Jahaan, (and Fran)

For what it's worth, this is my $.02 worth. I think this is something to
keep in mind as you read your e-mail answers and/or read the excellent
sources in the LLL publications, various nursing, medical and lactation
consultant journals and books, older and newer.

The dictionary offers different definitions for the word "sore". As an
adjective, it means "tender". As a noun, it means "wound". This
grammatical distinction gets forgotten or ignored in everyday
conversation, especially if the remark originates with the mother.

She knows no other word to use, and has no basis for knowing how to say,
"There is only tenderness, but no wound." or "There is a wound, as well
as tenderness." It is up to the HCP to look at, and sometimes, to palpate
in order to assess the source(s) of the pain, and this is seldom done
until it almost seems like an emergencey to the mom.

Over the years, I have seen mothers with very tender nipples without
visible damage given advice for wound healing. This is especially
prevalent in phone counseling, but also in the hospital when the doctor
may hurry into the room, ask how she's feeling, hear her say "sore"
nipples, prescribe a proprietary cream and hurry on out of the room to
the next mom.

Too many HCP's, even in the "hands-on" professions, with the privacy to
make a thorough assessment,  prefer to judge this symptom and attempt to
solve this problem solely on the basis of words, rather than have the
mother drop her flaps and INSPECT and (heaven forbid) perhaps PALPATE the
nipple-areolar complex.

It is also possible for a mom without skin damage to have a very painful
latch in the early days which is caused mainly by overfull milk
reservoirs. When compressed, vigorously and suddenly as in latching,  the
overstretched walls are PAINFUL, but since it seems to be coming from the
outer central area of the breast, everyone assumes it must be from the
nipple button.

Gentle manual extraction of 4-5 drops in opposing quadrants of the areola
can markedly reduce or totally eliminate early latch pain, soften the
subareolar tissue and help the jaws stay deep enough on the breast to
extend the nipple back nearer the soft palate. This can often decrease
the chance of nipple trauma and subsequent pain and/or damage. It is
easily taught to most mothers.

It is possible for a mom with visible damage of the skin to have very
little pain in the nipples. I have seen mothers who make ME wince when I
look at their nipples, casually latch on and describe a "tug" or maybe a
momentary 30 second discomfort.

There is an excellent article cited in the March '99 JHL by Brent, et al,
in Archives of Pediatric and Adolescent  Medicine, Nov. 98,  that states
there is no correlation between the appearance of the nipple and the
severity of the pain the mother describes. I agree totally. Better
assessment of the nipple areolar complex for the precise tissue level(s)
in which the mother is feeling the discomfort would be a better
foundation for intervention for many moms.

So when you receive answers to your query, unless you are  being specific
about descriptions about the meaning of "sore" in that particular case, I
think it might be about like the fable of the blind men trying to
describe an elephant. Every one sees one part of the picture, and thinks
his definition (and treatment) is "the solution."

Using the term "sore", especially if you are taking the mother's
subjective complaint as the basis, is sort of like talking about fruit
salad. I could be talking about oranges and bananas while you might be
visualizing strawberries and peaches etc.

Unfortunately, reading the published literature, not just the older
"research", but even a lot of more recent studies, use the term "sore" in
a very generalized, non descriptive way, and may be using it to describe
different meanings, some meaning for instance, "extreme tenderness
without visible damage" and sometimes meaning "actual visible damage that
is not especially tender", or any variation as individual as the mother
perceiving it.

For my money, some highly touted and oft-quoted research conclusions are
without value to me because their terms are  imprecise and nonspecific.

It is as if a medical article were to be written in this day and age
about treatments for "bellyache". No use of the term rebound tenderness,
or colic, or which quadrant, or whether in the suprapubic area or whether
constant or sporadic, or whether accompanied by frequency and painful
voiding or diarrhea, etc., etc. And no palpation of the abdomen, and
certainly no mention of the patient's perception of the severity of the
pain on a scale of 0-10.
Just call it a bellyache and give 'em calomel!

To sum up briefly, sources of nipple discomfort can be different at
various stages of lactation. Discomfort can come from trauma to the
nipple button  and/or nerve compression without visible damage, from
early overfull milk reservoirs, as well as skin damage, which could be
uninfected, or sooner or later infected with yeast, or infected with
various sorts of bacterial organisms, and sometimes from a combination of
both.

And for some moms who have used the word "sore", they get relief from any
kind of treatment because of the placebo effect. The nipples were due to
get over their pain or wound sooner or later anyway, but right now, they
hurt.

If someone can reassure her she's going to be alright and give her a
method of "doing something", anything,  including "getting a good latch"
(another term that could stand better definition), while she waits for it
to happen, she will associate it with having "cleared up her sore
nipples." I had a sister-in-law who 35 years ago was told to put
distilled vinegar on her nipples after every feeding to "toughen" them,
and lo and behold, they got better!

K. Jean Cotterman RNC, IBCLC
Dayton, Ohio

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