
On the nipple, as the opening of a skin gland, commensal bacteria are present at higher concentrations than in other areas of the breast skin, so wound colonization occurs quickly. The mother’s milk and its microbiome are important protective factors [3, 10]. Breast milk contains a variety of components with anti-inflammatory, immunomodulatory, antimicrobial, and healing-supportive properties, such as interleukins, lactoferrin, lactadhesin, lysozyme, SIgA (secretory IgA), antioxidants, growth factors, interferon, vitamin A, omega-3 and omega-6 fatty acids, mucin, and many others [11, 12].
Since the nipple is continuously exposed to milk with strong bacteriostatic properties, bacterial proliferation is more difficult in that area. It has been hypothesized that histatins (small molecular weight peptides secreted into the saliva of mammals) present
Monika Żukowska-Rubik, Magdalena Nehring-Gugulska, Beata Mrozikiewcz-Rakowska et al.
in the infant’s saliva may support epidermal regeneration by stimulating migration of epidermal cells, fibroblasts, angiogenesis, and additionally destroying bacteria [13].
It is worth adding that breastfeeding from an injured breast, even if the wound is infected, does not pose a risk to the breastfed infant.
The most common cause of nipple pain and damage is shallow latch, improper sucking, or clenching of the breast with the gums, usually caused by incorrect positioning of the mother or newborn during feeding or improper latching technique [14, 15]. Nipple damage often occurs during breast engorgement due to difficulties in latching caused by swelling of the areola [14]. Some infants generate excessively high suction pressure, both baseline and peak, and mothers of these infants more frequently experience nipple pain [16]. A shortened tongue frenulum is rarely the cause of nipple pain, contrary to the current trend of diagnosing ankyloglossia. The problem of a shortened frenulum affects only about 7% of infants [17], while feeding problems affect nearly 50% of these children [18]. In her study, Geddes examined infants with ankyloglossia who produced either insufficient or excessive suction pressure or overly compressed the nipple; however, milk intake remained adequate, and the mothers did not report pain. The causes of nipple damage are summarized in Table 1 [19].
Nipple damage is usually located at the nipple tip, but sometimes fissures and cracks may appear on the nipple shaft, its base, or the areola. They vary in depth and extent, ranging from epidermal lesions to deeper skin damage. Table 2 presents the types of skin lesions observed in relation to nipple damage [20–22]. The appearance usually differs for each mother, yet Woolridge et al. [23] identified some similarities and proposed a classification of nipple injuries based on their causative mechanisms:
• compression damage – flattening of the nipple visible after removing the breast from the infant’s mouth, longitudinal wounds at the nipple tip, fissures, crust referred to as positional streaks caused by incorrect positioning of the nipple-areola complex in the infant’s mouth (Figs. 1, 2);
• suction injury – damage to the nipple tip characterized by redness, blisters, petechiae, and star-shaped cracks on the nipple tip, caused by generating high suction pressure in the infant’s oral cavity (more often observed in mothers with low milk supply, impaired milk flow, or flat or inverted nipples).
Maternal causes Infant causes
Improper breastfeeding position, incorrect latching
Tense/engorged areola during milk oversupply or breast engorgement
Flat, inverted nipples, or other difficult-to-latch variants
Improper detachment of the baby from the breast
Inappropriate breast pump (lack of medical device certification) or improper use (excessive suction force, prolonged sessions, improperly sized flange)
Shallow latch during sucking
Anatomical abnormalities of the oral cavity (short lingual frenulum, high-arched palate, significantly retracted jaw)
Functional sucking disorders (abnormal oral reflex responses – excessive suction, biting, hyperactive gag reflex), compensatory behaviors
Abnormal muscle tone, asymmetry, torticollis
Restlessness, looking around, distraction – common in older infants
Biting the breast by a teething infant
Due to the need to protect mothers and infants from complications such as mastitis [6] or premature cessation of breastfeeding, effective treatment of nipple pain and wounds has become a subject of interest for clinicians and researchers. In previously published studies, the effectiveness of various methods has been assessed. Nipple pain and damage are generally considered together under the term “sore nipples”; however, the severity of the problem differs significantly, and many authors advocate for more precise definitions when examining study groups [5].
During breastfeeding, the nipple is positioned deeply in the infant’s mouth, with the nipple tip reaching almost to the hard and soft palate junction (HSPJ), approximately 6 mm from the HSPJ. This positioning prevents excessive compression and pressing against the bony part of the palate while stimulating the sucking reflex through the nerve endings located in this area. The nipple tip, along with the final segment of the hard palate and the back of the tongue, participates in creating the suction pressure necessary for milk extraction [24].
A recently published systematic review found that biological breastfeeding (with the mother’s body reclined, the baby positioned on her abdomen, and initiating breast latch independently) compared to traditional positions (cross-cradle, cradle, football, side-lying) reduced the risk of nipple pain and injuries. However, the study was criticized for the poor quality of the included research [25]. Bashiri did not observe any difference between the biological and cross-cradle positions regarding the frequency of nipple injuries [25]. Another study reported a higher risk of injuries when the infant’s face was incorrectly positioned at the breast (lack of contact of the nose,
chin, and both cheeks) and in cross-cradle and football positions compared to the cradle and lying positions [15]. The authors hypothesize that holding the infant by the anatomical structures of the head and neck restricts the freedom of cervical spine movements and the stabilizing function of the nuchal ligament, making it difficult for the baby to touch, smell, and taste to locate the nipple. It is also possible that this
Abrasion A minor wound caused by the rubbing off of the epidermis (see Fig. 12A)
Erosion Loss of the epidermis not exceeding the basement membrane, heals without scarring (see Fig. 13A)
Fissure, crack A linear split of the epidermis (fissure) or epidermis and dermis (crack), heals with scarring (see Figs. 12B, 14A)
Ulceration Loss of skin extending beyond the basement membrane, heals with scarring (see Fig. 14B)
Crust Forms as a result of drying of exudate, pus, or blood on the surface of vesicles and blisters, erosions, ulcers, or wounds (Fig. 3)
Scar A skin change usually resulting from damage to the dermis and replacement of the defect with fibrous connective tissue (Fig. 4)
Additionally, when describing skin lesions, it is essential to address the presence of exudate – its nature (serous, purulent) and the origin of the lesion, e.g., an erosion oozing serous fluid
Żukowska-Rubik, Magdalena Nehring-Gugulska, Beata Mrozikiewcz-Rakowska et al.
causes too shallow a breast latch, jaw dysfunction, and friction of the nipple against the hard palate. A recently presented concept of conflicting vectors – the child’s oral cavity and the breast axis – is associated with improper breastfeeding technique. According to the concept, unevenly distributed forces on the nipple surface cause stretching and pulling of the skin, leading to cytokine and histamine release, microvascular injuries, and consequently triggering an inflammatory response with interstitial swelling, nerve ending irritation, and pain. Repeated trauma results in damage (Figs. 5, 6) [3].
Education for mothers, technique guidance vs. different healing aids
The systematic review by Dennis (2014) [2] included four studies of good methodological quality involving 656 women, examining the effectiveness of nipple pain relief using expressed breast milk, a triple-component nipple ointment (mupirocin, miconazole, betamethasone), lanolin, protective shells, and hydrogel dressings. All mothers in the studies covered by the meta-analysis received guidance on how to position the baby as part of routine care. The results suggest that the absence of intervention or the use of expressed breast milk alone may be just as or more beneficial for short-term nipple pain relief compared to other methods. One of the key findings of this review is that, regardless of the treatment applied, nipple pain decreased to a mild level in most women approximately 7 to 10 days after childbirth, and mothers should be informed about this. In another large review, Niazi et al. [26] evaluated numerous interventions for nipple injuries. The primary measure taken for patients was also correcting the breastfeeding position.
Topical pharmacological agents for reducing pain, alongside other methods
Lanolin
A very popular remedy recommended to mothers is purified, hypoallergenic lanolin, cleansed of alcohols and pesticide residues. It is believed that the preparation creates a bacteriostatic barrier, maintains a moist environment, and accelerates healing. However, in the randomized study by Jackson and Dennis [1], lanolin showed no significant effectiveness in relieving nipple pain with visible nipple trauma in the early postpartum period, nor did it affect the duration of breastfeeding compared to routine care offered to mothers in the hospital after delivery. Mothers
using lanolin, however, reported greater satisfaction with the treatment. In another study, Vieira et al. [27] found that applying breast milk and protective shells to the nipples was more effective than lanolin in relieving pain. The use of lanolin on wounds raises concerns due to the risk of contact allergy. Lanolin preparations intended for nipple application are purified to remove alcohols, which reduces the risk of irritation; nevertheless, they should not be used on damaged skin or by patients with atopic dermatitis (AD) [28]. Most popular ointments and creams for nipple care during lactation have not been tested for effectiveness in relieving pain.
Various methods used in the treatment of nipple pain and damage
Among the studies included in the systematic review by Niazi et al. in 2018 [26], two examined the effect of mint on nipple cracking and pain; both had acceptable design and validation, and both demonstrated the effectiveness of menthol in the form of a gel or oil. The RCT by Lavergne [29] confirmed the effectiveness of using warm water or tea tree oil compresses in relieving nipple pain associated with irritation and damage early after birth (compresses were applied 4 times a day for 15 minutes over 5 days). Due to the small sample sizes in the studies mentioned above, strong recommendations regarding their use could not be made.
The use of low-level laser therapy had a significant effect on relieving nipple pain, but its high cost limits widespread adoption of this treatment. It is worth adding that besides the methods listed earlier, other treatments for nipple wounds have been tested, which often have a regional specificity. For example, there are reports on the use of extra virgin olive oil, turmeric extract, common yarrow, honey, aloe vera, a mixture of sesame, macadamia, and apricot oils, cream made from common purslane, and even phototherapy using wavelengths in the 360–1,000 nm range. It is difficult to draw definitive conclusions from these studies regarding the most effective treatment, and the results are sometimes contradictory.
Mechanical methods to prevent and treat nipple pain and damage
Protective shells
Sometimes it is beneficial to wear protective shells after feedings, which protect the nipples from contact with breast pads or clothing. The bra should be slightly looser in this case so that the shell does not
compress the breast. However, it should be remembered that the environment inside the shell is moist, and continuous use leads to skin maceration (due to prolonged moisture exposure, the skin softens and peels off). Research results regarding the effectiveness of shells are inconclusive (Fig. 7).
Protective covers (nipple shields)
A nipple shield, a protective cover worn during feeding, reduces pain for some mothers. If pain cannot be reduced by improving feeding technique or decreasing areola tension, a nipple shield can be used for a limited time, especially in cases of strong suction (high negative pressure in the newborn’s mouth) despite a deep latch [16, 30]. Use of a nipple shield may also be considered in anatomical or functional sucking disorders that do not improve immediately and where nipple wound healing progress is slow.
The impact of nipple shields on milk intake has been evaluated, but study results are inconclusive, so feeding progress and sucking efficiency must be closely monitored during shield use [29].
Moreover, it has been shown that if nipple shields are used by mothers without breastfeeding problems, it may negatively affect milk intake and nutritive sucking time; thus, nipple shields should only be recommended after careful consideration of indications [30]. The use of nipple shields has been associated with shorter breastfeeding duration, but not when supervised by lactation consultants [32, 33].
Nipple shields should be washed with detergent after each use and thermally disinfected once daily by immersion for 5–10 minutes in water at 90–100°C or in a special microwave sterilization bag. It is important to remember that lack of hygiene of the nipple shield and other equipment contacting the nipple skin increases the risk of wound infection (Fig. 8).
In the case of hard-to-heal or infected nipple wounds, improving breastfeeding technique, applying breast milk, or other methods described above will not be sufficient. Meanwhile, it is difficult to find reports on treating such wounds based on modern principles adopted in numerous consensus guidelines for wound treatment in surgery or dermatology, which discuss the use of classic lavaseptic solutions, surfactant-containing lavaseptic solutions, antiseptics, or specialized dressings [34–37]. Expert guidelines indeed concern a different type of wounds than nipple wounds, namely hard-to-heal wounds and ulcers associated with diabetic foot disease, leg ulcers, and pressure sores in typically elderly patients with multiple chronic health conditions. However, the action of lavaseptics and antiseptics is universal. These agents have been used in Poland for over a decade by lactation consultants to treat nipple wounds, showing good results in clinical observations, and the Center for Lactation Science includes them in their training protocols.
Until recently, the term chronic wounds was used to describe wounds that do not progress through the healing phases in an orderly and timely manner, with the healing process exceeding 6–8 weeks (ranging from 4 weeks to 3 months in various studies) [37]. Currently, a new definition according to Murphy is accepted, where instead of the term chronic wound, the term hard-to-heal wound is used. Any wound can be classified in this group, regardless of type or etiology. These are wounds in which factors that may impair healing exist and that do not respond to standard treatment. It has been documented that
almost all contain biofilm (Fig. 9). The key moment for classifying a wound as hard-to-heal is the third day, when the wound shows increased exudate, fibrin at the wound base, and an increase in size despite ongoing treatment [39].
BIOFILM is a complex multispecies ecosystem of microorganisms enclosed in an extracellular polymeric substance – a matrix. It causes subclinical local wound infection. Within the biofilm, bacteria create a metabolically and immunologically different environment, making them resistant to antibiotics and antiseptics. Biofilm can regenerate within several hours, reaching maturity after 48–72 hours. Signs of biofilm formation include a large amount of dead tissue in the wound, shininess (glossiness), fibrinous coating, increased exudate, and unpleasant odor [35]. Counteracting biofilm proliferation involves mechanically removing the polymer matrix structure and preventing the regeneration of its mature form (Fig. 9).
In clinical observations, small nipple wounds typical in the first days after childbirth heal quickly within a few days after improving breastfeeding technique. This is supported by the bacteriostatic properties of breast milk, especially rich in bioactive factors in the first days postpartum. In a small study conducted by Nehring-Gugulska et al. in 2018 [38], the average healing time was 4.15 days, and pain
Source: Żukowska-Rubik M., Nehring-Gugulska M. Pathology of breast and nipple during lactation. In: Żukowska-Rubik M., Godyń-Myśliwy Z., Nehring-Gugulska M. The Atlas of physiology and pathology of lactation. 1st Edition. Medycyna Praktyczna, Krakow 2025, with consent.
resolution occurred after an average of 5.86 days. However, in clinical practice, lactation consultants often encounter nipple wounds that are hard to heal. This usually concerns extensive, deep wounds that are more prone to infection. Healing of such wounds typically takes 2–3 weeks, but sometimes even several months. It is important to remember that factors causing nipple damage can also impair its healing, such as sucking dysfunction.
In nipple wounds, infection can develop through contact with microorganisms residing on the skin, transferred via the mother’s hands, medical staff, or present in the infant’s oral cavity. The most common pathogens are staphylococci, mainly methicillin-sensitive, rarely methicillin-resistant, enterococci, Escherichia coli, and other Gram-negative rods, streptococci [40].
Infection can spread to adjacent tissues, including breast skin, subcutaneous tissue, and the mammary gland, so it must be quickly diagnosed and treated. Infection is preceded by earlier phases of bacteria-host interaction, namely contamination and colonization (Table 3) [41–44].
Symptoms of nipple wound infection: significant increase in pain, nipple redness, swelling, warmth, swelling of wound edges, exudate – often purulent, presence of necrotic tissue [41], no healing progress despite proper breastfeeding technique and infant sucking function.
The TIMERS strategy is used to describe wound management methods. Each letter in the acronym represents a component. Below are the individual components of the TIMERS strategy with comments regarding nipple wounds.
Lavaseptics are preparations used for washing the wound and remove physical, chemical and biological contaminants. Regular wound cleaning is essential for maintaining proper, uncomplicated healing. Classic lavaseptics include Ringer’s solution and 0.9% NaCl. According to recent studies, 0.9% NaCl may increase the proliferation of mesothelial cells, disrupt the fibrinolysis system, and decrease interleukin-6 activity, thus adversely affecting tissue regeneration; therefore, other methods should be chosen. For this reason, regular use of 0.9% NaCl in the described procedures is increasingly being abandoned.
An ideal lavaseptic should contain a surfactant, which is a surface-active agent that, among other things, reduces surface tension and disrupts the biofilm. Examples of such substances include betaine, ethylhexylglycerin, and poloxamer. Lavaseptics can also contain antiseptic substances, such as octenidine dihydrochloride, at lower concentrations than those found in antiseptics. Hypochlorites (sodium hypochlorite and hypochlorous acid) are also used in lavaseptics, although they do not contain surfactants. The preparations can take the form of
Contamination
Colonization
Local latent infection (critical colonization)
Local overt infection
Spreading infection
Spread of infection to surrounding tissues with a systemic response
Microorganisms present in wound; pathogen proliferation (–); host immune response (–); healing delay (–)
Microorganisms present in wound; pathogen proliferation (+); host immune response (–); healing delay (–)
Pathogen proliferation (+++); host immune response (–); healing delay (+)
Pathogen proliferation (+++); host immune response (+); healing delay (+)
Further pathogen proliferation, as above
Deterioration of general condition, fever, leukocytosis, increased C-reactive protein and procalcitonin levels
No nipple swelling or redness, no swelling of wound edges, no exudate; healing occurs in typical time
As above
Bleeding, increasing exudate No healing progress
Increased pain, swelling, nipple redness, swelling of wound edges, warmth around wound, exudate with unpleasant odor, no healing progress
Expanding redness and swelling around wound > 2 cm
Pain, swelling, erythema, warmth of the breast or its part
Differential diagnosis: skin and subcutaneous tissue infection – erysipelas, subcutaneous tissue infection – cellulitis [43], infection of breast gland structures [44]
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a washing liquid or gel. These substances should have a broad spectrum of activity, effectively penetrate biofilm structures, and should not induce bacterial resistance.
