Hello,

With permission to post, I am wondering if anyone has some insight for persisting nipple pain situation. Baby is 6 months old, pain has fluctuated since 3 months of age when I first saw dyad. Referral at that time was for "thrush" but mother was not responding to 2 weeks diflucan and Newman's APNO. R nipple was red, cracked, inflamed. I suspected possible trauma/infection cascade as mother described having a plugged duct with concurrent biting latch that resulted in broken skin on the R side a few weeks prior. Recommended pumping on R side until healed, basic wound care with saline soaks, continued APNO, and a focus on optimal position and latch. I recommended getting culture to determine any specific infection as well. 

Mother got milk cultured through midwife and had a breast specialist appointment last week. Returned to me today per specialist recommendation due to continued pain, reporting "culture was clean and everything looks fine." Nipple looks better but still has red appearance and mild inflammation as does L side now. Pain is present usually just with initial latch. Mother is doing a combination of breastfeeding and pumping/bottle feeding for time at work and when pain is limiting. Baby had and continues to have highly efficient transfer (85ml today from L side in ~5 minutes) and weight gain (19lb 12oz today). Upper lip blisters noted as well which mother reports to be recurrent. Baby oral exam consistent with possible posterior tongue restriction, limited depression and what appears to be excess sublingual tissue. I am wondering if this could be a situation of posterior tongue restriction resulting in compensatory lip suction/nipple constriction that gets a lot of milk out quickly for good weight gain but perpetuates pain? Learned of this scenario in a course recently with Cathy Genna but not sure if this great weight gain would persist this far along? Nurse practitioner in peds office where I work took a look as well and feels scenario may be more of an allergenic situation. So we discussed switching from what was a new detergent 3 months ago as well as discontinuing the APNO which doesn't seem to be doing anything. I instead suggested Medihoney for topical relief. Mother is getting tired of pain and considering weaning soon if nothing seems to work. 

Thanks to anyone with more insight! Love this work but have a lot to learn!

Allyson Wessells, PT, IBCLC, LLLL
Columbus, Ohio
www.naturalnurturinglc.com

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