http:// ijp.mums.ac.ir Systematic Review (Pages: 10853-10863)

Comparison of the Effect of Vera Extract, Breast Milk, Calendit- E, Curcumin, Lanolin, Olive Oil, and Purslane on Healing of Breast Fissure in Lactating Mothers: A Systematic Reviwe Babak Pezeshki1, Malihe Pouredalati2, Shahrzad Zolala2, Somayeh Moeindarbary3, Kataneh Kazemi4, Mohsen Rakhsha5, Zahra Ramazanian Bafghi2, Roozbeh Nasibeh6, *Parisa Razmjouei71

1Noncommunicable Diseases (NCD) Research Center, Fasa University of Medical Sciences, Fasa, Iran. 2Students Research Committee, Razi School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran. 3Assistant Professor, Department of Obstetrics and Gynecology, Neonatal and Maternal Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. 4Assistant Professor, Department of Obstetrics and Gynecology, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran. 5Assistant Professor, Department of General Surgery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran. 6Mother and Child Welfare Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran. 7Shahid Faghihi Hospital, Department of Gynecology and Obstetrics, Shiraz University of Medical Sciences, Shiraz, Iran.

Abstract Background: Sore nipples are a common problem in breast-feeding women which can cause early cessation of breast-feeding. We aimed to evaluate the effect of Aloe Vera extract, breast milk, Calendit-E, Curcumin, Lanolin, Olive oil, and Purslane on healing of breast fissure in lactating mothers. Materials and Methods: All clinical trials evaluating the effect of Aloe Vera extract, breast milk, Calendit-E, Curcumin, Lanolin, Olive oil, and Purslane on healing of breast fissure in lactating mothers were searched on the online databases of Scopus, EMBASE, Cochrane, Web of Science and Medline with no language or time restrictions using the combination related keywords of Mesh. Study selection was done by two reviews. Results: Six studies were included here with a total sample size of 546 subjects. The results showed that aloe vera and Purslane cream are more effective than lanolin ointment for healing sore nipples. Calendit-E cream, and aloe vera gel were more effective than breast-fed milk for treating sore nipples. However, no significant difference was observed between the mother's breast milk group and olive oil. Concerning the limited side effects, as well as greater impact and antimicrobial activity of curcumin in the short term, it was suggested to use curcumin for treating sore nipples. Conclusion: Aloe vera gel and purslane cream, Calendit-E cream, and curcumin can have beneficial effects on improving sore nipples. Usage of these therapeutic methods is suggested to improve sore nipples given their low cost and limited side effects. Key Words: Breast Fissure, Mothers, Olive Oil, Aloe Vera Extract, Curcumin, Purslane.

*Please cite this article as: Babak Pezeshki, Malihe Pouredalati, Shahrzad Zolala, Somayeh Moeindarbary, Kataneh Kazemi, Mohsen Rakhsha, et al. Comparison of the Effect of Aloe Vera Extract, Breast Milk, Calendit- E, Curcumin, Lanolin, Olive Oil, and Purslane on Healing of Breast Fissure in Lactating Mothers: A Systematic Reviwe. Int J Pediatr 2020; 8(2): 10853-863. DOI: 10.22038/ijp.2020.46125.3760

*Corresponding Author: Parisa Razmjouei, Shahid Faghihi Hospital, Department of Gynecology and Obstetrics, Shiraz University of Medical Sciences, Shiraz, Iran. Email: [email protected] Received date: Nov.14, 2019; Accepted date: Jan. 12, 2020

