Cindy,
You wrote:
<she still has one
crack on each nipple, theses are different than any I have seen, one is
horizontal and one is vertical, if she gently separates the crack you can
see that deep in the crack at the base there is healed skin, but the
crack
above is still a crack and causing pain, we have changed positions
frequently, breastfeeding is ok but not really enjoyable for this mom. >
I wonder if this could partially be a developmental fissure, resulting
from a different depth and distribution of squamous epithelial cells
which normally line both the surface of the nipple and all the way down
and inside the pores of the nipple. I wonder if this is the case
especially on the side where the one "crack" is horizontal?
I have seen some nipples which, to the naked eye, look somewhat
bifurcated (as if partitioned in two, horizontally, by a crevice). I have
seen others where, prenatally, if one pulled apart at the base of the
nipple, the "button" spread open like a 4 petaled flower, displaying a
bright red, raw appearing lining, even brighter than the mucosal lining
of the mouth or eye. Pamela Morrison, from Zimbabwe, also found a mom
with nipples that fit this description.
(I do not, however, remember any appearance of normal skin at the center
of these "flowers" on the particular nipples I took close-ups of. I will
go back and look at the slides closely again.)
From this, it makes me wonder if another developmental variation might
just as easily cause a vertical bifurcation, and that such an appearing
nipple, when separated, might also look raw. I have assumed in these
cases that fetal downgrowth of the mammary pit did not proceed as far
downward before proliferation of connective tissue beneath it began the
process of nipple eversion.
I have cautioned these few mothers that this is left over from the fetal
development of their nipple, and that it is a perfectly normal condition
for them, and not to let any HCP's freak out over apparent "cracks" in
the nipple. But I have also cautioned them to be sure to allow the
internal surface to dry before letting it close after it was spread open
by the vacuum forces of nursing, as this type of surface would probably
put her at higher risk of developing yeast there.
It may be in need of further "APNO" treatment inside the crack, if
infection of any kind is in fact present. But then again, if it is
healthy tissue composed of normal cuboidal cells like the lining of the
interior ducts, it may look frightening, but be a normal "crack" never
noticed before nursing, that may not necessarily be the site of her pain.
It would be interesting to have you (or her) use a sterile q-tip to touch
or stroke just that red, raw appearing tissue and ask her to rate the
sensation on a pain scale. It might well be very painful if infected or
traumatized, but then again, both of you might be surprised not to find
it so. There are other parts of the nipple-areolar complex that can
produce severe pain on latch, even at 4 weeks. This can be assessed by
using different techniques, and relieved with different interventions
other than wound-healing tactics.
It would also be interesting to observe whether the pain is confined, or
much worse during the first 60-120+ seconds after latch, or if it slacks
off and/or reemerges at some point during the feeding. Some curious part
of me wishes I could be there to see and assess the situation in person.
I would be interested to hear what you find if you look at the situation
from this perspective.
Jean
*********************************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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