Jan Riordan said: I propose that we return to our earlier assumption that
there are two types of sore nipples,1) normal/transient, and 2)
pathologic/chronic.

I agree with much of what Jan said. (Though I think we do often have
transient pathologic sore nipples and don't like distinguishing by length
of time between what is normal and what is pathological: a short period of
intense pain is lots worse that a long period of mild discomfort.) It may
be news in America, but some of us haven't deviated from seeing a variety
of types of early sore nipples, despite emphasizing the critical importance
of watching for the signs of compression that indicate a poorly attached
(not necessarily poorly-positioned) baby. But I think we need to be very
cleazr about what is normal soreness and what pathological.

Remember that in the 1980's Roger Short showed in an elegantly simple
experimental study that there is a huge increase in sensitivity in the
breast during the last weeks of pregnancy, dramatically increasing around
and just after birth, peaking at four days post-partum. This natural
hypersensitivity (which no doubt magnifies the neuroendocrine effects of
suckling stimulus by the feeble prem or sick baby) can be uncomfortable for
some women, who find even the touch of their clothes hard to tolerate, and
the experience of suckling unpleasant. I refer to this as normal
physiological soreness/tenderness/ sensitivity, explain its origins,
reasure the mother that it naturally and INEVITABLY declines after day four
(as the breast is no longer under full endocrine control and autocrine
control switches into gear: coincidence??), empathise madly and tell her
that it's a sure sign that her brain is getting lots of milk-making
messages and she'll be fine: BUT TO TELL ME if soreness becomes pain or her
nipples look squashed as they come out of the baby's mouth. For from nipple
compression, nipple fissures develop. The diagnostic feeling there is of
fierce, lancing, breath-taking pain.

So: initial hyper-sensitivity (my term for this) can be experienced as
severe soreness by some women. Reassurance and TLC keeps virtually everyone
feeding despite it. Initial pain needs investigation and I agree with
Pardee that we should always review the feeding process. Just asking about
squashed/flattened nipples is often enough to get the presumptive diagnosis
of positional soreness, but it can be infant oral factors, in utero
thumbsucking, or birth trauma to the skull... or a host of other things.
The fact that the most common cause remains poor positioning (usually with
the baby's head ever-so-slightly flexed so that the jaw swings out from the
breast and lower gum comes up too close to the underside of the nipple:
extremely common in football-hold positioning) doesn't mean that there
aren't other reasons after you fix that one.

And of course dermatitis (skin inflammation) of whatever origin
(infectious, allergic, irritant..) can occur in the peripartum woman as at
other times. We may not know whether candida, eczema, psoriasis, or allergy
is the villain, and it often isn't, but an inflamed sore, dry, scaly, red
or other painful nipple-areola complex is experiencing dermatitis  of some
sort. The increased sensitivity referred to can make mild symptoms feel
intolerable - REALLY intolerable, not imagined or low-pain-threshhold
patronisingly intolerable. Sometimes acknowledging and not belittling the
reality of the pain with a diagnosis helps the mother greatly, even before
you find the cure.

By the way, TALC (Teaching AIds at Low Cost) has a graph slide of this
increased sensitivity in pregnancy and perinatally.Will find and post their
address. Very cheap resources, and very useful. MM