Nipple wounds – commentary: Nipple wounds can be mechanically cleaned with a stream of lavaseptic (spraying, rinsing), by wiping with a sterile gauze pad soaked in lavaseptic, or by using a dressing specifically designed for wound cleaning (a product made of monofilament fibers). If the wound contains fibrin, dried exudate, biofilm, or crust, it is beneficial to use a gauze soaked in lavaseptic or lavaseptic gel (applied for the duration recommended by the manufacturer) to moisten, soften the coating, and then gently clean with gauze. It is important to remember that all procedures should be performed gently because of the nipple’s extensive sensory innervation.
Gao et al. described a surgical method for cleansing chronic lesions, keratotic buildups, and necrotic changes from the surface of the nipple in breastfeeding women. This method was applied when there was no improvement after two weeks of other treatments. After skin cleaning, about half of the patients experienced wound healing and pain resolution within a week, significantly more often than in the control group [45]. There are no reports on other methods of nipple wound cleaning, such as enzymatic or negative pressure therapy.
I – infection and inflammation control
To control infection and inflammation, antiseptics and dressings containing antibacterial substances are used. Sometimes, systemic antibiotic administration is necessary. Antiseptics should be used as long as there are clinical signs of local infection and discontinued when the symptoms subside, and the wound begins to heal. Antiseptics are substances with antiseptic properties; some are registered as medicines, while others as medical devices. Antiseptics exhibit bactericidal activity.
Nipple wounds – commentary: the choice of preparations depends on the wound category, as discussed below.
A gel containing an antiseptic substance, which can remain on the wound until the next feeding, can act as a dressing. The gel is applied in a thin layer, and it is advisable to use a secondary dressing, such as sterile gauze.
Lavaseptics and antiseptics are discussed in detail in Annex 2.
M – maintaining moisture balance in the wound Specialist dressings have various properties, including providing a moist environment that promotes the proliferation and migration of epidermal cells [46]; some dressings have exudate-absorbing qualities and aim to reduce the risk of maceration of the skin around the wound; others contain antibacterial substances.
Depending on their structure, they can be divided into mesh, hydrogel, hydrocolloid, hydrofiber, foam, contact layer, and hydrogels with antibacterial substances.
Nipple wounds – commentary: A moist wound healing environment for nipple wounds, besides the mentioned benefits, reduces pain during breastfeeding by maintaining nipple skin elasticity and moisture. It also prevents crust formation, which, when disrupted during the next feeding, causes additional pain and damages the healing surface. It may be beneficial when the mother reports severe pain or the wound tends to dry out, sticking to the lactation pad or underwear. Annex 2 discusses dressings registered by manufacturers for use on nipples during lactation (Annex 2, Table I) and other types of specialist dressings that may be used for nipple wound treatment after considering the benefits and risks (Annex 2). Hydrocolloid and hydrofiber dressings adhere strongly to the wound and are unsuitable for nipple wounds.
E – protection of the wound edges and epidermization stimulation
To protect the skin from maceration, contact allergy, or irritation, it is recommended to use gentle cleansing agents with a slightly acidic pH, hypoallergenic moisturizing substances, petroleum jelly on the skin around the wound, active dressings, paraffin, epidermization-stimulating substances, and anti-inflammatory agents.
Nipple wounds – commentary: Nipple wounds are small enough that applying different substances to the wound and its edges is not feasible.
R – regeneration – supporting regenerative and repair processes
Nipple wounds – commentary: unless absolutely necessary, additional preparations from this group are not used. Due to good vascularization of the nipple, once appropriate conditions for wound healing are created through cleaning, maintaining a moist environment, and controlling infection, the wound begins to heal. An additional preparation is
an extra expense and requires washing off, which is inconvenient.
S – consideration of social factors related to the patient and their family
Many types of specialized dressings are available for both non-infected and infected wounds, including various dressings designed specifically for application on nipple wounds. Among antibacterial dressings, silver ion-containing dressings are frequently used in treating difficult-to-heal wounds. However, there are no conclusive studies on their effectiveness when applied to nipples in breastfeeding mothers and their safety for infants. One study investigated silver nipple shields that significantly reduced pain and accelerated healing on days 7 and 15 after application compared to standard nipple wound care (proper feeding technique, hygiene, milk application) [47]. Hale describes the use of silver-containing products applied locally, but not on nipples during lactation [48]. In vitro studies showed that silver nanoparticles have low absorption through intact skin (0.46 ng/cm²) and damaged skin (2.32 ng/cm²). It is unknown whether silver particles are absorbed through mucous membranes when an infant suckles a breast treated with such a product or how effective nipple cleaning before feeding would be. Animal studies indicate that colloidal silver may pass into breast milk. Although silver ions in sulfadiazine cream do not absorb through the skin, the exposure level of an infant suckling a treated breast is unknown. Silver sulfadiazine preparations are not recommended by PTLR for wound treatment.
There is no clear data regarding the topical use of silver or colloidal silver products in breastfeeding women. On the other hand, silver bioavailability via oral intake is below 10%, and silver toxicity occurs only with significant, prolonged exposure exceeding the liver’s ability to eliminate it. Cases of argyria have been reported after the ingestion of several grams of the element. It seems that infant exposure from treating nipple wounds with silver-containing dressings or products would be minimal, but the lack of data necessitates caution.
Among antimicrobial dressings are those containing Manuka honey. Their use has not yet been studied in nipple wound healing. In vitro studies observed cytotoxic effects on human keratinocytes and skin fibroblasts [49]. Infants under 12 months should not
consume honey. The absence of safety and efficacy data in breastfeeding mothers calls for caution.
According to current microbiological knowledge of wounds, topical antibiotics should not be used routinely, but in selected clinical situations their use is acceptable. Topical antibiotics are applied in the treatment of local skin infections, especially on the basis of eczema or atopic dermatitis [50, 51], in ophthalmology, and for the prevention of surgical wound infections [52]. The most common applications include mupirocin, fusidic acid (which shows activity in deeper skin layers), aminoglycoside antibiotics, and others. Retapamulin and ozenoxacin are recommended for infections with MRSA strains [51].
In practice, lactation consultants use topical antibiotics for difficult-to-heal nipple wounds with good outcomes reported, but there are no studies confirming their efficacy for this indication [53]. In a small observation of 29 patients from the CLS study, topical antibiotics were used only for infected, extensive wounds and achieved better therapeutic effects than dressings without antibacterial substances; however, the sample size is too small to draw definitive conclusions [38]. If despite proper use of lavaseptics, antiseptics, or antibacterial dressings there is no progress in wound healing, the use of a topical antibiotic based on the obtained antibiogram may be justified. This is the last step before systemic antibiotic therapy, which is reserved for cases resistant to topical treatment or when infection spreads from the wound to surrounding breast tissue. Treating a small local wound infection with systemic antibiotics seems too aggressive, considering breastfeeding and the priority of topical treatments in the pharmacotherapy of lactating women [54]. However, topical antibiotics should not be used routinely as first-line treatment without indications based on an antibiogram. The use of antibacterial and antifungal agents, especially those available over the counter, without proper indications prolongs the wound healing process and causes suffering to mothers.
Substances not recommended for treating nipple wounds
• Povidone-iodine (absorption from the wound, accumulation in milk)
• Chlorhexidine (cytotoxicity)
• Peruvian balm
• Hydrogen peroxide (short action, does not eliminate microorganisms)
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• Potassium permanganate (cytotoxicity)
• Rivanol (prolongs the viability of Pseudomonas aeruginosa, carcinogenic effect)
• Anesthesin
• Silver sulfadiazine (insufficient antimicrobial activity)
• Glucocorticosteroids (delay in healing; some preparations for skin lesions contain them, but their intended use according to the product’s characteristics is different)
The most common mistakes in treating nipple wounds
• Lack of improvement in feeding technique
• Failure to ensure proper nipple-areola latch
• Failure to check correct use of lactation accessories
• Poor hand hygiene, feeding accessories, or milk expression equipment
• Reassuring that “it will go away on its own”
• Excessive airing of nipples after feeding
• Failure to recognize at risk of infection or infected wound
• Lack of antiseptic treatment in the above-mentioned wounds
• Continuing the same treatment without progress within a reasonable time
• Lack of swab with antibiogram and untargeted treatment
• Using gel or hydrogel dressings on infected wounds
• Using lanolin and other care products (e.g., ointments with vitamins) on infected wounds (unjustified, non-targeted treatment)
• Using steroids in wound treatment (delaying healing)
• Using antifungal agents (unjustified, non-targeted treatment)
• Using OTC topical antibiotics
Lactation consultation
Medical history taking
During the interview, it is necessary to determine how long the injuries have been present, whether the pain is easing or worsening, assess the pain intensity using the numerical rating scale (NRS), ask under what circumstances the pain is most severe, whether the mother has noticed any purulent discharge, what
treatments have been applied, and what results these have brought. Information about previous care, hygiene of the breasts, hands, and lactation accessories is also important. Lack of healing progress may result from not following recommendations.
It is necessary to gather information about the health status of the mother and child, recent antibiotic use, and the presence of skin lesions in other areas.
Factors increasing the risk of wound infection
• Age over 35 yearss.
• Weakened immune system.
• Diabetes.
• Chronic diseases (kidney failure, heart failure).
• Malnutrition, obesity.
• Unhealthy lifestyle, tobacco smoking.
• Medications (glucocorticoids, insulin, cytostatic drugs, immunosuppressants).
During the child’s examination, special attention should be paid to muscle tone, symmetry of the face and body, presence of skin lesions, weight gain, anatomical structure of the oral cavity, condition of the mucous membranes, tongue mobility, and sucking function.
When examining the breasts, assess skin coloration, tissue consistency, presence of signs of inflammation in the gland or skin and subcutaneous tissue, and axillary lymph nodes. The shape of the nipples and the elasticity of the nipple-areola complex should be evaluated. The breast examination also serves to assess the condition of the nipples, the size and depth of the wound, shininess, swelling of the wound edges, the presence of erythema and swelling of the entire nipple, the spread of erythema and swelling around the nipple, or, conversely, signs of healing (Annex 1). If there are indications, a swab from the wound should be taken.
A key element necessary for diagnosis is observing the feeding process, often involving improving the position of the mother or child and the way the child latches onto the breast. Experience shows that women can breastfeed even with fairly large wounds, as long as the pain level is tolerable (7–8/10 points). Often, technique adjustments are minor but significantly improve the way the baby latches onto the breast. Even an extensive wound may not be felt by
the mother during feeding if the nipple is placed sufficiently deep in the child’s oral cavity.
A lactation consultation is conducted by a properly trained person to whom the mother and child should be referred (lactation consultant – doctor, midwife, nurse). The diagnosis is established based on the interview and examination, followed by selecting the appropriate treatment.
The primary goal in treating nipple pain and damage is to eliminate the cause.
A small observational study conducted by CLS in 2018 found that nipple wounds were accompanied by an average pain intensity of 7.5/10, and 90% of mothers required breastfeeding technique correction, which relieved the pain. 10% of mothers required repeated instruction during a follow-up visit. Nipple wounds treated according to the applied protocol healed within 4.15 days, and the pain disappeared completely within just under 6 days [38].
Improving breastfeeding technique is the primary action that allows most injuries to heal quickly without the need for additional methods.
The feeding position should be comfortable and stable for both the mother and the child. The baby should be held close to the mother’s body, with the head slightly tilted back, hands holding the breast from both sides, and the chin resting on the breast. Initially, the nipple is positioned at nose level, slightly raised, and directed toward the palate. When the baby tilts their head back and opens their mouth wide, the nipple is guided towards the palate. In reclined positions, when the baby lies on the mother, it can move its head forward and latch onto the breast independently. In other positions, the mother gently brings the baby close when the mouth opens wide (Figs. 10, 11).
If the areola is firm and engorged with milk, the mother should be advised to hand express a small amount of milk to reduce areola tension. Engorged breasts and a tense areola are primarily a problem during the first weeks after childbirth but can also occur in mothers with oversupply at any stage of lactation. For swelling of the breast and areola, the reverse pressure softening (RPS) technique is applied – manual drainage of the transudate fluid beneath the areola. The nipple-areola complex should be flexible enough to shape properly inside the infant’s mouth. Instruction on proper breastfeeding techniques and hand expression should be given during the hospital stay. It is the hospital staff’s duty to provide this training, as outlined in the Perinatal
10. Correct position for feeding – mother in a reclined position, infant cuddled, stabilised on mother’s stomach, arms around breast, head slightly tilted (photo by M.
Care Organization Standard. However, many mothers still need help after leaving the hospital. They seek assistance from primary care midwives, but if it is insufficient, they turn to professional lactation consultants [56].
For newborns with oral cavity abnormalities, it is advisable to use specific feeding positions and manual assistance techniques, and working with an early intervention speech therapist can be helpful. In cases of anatomical or functional sucking disorders, the use
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of a nipple shield may be considered. A restrictive tongue-tie should be clipped without delay. In cases of asymmetry or muscle tone disorders, parents should be advised on proper infant care principles, and in some situations, consultation with a neurologist or physiotherapist may be necessary.
For mothers who express milk using breast pumps, it is essential to check the suction strength and funnel size, considering that some pumps on the market are not registered as medical devices and may have uncontrolled suction strength, some lack replaceable funnels, and some mothers have not received assistance in selecting a flange suitable for their nipple type (diameter, elasticity). Sometimes, nipple size may change after a period of expressing milk. Some types of so-called shell pumps have opaque shells, preventing the mother from adequately controlling nipple positioning. It is also worth asking the mother how she ensures the hygiene of the equipment and correcting any mistakes. During the treatment of category 2, 3, and 4 wounds, enhanced equipment hygiene is recommended [57].
An integral part of the consultation is supporting the mother, showing understanding for her complaints, appreciating her commitment to breastfeeding, and encouraging her to persevere through the challenging wound-healing period.
At the time of the initial assessment, it is important to consider the type of wound based on the length of the medical history, the severity of local or both local and systemic symptoms, and whether any treatment has been applied so far – or if none has been given.
Recommendations for the mother must be simple and possible to perform repeatedly throughout the day – in accordance with the feeding schedule. Feeding involves the necessity of removing applied substances (which is troublesome and painful and concerns most preparations or dressings) and reapplying them after feeding. Moreover, these products are not cheap, must be financially accessible to the patient, and are usually needed for no longer than 1–3 weeks. Therefore, it is important to avoid using too many preparations. Dressings for breastfeeding women are not reimbursed because nipple wounds do not meet the criteria of chronic wounds as defined by the National Health Fund (NFZ).
It is important to monitor the course of treatment at short intervals and to change the strategy
if necessary. The choice of treatment depending on the wound category is described in Table 4, Figures 12–15. Systemic antibiotic therapy is rarely necessary in the treatment of nipple wounds; indications are listed in Text box. The optimal approach is to select antibiotics according to the antibiogram obtained from a wound culture. In special cases, empirical treatment may be started – in such cases, first-generation cephalosporins are used, as the most common pathogen causing infection is methicillin-sensitive Staphylococcus aureus (MSSA).
It should be remembered that medicinal agents will act in combination with the previously described interventions, eliminating the causative factor of the injury.
• Lack of improvement despite the proper implementation of all stages of local treatment
• Spread of infection to the areola
• Spread of infection to the skin of the breast, subcutaneous tissue, and glandular tissue
• Systemic infection symptoms
Table 5 lists antiseptic substances and their characteristics. Tables 6 and 7 describe the technique for collecting a swab from a nipple wound and skin lesions (Fig. 16). The indications for collecting a swab from a nipple wound or from the skin of the nipple and areola, as well as for collecting milk for culture in the case of mastitis, are presented in Text boxes.
Bites to the nipple or areola by a teething infant require prompt treatment. Management follows category three recommendations – a swab should be taken, the wound should be cleaned with a preparation containing a surfactant and antiseptic, a dressing with an antibacterial agent should be applied, and if healing does not occur within a few days, a broad-spectrum antibiotic or one based on an antibiogram should be administered. The substances of choice for a breastfeeding mother with a bite wound are sodium hypochlorite and hypochlorous acid, which can be used for wound irrigation. When used at low concentrations, hypochlorites offer high antimicrobial efficacy combined with safety, and are non-cytotoxic to healthy tissue. Additionally, hypochlorites have anti-inflammatory and antipruritic properties and are pH neutral (Fig. 17) [58, 59, 61].
Figure 18 presents example of infected niepple wound healing.
Treatment of nipple wounds during breastfeeding
Table 4. Categories of nipple wounds, management, and selection of medicinal agents. Prepared by M. Żukowska-Rubik, M. Nehring-Gugulska
Nipple wound – assess the wound category
Category 1. Uninfected Wounds:
• superficial (epidermal abrasions, fissures, erosions)
• small-sized – up to a few millimeters
• newly formed (contamination)
Category 2. At risk of infection 2A.
• Any wound in a woman with risk factors
• Extensive wounds covering more than half of the nipple surface, wounds on the nipple shaft and at the base of the nipple
• Deep wounds – ulcers, fissures (colonization)
2B.
