A patient came in yesterday describing nipple/areolar pain at a "10-15" at
latch-on, 5-6 at rest, on a scale of 0 to 10 (where 0 = no pain, 10 = most
imaginable). She said she had two areas of exquisite pain on her nipple,
both at the 11 o'clock position.  The larger one was a small, darkish area
approximately 1/8 to 1/4 mm on the areola, situated approximately 2 cm up
from the nipple, which she said felt "raw" although it appeared unabraded.
The other was a smaller, dot-sized area (approx. 1/10 mm) on the nipple
itself, undifferentiated by any color change from the surrounding tissue,
which she said felt like "an open nerve."

The dot on the nipple I considered to be a possible milk blister, based on
her description of the pain, and yet it didn't look remarkable in any way.
I call it a "dot," but it looked to me like a normal ductal opening,
possibly slightly swollen, but possibly not (since I didn't get a chance to
see the geography of her nipple tissue before the onset of pain).

Patient describes pain as existing prior to delivery and initiation of bf.
I don't think I clearly differentiated between the two to discover if the
pain of the lower area also began before breastfeeding.

I helped the baby to achieve a deep areolar latch.  The woman said that the
pain fell to 3-4 (lower than before the baby had latched on, which she had
described as a 5-6 at rest).  This is her third baby, almost her first
bfed, since the other two were only nursed in the immediate postpartum
period.

Would anyone have gone in with a needle in the absence of any visual sign
of a milk blister?  Would you, as I did, have sent the woman home with
instructions to achieve a deep areolar latch and wait to see if she healed?
Does anyone have a good explanation for what this woman presented with?

BTW, she had an accessory ductal opening or nipple which let down milk
simultaneously with let-down at the main nipple, at the 12 o'clock position
on her areola, approximately  4 cm above the nipple.  The amount,
appearance, and timing of the fluid causes me to believe it was not
proceeding from a Montgomery's gland.

Arly                [log in to unmask]
MS, CLE, IBCLC