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1- INTRODUCTION enhancing the mother's confidence in Exclusive feeding with breast-feeding breast-feeding and its persistence (10). In recent years, various treatments have been is considered as the best nutrition for a child up to six months of age. This has proposed with different effects for sore been one of the most important nipples. They include warm water recommendations of the World Health compress and teabag, curcumin, lanolin, Organization and UNICEF over the past antiseptic sprays, corticosteroids, hydrogel, few years (1). If globally every child is fed glycerin, Epicar ointment (honey therapy), with breastmilk exclusively within the first phototherapy, silver caps, menthol extract, six months of life, the lives of around 1.3 aloe vera, and, in many cultures, the million people will be saved annually (2). breastmilk itself (11, 12). Today, Meanwhile, sore nipples are one of the considering the failure of therapeutic common complaints among breast-feeding methods, researchers are working on using women and the second cause of early , where cessation of breast-feeding after failure to medicine is approved by around 80% of supply adequate milk. It is one of the main people as a branch of alternative medicine reasons of tendency of mothers to use (13). Olive oil and aloe vera are among artificial feeding (3). Cessation of breast- analgesic and anti-inflammatory herbal feeding deprives the infant of the major drugs (13). In , usage nutrients, growth factors, and important of olive oil promotes wound healing (14). immunological components in the In some studies, the effectiveness of olive breastmilk. Further, cessation of breast- oil on preventing sore nipples has been feeding increases post-delivery confirmed (15). Aloe vera enjoys healing, hemorrhage as well as the risk of ovarian anti-inflammatory, analgesic, antiviral, and breast cancer for the mother (4). antibacterial, antifungal, and moisturizing Prevalence of sore nipples has been effects (16). In some studies, its analgesic reported to be 34-96% (5), which can last and anti-inflammatory effects against sore up to six weeks for some women; its major nipples (17, 18) have been confirmed. The incidence occurs between the third and milk obtained from the mother's breasts seventh weeks post-delivery (6). Several has also been recommended for treating predictive factors have been mentioned for sore nipples. It is because the mother's sore nipples including poor attachment to milk has both softening and antiseptic the breast, improper position of the child properties and can be effective for during breast-feeding, wrong suckling treatment of sore nipples (19). because of functional or organic reasons, Dripping some drops of mother's milk on inappropriateness of the nipple for breast- the nipple has been confirmed by the feeding, unsuitable hygiene of the nipples, Ministry of Health and Medical Education atopic skin, or tight underwear (7). The as one of the solutions for treatment of healing of sore nipples is challenging sore nipples (20). Lanolin is the common because of frequent stimulation through treatment for sore nipples (21). However, the infant suckling and exposure to the oral different papers have mentioned flora of the infant. In case of failure of contradictory effects for lanolin on sore treatment, it may lead to problems such as nipples (22, 23). Burning, itching, and pain and bleeding (8). It can also function infection of sore nipples are among the as a site for entrance of bacteria, thereby complications of lanolin, as mentioned in causing edema and mastitis (9). Therefore, some studies (24, 25). Herbs have a long treatment of sore nipples immediately and history for wound treatment (26). One of effectively is an important factor in these herbs is porulaca (27). The anti-

Int J Pediatr, Vol.8, N.2, Serial No.74, Feb. 2020 10854 Pezeshki et al. inflammatory, analgesic, and restorative 2-1. Study design properties of this herb are attributed to Preferred Reporting Items for flavonoid, tannin, saponin, and terpenoids Systematic review and Meta-Analysis present in it (28). is one of the (PRISMA) checklist was used as a oldest herbs belonging to the family template for this review with the scientific term of Curcuma longa, (http://www.prisma-statement.org/). whose active ingredient is curcumin. This has been traditionally used in Asia 2-2. Eligibility criteria for treatment of skin diseases and wound Participants, interventions, comparators, healing (29). One of the properties of and outcomes (PICO) was used to curcumin making it suitable for therapeutic formulate the review objective and purposes is its low toxicity (30). Calendit- inclusion criteria. E cream is composed of a mix of Hydroalcohol extract of two : Participant: Lactating Mothers. known as pot Interventions: Any type of treatment of marigold along with Echinacea breast fissure with Aloe vera OR Breast Angustifolia, or narrow-leaved purple Milk OR Calendit-E Cream OR Calendula coneflower. These two compounds officinalis OR Curcumin OR Lanolin OR synergistically resolve skin inflammation Purslane OR Portulaca OR Olive oil as the and are very effective for wound healing. primary treatment. These two herbs have no proven toxic Comparators: Treatment vs. control effect and neither are allergic. Their group, treatment vs. different type of consumption during pregnancy and breast- treatment, before vs. after treatment. feeding has no established contraindication. Considering the Outcome: Reduction of breast fissure in established impact of the extract of lactating mothers. Echinacea herb present in this cream 2-3. Included studies causing increased rate of wound healing, Randomized controlled trials (RCT), promoting treatment of wounds, anti- clinical studies both randomized and inflammatory properties, antibacterial nonrandomized either retrospective or properties, this plant has no harmful effect prospective. Due to the limited number of for the body (31-34). published RCT in the literature other types Considering the high prevalence of sore of clinical studies were included. Pilot, nipples and since the pain in sore nipples is preliminary and case report studies were one of the important factors for cessation not included due to limited sample size of breast-feeding by mothers, and and higher risk of bias. Studies published regarding absence of any agreed treatment in Persian and English till November 2019. for this disease, the present study has been 2-4. Search strategy performed with the aim of reviewing the research conducted in this regard; so we All clinical trials evaluating the effect of aimed to evaluate the effect of some non- Olive Oil, Aloe Vera Extract, Pot pharmacological methods (Aloe Vera marigold, Curcumin, and Purslane on Extract, Breast Milk, Calendit-E, breast fissure were searched on the Curcumin, Lanolin, Olive Oil, and electronic databases of Scopus, EMBASE, Purslane) on healing of breast fissure in Cochrane, Web of Science and Medline lactating mothers. (via PubMed) with no language or time restrictions (till August 2019) using the 2- MATERIALS AND METHODS combination keywords of: (Sore OR