• Hard-to-heal wounds – worrying symptoms appear – exudate, fibrin, the wound enlarges or no signs of healing within 4 days of observation (increasing colonization)
Significant increase in pain, redness, swelling, nipple warmth, swelling of the wound edges, exudate – often purulent, presence of necrotic tissue [41]
Lack of healing progress despite no concerns regarding breastfeeding technique or sucking function in the newborn
Treatment
• Recommend smearing with mother’s milk after feedings, drying for several seconds
• Additionally, if needed, use dressings without antibacterial substances between feedings (gel dressings, hydrogel dressings) or warm wet compresses with boiled water (4 times a day for 15 minutes over 5 days) after feedings – to maintain a moist healing environment and reduce pain
• For decolonization, prevention of biofilm formation, and cleansing, use a lavaseptic with added surfactant or hypochlorite – rinse the wound or apply a compress with a gauze soaked in the preparation after every feeding (the recommended time of application on the wound depends on the manufacturera)
• Use dressings without antibacterial substances to maintain proper moisture in the wound between feedings
In the case of a wound showing signs of difficult healing
• use a lavaseptic with added surfactant and an antiseptic substancee
• consider dressings with antibacterial substances
• consider taking a wound swab
• Take a swab from the nipple wound
• To remove biofilm and for cleansing, use a lavaseptic with added surfactant and an antiseptice substance
• Rinse the wound or apply a compress with gauze soaked in the preparation after each feeding (the recommended time of application on the wound depends on the manufacturera)
• Once a day, clean the wound using a moistened gauze to remove excessive exudate, biofilm, loose scabs, or fibrin (moisten the wound beforehand)
• Use dressings containing antibacterial substances, a gel-basedb product may be applied after feedings at least 3–4 times a day or after each feedingc; in case of skin maceration, reduce the amount or duration of application
• Select a dressing suitable for the amount of exudate
Monitoring of treatment
Observation time: signs of healing should appear within 4 days*
Improvement / wound is healing: continue the above treatment until full healing No improvement / wound is not healing: verify if recommendations were properly applied, consider reclassification of the wound category
Observation time: signs of healing should appear within 4 days*
Improvement/wound healing: next checkup in 4 days, continue treatment until clear improvement in healing, then discontinue the antiseptic, maintain a dressing that ensures a moist healing environment
No improvement/wound not healing: verify whether the recommendations were correctly applied, consider changing the category
Observation time: 4 days
Improvement: follow-up in 4 days, continue treatment until the infection is under control**, and significant healing progress* is achieved. At that point, antiseptic use can be discontinued***, and a dressing that ensures a moist healing environment can be applied
No improvement/presence of infection symptoms/wound not healing:
• Verify whether the recommendations have been correctly implemented
• Continue using the lavaseptic with surfactant and the antiseptic substance
• Consider applying a topical antibiotic according to the antibiogram for 5–7 daysd Improvement / infection controlled / wound healing: discontinue the antiseptic substance, stop the topical antibiotic, and apply a dressing that ensures a moist environment until complete healing
No improvement/presence of infection symptoms/wound not healing:
• Continue using the lavaseptic with surfactant, the antiseptic substance, and dressings containing an antibacterial agent
• Administer a systemic antibiotic according to the antibiogram
Monika Żukowska-Rubik, Magdalena Nehring-Gugulska, Beata Mrozikiewcz-Rakowska et al.
Table 4. Categories of nipple wounds, management, and selection of medicinal agents (cont.)
Nipple wound – assess the wound category
Category 4. Spread of infection to surrounding tissues
Swelling and redness around the nipple (on the areola) > 2 cm erysipelas, cellulitis, infected mastitis
Systemic infection symptoms (fever, chills, malaise, elevated inflammatory markers in laboratory tests)
• Local treatment as in category 3 (except for topical antibiotics)
• If a wound swab was previously taken – administer systemic antibiotics based on the antibiogram
• If no swab was taken – collect one and administer an empirically selected systemic antibiotic
Monitoring of treatment
Observation time: improvement should occur within 3 days of antibiotic treatment
Improvement/resolution of systemic symptoms, improvement of local condition: continue antibiotic treatment according to established guidelines, and continue local treatment until significant wound healing improvement is achieved*
No improvement: reassess treatment depending on the situation:
• In the case of mastitis, collect milk for culture
• If the antibiogram result from the wound swab is available – change the empirically chosen antibiotic to one based on the antibiogram
• If no antibiogram is available – prescribe a broad-spectrum antibiotic
* Healing signs – reduced pain intensity, decrease in wound size and depth, epithelialization or granulation, closure of the wound from the edges.
** Infection control – reduction of pain intensity, decrease in exudate volume, subsidence of wound edge swelling, and reduction of nipple swelling and redness
*** Lack of improvement with antiseptic treatment within 2 weeks absolutely requires verification
a The recommended application time on the wound is provided by the manufacturer – refer to the appropriate documentation – in the case of drugs, the SmPC (Summary of Product Characteristics), and in the case of medical devices, the IFU (Instructions for Use of Medical Devices) (Annex 2, Table II).
b Primary dressings are applied directly to the wound. Some require the placement of a secondary dressing, which can be a sterile gauze pad. Sometimes it may be worth adding a secondary absorbent dressing depending on the exudate amount (e.g., foam dressing). Some dressings can function as both primary and secondary, e.g., foam dressings.
c Preparations and dressings should be washed off before the next feeding, except for antiseptic substances without a residual effect; it is essential to check the leaflet to see if the dressings intended for nipple application require washing.
d Routine treatment of wounds with topical antibiotics is not recommended; indications are limited to situations described in the article. The time given, based on experience, is sufficient for treating nipple wounds with topical antibiotics, in accordance with the SmPC of the products (usually 5–7 to 10 days). Longer treatment without signs of improvement is unjustified
e Antiseptic substances recommended depending on the clinical situation
First-line
Wounds at risk of infection
Infected wounds
Polyhexanide (0.02%, 0.04%, 0.1%), octenidine 0.05%
Octenidine/phenoxyethanol 0.01%
Second-line
Octenidine/phenoxyethanol 0.01%, hypochlorite
Octenidine 0.05%, polyhexanide
Figure 12. Category 1 of wounds: A) abrasion of the epidermis; B) fissure at the top of the nipple (9–13; C) healing fissure in the furrow of the nipple (in the 5–11 direction), without oozing, swelling of the wound edges (photos by M. Żukowska-Rubik).
Figure 13. Category 2 of wounds: A) erosions on top; B) fissure surrounding more than half of the circumference of the nipple at the base, slight swelling and maceration of the wound edges, abrasion on the top; C) wound of small size, but exceeding the depth of the epidermis, without features of infection (photos by M. Żukowska-Rubik).
Figure 14. Category 3 of wounds: A) crack at the top (lower part of the top of the nipple) and around the shaft) ; B) ulceration at the top, covered with separating epidermis; C) extensive wound of the top of the nipple, partially covered with fibrin, oozing purulent secretion, heavily swollen wound edges and nipple, not healing for 2 weeks (photos by M. Żukowska-Rubik),
Figure 15. Category 4 of wounds: A) cellulitis – inflammation of the skin and subcutaneous tissue of the breast, infected deep wound on the nipple, swelling, redness of the nipple, oozing purulent secretion (photo by M. Żukowska-Rubik); B) Abscess as a complication of an untreated infected nipplewound (photo by M. Żukowska-Rubik).
Table 5. A list of preparations containing antiseptic agents and their antimicrobial properties
Properties
Required contact time / time demonstrated in in vitro studies
Residual effect
Use in conjunction with silver-containing dressings
Development of resistant strains
Inhibition of healing
Deep wound, no drainage, eye [33]
Potentially higher risk of allergic reactions
Octenidine dihydrochloride 0.05%+ Ethylhexylglycerin
Polihexanide + betaine
Polihexanide + poloxamer
Hypochlorites [57–60]
Octenidine dihydrochloride 0.1% + phenoxyethanol 2%
Approx. 1–5 minutes / 60 seconds 15 minutes / 5–15 minutes 15 minutes / 5–15 minutes 15 minutes / 5–15 minutes 1 minute / 30 seconds
Residual effect – the active substance remains on the skin; these products should be rinsed/removed from the nipple surface before breastfeeding/milk expression.
Among antiseptic agents, the following are registered as medicinal products: Octenisept (octenidine dihydrochloride), Braunol and Betadine (PVP-I) (PVP-I-containing preparations are not recommended during lactation). Other products have the status of medical devices (see Annex 2).
Table 6. Technique for taking a swab from a nipple wound [62, 63]
Swabbing technique (Fig. 16)
1. Prepare the following materials:
• sterile transport medium
• sterile gauze pads
• saline ampoule
• sterile gloves
• referral for a swab to test for aerobic flora and, in some cases, also anaerobic flora (e.g., fistula, epibole, bite wound)
2. Rinse the wound thoroughly with saline; wipe the wound with saline-soaked gauze if it is covered with exudate, biofilm, or scabs
3. Assess the wound
4. Take a swab Levine technique – rotate the swab at the base of the wound, applying enough pressure to express fluid from the wound bed. The swab should be held perpendicular to the wound surface
5. Place the swab in the transport medium, label it, and send it with the referral for analysis
Comments
• Swabs should be collected before feeding
Comment
• Cleaning the wound of exudate
• Removal of ointments, creams, or gels applied by the patient from the wound surface
• Reduction of the risk of collecting contaminating flora from the wound
• Disinfecting the skin before sampling is not recommended, as it may lead to false-negative results
• If dry, moisten the swab with saline; if moist, use a dry swab
• Avoid touching the surrounding skin with the swab
• If a fistula or epibole is present, also collect material from that area
• The following are not recommended for microbiological analysis: pus, discharge from under a removed dressing, mucus from the wound bed, scabs, or material taken after applying an antiseptic [42]
Treatment of nipple wounds during breastfeeding
16. Wound swab collection using the Lewin method – culture tube positioned perpendicular to the wound, rolling motion with light pressure on the wound floor (photo by M. Żukowska-Rubik).
Figure 18. Example of healing. A) Course of healing of infected wound after application of lavaseptic with surfactant and antiseptic. Extensive nipple wound encompassing the entire top and deep in the centre, swelling of the wound edges, serous-purulent exudate observed on lactation pads. B) After a week, the wound begins to flatten out and become covered with epidermis, less exudate and edge swelling. C) After another week, there is a thin crust in the centre of the nipple and epithelialization around it (photos by M. Żukowska-Rubik).
Technique Description Comment
The Levine technique
The Z-technique (zigzag)
The swab should be rotated in the wound with adequate pressure to express fluid from the wound bed; the swab for culture should be held perpendicular to the wound surface
A zigzag motion should be performed over the skin lesions while simultaneously rotating the swab between the fingers
Indications for taking a swab from the nipple wound or skin of the nipple and areola include [57]
• Signs of wound infection
• Hard-to-heal wounds
• Persistent nipple pain despite improved latching technique
• Skin changes on the nipple or areola such as erythema, oozing, scaling, cracking
Indications for taking a breast milk sample for culture in cases of mastitis
• No improvement after 3 days of empirical antibiotic therapy
• Severe, septic course of mastitis
• Suspected nosocomial infection
• Recurrence of mastitis (symptoms reappearing in the same breast within 3 months of the last occurrence)
• Subacute mastitis
• Allergy to multiple antibiotics
The use of medicinal agents and breastfeeding
Medicinal agents applied to the nipple skin should be used after feeding the baby. Creams or ointments containing antibiotics should be applied before longer breaks in feeding, such as at night or before going for a walk. Antiseptics without residual effect do not need to be rinsed off before feeding, whereas other preparations should be rinsed off with preboiled water. To clean the breast before feeding when a cream or ointment has been applied, use expressed breast milk (squeezed onto a gauze pad) or a product with a slightly acidic pH. Similarly, the nipple surface should be cleaned after removing the dressing to minimise the infant’s exposure to medicinal substances and, for example, mineral oils used as a base [64, 65].
• Recommended (higher effectiveness in obtaining a valid culture)
• More painful for the patient
• Better tolerated by patients
• Recommended for collecting swabs from the nipple skin and areola
• Not recommended for nipple wounds due to higher risk of contamination from bacteria at the wound edges
During breastfeeding, especially when nipples are cracked or injured, hygiene rules must be followed:
• wash your hands before breastfeeding;
• wash your hands before dressing the wound;
• wash the breasts during your regular body hygiene routine (at least once a day), using water and a mild soap, or preferably a cleanser with a slightly acidic pH (syndet) [66]. The use of soaps or products containing antibacterial agents for washing the breasts is not recommended. Washing the breasts before each feeding is also not recommended;
• wash and thermally disinfect accessories that come into contact with the breast (nipple shields, breast pump parts) once a day, and after each use for category 2, 3, and 4 wounds (increased hygiene of lactation equipment). Thermal disinfection is done by soaking the equipment for 5–10 minutes in water at 90–100°C;
• frequent replacement of nursing pads;
• hand disinfection by medical staff prior to contact with the mother or infant;
• hand hygiene by family members before contact with the mother, infant, or nursing equipment
The mother should be offered short-term analgesics, selecting the safest options for use during lactation (Hale’s classification L1–2), such as paracetamol or NSAIDs (ibuprofen, ketoprofen, diclofenac). Another method of pain relief involves manual expression of milk before breastfeeding to stimulate the milk ejection reflex and trigger the analgesic effects of oxytocin in the central nervous system. Improving breastfeeding technique is of fundamental importance.
Temporary cessation of breastfeeding
Breastfeeding is safe for the infant but may be too painful for the mother. In such cases, a temporary
Treatment of nipple wounds during breastfeeding
cessation of breastfeeding can be considered for several hours, up to several days, with regular expression of milk and feeding the infant with expressed milk until the wounds heal, provided that milk expression is less painful than breastfeeding, does not disrupt the wound, and ensures effective breast emptying.
Special attention should be given to women with a complicated medical history, in whom wound healing may be impaired and the risk of infection is higher than in the healthy population (see Factors increasing the risk of wound infection in Text box). Delayed wound healing is an indication to assess the mother’s overall health and to perform additional tests, for example, to rule out anemia or abnormal blood glucose levels. Nutritional assessment is also necessary, as approximately half of Polish mothers follow elimination diets during lactation. They most commonly avoid dairy products, including eggs, as well as many other sources of energy, protein, and vitamins, allegedly to protect the infant from colic, allergies, and other conditions. Such nutrient-deficient diets may delay wound healing [67]. Malnutrition increases the risk of wound infection. According to recommendations, a patient with a chronic wound should receive 30–35 kcal/kg body weight/day (no less than 1,800 kcal) and an adequate amount of protein (1.5–2.5 g/kg body weight), carbohydrates (55–60%), and fats (20–25%).
Summary of treatment rules for nipple wounds in breastfeeding mothers
• Correction of breastfeeding technique and reduction of areolar tension before infant latch (if indicated)
• Appropriate interventions to improve the infant’s sucking function when indicated (consultations with lactation consultants, speech therapists, physiotherapists, frenotomy)
• Selection/correction of the flange size and pump strength to ensure the mother’s comfort during milk expression
• Hand, breast, and pump equipment hygiene
• Use of lavaseptics, antiseptic agents, specialized dressings, antibiotics as appropriate to the wound category
• Pain management; in exceptional cases, breastfeeding interruption for 1–2 days with continued milk expression and feeding expressed milk
• Proper maternal nutrition
WHAT TREATMENT WOULD YOU APPLY?
• Task 1 (Fig. 19): Wound healing has not progressed for 3 weeks; at the nipple base, there is a fissure affecting most of the nipple’s circumference, with varying depths, exuding discharge, and severe pain; the mother is close to stopping breastfeeding. So far, she has been applying breast milk to the wound after feedings and using hydrogel dressings. Breastfeeding technique is correct.
• Task 2 (Fig. 20): A deep wound present for one month involving the tip and sides of the nipple, covered with biofilm, swollen wound edges, oozing discharge, nipple swelling, and pain. The mother breastfeeds several times a day, but feeding is very painful, so she expresses milk more often. So far, she was recommended nursing creams, protective shells, and used an antiseptic for several days.
Figure 19. Task 1 – what treatment: wound at the nipple base covering most of the periphery of the nipple, of varying depth, with oozing exudate, no progress of healing for 3 weeks (photo by M. Żukowska-Rubik).
20. Task 2 – what treatment. Deep wound involving the top and sides of the nipple, covered with biofilm, swelling of the wound edges, oozing of exudate, swelling of the nipple (photo by M. Nehring-Gugulska).
Source: Żukowska-Rubik M., Nehring-Gugulska M. Pathology of breast and nipple during lactation. In: Żukowska-Rubik M., Godyń-Myśliwy Z., Nehring-Gugulska M. The Atlas of physiology and pathology of lactation. 1st Edition. Medycyna Praktyczna, Krakow 2025, with consent.
–depending on the cause and nipple condition: Improve feeding technique, latch of the nipple–areola complex, sucking function, method of milk expression
Consider: pain medication, nipple shields, protective shells, temporary pause in direct breastfeeding (regular expressing needed) Wound or skin lesion swab –if infection is suspected
DIAGNOSIS
ASK: When did the pain/damage begin? Pain intensity? Is it related to breastfeeding? Breast hygiene? Previous treatments? Depending on the situation –ask targeted questions related to the specific issue, e.g. expressing, teething.
Refer the patient to a doctor –treatment of the wound according to the antibiogram, treatment of skin diseases or other problems
Refer the infant to a specialist if indicated (pediatrician, neurologist, speech therapist, physiotherapist, others) Monitor breastfeeding and the child’s weight gain
* Wash breasts with gentle soap during full-body hygiene, preferably with slightly acidic pH cleanser; wash hands before feeding; staff –clean and disinfected hands ** Apply breast milk after feeding, or products designed for use on nipples during lactation *** Increased equipment hygiene –thermal disinfection before/after each use
Yellowish lump on nipple –consider: plugged milk duct on the nipple, inflammatory bleb) -Causal treatment Sebaceous cyst, sebaceous adenoma -Surgical treatment Unilateral lesion –erosion, oozing, crusting, scaling + prolonged symptoms, no improvement after treatment –consider Paget’s disease –refer to specialist
Erythematous, weeping, scaling changes on nipples/areolas –consider: eczema, bacterial, mixed or fungal infection, psoriasis, other skin irritation due to improper care -Causal treatment Blisters on nipple/areola skin –consider: excessive suction, nipple friction, skin infection –herpes, shingles, impetigo –Causal treatment
Fungal infection
Thrush
Diaper rash
Antibiotics
Immunosuppressive drugs
Diabetes
Dysbiosis Nipple damage postpartum Antibiotics Incorrect care
Inflammatory bleb
Unilateral lesion
White-yellow spot/ lump on nipple Stabbing, deep pain
EXAMINE: Infant: Abnormal muscle tone, asymmetry? Skin infection?
