I have a theory on nipple pain which has been born out anecdotally and
experientially, but not scientifically -- IOW, this is not documented
EBP....yet.

First of all, I am fairly convinced after 17 years in practice that most
women experience "tenderness" on latch on for the first few days -- after
all, this is unaccustomed activity on the breasts.  If you go barefoot to
take the garbage out in May, the bottoms of your feet will be tender, and you
will ouch, ouch, ouch all the way to the street.  By August, if you continue
doing it, you won't think anything of it.  Feet will be "tougher."  If you
start an exercise regimen -- doesn't matter how much you stretch
appropriately ahead of time, the first few times you exercise, your muscles
will be sore.  It doesn't last.  If it does, you are probably doing something
wrong.  Same for initial latch on for the first few days.  Some women are
going to feel it as pain, some as discomfort, some as ??? depending on their
own sensations.   Caveats to nursing moms should always be:  if there are any
cracks, bleeding, blisters -- or IF the pain is lasting more than the first
few seconds -- minutes into the feed, then we need to check on it.

2.  Blisters on the ends of the nipples which occur in the first two or three
days are from prolonged hanging out of the baby -- constant negative pressure
on the ends of the nipples with no break from a swallow.  I often see them
when the mom tells me the baby nursed for "45 minutes on each side" the first
time.  Hmmm.....  Once the blisters break, they bleed a bit, scab over, and
it's done with.  Some women are more prone to them than others.

3.  Women whose areolas don't change appreciably in color are more prone to
sore nipples than women whose areola got very dark during the pregnancy in
comparision to what they were before.  I don't have a way of quantifying
this, but I do know that when I see a woman with very light areola, she's
more likely to experience true nipple pain longer than a woman whose areola
is considerably darker.  You are more likely to see this on a woman with
extremely fair skin than on a woman with darker skin, but it can also happen
with women of color as well.

3 1/2.  We've speculated as to why areola get darker during pregnancy, and
some wags have suggested it is to make a "bullseye" for the baby to hone in
on as they are latching.  Watch babies latch, especially initially -- how
many have their eyes open, checking for nipple placement?  Looking at the
bullseye?  I don't think so.  But I DO think that the extra melanin that
causes the darkening of the areola is designed to make the nipples/areola a
bit "tougher" to withstand the rigors of breastfeeding.

4.  If a woman *normally* has tender breasts and nipples (during pregnancy,
her periods, lovemaking) then she is going to have more difficulty with
painful nipples as they are becoming accustomed to breastfeeding.

5.  We have to make sure we aren't always blaming the mother for doing
something wrong -- or the baby for doing something wrong -- when sore nipples
are present.  That doesn't mean we ignore it -- we investigate it.  But
sometimes as Fio pointed out, everything can be "right" and sore nipples are
still present.

So lets do our teaching right, evaluate breasts and nipples, ask questions,
look at babies latching on and breastfeeding (standing at the door and
looking at the latch AFTER they've done the deed doesn't always tell the
story either as a baby can suck up a longish nipple like a piece of spaghetti
and cause pain), and not make an assumption that if there is nipple pain it's
because the mother didn't do something correct.  Elasticity of the breast
tissue (rather, lack of it) itself can also cause problems as the nipple
doesn't elongate during suckling which can then lead to the infamous
compression stripe.

Remember, the above is NOT based on research, just observation and a lot of
thinking over the past few years.  I'd love to hear your thoughts on it,
however!

Jan Barger, RN, MA, IBCLC -- Wheaton IL
Lactation Education Consultants
www.lactationeducationconsultants.com

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