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Nipples OR, Nipple OR Treatment OR combinations, were searched in the Therapeutics OR Therapy OR Trauma OR national databases (Magiran, SID, and Wound OR Fissure) AND (Breastfeeding) Iran.Doc). PRISMA flow diagram was AND (Aloe vera OR OR Milk OR Milk, used to show the process of study selection Human OR Breast Milk OR Calendit-E (Figure.1). Two independent researchers Cream OR Calendula officinalis OR performed the search process and a Curcumin OR Lanolin OR Purslane OR supervisor judged any disagreement in this Portulaca OR Olive oil) and their Persian regard. synonyms and all their possible

Fig1: PRISMA flowchart.

used relevant references were also 2-5. Selection process reviewed to find further studies. Any The relevant studies were chosen disagreement was judged by the third independently by two reviewers, who party. initially reviewed the abstracts of searched articles and then downloaded their full text 2-6. Data extraction to review carefully. Finally, the articles Table.1 shows a checklist containing the that met the inclusion criteria were required data for our systematic review, enrolled in the systematic review, and their including name of first author, year of

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publication, study design, sample size, 2-7. Quality assessment intervention period, intervention results, Jadad scale (35) as a valid and reliable tool drop out, and assessment tool. Two was applied to assess the quality of independent reviewers were responsible included studies, indicating randomization, for the data collection and analysis. The blindness, and dropout or withdrawal. The third party judged any discrepancies. We scores of this tool range between 0 and 5. were unable to implement the meta- This step was also accomplished by the analysis because of high heterogeneity two independent reviewers and any between the outcomes and the small discrepancy was judged by the third party number of included studies, thereby (Table.2). forcing us to report the results qualitatively.

Table-1: General characteristics of studies included in systematic review. Author, Year, Study Sample Intervention Drop Assessment Adverse Intervention Control Results Reference design size period out tool effects Shinizadeh et.al, RCT 84 two times a Curcumin Breast - Storr scale Curcumin was 2015,(37) day for seven milk recommended for - days treatment of nipples fissure. Saeidi et al., RCT 100 three times a Aloe Vera Lanolin - Storr scale Aloe Vera is more 2015, (39) day for seven gel effective than lanolin on - days nipple soreness healing. Kazemirad et.al, RCT 82 three times a Calendit -E Breast - Storr scale Calendit -E is more 2013, (36) day for seven milk effective than breast - days milk on nipple soreness healing. Tafazoli et.al, RCT 100 three times a Olive oil Lanolin - Storr scale Aloe Vera is more 2010, (9) day after effective than lanolin on - breastfeeding nipple soreness healing. Niazi et.al., RCT 86 three times a Purslane Lanolin 6% Storr scale Purslane cream was 2018,(38) day for seven more effective in the - days treatment of nipple pain. Eshghizade RCT 90 after Olive oil Breast - Storr and Aloe Vera is more et.al., 2016,(40) breastfeeding and milk effective than Olive oil visual - for seven Aloe Vera analog and breast milk. days scale RCT: randomized controlled trial.

Table-2: Quality Assessment using Jadad scale (35). Authors, Year, Reference Randomization Blinding Report of Mention Appropriate Inappropriate Mention Appropriate Inappropriate dropping out randomization method Method blinding method method Tafazoli et.al, 2010, (9)

Kazemirad et.al, 2013, (36)

Sheinizadeh-Emadi et al., 2015, (37) Niazi et al., 2018, (38)

Saeidi et al., 2015, (39)

Eshghizade et.al., 2016,(40)

: Yes; : No; : Unclear.