Oral cavity –abnormal anatomy or function? Mucosal changes?
Mother: Appearance of lesions on nipples/areolas, signs of wound infection?
Shape and elasticity of the nipple–areola complex
Feeding: Poor technique or latch? Nipple being pulled in? Shallow latch, clamping, tugging?
Painful nipples without lesions –consider: Early transient hypersensitivity –standard hygiene*, neutral care** Raynaud’s phenomenon –treat the underlying cause: dry heat, calcium channel blockers Damaged nipples without signs of infection –standard hygiene*, breast milk, warm moist compresses, gel or hydrogel dressings if needed
Wounds at risk of infection –after feeding, cleanse using a lavaseptic containing a surfactant, consider an antiseptic and specialist dressings with antibacterial agents; increased equipment hygiene***
Damaged nipples with signs of infection –standard hygiene*, elevated equipment hygiene*** + after feeding, cleanse wounds using a lavaseptic with a surfactant, use antiseptic agent and specialist antibacterial dressings; in severe cases topical antibiotic according to antibiogram; if infection spreads –systemic antibiotic
Eczema
Cleaning agents Cosmetics Breast pads Medications and new foods (in the infant)
Blanching/Raynaud’s phenomenon Blanching, triphasic colour changes Cold sensitivity Tendency to have cold fingers Vasoconstrictive medications Illnesses of the mother Smoking
Expressing
Suction strength Nipple placement in pump flange Flange size Session duration Equipment hygiene
QUESTIONS FOR SPECIFIC ISSUES
TARGETED
Figure 21. Algorithm –painful and damaged nipplesdifferentiation and management. Prepared by M. Żukowska-Rubik.
In breastfeeding mothers, injuries usually occur due to incorrect breastfeeding or breast pump use techniques. However, nipple lesions may also be caused by systemic diseases, e.g., viral infections (Herpes simplex, Herpes zoster, Varicella zoster), bacterial infections (syphilis, gonorrhea), or systemic conditions (psoriasis, ichthyosis, eczema, atopic dermatitis). Oncological vigilance is essential for lesions that do not heal within the expected time, and patients should be referred for diagnostics (e.g., Paget’s disease of the breast). An algorithm on nipple pain and injury collects key information for managing painful and wounded nipples (Fig. 21). It briefly addresses other common lactation issues relevant to differentiating nipple pain causes.
Nipple wounds are a frequent problem, especially shortly after delivery, and one of the main reasons mothers prematurely stop breastfeeding. Knowledge of the basic principles of nipple wound treatment is essential for all healthcare workers caring for the mother or infant during lactation at various levels of the healthcare system and in different roles, including midwives, nurses, lactation consultants, gynecologists, neonatologists, pediatricians, and family doctors. Their expertise and cooperation serve public health. Improving breastfeeding technique and ensuring the nipple-areola complex is compliant enough to allow the infant to latch deeply are fundamental to treatment. It is important to frequently monitor the progress of wound healing to promptly respond to signs of emerging infection. In the study, the authors highlight when maternal milk, modern lavaseptics, antiseptic substances, or specialized dressings can be used for wound treatment depending on the wound category, taking into account the specific location of these wounds and the contact between the baby’s oral cavity and the treated breast.
• Task 1 (Fig. 19): Category 2B wound, hard to heal, the following should be recommended:
• collect a wound swab for culture;
• option 1 – cleansing after feeding with a lavaseptic containing surfactant and antiseptic; between feedings apply foam dressing;
• option 2 – surfactant and antiseptic gel applied in a thin layer after feedings, left until the next feeding;
• pain medication;
• hygiene measures;
• follow-up after 4 days.
• Task 2 (Fig. 20): Category 3 wound, the following should be recommended:
• improve breastfeeding technique!
• collect a wound swab for culture;
• cleansing the wound with a surfactant-containing lavaseptic after breastfeeding/expressing, ideally in the form of a compress made from gauze soaked in the solution; a first-line antiseptic is optimal for infected wounds;
• cleaning the wound surface of biofilm once daily;
• between feedings, dressings containing antibacterial agents and monitoring of discharge;
• pain medication;
• hygiene (increased hygiene of expression equipment);
• follow-up after 4 days.
Beata Mrozikiewicz-Rakowska: consultations and lectures for: Convatec, Hartmann, Schulke, Smith@ Nephew, Urgo.
Monika Aleksy-Polipowska: consultations and lectures for: ConvaTec, Verco, Schulke, Urgo. The other authors declare no conflict of interest. This research received no external funding. Approval of the Bioethics Committee was not required.
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27. Vieira F, Mota DDCF, Castral TC, et al. Effects of Anhydrous Lanolin versus Breast Milk Combined with a Breast Shell for the Treatment of Nipple Trauma and Pain During Breastfeeding: A Randomized Clinical Trial. J Midwifery Womens Health 2017; 62: 572–579. DOI: 10.1111/jmwh.12644.
28. Lis K. Hypersensitivity to Lanolin: An Old-New Problem. Life Basel Switz 2024; 14: 1553. DOI: 10.3390/life14121553.
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31. Coentro VS, Perrella SL, Lai CT, et al. Impact of Nipple Shield Use on Milk Transfer and Maternal Nipple Pain. Breastfeed Med 2021; 16: 222–229. DOI: 10.1089/bfm.2020.0110.
32. Kronborg H, Foverskov E, Nilsson I, Maastrup R. Why do mothers use nipple shields and how does this influence duration of exclusive breastfeeding? Matern Child Nutr 2017; 13: e12251. DOI: 10.1111/ mcn.12251
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38. Nehring-Gugulska M, Nadratowska I, Fajdek J, et al. Czy to przełom w leczeniu ran brodawek? Prezentacja wyników badania. Mater Konf XI Zjazd CNoL. Published online 2018.
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40. Kulińska R. Różnicowanie zmian skórnych u matek karmiących. XVI Zjazd Centrum Nauki o Laktacji Warszawa. Published online 2023.
41. McClellan HL, Hepworth AR, Garbin CP, et al. Nipple pain during breastfeeding with or without visible trauma. J Hum Lact Off J Int Lact Consult Assoc 2012; 28: 511–521. DOI: 10.1177/0890334412444464.
42. Sopata M, Mrozikiewicz-Rakowska B, Jawień A, et al. Uaktualnienie dokumentu: Wytyczne postępowania miejscowego w ranach niezakażonych, zagrożonych infekcją oraz zakażonych – przegląd dostępnych substancji przeciwdrobnoustrojowych stosowanych w leczeniu ran. Zalecenia PTLR 2020. Leczenie Ran 2023; 20: 125–141 DOI: 10.60075/lr.v20i4.59.
43. Baran A, Flisiak I. Choroby infekcyjne skórne. In: Rudnicka L, Olszewska M, Rakowska A, Sar-Pomian M (eds.). Współczesna dermatologia. Vol. 1. PZWL, Warszawa 2024; 114–116.
44. Nehring-Gugulska M, Kowol-Trela K. Schorzenia brodawek sutkowych w okresie laktacji. Ginekol Po Dyplomie. Published online 2022.
45. Gao H, Wang J, Ding S, et al. A retrospective analysis of debridement in the treatment of chronic injury of lactating nipples. Sci Rep 2021; 11: 3625. DOI: 10.1038/s41598-021-83172-6.
46. Cable B, Stewart M, Davis J. Nipple wound care: a new approach to an old problem. J Hum Lact Off J Int Lact Consult Assoc 1997; 13: 313–318. DOI:10.1177/089033449701300417.
47. Marrazzu A, Sanna MG, Dessole F, et al. Evaluation of the effectiveness of a silver-impregnated medical cap for topical treatment of nipple fissure of breastfeeding mothers. Breastfeed Med Off J Acad Breastfeed Med 2015; 10: 232–238. DOI: 10.1089/bfm. 2014.0177.
48. Hale TW, Krytsch K. Hale’s Medications & Mothers’ Milk 2023 Twentieth Edition. 2023. Available at: https://www.springerpub. com/hale-s-medications-mothers-milk-2023-9780826160638.html (Access: 13.07.2024).
49. Yabes JM, White BK, Murray CK, et al. In Vitro activity of Manuka Honey and polyhexamethylene biguanide on filamentous fungi and toxicity to human cell lines. Med Mycol 2017; 55: 334–343. DOI: 10.1093/mmy/myw070.
50. Bonamonte D, Belloni Fortina A, Neri L, Patrizi A. Fusidic acid in skin infections and infected atopic eczema. G Ital Dermatol E Venereol Organo Uff Soc Ital Dermatol E Sifilogr 2014; 149: 453–459.
51. Galindo E, Hebert AA. A comparative review of current topical antibiotics for impetigo. Expert Opin Drug Saf 2021; 20: 677–683. DOI: 10.1080/14740338.2021.1902502.
52. Heal CF, Banks JL, Lepper PD, et al. Topical antibiotics for preventing surgical site infection in wounds healing by primary intention. Cochrane Database Syst Rev 2016; 11: CD011426. DOI: 10.1002/14651858. CD011426.pub2.
53. Livingstone V, Stringer LJ. The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study. J Hum Lact Off J Int Lact Consult Assoc 1999; 15: 241–246. DOI: 10.1177/089033449901500315.
54. Livingstone VH, Willis CE, Berkowitz J. Staphylococcus aureus and sore nipples. Can Fam Physician Med Fam Can 1996; 42: 654–659.
55. Kent JC, Ashton E, Hardwick CM, et al. Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments. Int J Environ Res Public Health 2015; 12: 12247–12263. DOI: 10.3390/ijerph121012247.
56. Czy Polska jest krajem przyjaznym matce karmiącej? Wizyty położnej podstawowej opieki zdrowotnej i u ginekologa-położnika. Raport zbadania ankietowego 2017. Available at: http://cnol. kobiety.med.pl/wp-content/uploads/2019/01/raport_2017.pdf (Access: 13.03.2019).
57. Żukowska-Rubik M. Bolesność brodawek. In: Nehring-Gugulska M, Żukowska-Rubik M, Pietkiewicz A (eds.). Karmienie piersią w teorii i praktyce. Medycyna Praktyczna, FTK, Centrum Nauki o Laktacji, Kraków, Warszawa 2017; 209–229.
Treatment of nipple wounds during breastfeeding
58. Draelos ZD. Antipruritic hydrogel for the treatment of atopic dermatitis: an open-label pilot study. Cutis 2012; 90: 97–102.
59. Gold MH, Andriessen A, Dayan SH, et al. Hypochlorous acid gel technology – Its impact on postprocedure treatment and scar prevention. J Cosmet Dermatol 2017; 16: 162–167. DOI:10.1111/jocd.12330.
60. Raport Br-0197-22 Mikrodacyn 60 ® Wound Care. Narodowy Instytut Leków z 31.08.2022.
61. Gold M, Andriessen A, Bhatia A. Podawany miejscowo stabilizowany kwas podchlorawy: Przyszły złoty standard w leczeniu ran i blizn w zabiegach dermatologicznych i chirurgii plastycznej. J Cosmet Dermatol 2020; 19: 270–277. DOI: 10.1111/jocd.13280.
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65. Concin N, Hofstetter G, Plattner B, et al. Mineral oil paraffins in human body fat and milk. Food Chem Toxicol Int J Publ Br Ind Biol Res Assoc 2008; 46: 544–552. DOI:10.1016/j.fct.2007.08.036
66. Mijaljica D, Spada F, Harrison IP. Skin Cleansing without or with Compromise: Soaps and Syndets. Mol Basel Switz 2022; 27: 2010. DOI:10.3390/molecules27062010.
67. Nehring-Gugulska M, Bębenek D, Krauze A, et al. Stosowanie diety eliminacyjnej przez polskie matki karmiące piersią w świetle aktualnej wiedzy. Pediatr Po Dyplomie 2023; 6: 57–65.
68. Augustin M, Herberger K, Wille A, Twarock S. Impact of human wound exudate on the bactericidal efficacy of commercial antiseptic products. J Wound Care 2023; 32: 422–427. DOI: 10.12968/ jowc.2023.32.7.422.
69. Radischat N, Augustin M, Herberger K, et al. Influence of human wound exudate on the bactericidal efficacy of antiseptic agents in quantitative suspension tests on the basis of European Standards (DIN EN 13727). Int Wound J 2020; 17: 781–789. DOI: 10.1111/iwj.13336.
Wound assessment
The wound assessment triangle is a fundamental tool, especially useful for beginners starting to manage wound care. Assessment is conducted as follows:
• wound bed,
• wound edges,
• surrounding skin.
Figure I. The wound assessment triangle
Assessment of the wound bed
1. Tissue type.
2. Exudate.
3. Infection.
Assessment of wound edges
1. Maceration.
2. Dryness.
3. Epibole.
Assessment of surrounding skin
1. Maceration.
2. Excoriation.
3. Dry skin.
4. Hyperkeratosis.
5. Induration.
5. Eczematous lesions.
1. Tissue type
• Necrotic.
• Liquefactive necrosis.
• Granulating.
• Epithelializing.
2. Exudate
• Amount: none; small; moderate; large.
• Type: watery; dense; clear; cloudy; purulent; pink/red.
3. Infection
• Local: increased pain; erythema; swelling; localized warmth; increased exudate; friable granulation tissue; unpleasant odor; epibole.
• Spreading/systemic: intense erythema; fever; abscess/pus; wound dehiscence; cellulitis; general weakness; leukocytosis; lymphangitis.
• Dryness – low moisture level preventing the formation and migration of cells necessary for new tissue growth. Keratinocytes become flat and flaky. The skin feels rough and peels.
• Eczematous changes – inflammatory condition characterized by itching, redness, and rash.
• Epibole – epidermal tissue building up inward into the wound rather than covering its entire surface. It may occur in wounds with an inflammatory basis, including those caused by tumors, and can result in delayed healing if appropriate measures are not taken.
• Epithelializing – pink tissue at the final healing stage, when epidermal cells appear on the wound surface.
• Excoriation – damage to the skin surface caused by repeated trauma such as scratching or abrasion
• Exudate – inflammatory fluid discharged from the wound; during a normal healing process, the amount of exudate increases in the inflammatory phase to cleanse the wound and maintain optimal moisture, which accelerates healing. In chronic wounds, exudate has a different biochemical composition, leading to the breakdown of protein structures in the wound and further tissue degradation.
• Granulation – new, red tissue and capillaries forming on the wound surface during healing.
• Hyperkeratosis – excessive thickening of the epidermis.
• Induration – thickened and hardened skin or soft tissue, especially in areas previously subjected to friction or pressure.
• Infection – the presence of bacteria and other microorganisms in sufficient quantities to damage tissue and impair healing. Clinical signs of infection may be absent in patients with immunosuppression, perfusion disorders, or chronic wounds.
• Liquefactive necrosis – yellow, fibrous tissue composed of fibers, pus, and protein material.
• Maceration – a process during which the tissues at the wound edge soften due to prolonged exposure to moisture from the wound exudate. The affected tissue is usually white in color.
• Necrotic tissue (dead tissue) – black, dead tissue containing dead cells and remnants of tissue resulting from the breakdown of dying cells.
• Undermining – tissue breakdown or ulceration spreading beneath the wound edge, resulting in a wound base wider than the skin surface opening.
Lavaseptics, which may be sterile or non-sterile medical devices, are classified as products used for care, cleansing, washing, and rinsing of the skin or mucous membranes. They are used for wound cleansing and the removal of fibrin, clotted secretions, and scabs. They should be used according to recommendations, including prior to the application of the proper antiseptic.
Lavaseptics can be divided into those containing surfactants (substances that facilitate cleansing by reducing surface tension of secretions or bacterial biofilm on the wound surface) and those without surfactants. Some lavaseptics also contain antimicrobial substances in lower concentrations than antiseptics. Lavaseptics may come in liquid or gel form.
The use of soap and water for wound cleansing is not recommended due to the high, non-physiological pH of soap, which promotes tissue tension and dryness.
The preparations and dressings listed below are commercially available and have been described based on the IFU and SmPC, in accordance with the data available at the time of publication.
NaCl 0.9%
• Form: solution.
• Sterility: depends on the manufacturer and packaging.
• Notes Scientific literature reports the irritating effect of NaCl 0.9% on tissues.
• Suggested use: for short-term rinsing of the nipple.
Ringer’s solution
• Form: solution.
• Sterility: depends on the manufacturer and packaging.
• Notes: none.
• Suggested use: for rinsing the nipple.
Solutions containing low concentrations of hypochlorous acid and/or sodium hypochlorite
The anti-inflammatory effects of hypochlorite solutions have been proven, and they are used in dermatology, e.g. in atopic dermatitis. Literature indicates their ability to reduce microbial load on tissue surfaces through rinsing. Research results on their antimicrobial activity are inconsistent due to the lack of a residual effect, as hypochlorites break down and deactivate. On the other hand, this also contributes to their high safety profile. Hypochlorites are substances with high oxidative potential, which is the main mechanism responsible for destroying microbial structures. Human cells are not sensitive to low concentrations of around 40/50 ppm, as they possess a natural detoxification mechanism. This results from the natural production of HOCl during the process of phagocytosis.
• Form: solution. Medical device.
• Sterility: none – the manufacturer guarantees microbiological purity (statement available).
• Contraindications and safety measures: see IFU. Hypersensitivity to any component of the formulation. Do not ingest.
• Notes The manufacturer recommends a contact time of 15 minutes.
• Suggested use: for rinsing wounds on the nipple.
• Form: solution. Medical device.
• Sterility: none; the manufacturer guarantees microbiological purity.
• Contraindications and safety measures: see IFU. Hypersensitivity to any component of the formulation. Do not ingest.
• Notes The manufacturer recommends a contact time of 15 minutes.
• Suggested use: for rinsing wounds on the nipple.
Granusept
• Form: solution. Medical device.
• Sterility: none; the manufacturer guarantees microbiological purity
• Contraindications and safety measures: see IFU. Hypersensitivity to any component of the formulation. Do not ingest.
