Michael Woolridge's insightful articles in 1986 in Midwifery talk about the
Anatomy of Infant Sucking, and The Aetiology of Sore Nipples.  In the
latter, he makes the point that the two primary (initial) reasons for sore
nipples are inadequate teat formation and inadequate milk flow.  Other,
secondary issues such as opportunistic infection with fungal, bacterial, or
viral pathogens follow-on from the broken skin.  Certainly anatomic
variations such as tongue-tie, unusual palate configuration, mis-fit between
nipple size and oral anatomy, etc contribute to inadequate teat formation.
Inadequate latch contributes to poor breast emptying and down regulation of
milk supply.  Milk supply can be low because of other primary issues
(hormonal inbalances, maternal infection, retained placenta, etc).  When
milk supply won't flow because milk isn't there to begin with, baby will
apply over-zealous negative pressure (suction) trying to pull down some
food.  This creates a skin-off-the-tip sort of wound.  The pinch-off of the
inadequate teat formation creates a wound that looks like a scabbed-over
stripe.  Be sure to observe the shape of the nipple as the baby comes off
the breast.  Distortion gives you some information.

 In the case posted by Bonnie Jones, the 7 weeks use of the nipple cream
ought to mitigate against infection by now. Of course, it could also have
contributed to contact dermatitis.

 I suspect that there are still primary reasons for the truama.  If the milk
supply is very low, or has down regulated due to nipple-sucking that pinches
off the stream and fails to empty the breast, then the baby stratigically
applies too much negative pressure to try to draw a milk flow.

 In this case, I would try to supplement the baby at breast with a feeding
tube device.  Baby sounds hungry; supply sounds low.  Oral-digital exam
might be useful to see if there are oral anomolies.  I would look at the
diameter and length of the nipple to see if baby has enough ability to
'reach' the breast. Look at the baby's chin.  A very recessed chin needs to
be tipped in rather dramatically to insure that the lower jaw is closing
over breast - not nipple -- tissue.  Galactogogues are not a bad idea, but
time's a-wasting, as she is heading for the end of the calibration time
frame.

Barbara Wilson-Clay BSEd, IBCLC
Austin Lactation Associates
http://www.lactnews.com

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