Have you investigated possible Raynaud's syndrome? This may be part of the puzzle. Often the nipple and areola start to blanch after (or during) breastfeeding, even with a good latch with no risk factors. The blanching spreads (and is easy to miss if you aren't looking for it) and the mom may have a hx of very cold and blanching fingers and toes, pain in fingers, toes and nipples when exiting the shower and "unexplainable" nipple pain while breastfeeding. 

Warming the nipple and areolar area immediately after the baby unlatches is helpful, I have my Raynaud's clients keep a container of very warm water nearby when nursing or use a heating pad with moist heat or a moist towel underneath. There are also medications for Raynaud's that an MD can prescribe that can help in moderate to severe cases. 

Of course, careful observation and examination of the latch and the baby's mouth for possible midline oral anomalies is essential as well. Posterior and/or submucosal Ankologlossia is an often hidden cause, as is tight or short maxillary labial frenulum. 

Warmly,

Mary Jozwiak, IBCLC, RLC
Board Certified Lactation Consultant
Senior Post Partum Doula
Birthways inc
Chicago IL 

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