• Notes The manufacturer recommends a contact time of 15 minutes.
• Suggested use: for rinsing wounds on the nipple.
Aquitox D
• Form: solution. Medical device.
• Sterility: none; the manufacturer guarantees microbiological purity.
• Contraindications and safety measures: see IFU. Hypersensitivity to any component of the formulation. Do not ingest.
• Notes The manufacturer recommends a contact time of 2 minutes.
• Suggested use: for rinsing wounds on the nipple.
Octenilin® Wound Irrigation Solution
• Form: irrigation solution.
• Ingredients: octenidine, ethylhexylglycerin, glycerol.
• Surfactant: ethylhexylglycerin.
• Sterility: yes.
• Antimicrobial effect.
• Medical device. Studies show that the concentration of octenidine used in the medical product Octenilin exhibits bactericidal activity – reducing bacterial count by 5 log levels – against both Gram-positive and Gram-negative microorganisms as early as 15 seconds after exposure (incubated with exudate).
• Contraindications and safety measures: see IFU. The product is non-irritating, non-allergenic, painless to use, non-toxic to tissue, and does not hinder granulation or epithelial regeneration. The solution has good tissue tolerance. Octenilin® Wound Irrigation Solution, due to its low surface tension, provides excellent moisturizing and cleansing properties, even in hard-to-reach areas such as fissures, cracks, and the inside of
wound pockets. For external use only on skin wounds. Interactions: Do not use in combination with anionic surfactants or other wound-cleaning agents such as soaps, ointments, oils, enzymes, etc., as this may adversely affect its preservation. Do not use in combination with PVP-iodine, as this may cause discolouration and reduce the antiseptic effect of PVP-iodine. If an allergy or suspected allergy to one or more ingredients is present, Octenilin® Wound Irrigation Solution must not be used. If unsure, consult your physician. To avoid potential tissue damage, Octenilin® Wound Irrigation Solution must not be applied to hyaline cartilage, eyes, ears, nose, bladder, or the abdominal cavity. Do not use for infusion or injection. Do not ingest. To prevent tissue injury, do not inject or apply the product under pressure into tissue. Proper drainage from wound cavities must always be ensured.
• Notes: Octenidine is not absorbed into the bloodstream, and the risk of its presence in breast milk is very low. Residual effect. Time of action – 1 minute.
• Suggested use: for rinsing nipple wounds to cleanse the area and reduce microbial burden. Due to the residual effect, rinsing before breastfeeding is recommended.
Prontosan® Wound Irrigation Solution
• IFU dated 22.04.2025 – Pregnancy and lactation There is no evidence of mutagenic or embryotoxic effects related to the ingredients of this product. However, due to the lack of adequate clinical studies and experience, Prontosan Wound Irrigation Solution should not be used in pregnant or breastfeeding women.
SutriSept® Płyn na rany [Wound cleansing fluid]
• Form: wound cleansing fluid.
• Ingredients: Water, poloxamer 188, polyhexamethylene biguanide (polyhexanide, PHMB) 0.1%.
• Surfactant: poloxamer 188.
• Sterility: no.
• Antimicrobial effect. Medical device.
• Contraindications and safety precautions (IFU): Polyhexanide is not absorbed into the systemic circulation, and the likelihood of it being excreted into breast milk is nearly zero. Due to the lack of clinical studies and experience in using the product in pregnant and breastfeeding women, the SutriSept® Wound cleansing fluid
should be used with caution, following a medical assessment.
• Newborns and infants: Due to insufficient clinical data for newborns and infants, the SutriSept® Wound cleansing fluid should only be used under strict medical supervision.
• To date, no adverse reactions have been reported for the SutriSept® Wound cleansing fluid, but rare cases (frequency less than 1 in 10,000) of anaphylactic shock caused by polyhexanide have been reported. The SutriSept® Wound cleansing fluid may cause allergic reactions such as itching (urticaria) and rash. Do not use the product in individuals with hypersensitivity to this substance. In very rare cases, a mild burning sensation may occur after applying the SutriSept® Wound cleansing fluid, but it subsides within a few minutes.
• The SutriSept® Wound cleansing fluid is compatible with all modern wound dressings.
• Do not use the SutriSept® Wound cleansing fluid in the following cases:
• it is not suitable for application to hyaline cartilage or for use in aseptic joint surgeries, in the middle or inner ear, or in the eyes. It must also not be applied to the central nervous system or the meninges. If used in combination with anionic surfactants, soaps, creams, oils, or enzymes, these substances must be thoroughly removed from the wound surface before applying the product.
• For external use on the skin only.
• The SutriSept® Wound cleansing fluid must not be administered via intravenous infusion or injection.
• Note: PHMB is not absorbed into the bloodstream, and it is unlikely to pass into breast milk. Residual effect. Time of application – 15 minutes.
• Suggested use: for rinsing nipple wounds to cleanse the area and reduce microbial burden. Due to the residual effect, rinsing afterwards is advised.
• To be used as a moisturising wound dressing.
• Medical device.
• Contraindications and safety precautions: same as for solutions.
• Warning. For external use only, under the supervision of a medical proffesional. No studies have been conducted in breastfeeding women. Apply
Treatment of nipple wounds during breastfeeding
to the nipple after breastfeeding. The product may remain on the wound surface until the next dressing change. Before feeding the baby, the gel must be thoroughly rinsed off the nipple, as hydrogels liquefy upon contact with water.
• Aquitox 0.03%
• Granudacyn 0.004%
• Microdacyn Hydrogel 0.006% Hydrogels with added surfactant:
• Octenilin gel 0.05% (+ oxadermol)
• SutriSept gel 0.1% (+ poloxamer)
The percentage indicates the concentration of the antiseptic agent.
Octenisept® Spray
• Contains a surfactant – betaine.
• Composition: octenidine 0.1%, phenoxyethanol 2%, betaine.
• Medication for the disinfection of wounds, mucous membranes, and skin.
• Indication: for superficial wounds, especially in cases of infection or suspected colonisation with multidrug-resistant strains.
• Time of action – 1 min.
• To be used as a spray, swab, or compress for up to 5 minutes.
• Commonly used for everything from ulcers to acute wounds.
• Available in various forms: liquid, gel, cleansing emulsions, dressings.
• Octenidine has a high safety profile and can be used from the first day of life.
• It shows a broad-spectrum bactericidal effect against multidrug-resistant Gram-positive and Gram-negative bacteria, fungi, and yeasts.
• Compared to other substances, it has an effective bactericidal action even with a short contact time and low concentration, and remains active in the presence of protein load (exudate, blood) – 30 seconds.
• It has anti-inflammatory and immunomodulatory properties that support the healing process.
• It shows a residual effect.
Povidone-iodine (source: Braunol 7.5% skin solution, SmPC)
• Does not contain a surfactant.
• Medication.
• During pregnancy and breastfeeding, Braunol – like all iodine-based products – should only
Żukowska-Rubik, Magdalena Nehring-Gugulska, Beata Mrozikiewcz-Rakowska et al.
be used under strict medical indication, and its use should be very limited. After use, assessment of the infant’s thyroid function is recommended. If hypothyroidism is diagnosed, early hormone therapy should be initiated until normal thyroid function is restored. During breastfeeding, care should be taken to prevent accidental entry of Braunol into the child’s mouth from the treated areas of the mother’s body.
• Contraindications for the use of PVP-I include hypersensitivity to the active substance, toxic goiter, Hashimoto’s disease, Duhring’s disease, and peritoneal cavity irrigation.
• It passes into breast milk, and the concentration of iodides in breast milk increases to a greater extent than in blood serum.
• Antiseptics containing povidone-iodine should not be used during pregnancy and breastfeeding.
• Due to potential side effects, it is not recommended for use on cracked or wounded nipples.
Povidone-iodine (source: SmPC BETADINE, 100 mg/ml, skin solution)
• Does not contain a surfactant.
• Medication.
• The product may only be used after the second month of pregnancy and during breastfeeding if a thorough diagnosis has been made and there are strict indications for its use. In such cases, thyroid function in both mother and child should be monitored. The duration of treatment must be limited to the shortest possible time.
• Iodine crosses the placenta and is excreted in breast milk. Moreover, iodine reaches higher concentrations in breast milk than in serum. Povidone-iodine may cause transient hypothyroidism in the newborn.
• The infant must be strictly protected from ingesting the product!
• Povidone-iodine should not be used during pregnancy and breastfeeding.
• Due to potential side effects, it is not recommended for use on cracked or wounded nipples.
Table I. Classification and types of dressings registered by manufacturers for use in nipple pain and wounds
Brand Name
Ardo Ardo Care Compresses
Multi-Mam Multi-Mam Compresses
Canpol babies
Gel pads and dressings
Water, pentylene glycol, xanthan gum, betaine, sodium hyaluronate, sodium anisate, lactic acid
Aloe leaf extract (2QR complex: patented bioactive polysaccharides), water, glycerine, xanthan gum, citric acid, caprylyl glycol, sodium benzoate, potassium sorbate, sodium hydroxide
Hydrogel pads and dressings
Soothing hydrogel breast pads with lanolin
Chicco Hydrogel nipple compress – currently unavailable
Lansinoh SOOTHIES® cooling gel pads
Medela Hydrogel pads
Ferris Mfg. Corp. Nursicare
Water, glycol, polymer, lanolin
Yes
Yes
Yes
Polyester, water, glycerol, polymer Yes
Plant-based glycerine, polymer, water Yes
Water, glycerol, polymer (sodium AMPs) Yes
Foam dressings
Polyurethane matrix, glycerine, surfactant: surfactant F-68; absorbent: starch copolymer
Yes
Specialist dressings whose use may be considered for nipple wounds, after weighing the benefits and risks
Specialist dressings are classified as medical devices. They should be used in accordance with the instructions for use, and under the supervision of a medical proffesional.
RECOMMENDATION: After removing the dressing, the wound and surrounding skin should be thoroughly cleansed. Follow the standard protocol for breast preparation before breastfeeding.
It is important to remember that nipple wounds during lactation differ in nature from other chronic or hard-to-heal wounds. When selecting a specialist dressing for these wounds, this distinction must be taken into account! Potential benefits of using dressings include the creation of a moist healing environment, absorption of exudate, antimicrobial action, and protection of the wound from external exposure. Potential drawbacks include the need to frequently remove the dressings for breastfeeding and to clean off any residue from the nipple surface, which may damage healing tissue and cause pain. Therefore, the benefits and risks must be assessed on a case-by-case basis.
The Annex includes examples of dressings available at the time of publication.
• Dressing indicated, among other uses, for the treatment of “abrasions and other superficial skin injuries”
• The Aqua-Gel® hydrogel dressing is a specialist dressing. It is composed of 91.5% pharmacopeia-grade water and natural and synthetic polymers that are permanently cross-linked using an electron beam. These polymers form a network that provides the dressing with a stable structure.
• Thanks to its hydrogel structure, the dressing has a soothing and analgesic effect, improving patient comfort.
• It supports autolytic wound debridement.
• The dressing is hypoallergenic and non-sensitising. Its ingredients are fully biocompatible.
• The dressing’s transparency is an advantage during treatment, allowing for continuous monitoring of the wound and early detection of any adverse changes.
• Important: prolonged use of a sterile hydrogel dressing may lead to maceration of the skin surrounding the wound.
• The frequency of dressing changes depends on the amount of wound exudate.
• When changing the dressing, the wound should be rinsed with a wound decontamination solution; the manufacturer recommends, for example, Microdacyn.
Main characteristics:
1. Do not contain antimicrobial agents.
2. Sterile.
3. Protect the wound from drying out while allowing free exudate transfer to the secondary dressing.
4. Require a secondary dressing, such as a sterile gauze pad, high-absorbency dressing, polyurethane foam, and fixation with adhesive tape or clothing.
5. The dressings form a breathable protective barrier.
6. They enable unrestricted drainage of exudate to the secondary dressing.
7. Intended for superficial wounds without signs of infection!
Mesh dressing impregnated with neutral ointment
• A mesh dressing that does not contain any active substances. (GRASSOLIND).
Mesh dressing impregnated with paraffin
• Paraffin dressing. Made of sterile gauze coated with white paraffin. It is compatible with ointments, including those containing antibiotics. Made from high-quality cotton gauze providing effective wound protection. (JELONET).
• Gauze dressing impregnated with paraffin. Helps maintain proper wound moisture, prevents drying and maceration of the wound edges. The neutral properties of paraffin allow the dressing to be used in combination with other products containing medicinal substances or antiseptic agents. (PARAFFINET).
Mesh dressing – various structures
• Thin, hydrophobic tulle mesh dressing, impregnated with a neutral, non-active, and non-allergenic ointment. Ensures good ventilation. (ATRAUMAN). Made from smooth viscose knit impregnated with an oil-in-water emulsion; mesh size 1×1 mm to prevent ingrowth of granulation tissue. It is a contact layer dressing with moisturizing and emollient effects that prevents adherence to the wound surface. (ADAPTIC).
• A hydrogel dressing in the form of a polyester fiber tulle mesh impregnated with a coating mass consisting of a polymer matrix. This is a flexible fixing mass that allows flexible shaping. Additional components include petrolatum and hydrocolloid. (LOMATUELL PRO).
• A non-adherent dressing made of tulle mesh impregnated with a polymer matrix containing fat and hydrocolloid. In contact with wound fluids, hydrocolloid particles form a gel, which, together with petrolatum, creates an amphiphilic layer (hydro-lipo-flow). This promotes wound healing and prevents adhesion to the wound. The dressings are sterile and individually packed. (LOMATUELL® PRO).
Group 2. Mesh dressings containing antimicrobial substances
Features
• They contain antimicrobial agents, mainly silver particles.
• Recommended for wounds showing signs of infection or at risk of infection.
• The mesh form allows cutting the dressing to fit the wound size, ensuring efficient use and reducing the risk of maceration of the skin surrounding the wound.
• + same as in Group 1
Antibacterial dressing with neutral ointment containing metallic silver
• A low-cytotoxicity dressing with metallic silver for infected wounds or those at risk of infection. Recommended as a complementary treatment for infected wounds or wounds exposed to contamination.
• Based on research, the manufacturer recommends it for use against Gram-negative and Gram-positive bacteria, including strains of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, and Bacillus subtilis.
• The dressing’s carrier material consists of a hydrophobic polyamide mesh impregnated with an ointment containing plant-derived fatty acids. The ointment cares for the wound edges and maintains their elasticity. This specialist dressing contains no vaseline or other paraffin-based components, preventing adherence to the wound and allowing painless removal. (ATRAUMAN AG).
Antibacterial dressing impregnated with silver salts, made using lipid-coloid technology
• A dressing impregnated with silver salts. It contains a healing matrix with silver, made of polyester mesh impregnated with hydrophilic particles (carboxymethylcellulose), vaseline, cohesive polymers, and silver salts.
• Bactericidal efficacy against bacteria (Pseudomonas aeruginosa, Staphylococcus aureus).
• Suitable for deep and fissure wounds.
• Indicated for treatment of wounds with risk or signs of local bacterial infection with small amounts of exudate. (UrgoTul Ag/Silver).
Dressing with nanocrystalline silver
• Exhibits bactericidal activity. The dressing is intended for the treatment of superficial, hardto-heal wounds with a tendency to exude, as well as wounds located in areas difficult to dress.
• The nanocrystalline silver coating releases silver ions. Polyethylene mesh with a high-density weave. Low adhesion facilitates easy dressing removal.
• Recommended for infected as well as infection-prone superficial and deep wounds. (ACTICOAT FLEX 3).
Dressing with ionic silver (1.2%), made using hydrofiber™ technology. antibiofilm dressing –contains ethylenediaminetetraacetic acid (EDTA) and benzethonium chloride (BEC)
• It consists of two layers made from sodium carboxymethylcellulose fibers, reinforced with stitching. It is created using the More Than Silver™ and Hydrofiber™ technologies.
• Recommended for wounds with moderate and/or heavy exudate and biofilm formation.
• Forms a coherent gel when in contact with exudate. This creates an ideal environment supporting the wound healing process. Thanks to Hydrofiber™ technology, the dressing locks excess exudate, bacteria, and biofilm within its structure.
• For deep wounds, fill only up to 80% of the wound cavity with the dressing. This is due to the dressing’s properties, which initially contract slightly upon contact with exudate during gel formation, then expand to fill the empty space.
• It requires the use of a secondary dressing. (AQUACEL AG +EXTRA).
Features
1. Allow the skin to breathe.
2. Protect the wound from drying out, absorb exudate through various mechanisms – depending on the structure of the dressing.
3. Intended for superficial wounds without signs of infection!
4. Versions available – adhesive and non-adhesive. NON-ADHESIVE versions must not be cut.
5. Can be used as primary dressings (for shallow wounds, e.g. abrasions) or as secondary ones, to cover e.g. a mesh dressing with an antimicrobial substance.
6. All foam dressings have cushioning properties.
7. They are waterproof, transparent, and flexible, which increases user comfort.
8. They do not stick to the wound, making dressing changes painless.
9. They protect the wound from the entry of bacteria and microorganisms.
10. They help maintain an optimal environment for wound healing.
• Foam dressing with a wound contact layer made using Hydrofiber™ technology. Thanks to its absorbent properties and the use of silicone adhesives, the dressing is well suited for treating wounds of various etiologies.
• It is composed of a waterproof, highly breathable polyurethane outer film, a soft absorbent foam layer, a Hydrofiber™ wound contact layer, and a gentle silicone adhesive (in the adhesive version).
• The outer polyurethane layer makes the dressing waterproof, which protects the wound from viruses and bacteria, while allowing the patient to wash without removing the dressing.
• Thanks to the outer polyurethane film, the wound environment maintains an optimal moisture level, with any excess moisture being evaporated.
• The dressing absorbs and retains exudate in its structure, reducing the risk of skin maceration.
