Hello!
Case study for H.R., 2nd time mom with previous and current unusual nipple
pain and damage. Mom has given permission to post.  Has anyone seen this
before or have thoughts on how to treat this?
I cannot post the very helpful pictures here, but you can e-mail me at
[log in to unmask] and I will send you the attachment, or you can go to

https://drive.google.com/file/d/0B0dBKhEyYLmVWGhva2dCYVpxUzcxWXRPeUZzLXpQSzUyQkdj/edit?usp=sharing
for
pictures and full history



Brief History:

H.R. had her 1st baby 11/25/11, Charlie.

With Charlie, mom had significant latch issues, milk supply issues and
nipple damage.

Nipples got breadcrumb like “flakes” that built up and then came off.  There
was raw skin left when they came off. Mom had blisters over the entire
surface of her nipples at times. By 5 months, the damage was so severe that
her very breastfeeding-supportive MD encouraged her to stop breastfeeding
and pumping, and everyone involved in the case agreed.

Currently, mom has twins, born at 32.5 weeks on 08/11/14.

Mom is pumping, getting excellent volumes of milk, but having nipple pain,
same breadcrumb like flaking and blistering.



The blistering does not happen every time, and is only on the left side
with these babies. With Charlie, it did happen on both sides. The blisters
are on the sides of her nipple as well, and extend into a deep crevice on
the outer aspect of the nipple.



Nipples hurt significantly when exposed to air, so there is pain before
pumping, and immediately after pumping.  Right nipple has area in left
lower quadrant that turns bright purple with pumping.

Mom reports that there is a blister-like appearance over the entire tip of
the nipple immediately following pumping at times on the left side.  Mom
continues to have flaking of both nipples that is breadcrumb like in
appearance. Flakes “build up” over a few days, then flake off, and skin
left behind is reddened, like an excoriated area.



With less pain medication, mom is noticing what we believe is vasospasm
more.  After pumping, when moving from hotter upstairs right after pumping
to colder downstairs pain gets worse.  Pain lasts for 30 minutes or more
after every pumping session.  Total of 4+ hours of significant nipple pain
a day.  Pain after is way worse than pain during pumping.  Pain during
pumping on low suction level is 1-2 during pumping (on 0-10 pain scale).
Pain after pumping is 4-5 for 30ish + minutes.  It is a constant pain and
is distracting consistently. Nipples stay erect for entire time pain is
present. Mom describes nipple pain as “throbbing, burning.”



Mom has nipple pain with towel brushing against nipples, anything touching
nipples. Any friction on nipples is excruciating.


Mom pumping enough volume, but was spending 40 minutes total pumping.  We
revised the pumping plan and she is now spending about 30 minutes.  The
issue is that mom cannot turn the suction up high enough to get a fast
enough flow to finish in 15 minutes without severe pain.  Milk drips slowly.
Mom has observed sprays with increased suction, but this is intolerably
painful.

Thank you for any thoughts you may have! This family had quite the
infertility journey as well as the challenges with their 1st and twins. We
would love to see breastfeeding be easier for them!

Leah Roy-Ehri RN,BSN,IBCLC
Ann Marie Neely BA,IBCLC

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