Amberly, I wonder if we are seeing more such cases of intractible nipple
and/or breast pain, now that mothers are less likely to quit early (which is
what they did in previous decades). I have had two mothers this year with
multifactorial intense nipple pain, and no clear answers. I also saw a
mother a couple of years ago who I now realise was nipple psoriasis as the
cause of intense nipple pain. (There's not always a clear history for this.)
These mothers have usually already seen multiple good people - from medical,
midwifery and lactation consultant professions - who would be able to help
in normal circumstances.
Think multiple factors, rather than a single cause. Most likely by the time
the mother has got to you, latch will have been thoroughly investigated and
is unlikely to be the issue, but it is always wise to check it again and
offer other positions so that the mother can find what best suits her and
her baby. Other possibilities I check for are:
- infection (more common than is generally thought);
- nipple vasospasm (Raynaud's-like symptoms with colour changes);
- contact dermatitis (which can take some ingenuity to investigate);
- incompletely treated thrush (espec if a long family history);
- psoriasis of the nipple.
You can add to that list something I identified in a client ssome years ago,
and have seen in others since - referred pain from the spine, where there
has been an old spinal injury. Remember where the enervation for the breast
comes off the spine? This manifestation of pain seems, in the cases I've
seen, to be generalised in the breast, not specific to the nipples, and the
mother reports it is overwhelming. When I see someone with unexplained
breast pain, I ask the mother if she has had a spinal injury at some stage
in the past. Remember, the mother has been through a pregnancy with her
spinal posture changing as the baby grew, followed by a labour or surgical
birth, which are not kind to her vulnerable spine. Oddly enough, sometimes
the injury is higher than the region where the nerves to the breast come off
the spine. My next question is:who is/was treating the mother for her spinal
pain since the injury, and to recommend she go back. This may involve a pain
specialist, her GP and/or a physiotherapist. Once the spinal matter is
being treated, the mother is better able to deal with improving the
breastfeeding.
A useful reference, and one that can be recommended to other members of the
health team to read, is a very breastfeeding-friendly paper in a dermatology
journal, which describes several conditions, some of which are often ignored
when nipple or breast pain is investigated. Yes, despite the title, multiple
factors are covered. See:
- Heller MM et al. Caring for new mothers: diagnosis, management and
treatment of nipple dermatitis in breastfeeding mothers. International
journal of dermatology 2012; 51: 1149-1161.
One further factor that exacerbates nipple pain is one that I first
identified in the mid-1990s and have seen time and again - flinching by the
mother at the moment of latching, when she sees the baby's open mouth,
triggering her fear of pain. Flinching raises her baby (mouth and all) and
lowers her breast. See my two articles in which I have described this, one
in Breastfeeding Review, the other (a long letter) in the Journal of Human
Lactation. I'vc explained it, and how to work with the mother who is doing
it, a lot better in these two articles than I can in a few words here.
- Thorley V. Latch and the fear response: overcoming an obstacle to
successful breastfeeding. Breastfeeding Review 2005; 13(1):9-11.
- Thorley V. Mothers’ behavior that undermines breastfeeding latch: the fear
response (letter) J Hum Lact 2005;21(3):243-244.
To conclude, it may be impossible to find and treat all the factors in
intractible nipple/breast pain, and my heart goes out to the mothers. If
some of the factors can be dealt, the mother may welcome any improvement.
She is also likely to appreciate being listened to and to every effort being
made to find the underlying factors, even if the situation is unresolved.
Bear in mind that the same mother may have a similar situation after a
subsequent birth.
Virginia
Virginia Thorley, OAM, PhD, IBCLC, FILCA
Private Practice Lactation Consultant (original cohort of 1985)
Brisbane, Queensland, Australia
email: [log in to unmask]
website: www.virginiathorley.com
----- Original Message -----
From: "Amberly Renfroe" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, October 21, 2013 5:25 AM
Subject: Breast and nipple pain evades 4 medical personnel
With permission from the mother, I am writing in hopes that someone can help
figure this out.
Please let me know if I am missing any information. This is my first time.
I appreciate any advice in terms of etiquette and dyad details. I am a
newly accredited LLLL and have recently volunteered to be on a week long
call list for the Denver Metro area. One call surprised me because the
mother has already seen 3 OBGYNs, 1 acupuncturist, 1 midwife, and 1
lactation consultant, and to no avail. Her mother- in- law suggested calling
LLL.
First time mother, 7.5 month old baby, mother has had unbearable pain for
the last 2 months on right side only. Baby will pop on and off. Right side
had an inverted nipple. Baby nurses 2xs as long on right (painful) side than
left. She was using a nipple shield. Since birth, the breastfeeding has
caused the inverted nipple to no longer be inverted anymore. It does look
clamped, blanched, and has a white line on the side after nursing. When
squeezing nipple with her fingers, it does NOT change color. She has felt
pain in the same spot, on 1/3 of her breast tissue, near where her ribs meet
her body, at the inner portion of the breast. It is deep into the tissue,
but she also said that it changes, which is why it stumped all of the
medical personnel she sought out. I thought it was a latch problem, and we
talked about vasospasm. She was researching Raynaud’s when someone
suggested that. She has had mastitis 2xs, complete with fever, so she is
aware of what that feels like. I thought perhaps teething. She did seem to
think it was timed with teeth coming in. There is a very intense throbbing
pain, at the nipple at times, too. Like a twisting burning pain that is
recurrent on the same side (right side). I suggested skin to skin
biological nursing to work on a nice latch, in case it was due to teething.
I suggested lecithin in case it was a leftover clogged duct. We talked a
little bit about Raynaud’s, but not as much as latch since Raynaud’s was
already suggested previously. I also suggested laying down to nurse. She
is to the point now where it is really affecting her will to breastfeed.
Because her left side is doing so well, the pain with the right side is
almost unbearable and is frustrating her and she wants to do everything
possible to continue nursing, but just cannot nurse through the pain any
longer. She is on vacation visiting family and will get back to me this
week if anything has helped or not helped. I sent her the kellymom.com link
on blanching and the llli.org link on vasospasms. Thoughts? Suggestions?
Many thanks,
Amberly Renfroe
LLL of Vail Valley
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