• Hydrofiber™ technology also helps reduce the level of active matrix metalloproteinases in chronic wounds and stimulates angiogenesis, which greatly benefits the healing process. (AQUACEL FOAM).
Foam dressing
• Dressing made of a three-layer construction consisting of:
• a perforated wound-contact layer that allows even sticky exudate to pass into the dressing,
• a hydrocellular core that absorbs and retains fluid in its microscopic structure,
• a breathable outer surface that allows excess moisture to evaporate from the dressing, while serving as a tight barrier against bacteria and foreign matter.
• This dressing is suitable for exudate absorption and for treating partial- or full-thickness wounds.
• Dressings should not be used with oxidising agents such as hypochlorite solutions or hydrogen peroxide, as these may break down the absorbent hydrocellular component of the dressing. (ALLEVYN).
Foam dressing with Safetac® soft silicone contact layer
• It is soft and conformable to the surrounding skin
• The dressing has a unique pain-minimising contact layer made of Safetac® soft silicone. Clinical studies show that dressings with Safetac® technology minimise wound and skin damage during removal. By sealing the wound edges, they help prevent maceration. Because they do not damage the wound or surrounding skin, pain during dressing changes is minimised. For shallow wounds with low to moderate exudate. (MEPILEX).
Foam dressing for low exudate wounds – 3-layer structure
• The dressing consists of an outer polyurethane layer that is waterproof and provides effective protection against bacteria and viruses, while allowing optimal moisture evaporation from the wound environment. The middle layer is a thin, flexible, and soft foam that absorbs exudate and maintains a moist wound environment conducive to healing. The adhesive contact layer is made of silicone. The silicone layer is gentle and skin-friendly, allowing safe and painless application, removal, and repositioning.
• Its soft and elastic design allows it to adapt effortlessly to different areas of the body. The dressing effectively protects, secures, and cares for low-exudate wounds. (Foam Lite™ ConvaTec).
Żukowska-Rubik, Magdalena Nehring-Gugulska, Beata Mrozikiewcz-Rakowska et al.
Foam dressing with silicone – Kliniderm®
• Soft, conformable, and absorbent polyurethane foam dressing with a silicone contact layer. This layer protects the surrounding skin and reduces pain during dressing changes. Exudate is retained inside the dressing, while the outer layer allows for free gas exchange.
• Suitable for superficial wounds. (Kliniderm Foam Silicone).
Foam dressing with contact layer made using TLC technology
• Contact dressing intended for clean wounds with slight exudate, especially during granulation and epithelialization stages. (UrgoTul Absorb).
Group 4. Foam dressings with antimicrobial substances
Polyurethane dressing containing 0.5% PHMB and 0.1% B-panthenol
• The dressing consists of a polyurethane foam core with an open-cell structure. The foam core absorbs and retains exudate, reducing maceration of the surrounding skin. The antimicrobial agent PHMB (polyhexamethylene biguanide) reduces and prevents bacterial growth in the wound and dressing. B-Panthenol moisturises and improves skin hydration. The dressing also features a breathable outer polyurethane layer that allows internal moisture transfer while being resistant to external bacteria and water, thus maintaining a moist wound environment.
• It can be used as a primary or secondary dressing. (KLINIDERM FOAM PHMB).
Antibacterial foam dressing with a Safetac® silicone contact layer
• Antibacterial foam dressing for wounds with low to moderate exudate.
• The dressing gently adheres to the skin thanks to the unique Safetac® silicone contact layer, which reduces pain. This significantly lessens the pain experienced by patients during dressing changes.
• It exhibits rapid and long-lasting antibacterial activity.
• In vitro studies have shown that the silver foam dressing can inactivate wound pathogens (bacteria and fungi) within 30 minutes. According to international consensus, antibacterial action is essential and key to reducing biological
contamination in infected wounds. The dressing acts as an antibacterial barrier where there is a high risk of infection or reinfection. (Mepilex Ag).
Multilayer foam dressing with silver ions
• The dressing is suitable for shallow wounds that are infected or suspected of infection, with moderate to heavy exudate.
• The dressing can be used as either a primary or secondary dressing.
• Thanks to the presence of silver ions, the dressing is effective against a wide range of microorganisms, including MRSA, VRE, and other antibiotic-resistant strains.
• Thanks to Hydrofiber technology, the dressing can also be used on heavily exuding wounds. When in contact with wound exudate, the dressing’s contact layer transforms into a cohesive gel, allowing it to conform closely to the wound surface and fill empty spaces where bacteria might grow.
• The dressing also supports the removal of necrotic tissue (autolytic debridement), without damaging healthy tissue. It also reduces the risk of cross-infection during dressing changes by retaining exudate and its harmful components within the dressing. (AQUACEL® Ag Foam).
According to Article 2(1) of the Polish Act of 7 April 2022 on Medical Devices (Journal of Laws 2022, item 974):
A medical device is a tool, apparatus, appliance, software, implant, reagent, material, or other article intended by the manufacturer to be used on humans for medical purposes such as:
• diagnosing, preventing, monitoring, treating or alleviating disease,
• diagnosing, monitoring, treating, alleviating or compensating for injury or disability,
• examining, replacing or modifying the anatomy or a physiological process,
• controlling conception.
Additionally:
• A medical device does not achieve its principal intended action by pharmacological, immunological or metabolic means, but its function may be assisted by such means.
The differences between a medical device and a medicinal product
Definition and mechanism of action
• A medical device works through mechanical, physical or electronic means – e.g., implants, syringes, diagnostic equipment, dressings. It may contain pharmacological substances, but these are not its main mechanism of action.
• A medicinal product acts on the human body through pharmacological, immunological or metabolic means – e.g., antibiotics, vaccines, painkillers. Regulations
• Medical devices are governed by Regulation (EU) 2017/745 (MDR).
• Medicinal products are regulated by the Pharmaceutical Law and Regulation (EU) 2001/83/ EC.
• Assessment and marketing authorization
• Medical devices require a conformity assessment and CE certification, often involving a notified body.
• Medicinal products must undergo clinical trials
and receive marketing authorization from bodies such as the EMA (European Medicines Agency) or URPL (Polish Office for Registration of Medicinal Products)
• In summary: a medical device is not a drug, although some products (e.g., inhalers with medication) may combine characteristics of both categories.
• The definition of a biocidal product can be found in the Act of 9 October 2015 on Biocidal Products (Journal of Laws 2022, item 2178).
According to Article 2(1)(1) of this Act:
A biocidal product is “a substance, mixture or article, in the form in which it is supplied to the user, consisting of, containing, or generating one or more active substances, intended to destroy, deter, render harmless, prevent the action of, or otherwise control harmful organisms by means other than purely physical or mechanical action”.
This definition aligns with and implements Regulation (EU) 528/2012 into national law.
Table II. Differences between a medicinal product, a medical device and a biocidal product
Feature Medicinal product
Purpose
Mechanism of action
Treatment, prevention of diseases, diagnosis or modification of body functions
Pharmacological, immunological or metabolic agents that affect the human body
Examples Antibiotics, vaccines, painkillers
Regulations
Pharmaceutical Law (Journal of Laws 2022, item 2301)
Medical device
Diagnosis, prevention, monitoring, treatment or alleviation of diseases and injuries
Physical, mechanical or electronic action (possibly supported by pharmacological means)
Syringes, implants, CT scanners, contact lenses, medical software
Medical Devices Act of 7 April 2022 (Journal of Laws 2022, item 974)
Biocidal product
Destruction, deterrence, neutralization of harmful organisms
Chemical or biological action against microorganisms (e.g. bacteria, viruses, fungi)
Disinfectants, insecticides, anti-mould agents
Biocidal Products Act of 9 October 2015 (Journal of Laws 2022, item 2178)
Praca oryginalna | Original paper
LECZENIE RAN 2025; 22 (2): 80–87
DOI: 10.60075/lr.v22i2.100
Ekspozycja na materiał potencjalnie zakaźny
Katarzyna Cierzniakowska1,2, Daria Kaniewska1,3, Elżbieta Kozłowska1,2, Aleksandra Popow1
1 Katedra Pielęgniarstwa Zabiegowego, Wydział Nauk o Zdrowiu, Collegium Medicum w Bydgoszczy, UMK w Toruniu
2 Klinika Chirurgii Ogólnej i Małoinwazyjnej, Szpital Uniwersytecki nr 2 im. dr J. Biziela w Bydgoszczy
3 Oddział Pediatrii, Pneumonologii i Alergologii, Wojewódzki Szpital Dziecięcy im. Józefa Brudzińskiego w Bydgoszczy
Streszczenie
Wstęp: Ekspozycja na materiał potencjalnie zakaźny umożliwia transmisję zakażenia i w sposób szczególny podnosi ryzyko poważnych konsekwencji zdrowotnych pracowników medycznych.
Cel pracy: Ocena zakresu występowania ekspozycji zawodowej i zastosowania profilaktyki poekspozycyjnej.
Materiał i metody: W badaniu wzięło udział 229 pielęgniarek i 13 pielęgniarzy. Zastosowano metodę sondażu diagnostycznego z wykorzystaniem anonimowej ankiety własnego autorstwa, które przeprowadzono drogą elektroniczną. Wyniki: Ekspozycja zawodowa wystąpiła u 53,7% badanych. Do ekspozycji dochodziło ze zbliżoną częstotliwością podczas pobierania krwi (28,5%), podawania leków (26,2%) oraz wykonywania innych czynności terapeutyczno-pielęgnacyjnych 23 (20%). Nie występowały różnice statystyczne względem poszczególnych przyczyn ( p > 0,05). W przypadku 8,2% badanych do ekspozycji przyczynił się brak bezpiecznego sprzętu medycznego. Istotnie statystycznie częściej do ekspozycji przyczyniało się pobudzenie psychoruchowe chorych (26,9%) i brak ostrożności (24,6%). Nie obserwowano związku pomiędzy występowaniem ekspozycji, a stażem, wykształceniem, miejscem pracy, systemem pracy czy formą zatrudnienia (p>0,05). Czynności ryzykownych nie podejmowało w badanej grupie jedynie 45 osób (18,6%). Zgłaszalność ekspozycji wynosiła 80,8%.
Wnioski:
• Ponad połowa badanych doznała ekspozycji zawodowej.
• Najczęstsze procedury podczas których dochodziło do ekspozycji zawodowej ze zbliżoną częstotliwością, to: pobieranie krwi, podawanie leków oraz czynności pielęgnacyjne.
• Jako najczęstsze przyczyny ekspozycji badani podawali pobudzenie psychoruchowe chorych lub nieadekwatną reakcję na wykonywaną u nich czynność zabiegową.
Adres do korespondencji
Katarzyna Cierzniakowska, Katedra Pielęgniarstwa Zabiegowego, Wydział Nauk o Zdrowiu Collegium Medicum w Bydgoszczy, ul. Łukasiewicza 1, 85-821 Bydgoszcz, e-mail:
Nadesłano: 25.05.2025; Zaakceptowano: 1.06.2025
Abstract
Introduction: Exposure to potentially infectious material enables the transmission of infection and particularly increases the risk of serious health consequences for medical workers.
Aim of the study: Assessment of the scope of occupational exposure and the use of post-exposure prophylaxis.
Material and methods: The study involved 229 nurses and 13 male nurses. The diagnostic survey method was used using an anonymous self-authored questionnaire, which was conducted electronically.
Results: Occupational exposure occurred in 53.7% of the respondents. Exposure occurred with similar frequency during blood collection (28.5%), drug administration (26.2%) and performing other therapeutic and nursing activities 23 (20%). There were no statistical differences in terms of individual causes ( p > 0.05). In the case of 8.2% of the respondents, the lack of safe medical equipment contributed to the exposure. Psychomotor agitation of patients (26.9%) and lack of caution (24.6%) contributed to the exposure significantly more often. There was no relationship between the occurrence of exposure and seniority, education, place of work, work system or employment form (p>0.05). Only 45 people (18.6%) did not undertake risky activities in the study group. The reporting of exposure was 80.8%.
Conclusions:
• More than half of the respondents experienced occupational exposure.
• The most common procedures during which occupational exposure occurred with similar frequency were: blood collection, medication administration and nursing activities.
• The most common causes of exposure were psychomotor agitation of patients or inadequate reaction to the surgical procedure performed on them.
• Ryzyko ekspozycji zawodowej dotyczy całej grupy zawodowej pielęgniarek i pielęgniarzy niezależnie od ich poziomu wykształcenia, stażu pracy, miejsca pracy, sposobu zatrudnienia czy systemu pracy.
• Tylko, niespełna co piąta ankietowana osoba wskazała, że nie podejmuje działań ryzykownych uznawanych za potencjalne czynniki prowadzące do ekspozycji. Słowa kluczowe: ekspozycja zawodowa, materiał zakaźny, profilaktyka.
Ekspozycja na materiał potencjalnie zakaźny oznacza narażenie na krew lub inny potencjalnie zakaźny materiał biologiczny w czasie wykonywania obowiązków zawodowych przy udzielaniu świadczeń zdrowotnych. Do ekspozycji zawodowej dochodzi w wyniku zranienia skóry ostrym skażonym narzędziem, kontaktu błon śluzowych, uszkodzonej lub nieuszkodzonej skóry z materiałem pochodzącym od pacjenta, ugryzienia [1, 2].
Narażenie pracowników medycznych na materiał biologiczny pochodzący od pacjenta może następować, zarówno poprzez bezpośredni kontakt z chorymi (drogą kropelkowa) bądź kontakt z narzędziami i sprzętem zanieczyszczonym krwią lub innymi wydalinami chorego (drogą krwiopochodną) [3].
Ekspozycja na materiał potencjalnie zakaźny umożliwia transmisję zakażenia i w sposób szczególny podnosi ryzyko poważnych konsekwencji zdrowotnych, dlatego też konieczne jest rozważenie profilaktyki poekspozycyjnej.
Czynniki etiologiczne przenoszone drogą krwi Wykonywanie zadań związanych z dużym ryzykiem przerwania ciągłości skóry, takich jak: udział w zabiegach chirurgicznych, opatrywanie ran, pobieranie krwi, wykonywanie iniekcji, intubacji, badań endoskopowych, charakteryzuje się wysokim prawdopodobieństwem zakażenia wirusami przenoszonymi droga krwiopochodną. W grupie zawodów medycznych najwyższe ryzyko ekspozycji występuje wśród pielęgniarek i lekarzy [4].
Przyczynę zakażeń wynikających z narażenia na kontakt z krwią i płynami ustrojowymi może stanowić ponad 30 różnych patogenów. Wśród nich, największe zagrożenie stanowi ekspozycja na wirusy hepatotropowe. Wirus zapalenia wątroby typu B (hepatitis B virus – HBV), wirus zapalenia wątroby typu C (hepatitis C virus – HCV) i ludzki wirus niedoboru odporności (human immunodeficiency virus – HIV), powodują najwyższy odsetek zakażeń
• The risk of occupational exposure applies to the entire professional group of nurses and male nurses regardless of their level of education, seniority, place of work, employment method or work system.
• Only less than every fifth person surveyed indicated that they did not undertake risky activities considered to be potential factors leading to exposure.
Key words: occupational exposure, infectious material, prevention.
rozpoznawanych wśród personelu medycznego. Wskaźniki zachorowań wśród personelu medycznego na świecie powstające na skutek swoistego rodzaju ekspozycji zawodowych podawane przez Światową Organizację Zdrowia (World Health Organization – WHO) (2003 r.) wynoszą odpowiednio: 37,6% zachorowań na wirusowe zapalenie wątroby typu B (WZW B), 39% na wirusowe zapalenie wątroby typu C (WZW C) oraz 4,4% zakażeń HIV, co jest konsekwencją rozpowszechnienia tych wirusów w populacji [1, 4–6].
Analiza wielu badań dotyczących wszystkich aspektów zapalenia wątroby typu B u pracowników ochrony zdrowia opublikowanych od 2017 r. do kwietnia 2023 r, ujawniła duże zróżnicowanie częstości występowania zakażenia od 0,6% w Europie do > 8,7% w Afryce, prawie zawsze w powiązaniu z bardzo niskim wskaźnikiem szczepień. Wiedza i poglądy pracowników medycznych na temat WZW B i szczepienia przeciwko WZW B determinują ich status szczepień oraz ogólne postawy i praktyki dotyczące zakażenia WZW B [7].
Szczepienie przeciw WZW B w Polsce jest szczepieniem obowiązkowym dla noworodków od 1994 roku.
Czynniki etiologiczne przenoszone drogą kropelkową
Pracownicy medyczni, obok ryzyka zakażeń krwiopochodnych, są również narażeni na wysokie ryzyko zakażeń układu oddechowego. Ze względu na łatwość zakażenia drogą wziewną, kontakt z chorymi na grypę [wirusy grypy typu A, B i C (Orthomyxoviridae)] czy gruźlicę [prątki gruźlicy (Mycobakterium tuberculosis)] stanowi poważne zagrożenie dla personelu medycznego. Najlepszym sposobem prewencji zachorowań jest stosowanie środków ochrony osobistej oraz szczepienia ochronne [3].
W świetle badań, za procedury medyczne, które prawdopodobnie generują aerozole i kropelki jako źródło patogenów układu oddechowego i tym samym stwarzają zwiększone ryzyko przeniesienia infekcji
Beata Wieczorek-Wójcik, Paulina Mościck,a Katarzyna Kowalska, Katarzyna Cierzniakowska
na personel, uznano intubację tchawicy, wentylację nieinwazyjną, tracheotomię i wentylację manualną przed intubacją. W przypadku innych procedur stymulujących kaszel i sprzyjających powstawaniu aerozoli, takich jak: odsysanie płynów ustrojowych, bronchoskopia, nebulizacja, tlenoterapia, defibrylacja, uciskanie klatki piersiowej, zakładanie sondy nosowo-żołądkowej i pobieranie plwociny, ryzyko przenoszenia przez nie infekcji nie zostało udowodnione [8].