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3- RESULTS sore nipples", where 50 mothers with sore Six clinical trial studies with a total nipples were randomly assigned into two groups: treatment with Lanolin ointment sample size of 546 subjects were included here. Kazemirad et al. (2012) performed a and aloe vera gel. Further, both groups single blind randomized clinical trial received treatment on proper techniques of study. The research subjects consisted of breast-feeding and method of drug usage. 82 breast-feeding women with sore There was a significant difference between nipples. The samples were randomly the two groups in terms of the mean score categorized into two groups: Calendit-E of sore nipples on the third and seventh cream and expressed breastmilk, who days, where aloe vera gel was more underwent treatment for one week. Both of effective than Lanolin ointment for the groups received training about the treating sore nipples (9). Niazi et al. (2018) proper way of breast-feeding as well as the performed a double-blind randomized method of applying the cream or breast clinical trial study on 86 breast-feeding milk. The results showed that reduction in women with sore nipples and Mashhad. the severity of sore nipples on the third day The subjects were randomly assigned into did not differ significantly between the two two groups: purslane cream and lanolin groups. However, on the seventh day in (n=43 in each group). Subjects of both Calendit-E cream, this reduction was groups were trained on the proper way of greater and significant. Thus, Calendit-E breast-feeding and method of applying the cream was more effective than breastmilk drug. They were asked to continue the for treatment of sore nipples (36). treatment for one week, three times a day. Based on the results of Mann-Whitney Sheinizadeh-Emadi et al. (2015) in a randomized clinical trial study examined test, the two groups before the intervention 88 breast-feeding mothers with sore were homogeneous in terms of the mean nipples by dividing them randomly into score of sore nipples. However, there was two equal groups: treatment with curcumin a statistically significant difference group and leaving milk drop on the between the two groups on the third and mother’s breast group. On the third day, eighth days; improvement was faster in the the mean score of sore nipples was purslane cream than in the lanolin group significantly lower in the curcumin group (38). Saeidi et al. (2009) in Mashhad did a compared to the group in which the clinical trial study on breast-feeding mothers' breast milk drop was remained. mothers and performed the sampling as Further, the mean difference of the sore nonrandomized and purposeful. The scores was significant before and treatment samples were randomly assigned into two with the third day as well as with the groups: aloe vera and lanolin (n=50 in seventh day post-treatment in both groups each group). There was a significant (37). Hence, curcumin and mother's milk difference between the two groups are both effective for the treatment of sore between the third and seventh days; the nipples. However, considering the limited score of the nipple pain on the third and side effects as well as greater antimicrobial seventh days diminished considerably. activity and impact of curcumin in the They concluded that aloe vera is more short run, it was suggested to use curcumin effective than lanolin for mitigating the for treatment of sore nipples. Tafazoli et pain of sore nipples (39). Eshgizade et al. al. (2010) conducted a single blind two- (2016) conducted a clinical trial study in group clinical trial study entitled which 90 breast-feeding mothers with sore "comparing the impact of Aloe vera gel nipples were randomly assigned into three and Lanolin ointment on the treatment of 30-subject groups. Group I mothers

