Christine
Thanks for asking such an interesting question - it's been a while, I
think, since we've been challenged to be specific about positioning....
You gave a good history of what is happening with this mom's nipple,
and especially that it sounds like a soft form of history repeating
itself - this baby being only 8 days old with a crack beginning on
the L nipple, using the cradle hold, at the same site as a previous
crack which extended all round the nipple with the first baby. And
you note also that the situation is improving when the mom nurses
using the football hold.
From what you describe, to make a Dx of exclusion, to see what the
problem is _not_ ....it can't be caused by a lip tie, or both nipples
would be affected, and besides which your observation is that there
is no excessive labial frenulum.
I'd go with Sue's suggestion that it's either something the mom is
doing (holding the breast away from the baby's nose) or some
mis-alignment with the way the baby is being positioned at the breast
- Michaela also suggested that the baby's bottom needed to be held
closer in, but actually I'd imagine that that would exacerbate the
problem and that the baby needs to be swivelled outwards a little so
that the nose is closer to the breast, ie so that the baby's torso is
perhaps not quite so close to the mom's body? I like to think of the
nipple as being like a flower in the baby's mouth - does the stalk go
straight to the back of the baby's throat, or it it being bent or
twisted from one side or the other, or up or down. For a crack to be
happening where the baby's upper gum line is in the cradle hold
(about 2 or 3 o'clock?) there must be an area of stress in that
position - the areolar/nipple junction is being stretched too far,
ie the stalk is being bent downwards. Sometimes while the baby is
sucking you can see the skin of the breast above the upper lip
stretching tight and relaxing with each suck. You could try either
dropping the breast or lifting the baby a little, holding the baby a
touch closer to the mother's armpit, and/or adjusting the angle of
the baby's body in relation to the mother's so that this no longer
happens, so that the nose is closer to the breast - actually the tip
of the nose should perhaps be just touching....
Alternatively, as you've found, changing positions to the football
hold would avoid that area of stress - because the upper gum would
perhaps be between 10 and 12'oclock?? Once again, in this changed
position, it would be a good idea to ensure that that stalk is not
being bent, ie there is no stretching of the breast skin near the
baby's upper lip and if so, adjust the baby or the breast so that it
no longer happens.
And one more thing.... with this kind of damage, it would be
important to keep the affected breast extremely well drained to avoid
the risk of mastitis - feed from that side often, and if it needs
more drainage, using hand-expression rather than pumping would cause
the least damage.
I find with cracks where nipple joins areola that they take quite a
while to heal - you'd like the crack to close, and stay closed, but
it doesn't because it breaks open again with each nursing, and it
seems to heal slowly from the base of the V which is the crack - I
find it can be helpful for the mother not to cover everything with a
bra immediately after nursing - leave it open. This has the effect
of allowing the crack to dry open, and ultimately slightly
lengthening the nipple, which is helpful.
Lastly, I don't like jumping to a conclusion about Thrush for every
case of sore nipples (my experience is that bacterial infections are
much more likely....) but I find that Thrush can often be the cause
with just this kind of nipple damage - a crack exactly where nipple
meets areola.... if the baby has any Sx, then you could think about
treating for that too, but still, positioning is just as important,
even if not more so, to enable the damage to heal.
I hope this makes sense?
Pamela Morrison IBCLC
Rustington, England
----------------------------------------
Hi. I am working with a mother and her 8 day old baby. She has a
crack developing at the base of her nipple where baby's upper gum
would be with cradle hold. She is doing football hold now and it is
better. It is only on her left nipple. Right nipple is not sore or
cracked. She had the same issue with her first baby on the left
nipple and the crack continued to get worse and went around the
entire nipple. This lasted for over 2 months and she worked with a
lactation consultant part of that time.. I watched baby nurse today.
I did not see any evidence of lip or tongue or palate issues. Baby
appears to latch well, calm during feeding, no clicking or gulping.
Baby is gaining weight and has plenty of diapers. She is not a fussy
baby. I read a crack in that position could be from a lip tie. This
baby does not appear to have a lip-tie, although using Dr. Kotlow's
classification it would be a class 2. I have recently learned of Dr.
Kotlow's lip-tie classifications so I make note of babies I
assess. Either I do not know what I am looking for or most all
newborns have some degree of lip-tie. I have yet to see a class
I. Most look to be between a 2 and 3. Any suggestions on what I can
look for that may cause a crack in this spot? It is interesting that
the exact same thing happened with her first baby. Could it be
something with the mother and not related to baby at all? Thanks!
Christine Lichte, BS, IBCLC
Warrensburg MO
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