Podczas czterotygodniowej obserwacji oraz na podstawie pobieranych z nosogardzieli wymazów od personelu medycznego w czterech chińskich szpitalach (223 osoby z klinik gorączkowych oraz oddziałów pulmonologicznych, pediatrycznych, ratunkowych/intensywnych) u 88% zidentyfikowano kolonizację bakteryjną, a u 22% z nich stwierdzono współzakażenie wirusem [9].
Leczenie ran a ryzyko ekspozycji
Zaopatrywanie ran – zarówno ostrych (szycie ran pourazowych, usuwanie szwów), jak i ran trudno gojących się (konieczność oczyszczania z tkanek martwiczych) – wiąże się z używaniem ostrych narzędzi, co stanowi potencjalne ryzyko ekspozycji zawodowej.
Z uwagi na to, że nie każdy chory hospitalizowany bądź leczony ambulatoryjnie ma określany profil serologiczny, zawsze ludzki materiał biologiczny należy traktować jako potencjalnie zakaźny. Szacuje się, że w Polsce liczba zakażonych HIV może sięgać 35 tys. osób, a zakażonych wirusem zapalenia wątroby typu C 150–200 tys. osób. Często, bezobjawowy przebieg choroby sprawia, że nawet 90% z tych osób może nie być świadoma zakażenia [1, 10, 11].
Tran i wsp. podkreślają, że brakuje dowodów naukowych dotyczących ryzyka i mechanizmów przenoszenia drobnoustrojów w wytwarzanych aerozolach z dróg oddechowych chorego oraz trudno stwierdzić, czy pracownicy ochrony zdrowia opiekujący się pacjentami poddawanymi procedurom generującym aerozol są bardziej narażeni na zarażenie się chorobami w porównaniu z pracownikami ochrony zdrowia opiekującymi się pacjentami niepoddawanymi takim procedurom [8].
W badaniach mikrobiologicznych ran trudno gojących się, a w szczególności owrzodzeń żylnych goleni, najczęściej izolowane są: Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacter cloacae complex, Enterococcus faecalis i Klebsiella oxytoca [12, 13]. Prawdopodobnie, wysoki stopień narażenia na materiał biologiczny występuje również podczas mechanicznego oczyszczania ran zakażonych. Płukanie rany,
sonoterapia, VersaJet, czy inne sposoby opracowania rany, podczas których powstaje aerozol, poprzez kontakt z błoną śluzową dróg oddechowych lub spojówek, mogą prowadzić do infekcji u personelu medycznego. Niestety, nie ma badań w zakresie ryzyka narażenia i zachorowań w grupie pielęgniarek i lekarzy zajmujących się leczeniem ran.
Profilaktyka
Obszary działania w przypadku pracowników sektora medycznego, którzy są narażeni na wpływ czynników biologicznych z zakresu wczesnej profilaktyki, dotyczą rozwiązań technicznych, organizacyjnych i prawnych. Ryzyko ekspozycji obniżają między innymi: przygotowanie pomieszczeń do pracy, klimatyzacja, dezynfekcja powietrza, dezynfekcja i sterylizacja narzędzi lub sprzętu, stosowanie jednorazowego sprzętu medycznego, zaopatrzenie pracowników w środki zabezpieczenia indywidualnego, zmniejszenie długości czasu pracy, przestrzeganie zarządzeń i rozporządzeń, standardowych postępowań poekspozycyjnych, szczepienia obowiązkowe i zalecane oraz szkolenia z zakresu zagrożeń zawodowych i zasad BHP [14–18].
Cel pracy
Celem pracy była ocena zakresu występowania ekspozycji zawodowej i zastosowania profilaktyki poekspozycyjnej.
Materiał i metody
Badanie zostało przeprowadzone w wersji elektronicznej w okresie od lutego do kwietnia 2023 r. Respondentów poinformowano na wielu forach internetowych, grupach zrzeszających pielęgniarki i pielęgniarzy, głównie poprzez portal Facebook. com. Aby zapewnić anonimowość, kwestionariusz umieszczono na odrębnej stronie WWW, niewymagającej logowania i podawania danych personalnych. Przystąpienie do badania było dobrowolne. Ankieta składa się z 19 pytań zamkniętych i podzielona została na dwie części. Część pierwsza składa się z ogólnych pytań określających ankietowanego oraz jego doświadczenia związane z możliwością narażenia na ekspozycję zawodową. Część druga skierowana była do osób, które kiedykolwiek doświadczyły ekspozycji zawodowej.
Charakterystyka osób badanych
W ankiecie łącznie udział wzięły 242 osoby, w tym 229 kobiet (94,6%) oraz 13 mężczyzn (5,4%). Średni wiek ankietowanych wynosił 37,4 roku (min. 22, maks.
65, mediana 35 lat). Wśród ankietowanych 13 osób (5,4%) posiadało wykształcenie średnie, 139 (57,4%) wykształcenie licencjackie, 56 (23,1%) magisterskie, a 34 (14,1%) posiadało dodatkowo specjalizację.
Średni staż pracy w zawodzie wynosił 14,18 roku (min. 4 miesiące, maks. 42 lata, mediana 10 lat). Wśród ankietowanych przeważającą większość stanowiły osoby zatrudnione na podstawie umowy o pracę. Tylko 22 osoby były zatrudnione w formie umowy zlecenie lub umowy cywilno-prawnej.
Przeważająca część (33,1%) ankietowanych pracuje na oddziałach zachowawczych, 64 osoby (26,4%) pracują na oddziałach zabiegowych, w przychodniach lub pracowniach 34 osoby (14%), a pozostałe 64 osoby (26,4%) w innych miejscach, w tym na bloku operacyjnym, oddziale ratunkowym, intensywnej terapii.
Jeżeli chodzi o system pracy, to zdecydowana większość respondentów pracuje w systemie dwuzmianowym (79,8% odpowiedzi).
Analiza statystyczna
Dane opracowano za pomocą metod statystycznych przy użyciu programu Excel i programu IBM SPSS Statistics 28. Jako poziom istotności statystycznej przyjęto p≤0,05.
Standardy bioetyczne
Na prowadzenie badań uzyskano zgodę Komisji Bioetycznej przy Collegium Medicum w Bydgoszczy (KB 528/2022)
Wyniki
Szkolenia związane z ekspozycją zawodową
Wśród ankietowanych 55 osób (22,7%) nie uczestniczyło w szkoleniach dotyczących ekspozycji zawodowej, w tym 53 (21,9%) z nich nie spotkało się z takimi szkoleniami, a dwie (0,8%) nie przejawiały zainteresowania tego typu szkoleniami. Pozostałe 187 osób (77,3%) uczestniczyło w tego typu szkoleniach, przy czym 82 (43,85%) tylko w dniu rozpoczęcia pracy, 86 (45,99%) uczestniczy w tego typu szkoleniach systematycznie, a 19 (10,16%) poza szkoleniami uzupełnia jeszcze wiedzę w ramach samokształcenia.
Zranienia bez ekspozycji na materiał zakaźny
Wśród ankietowanych 181 osób (74,8%) przyznało, że w czasie wykonywania czynności zawodowych doszło u nich do zranienia bez ekspozycji na materiał zakaźny, przy czym u dwóch osób (0,8%) było to jednokrotne zranienie, u 146 (60,3%) takie zranienia zdarzają się sporadycznie, rzadziej niż raz w roku,
a u 33 (13,6%) wielokrotnie, kilka razy w roku. Wśród pozostałych ankietowanych, 29 (12,0%) nie przypomina sobie takiego zdarzenia, a 32 (13,2%) nigdy się nie zraniły w czasie wykonywania czynności zawodowych. Do zranienia tego typu najczęściej dochodziło podczas otwierania ampułki (46,7%), posługiwania się nie zainfekowanym skalpelem lub innym ostrym narzędziem (20,6%) lub podczas przygotowywania roztworów leków (9,5%).
Ekspozycja zawodowa
W odniesieniu do ekspozycji na materiał zakaźny w trakcie wykonywania czynności zawodowych, wystąpiła ona u 130 osób (53,7%). Przy czym u jednej osoby (0,8%) było to jedno zdarzenie, u dwóch (1,5%) sytuacja taka wystąpiła dwukrotnie, 119 (91,5%) przyznało, że sytuacje takie występują sporadycznie, rzadziej niż raz w roku, a 8 (6,15%), że wielokrotnie, nawet kilka razy w roku. Ponadto 47 ankietowanych (19,4%) uznało, że sytuacja taka u nich nigdy nie wystąpiła, a 65 (26,8%) nie przypomina sobie takiej sytuacji.
Narażenie na ekspozycję zawodową potęguje wykonywanie czynności w stresie, w pospiechu, niezgodnie z zasadami czy z przepisami bezpieczeństwa i higieny pracy (BHP). Tylko 45 ankietowanych (18,6%) uznało, że nigdy nie wykonywali oni czynności ryzykownych w trakcie pracy. Wśród pozostałych, 85 osób (35,1%) nakładało nasadkę na zainfekowaną igłę, 62 (25,6%) nie zwracało uwagi na przepełnione pojemniki przeznaczone do wyrzucania ostrych odpadów, 25 (10,3%) niewłaściwie zabezpieczyło ostre przedmioty podczas wykonywania zabiegów medycznych, 22 (9,1%) wykonywało czynności pielęgnacyjne / zabiegowe bez należytego zastosowania środków ochronnych, a 3 (1,2%) zaniedbały przepisy BHP. Kolejne pytanie dotyczyło zgłaszania ekspozycji: Czy jeżeli doszłoby u Pani / Pana lub innej osoby obecnej na dyżurze do zranienia / ekspozycji, zgłosiłaby Pani / zgłosiłby Pan tą sytuację bezpośredniemu przełożonemu / pielęgniarce epidemiologicznej / do działu BHP?. W odpowiedziach 192 osoby (79,3%) na pewno taką sytuację za każdym razem zgłosiłyby przełożonemu lub innej odpowiedniej osobie. Natomiast 46 osób (15,8%) takiej sytuacji by nie zgłosiło, przy czym 20 z nich (8,3%) uznało, że procedura poekspozycyjna zawiera zbyt wiele formalności do realizacji, 24 (5,8%) jest zdania że jest to błahe zdarzenie bez konsekwencji, 5 osób (2,1%) wstydziłoby się tego, 3 (1,2%) nie mają w pracy tego typu procedur, a po dwie osoby (0,8%) odpowiedziały, że w ich pracy zdarzenia takie nie podlegają rejestracji oraz że nie miało świadomości,
Beata Wieczorek-Wójcik, Paulina Mościck,a Katarzyna Kowalska, Katarzyna Cierzniakowska
że należy zgłosić gdzieś tego typu zdarzenie. Żadnej odpowiedzi nie zakreśliły 4 osoby.
Dalsza część ankiety przeznaczona była dla osób, które kiedykolwiek doświadczyły ekspozycji zawodowej (130 osób).
Do ekspozycji najczęściej dochodziło podczas pobrania krwi (28,5%), podawania leków (26,2%), podczas czynności terapeutyczno-pielęgnacyjnych (20%), posługiwania się skalpelem lub innym ostrym narzędziem (14,6%) lub też podczas czynności porządkowania stanowiska pracy (10,8%). Ekspozycja miała miejsce w 70 przypadkach (53,8%) przy łóżku chorego, w 45 przypadkach (33,1%) w gabinecie zabiegowym lub opatrunkowym, w 15 (11,5%) na sali operacyjnej lub porodowej, a w 2 przypadkach (1,5%) w karetce. Zdecydowana większość osób, które uległy ekspozycji (80,8%) zgłosiła ten fakt bezpośredniemu przełożonemu lub pielęgniarce epidemiologicznej i wdrożyła we właściwy sposób procedurę poekspozycyjną. Pozostałe nie poinformowały o ekspozycji, ponieważ (według częstości odpowiedzi): procedura poekspozycyjna zawiera zbyt wiele formalności do realizacji; miały pewność, że po ekspozycji nie ulegną zakażeniu; nie było na to czasu; nie miały świadomości, że trzeba zgłaszać takie zdarzenia; obawiały się wyników badań serologicznych; wstydziły się, że doszło do takiego zdarzenia.
W procesie badawczym przyjęto hipotezę, że do zwiększonego ryzyka ekspozycji może przyczynić się brak wyposażenia stanowisk pracy w odpowiedni sprzęt. Jednak okazało się, iż na brak bezpiecznego sprzętu medycznego zmniejszającego ryzyko ekspozycji wskazało 8,2% badanych, którzy ulegli ekspozycji. Istotnie częściej w porównaniu z tym czynnikiem ryzyka ankietowani zgłaszali jako przyczynę ekspozycji: pobudzenie psychoruchowe chorego lub jego nieadekwatną reakcję na wykonywaną czynność (26,9%; Z-test, p < 0,001), brak ostrożności i zlekceważenie zasad bezpieczeństwa (24,6%; Z-test, p < 0,001), zmęczenie i brak koncentracji (17,9%; Z-test, p = 0,018). Ponadto 12,7% badanych wskazało, że do ekspozycji przyczyniły się inne osoby (np. pozostawiono ostre niezabezpieczone narzędzie, doszło do popchnięcia w trakcie czynności, nastąpił nieoczekiwany zbieg okoliczności,
zaskoczenie). Nieco rzadziej ekspozycja nastąpiła w wyniku wykonywania pracy w stresujących warunkach np. podczas reanimacji (9,7%).
Analiza szczegółowa danych nie potwierdziła zależności pomiędzy ekspozycją zawodową a wykształceniem badanych (test test χ 2 = 0,437, p = 0,933), formą zatrudnienia (test χ 2 = 2,319, p = 0,677) czy systemem pracy (test χ 2 = 0,680, p = 0,410). Największa liczba badanych doznających ekspozycji zawodowej pracowała na oddziałach zabiegowych, a nieco mniejsza, na bloku operacyjnym, na oddziałach ratunkowych i na oddziale intensywnej terapii. W odniesieniu do pozostałych miejsc pracy (oddziały zachowawcze i przychodnie) różnica w występowaniu ekspozycji nie była istotna statystycznie (test χ 2 = 0,680, p = 0,410). Nie potwierdziło się również założenie, że osoby z dłuższym stażem pracy, z racji swojego doświadczenia, rzadziej ulegają ekspozycji niż osoby z krótszym czasem. Dane dowiodły braku istotnej zależności w stażu pracy pomiędzy osobami, które uległy ekspozycji, i pomiędzy pozostałymi ankietowanymi (test U Manna-Whtneya, p = 0,353) (tab. 1).
Ryzyko transmisji zakażeń po ekspozycji zawodowej wg Centers for Disease Control and Prevention (CDC) wynosi 6–30% dla HBV, 0–7% dla HCV i < 0,3% dla HIV. Ekspozycja zawodowa, a właściwie jej potencjalne skutki zdrowotne, stanowią ważny współczesny problem wśród personelu medycznego na całym świecie. Oprócz zagrażających życiu skutków wywoływanych przez te patogeny, zaobserwowano znaczący wzrost strachu i lęku wśród pracowników ochrony zdrowia oraz wzrost obciążenia finansowego systemu opieki zdrowotnej z powodu nadzoru i profilaktyki poekspozycyjnej [19].
Niemal 75% badanych przyznało, że w czasie wykonywania czynności zawodowych doszło u nich do zranienia bez ekspozycji na materiał zakaźny. Z kolei u ponad połowy badanych w trakcie wykonywania pracy doszło u ekspozycji na materiał zakaźny. Wyniki te nie odbiegają od innych badań prowadzonych w Polsce [20] i w innych krajach [21–23]. Wiele doniesień wskazuje, że ekspozycji najczęściej ulegają pielęgniarki, głównie poprzez ukłucie igłą [5, 19, 24–26].
Tabela 1. Statystyki opisowe stażu pracy wśród ankietowanych, którzy ulegli ekspozycji oraz wśród pozostałych ankietowanych
Ekspozycja N Średnia Mediana SD Min Maks p Staż pracy w zawodzie [lata]:
W związku z tak wysokim narażeniem personelu na zranienie, należy dążyć do zwiększenia dostępności do sprzętu bezpiecznego, posiadającego zabezpieczenia przed zakłuciem. Stosowanie urządzeń zaprojektowanych pod kątem bezpieczeństwa w połączeniu z odpowiednimi programami szkoleniowymi oraz zaangażowaniem kierownictwa szpitala i personelu medycznego w dobór urządzeń zabezpieczających, może doprowadzić do zmniejszenia częstości występowania urazów przezskórnych nawet o 50% [27, 28]. Dyrektywy unijne i krajowe przepisy regulują konieczność zastosowania bezpiecznego sprzętu medycznego ograniczającego ryzyko ekspozycji zawodowej [29]. Jednak to nie wystarczy. Niezbędne są szkolenia w zakresie wykorzystania bezpiecznych igieł, kaniul, cewników, urządzeń do próżniowego pobierania krwi i innych ostrych narzędzi, ponieważ nawet 30% urazów czy zakłuć z udziałem sprzętu bezpiecznego było spowodowane ich niewłaściwym użyciem [30].
Dulon i wsp. podają, że szycie i zabiegi chirurgiczne były związane z 27,6% wszystkich ekspozycji zawodowych w badanych szpitalach, przy czym w niewielu sytuacjach wykorzystywano bezpieczny sprzęt medyczny (z konstrukcją zabezpieczającą przed zranieniem). W gabinetach lekarskich używano sprzętu bezpiecznego średnio do co trzeciej procedury zabiegowej [31]. Również w polskich szpitalach większość zgłoszonych przypadków urazów miała miejsce podczas zabiegów chirurgicznych, takich jak szycie i używanie skalpeli, do których nie ma dostępnego mechanizmu zapobiegania urazom [28]. Istotnym elementem ochrony przed ekspozycją błon śluzowych jest stosowanie masek i okularów ochronnych. Dzieje się tak również podczas płukania ran, nacinania ropni, pobierania krwi czy innych zabiegów gdzie teoretycznie można spodziewać się rozprysku wydzieliny na twarz. Kaur i wsp. opisali obrażenia, które wystąpiły z powodu braku środków ostrożności w zakresie ochrony twarzy. Wystąpiły one głównie na oddziale intensywnej opieki medycznej (16%), w obszarach angiografii, endoskopii i radiologii (13%) i na sali operacyjnej (11%) [30]. Wśród pracowników medycznych dochodzi do lekceważenia ryzyka skażenia oczu. Okazuje się również, że niektórzy nie używają środków ochrony osobistej, ponieważ nikt tego nie robi, a oni sami boją się, że staną się obiektem drwin [32].
