Linda,

I have never observed a situation such as the one you described and don't
have a clue as to what is actually happening. But I do enjoy
contemplating the anatomy and physiology of the nipple-areolar complex
and trying to see in my mind's eye what might be happening to it when
there are problems.

<As the feeding progressed the vein became more and more dilated and more
painful.  Milk transfer was good, nipple was still slightly pinched after
feeding and pale just at the tip but rapidly returned to pink.  The veins
remained dilated and the pain persisted for several minutes after the
feed.>

Some questions and observations come to mind.

Regardless of the source of the pain, the dread of it is exacting a
psychological cost from the mother, maybe some miniscule variation of
PTSD left over from her twins. This might have potential to skew her
judgement, as nipple/areolar pain is such a subjective thing. It is very
hard to be objective about it.

A wonderful "first aid" for any sort of pain in the nipple-areolar
complex is a folded washcloth, comfortably wet with the hottest water
that the mother can stand on her wrist, placed over the areola and nipple
and held there till it begins to cool (3-4 minutes). This seems to raise
the pain threshhold in that area for a while. (It has even been suggested
in ultrasound textbooks for relief of pain occasionally encountered
during ductography.) Till the cause of the problem is identified and
resolved, this could give the mother some feeling that she has a way to
control her experience of pain. It might even help lessen the perception
of pain if a little slow abdominal breathing, imaging and conditioned
relaxation could take place during these 3-4 minutes.

I presume these are being called veins because they are visible, and we
don't ordinarily see arteries. But for a vein to swell, since blood is on
it's way out of the tissue and back to the heart, the occlusion must come
from above the area where the swelling is being observed, and the
swelling in a vein often comes from the failure of the valves above the
swollen area of the vein to close completely during the diastolic phase
of circulation. (e.g. don't cross your legs at the knee or wear knee high
stockings with elastic in the top if you don't want to increase your
chances of varicose veins in your lower legs.)

So if these are truly veins, and are in fact swelling and remaining
swollen for a while, it doesn't sound to me as if it could be from the
pressure of the baby's mouth below that area that could be occluding
them. Is there any compression from a bra during the time this is
happening? Can you have the mother use a fingertip to touch and gently
press on what is assumed is the swollen vein when it is still dilated
after the feeding, and see if the pressure of her finger adds to the
pain, or whether there is indeed any pain coming from that area when she
presses on it? On a scale of 1-10, how much is that pain caused by her
finger? Perhaps this may be a way to prove or disprove to herself that
this is (or is not)the actual area where the pain is coming from.

There is also such a thing as referred pain, and if the nipple is being
traumatized, this makes it more likely.

Has a breast pump of any sort been used on the breasts as yet? If maximum
vacuum has been used, or vacuum used for too long at one time, it can
also cause pain from internal bruising or shear stress on tissue -damage
that may or may not be visible on the outer surface.

While I myself have never noted a swelling in the areola during the
occurrence of the let-down reflex, I have heard others say they watched
the un-nursed breast of a particular individual mother when a let down
came, and are positive that they have seen the lactiferous sinuses
distend. If this is true, then maybe there are sinuses hidden beneath the
distended appearing veins that are giving that appearance of swelling.

I have often also observed that pain may be coming from a different area
of the nipple-areolar complex than what the visual focus leads one to
believe. I have found value in a 4-zone model I worked out for assessing
just what portion(s) of the nipple-areolar complex is the actual
source(s) of the early breasfeeding pain, and how much, using a standard
pain scale. Identifying the source of pain helps track down the cause.
Cotterman KJ, "Zone Model" Tool for Assessing Early Nipple Discomfort:
Part 2: The Assessment Process, Lactation Currents, Florida Lactation
Consultant Association Newsletter, September, 2002, p. 5-9.
For instance, many people assume that if a nipple appears to be damaged,
that it is the damaged area that is the most painful part of the
nipple-areolar complex. Yet when touched, it may have a pain score much
lower than other parts of the nipple-areolar complex.

I have noted that much of the initial latch pain comes from direct
compression of the walls of distended milk sinuses, but usually subsides
when the distention is relieved. Gentle fingertip extraction of 10-15
drops often works wonders to relieve latch pain. Reverse Pressure
Softening before latching can also help relieve distention in the
lactiferous sinuses by painlessly moving some of the colostrum/milk
slightly back up into the contributing ducts, leaving the sinuses supple
enough to ripple with or withstand compression without discomfort.

Are you absolutely sure there is no possibility of developing thrush,
even at 7 days? I used to believe it couldn't begin so soon, but I have
to admit I have seen a few very early cases lately. The intensity of her
pain might be a red flag.

It will be interesting to find out what you observe as you hunt for the
cause of the pain. I'm sure you will get a lot of interesting
suggestions.

Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, OH USA

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