Int J Pediatr, Vol.8, N.2, Serial No.74, Feb. 2020 10858 Pezeshki et al. received 0.5 ml of olive oil, Group II was more effective than Lanolin ointment received 0.5 ml of aloe vera extract plus 3- for treating sore nipples (9). In addition, in 4 drops of their own milk three times a day the studies by Eshgizade et al. (40), and (they rubbed it on their nipples and areola Alamolhoda et al. (17), the effect of aloe after every breast-feeding). Group III vera on sore nipples has been examined. rubbed 3-4 drops of their own milk on the Aloe vera is an herb traditionally used nipple and areola after every breast- since 1500 B.C. in many countries feeding. At the end of the intervention, including Greece, China, and Mexico. For there was a significant difference between centuries, it has been used as a traditional the three groups in terms of severity of drug for different diseases and skin lesions pain and sore nipples; the group receiving (12). Further, aloe vera has anti- aloe vera extract experienced less pain and inflammatory, antiseptic, antibacterial, sore nipples compared to the other groups. antiviral, and antifungal effects. It is also No significant difference was found nutritious for tissues and causes enhanced between the mother’s breast milk and olive immunity and prevention of itching and oil groups (40). skin irritation. On the other hand, an established effect has been presented for 4- DISCUSSION the collagen and aldehydrate content and In recent years, various treatments thus rapid wound healing. The effect of with different impacts have been aloe vera on wound healing has been propounded for sore nipples. They include found in different papers for various warm water compress and teabag, diseases including ulcerative colitis, , curcumin, lanolin, antiseptic sprays, dermatitis, , oral ulcers, diabetic corticosteroids, hydrogel, glycerin, Epicar ulcers, herpes, and even bedsores (9). By ointment (honey therapy), phototherapy, inhibiting interleukin-6 and interleukin-8, silver caps, menthol extract, and in many aloe vera is effective in reducing adhesion cultures breastmilk (11, 12). Meanwhile, of leukocytes, increasing the level of the special attention paid to progressive interleukin-10, and reducing the level of use of aloe vera, purslane, and olive oil in tumor necrotizing factor-alpha for all these studies highlights the importance inhibiting inflammatory reactions. of these three treatment. The results of this In animal models, aloe vera has been used review study showed that aloe vera gel and for treatment of , wound healing, purslane cream are more effective than tumors, and inflammatory bowel diseases lanolin ointment for treating sore nipples. both orally and parenterally (41). Lanolin, Calendit-E cream, menthol, and aloe vera by creating moisture, prevents new ulcers, are more effective than the breast milk which promotes wound healing by itself for treatment of sore nipples. increasing the epithelial regrowth. Ester is However, no significant difference was the active ingredient of lanolin. Esters observed between the mother’s breast milk possess wound healing properties in a and olive oil. In a study performed by moist environment. Further, they are anti- Tafazoli et al. for comparing the impact of inflammatory, antibacterial, and protective aloe vera gel and lanolin ointment on for damaged breast skin (42). Purslane is treating sore nipples, 50 mothers with sore an herb with anti-inflammatory, analgesic, nipples were randomly assigned into two and restorative properties because of groups: treatment with lanolin ointment containing flavonoid, tannin, saponin, and and aloe vera gel. There was a significant terpenoids (28), for which no proximity difference between the two groups in terms has been reported (43). Niazi et al. (2016) of the mean score of sore nipples on the performed a double-blind randomized third and seventh days, where aloe vera gel

Int J Pediatr, Vol.8, N.2, Serial No.74, Feb. 2020 10859 Effect of Non-pharmacological Methods on Healing of Breast Fissure clinical trial study on 86 breast-feeding curcumin. Curcumin covering 6-70% of women with sore nipples in Mashhad. The the raw turmeric extract has different subjects were randomly assigned into two properties. They include anti-inflammatory groups: purslane cream and lanolin (n=43 and analgesic, antibacterial, antifungal, in each group). The proper way of breast- antioxidant, and healing properties (44). feeding and method of applying the drug Topical use of curcumin even at low doses were trained to the subjects of both groups. has beneficial effects on redness, They were asked to continue the treatment inflammation, and pain of the skin soft for one week, three times a day. Based on tissue. Alcoholic extract of turmeric as the results, the two groups before the well as ointments made of curcumin intervention were homogeneous in terms significantly improve skin lesions, and no of the mean score of sore nipples. special complication has been reported for However, there was a statistically its topical usage (45). Further, breastmilk significant difference between the two contains fat-soluble vitamins especially groups on the third and eighth days; vitamins A and E, causing lubrication of improvement was faster in the purslane the skin and wound healing. There is cream than in the lanolin group (38). usually no need to cleanse the nipple after Olive oil compounds including oleuropein rubbing milk on it and before the next with antioxidant and anti-inflammatory breast-feeding, as it does not cause properties, polyphenol with free radical (46). Leaving one or two drops of and cell repair properties, and breastmilk on damaged nipples is one of Oleocanthal with prostaglandin synthesis the oldest therapeutic methods. inhibiting properties are analgesic and On the other hand, some studies have anti-inflammatory. The anti-inflammatory shown that complete improvement of sore effects of aloe vera are attributed to nipples symptoms such as pain and presence of salicylic acid (effective in soreness can be achieved 3 to 4 weeks inhibiting formation of bradykinin and after initiating the treatment by leaving the histamine), and oxidation of arachidonic breast milk drops, which is considered a acid (effective in the synthesis of long course for improving the soreness. prostaglandin). In a randomized clinical Accordingly, one third of mothers who trial, it was found that olive oil, aloe vera particularly experience these symptoms at extract, and breastmilk resulted in six weeks post-delivery become diminished severity of pain of sore nipples psychologically and clinically disturbed, and long breast-feeding mothers, but aloe and change their infant feeding method vera extract was more effective than olive alternatively and use sugar water or oil and breastmilk (40). The results of a powdered milk (47). Considering the study to determine the impact of effects of curcumin in accelerating nipples Hydroalcohol extract of curcumin showed wound healing, it has been suggested to that curcumin and breastmilk are both use this drug as a sore nipple healing effective for the treatment of sore nipples. promoting and accelerating agent However, considering limited side effects alongside training the proper method of as well as greater antimicrobial activity breast-feeding as well as application of the and impact of curcumin in the short-term, breastmilk drop in breast-feeding women it was suggested to use this drug for (37). Comparing the effect of Calendit-E treating sore nipples (37). Turmeric is one cream and the mothers' breast milk on of the oldest herbs belonging to the ginger treating sore nipples, a research found that family with the scientific term of Curcuma Calendit-E cream is more effective than longa, whose active ingredient is breastmilk for treating sore nipples.