Ekspozycja zawodowa jest zjawiskiem często występującym w pracy personelu medycznego i wydaje się, że stanowi mocno niedoceniany problem. Prawdopodobnie nigdy nie uda się jej wyeliminować, ale zastosowanie mechanizmów ochronnych,
przestrzeganie procedur i eliminowanie innych czynników ryzyka, takich jak: stres, presja czasu, przeciążenie, nieostrożność i rozproszenie uwagi, niewłaściwa lub wykonana z opóźnieniem utylizacja przedmiotu może przyczynić się do zmniejszenia liczby urazów, a tym samym do zmniejszenia konsekwencji dotyczących zdrowia i aspektów finansowych. Obrażenia możliwe do uniknięcia mieszczą się w przedziale 30,9–55,2% [30]. W prezentowanych wynikach badań co trzecia osoba przyznała się do zachowań ryzykownych (np. nakładanie nasadki na używaną igłę, brak wymiany przepełnionych pojemników na ostre narzędzia bądź świadome niestosowanie środków ochrony osobistej).
Ponad 80% badanych zgłosiło fakt ekspozycji i przystąpiło do realizacji procedury poekspozycyjnej. Ten dość wysoki odsetek należy ocenić pozytywnie, ponieważ przywoływane w piśmiennictwie badania podają często zgłaszalność na niskim poziomie: ok. 40% [33, 34], ok. 60% [35], ale są również polskie badania wskazujące na zgłaszalność sięgającą 90% [36]. Brak zgłoszenia ekspozycji lub późne zgłoszenie może wynikać z braku czasu i możliwości zgłoszenia ekspozycji podczas pracy na zmianie popołudniowej, wstydu po urazie powstałym z własnej winy pracownika [37], z niedoborów kadrowych [38, 39], braku doświadczenia [39] czy bagatelizowania wyniku serologicznego [33].
W prezentowanym badaniu nie zaobserwowano istotnych zależności między wiekiem, stażem pracy, wykształceniem czy rodzajem zatrudnienia a skalą występowania zjawiska ekspozycji zawodowej. Z kolei wg analizy Gregorowicz-Warpas [35] u pielęgniarek z wieloletnim doświadczeniem zawodowym (≥ 50 lat) zdecydowanie częściej występowały zakłucia i zranienia (70%) niż w przypadku osób młodszych w wieku 22–25 lat z krótszym stażem pracy. Autorka przyczynę tego problemu dostrzega w braku znajomości procedur oraz traktowaniu ekspozycji jako nieunikniony element pracy [35]. Dane ze szpitali w centralnej Polsce wskazują, że urazom najczęściej ulegali pracownicy powyżej 40. roku życia, na zmianach porannych od 7:00 do 13:00. Na oddziałach chirurgicznych odnotowano dwa razy więcej zakłuć igłą i ostrymi narzędziami niż na oddziałach niechirurgicznych, ale różnice te nie były istotne [40]. Z doniesień z jednego ze szpitali w Hiszpanii wynika, że wyższe ryzyko wystąpienia wielokrotnych wypadków o ryzyku zakażenia materiałem biologicznym zaobserwowano u kobiet, zatrudnionych na umowę o pracę na czas nieokreślony, pracujących w obszarze chirurgicznym i były to osoby z dłuższym stażem pracy [37]. Ciekawe
Beata Wieczorek-Wójcik, Paulina Mościck,a Katarzyna Kowalska, Katarzyna Cierzniakowska
obserwacje poczynili Santos i wsp., wnioskując, że wyższe ryzyko ekspozycji dotyczyło pracowników samotnych (brak partnera, p = 0,010), ze stażem pracy w szpitalu wynoszącym 6–15 lat ( p = 0,007) lub ≥ 16 lat ( p = 0,013). Natomiast z niższym ryzykiem wypadków w grupie lekarzy wiązał się wiek między 30. a 39. rokiem życia ( p = 0,022), posiadanie ≥ 1 dziecka ( p = 0,030) i świadomość zasad powiadamiania o narażeniu w szpitalu ( p = 0,023) [41].
W celu uniknięcia ekspozycji zawodowej oraz zwiększenia wiedzy personelu na temat procedury postępowania poekspozycyjnego konieczne jest przeprowadzanie regularnych szkoleń. Okazuje się, że większość pracowników medycznych zmienia swoje zachowania pod wpływem świadomości opieki nad pacjentem zakażonym. Jednakże niepokojący wydaje się brak świadomości, że każdy chory powinien być traktowany jako potencjalne źródło zakażenia [35].
Wnioski
• Ponad połowa badanych doznała ekspozycji zawodowej.
• Najczęstsze procedury, podczas których dochodziło do ekspozycji zawodowej ze zbliżoną częstotliwością, to: pobieranie krwi, podawanie leków oraz czynności pielęgnacyjne.
• Jako najczęstsze przyczyny ekspozycji badani podawali pobudzenie psychoruchowe chorych lub nieadekwatną reakcję na wykonywaną u nich czynność zabiegową.
• Ryzyko ekspozycji zawodowej dotyczy całej grupy zawodowej pielęgniarek i pielęgniarzy niezależnie od ich poziomu wykształcenia, stażu pracy, miejsca pracy, sposobu zatrudnienia czy systemu pracy.
• Tylko niespełna co piąta ankietowana osoba wskazała, że nie podejmuje działań ryzykownych uznawanych za potencjalne czynniki prowadzące do ekspozycji.
Oświadczenia
Autorki deklarują brak konfliktu interesów. Praca nie uzyskała finansowania zewnętrznego. Na prowadzenie badań uzyskano zgodę Komisji Bioetycznej przy Collegium Medicum w Bydgoszczy (KB 528/2022).
Piśmiennictwo
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Sprawozdanie | Report
LECZENIE RAN 2025; 22 (2): 88–90
W dniach 28–29 kwietnia 2025 r. w Warszawie odbyła się II Międzynarodowa Konferencja Naukowo-Szkoleniowa „Zaawansowana praktyka pielęgniarska i położnicza w Polsce jako odpowiedź na potrzeby zdrowotne pacjentów” zorganizowana przez Naczelną Izbę Pielęgniarek i Położnych, Polskie Towarzystwo Pielęgniarskie i Polskie Towarzystwo Położnych.
Bogaty program konferencji obejmował sesje wykładowe, panele kliniczne, panele dyskusyjne i warsztaty prowadzone przez ekspertów medycyny, pielęgniarstwa, przedstawicieli agend i instytucji rządowych, menedżerów oraz przedstawicieli organizacji pacjentów. Były to dwa dni intensywnych dyskusji na temat przyszłości pielęgniarstwa i położnictwa w Polsce, poszerzania obowiązujących i nowych rozwiązań kompetencyjnych pielęgniarek i położnych oraz wyzwań stojących przed systemem opieki zdrowotnej.
Poruszane zagadnienia dotyczące rozwoju zaawansowanej praktyki pielęgniarskiej (Advanced Practice Nursing – APN) i zaawansowanej praktyki położniczej (Advanced Practice Midwife – APM) wzbudzały ogromne zainteresowanie uczestników konferencji, a emocjonujące dyskusje były kontynuowane podczas przerw w obradach.
W pierwszej sesji dominowała tematyka związana z zaawansowaną praktyką pielęgniarską postrzeganą jako zmiana kompetencyjna, systemowa i kulturowa.
W kolejnej sesji zaprezentowane zostały przykłady dobrych praktyk klinicznych w kierunku APN w wybranych dziedzinach, w tym: w zaawansowanej praktyce położnej, w dziedzinie pielęgniarstwa diabetologicznego, w dziedzinie kardiologii i pielęgniarstwa kardiologicznego oraz w opiece i leczeniu pacjentów ze stomią.
W pozostałych panelach prelegenci przedstawiali kierunki działań dla usankcjonowania APN
w ustawodawstwie i systemie opieki zdrowotnej, kontynuowano merytoryczne dyskusje w odpowiedzi na pytanie, czy wdrożenie APN oraz APM poprawi dostępność i jakość opieki dla wybranych grup odbiorców, oraz zostały wskazane propozycje systemu uzyskiwania uprawnień APN w Polsce.
Drugi dzień konferencji w całości był poświęcony warsztatom specjalistycznym dotyczącym APN w różnych obszarach pracy pielęgniarek. Były to warsztaty poświęcone żywieniu klinicznemu w praktyce pielęgniarskiej, kierunkom rozwoju zaawansowanej praktyki w POZ, w opiece długoterminowej, w neonatologii, w opiece paliatywnej, w opiece diabetologicznej, w anestezjologii, w położnictwie i w leczeniu ran. Największą frekwencją cieszyły się zajęcia dotyczące wykorzystania Chatu GPT w praktyce pielęgniarskiej i położniczej, jako nowe możliwości wspierania pracy zespołów interdyscyplinarnych. Rozwój zaawansowanych kompetencji w leczeniu ran (ryc. 1), był jednym z ostatnich warsztatów w programie konferencji, a mimo to zgromadził bardzo dużą grupę pielęgniarek i położnych zainteresowanych tą tematyką. Warsztat prowadziły: dr Beata Wieczorek-Wójcik, dr Katarzyna Cierzniakowska, dr hab. Paulina Mościcka i mgr Katarzyna Kowalska (ryc. 2). Celem spotkania była prezentacja założeń pilotażu dla zaawansowanych kompetencji pielęgniarki w leczeniu ran, wskazanie propozycji szerokospektralnych uprawnień niezbędnych do całościowej opieki nad chorym z raną oraz uzyskanie od uczestników opinii dotyczących decyzji klinicznych i propozycji kompetencji APN w leczeniu ran. Wypracowane przez Zespół, ogólne założenia pilotażu APN w zakresie leczenia ran i przetok były w ubiegłym roku opublikowane w na łamach „Leczenia Ran” (Wieczorek-Wójcik B, Kowalska K, Leyk-Kolańczak M i wsp. Działania na rzecz rozwoju pielęgniarki zaawansowanej
praktyki w Polsce – projekt pilotażu APN w zakresie leczenia ran i przetok. Leczenie Ran 2024; 21: 92–97). Projekt zawierający kluczowe dla APN uprawnienia w prowadzeniu procesu diagnostycznego i terapeutycznego u chorych z ranami, wzbogacony o opisy przypadków, ryciny i filmy spotkał się z pozytywnym odbiorem uczestników konferencji. Podkreślano wielokrotnie znaczenie rozszerzonych kompetencji APN w leczeniu ran w kontekście korzyści dla chorych, u których efektywne leczenie ran przyspiesza proces powrotu do zdrowia, łagodzi dolegliwości bólowe, obniża ryzyko izolacji społecznej, poprawia stan psychiczny, poprawia jakość życia, a nierzadko umożliwia powrót do pracy i innych aktywności. Moderatorki warsztatu zwróciły również uwagę na fakt, że szersze uprawnienia dla pielęgniarek oznaczają większe i szybsze możliwości dostępu chorych do opieki zdrowotnej, objęcie ich opieką holistyczną, uwolnienie zasobów medycznych lekarzy specjalistów, którzy w tym czasie mogą realizować bardziej skomplikowane działania medyczne i zabiegowe, a w konsekwencji obniżenie kosztów opieki.
APN w leczeniu ran opiekuje się chorymi w każdym wieku i w różnych miejscach świadczenia opieki. Autonomia pielęgniarki zaawansowanej praktyki będzie przejawiać się w AOS, POZ, opiece długoterminowej i hospicyjnej, w opiece doraźnej oraz w ramach konsultacji międzyoddziałowych w szpitalu. Kontynuacja prac nad modelem zaawansowanej praktyki pielęgniarskiej w Polsce powinna być prowadzona w oparciu o konsensus środowisk medycznych, we współpracy z instytucjami rządowymi, Ministerstwem Zdrowia oraz Narodowym Funduszem Zdrowia, tak by właściwa opieka i pomoc w leczeniu ran docierała do chorego na czas. W ostatnim etapie warsztatu, w dyskusji, głos zajmowali uczestnicy. Zgłoszono m.in. postulat, aby
Rycina 1. Strona tytułowa prezentująca temat warsztatu.
Rycina 2. Moderatorki warsztatu: od lewej Paulina Mościcka, Katarzyna Kowalska, Katarzyna Cierzniakowska, Beata Wieczorek-Wójcik
do kompetencji APN należała również możliwość wystawiania zaświadczeń o zakończonym leczeniu rany w ramach leczenia że środków publicznych AOS czy POZ. Brak odpowiedniego finansowania porady w AOS (1,8 zł × 17 pkt.) nie daje możliwości zakupu odpowiednich materiałów medycznych za tą kwotę. Ponadto dyskusja dotyczyła również jakości kształcenia podyplomowego pielęgniarek na kursach specjalistycznych i szkoleniach specjalizacyjnych. Wskazano na różnice w kompetencjach pielęgniarek i położnych, chociażby w zakresie szycia ran. Położne również zgłaszały potrzebę aktualizacji programu kształcenia i zwiększenia kompetencji po ukończeniu kursu „Leczenie ran dla położnych”. Zauważono również konieczność modyfikacji wykazu leków, które pielęgniarka może stosować bez zlecenia lekarskiego.
Dzięki zaangażowaniu dużej grupy osób z pośród wszystkich uczestników warsztatu, udało się pozyskać drogą elektroniczną 71 opinii na temat proponowanych uprawnień APN. Odpowiedzi na pytania udzieliło 66 kobiet i 5 mężczyzn. Wiek ankietowanych zawierał się w przedziale 29–67 lat (średnia 47,62 roku, mediana 50). Staż pracy mieścił się pomiędzy 5 a 41 lat (średnia 23,44 roku, mediana 26). Tylko 2 osoby nie posiadały specjalizacji w żadnej z dziedzin pielęgniarstwa. Najwięcej było specjalistek w dziedzinie pielęgniarstwa chirurgicznego (18, 25%). Kadrę zarządzającą reprezentowało 29 osób (40,8%). Przygotowana na potrzeby ewaluacji warsztatów ankieta zawierała 7 pytań. Poniżej zamieszczono pytania i odsetek odpowiedzi.
• Czy uważasz, że wdrożenie APN w leczeniu ran poprawiłoby obecny stan opieki nad chorymi z ranami w Polsce? Tak: 70 (98,6%); Trudno powiedzieć: 1 (1,4%)
Beata Wieczorek-Wójcik, Paulina Mościck,a Katarzyna Kowalska, Katarzyna Cierzniakowska
• Czy zasadne jest poszerzenie kompetencji APN w leczeniu ran o drobne zabiegi w diagnostyce i zaopatrywaniu ran ostrych (szycie rany, nacięcie, pobieranie wycinków do badania)? Tak: 70 (98,6%); Trudno powiedzieć: 1 (1,4)%
• Czy uważasz, że APN w leczeniu ran powinna mieć kompetencje do zlecenia konsultacji anestezjologicznej w zakresie preskrypcji leków z grupy adiuwantów oraz II i III stopnia drabiny analgetycznej? Tak: 64 (90,1%); Nie: 3 (4,2%); Trudno powiedzieć: 4 (5,6%)
• Czy uważasz, że APN w leczeniu ran powinna mieć kompetencje do znieczulenia nasiękowego z wykorzystaniem lignokainy? Tak: 69 (97,2%); Trudno powiedzieć: 2 (2,8%)
• Czy uważasz, że APN w leczeniu ran powinna mieć prawo do opracowania planu leczenia ran u chorych, w tym również do podejmowania decyzji o odstąpieniu od leczenia i skierowaniu pacjenta do lekarza lub zakończeniu leczenia? Tak: 70 (98,6%); Trudno powiedzieć: 1 (1,4%)
• Czy uważasz, że podejmowanie decyzji klinicznych przez APN w leczeniu ran jest równoznaczne
z ponoszeniem odpowiedzialności za efekty końcowe leczenia rany u chorego? Tak: 66 (92,9%); Nie: 1 (1,4%); Trudno powiedzieć: 4 (5,6%)
• Czy uważasz, że jesteś gotowa/gotowy do wykorzystania poszerzonych kompetencji APN w leczeniu ran w swojej codziennej pracy? Tak: 50 (70,4%); Nie: 12 (16,9%); Trudno powiedzieć: 9 (12,7%)
„Model praktyki APN został wdrożony w wielu krajach na świecie, a jego zasadność potwierdzona w licznych badaniach naukowych jako działania mające wpływ na optymalizację opieki zdrowotnej oraz jej efektywność” (stanowisko Polskiego Towarzystwa Pielęgniarskiego). Konferencja była doskonałą przestrzenią do kontynuacji merytorycznych dyskusji dotyczących rozwoju APN i APM w Polsce. Organizatorom bardzo dziękujemy za przestrzeń do nauki i wymiany doświadczeń, a wszystkim uczestnikom za inspirujące spotkania i rozmowy.
Beata Wieczorek-Wójcik
Paulina Mościcka
Katarzyna Kowalska Katarzyna Cierzniakowska
Kwartalnik | Zeszyt 2 | Tom 22 | Rok 2025
Kwartalnik | Zeszyt 2 | Tom 20 | Rok 2023
ISSN: 1733-4101 eISSN: 1733-7607 MNiSW: 20 IC: 86,65
ISSN: 17334101 eISSN: 1733-7607 MNiE: 20 IC: 72,67
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