I met with a mom of a 4-month old baby boy today about persistant nipple 
soreness and I am not sure how to help her. She is sore from the first 
breastfeed and is desperately considering weaning because she can't stand 
the constant struggle and pain. 
Positioning and latch were ok and she is trying really hard on that, but she is 
still sore despite trying different positions. Mom is using nipple shields from the 
start (because of slightly flattish nipples - I would rather not comment on this, 
she didn't get any help in the hospital after her cs, tried lots of things alone 
and shields made breastfeeding possible, so she presevered till now). Weight 
gain is excellent and even above average and she is not willing to try  getting 
rid of the shield because of the pain she experiences with every feed, so I let 
things the way they are. The shields are the Avent ones, a bit big for her 
nipples and nipples are not drawn very well in the shield - maybe just halfway.
Her left breast is ok and mom reports no problems there, but the right one 
appears divided, with something like a fold on the inner part at 3 o'clock - part 
of the nipple is folded and somehow held by adhesions in the base, one can 
feel the areola is harder around the base on this spot and soft and pliable on 
the normal looking side. The nipple does not look inverted, nor does it invert 
while doing the test for flat or inverted nipples. It is just not pliable on that 
spot and baby cannot draw the nipple good enough to latch deep. The latch is 
quite shallow despite the shield and mother has a small horizontal crack on the 
midline on face of the nipple. She has also persistant plugged duct every time 
on the same spot on this breast, upper outer quadrant (maybe because baby 
cannot drain the breast good enough?). Mom denies breast trauma on this 
breast, didn't have any breast problems before birth (although she states her 
breasts get very tender before menstruation and the same breast gets hard on 
this spot even when she is not pregnant or lactating). 
On the baby's part - his palate looks just as if someone has put his thumb on 
the palate and pressed hard enough to leave a deep imprint. I am not sure if 
this is a high palate? He is sucking well, stayes quite long on the breast (about 
half an hour), sucking happily - he is feeding only 5 times a day, getting only 
one breast per feed, so he doesn't have much opportunities to suck, but as 
long as weight gain is great and he is very contented and happy I think it is 
ok. 
Mother and I talked about measures to cope with the plug and the crack and I 
made my best of reassuring her that she is coping really good with 
breastfeeding under these circumstances (constant pain for 4 months!). But I 
don't know how to help her further to solve the problem and she is really on 
the edge, so we will be grateful for your suggestions on what to try.
Just a reminder - there are NO lactation consultants in my country and the 
only doctor who I know could help in a situation like this is not available till the 
end of the month. So we need some ideas on what to try now.

Christina in Bulgaria

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