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Calendit-E cream is composed of a mix of 6- CONFLICT OF INTEREST: None. Hydroalcohol extract of two plants: 7- REFERENCES Calendula Officinalis known as pot marigold along with Echinacea 1. Aghajani F, Radmehr M. Infant Angustifolia, or narrow-leaved purple Temperament in Exclusive Breastfeeding and coneflower. These two compounds Dominant Formula Feeding. Journal of synergistically resolve skin inflammation Nursing Education. 2019;8(4):19-26. and are very effective for wound healing 2. Hosseini F, Rasekhi A, Lamyian M. (36). These two herbs have no proven Factors associated with exclusive toxic effect and are not allergic. Their breastfeeding among primiparous women. Journal of Nursing Education (JNE). consumption during pregnancy and breast- 2019;8(2):52-7. feeding has no established contraindication (29, 30). 3. As’adi N, Kariman N, Mojab F, Pourhoseingholi MA. The effect of Saqez 4-1. Limitations of the study (Pistacia atlantica) ointment on the treatment of nipple fissure and nipple pain in The methodologic quality of some of the breastfeeding women. Electronic physician. studies examined in this systematic review 2017;9(8):4952. was low. The defects included lack of or unsuitable report on randomized allocation 4. Campos TM, dos Santos Traverzim MA, Sobral APT, Bussadori SK, Fernandes sequence, lack of or inappropriate report KSP, Motta LJ, et al. Effect of LED therapy on blinding, lack of intention to treat for the treatment nipple fissures: Study analysis. Accordingly, it is proposed that protocol for a randomized controlled trial. future studies be designed and report their Medicine. 2018;97(41). findings based on consort. Another 5. Shahrahmani N, Akbari SAA, Mojab limitation was limited number of studies F, Mirzai M, Shahrahmani H. The Effect of and their low sample size, highlighting the Zizyphus Jujube Fruit on Breast Fissure need forfurther studies with larger sample in Breastfeeding Women. Iranian journal of sizes in this regard. pharmaceutical research: IJPR. 2018;17(Suppl):101. 5- CONCLUSION 6. Cunningham F. Williams obstetrics. Aloe vera gel and purslane cream are New York: McGraw Hill Professional; 2014. more effective than lanolin ointment for P.674. treating sore nipples. Calendit-E cream 7. Marrazzu A, Sanna MG, Dessole F, also has beneficial effects on improving Capobianco G, Piga MD, Dessole S. sore nipples. Considering limited side Evaluation of the effectiveness of a silver- effects, as well as greater antimicrobial impregnated medical cap for topical treatment activity and impact of curcumin in the of nipple fissure of breastfeeding mothers. short-term, it was suggested to use Breastfeeding Medicine. 2015;10(5):232-8. curcumin for treating sore nipples. 8. Niazi A, Yousefzadeh S, Rakhshandeh Considering the interest of patients in H, Esmaily H, Askari VR. Promising effects of alternative medicine and the purslane cream on the breast fissure in inexpensiveness of these therapeutic lactating women: A clinical trial. Complementary therapies in medicine. methods, use of their beneficial effects is 2019;43:300-5. suggested for improving sore nipples. The findings of this study should be interpreted 9. Tafazoli M, Saeedi R, Gholami Robatsangi M, Mazloom R. Aloevera gel Vs. with caution because of great lanolin ointment in the treatment of nipple heterogeneity across studies as well as sore: a randomized clinical trial. Tehran limited number of studies and small University Medical Journal.2010;67(10):699- sample size. 704.

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