Marie,  any chance of your getting her consent to do serial close-up medical photography of her nipples at various stages?? I think it might provide learning opportunities for all of us if you wrote it up for Clinical Lactation.

<Her first baby gained weight well, but she had nipple pain with every feeding, along with repeated bouts of nipple bleeding, plugged milk ducts and mastitis. She says she worked with a lactation specialist who thought her latch was great, but the pain and other problems continued no matter how good the latch was. >


While an obviously inadequate latch can be easily observed, how "good" a latch may look from outside cannot possibly reveal all that may be going on hidden inside! Some nipples function with retraction upon areolar compression, especially if the areola is not very pliable. (Adequate RPS on the areola before latching can often reduce functional retraction a great deal.) There is always the way the tongue is covering or not covering any particular area that changes what parts of the nipple are exposed to vacuum, causing skin cells, interstitial tissue fluids, walls and contents of blood vessels, etc. to push themselves forward to try to equalize the negative pressure with the internal pressures of these various tissues + whatever amount of atmospheric pressure is combined with them. 


When bleeding occurs on the tip of the nipple, one thing I have noticed is that it often occurs in a straight line that parallels the junction of the tongue and palate, indicating that the nipple is not far enough back. Only this area is exposed to vacuum.   When the pressure inside the capillaries and the skin cells themselves try to move forward toward the vacuum to try to "equalize" pressures, the skin cells and capillaries often sustain damage in the process.  Mavis Gunther described this pattern of nipple damage way back in the 1950's, labeling it a "positional sore nipple", I believe. This may be mentioned in the Breastfeeding Atlas. I am away from my references now.


Just for curiousity's sake, would the mom permit you to do an oral examination on her first child?? Is there a possibility that one or both babies is tongue-tied to some degree? A type 4 tongue tie has been described as causing the back part of the tongue to hump up and "crowd" the nipple near the palatal junction (Does it look "pinched" or "like a new lipstick" at all when it comes out?). Yet Type 4 TT is not easily "spotted" visually due to being behind membrane at the base of the tongue. Check Catherine Watson Genna's book "Supporting Sucking Skills" and/or Dr. Kotlow's website www.kiddsteeth.com.


<I watched her latch this 2nd baby today.  The baby is 2 days old. Her technique was great - skin-to-skin, baby-led, wide latch, immediate swallowing.> Wonder if my comments above might apply??


<Her nipples were unusual. The face of both nipples was slightly bumpy (similar to most women) but by the time the baby was done with the feeding, it looked like the nipple was covered with blisters. Looking closer, I realized that these were not blisters (no fluid, no blood). This was just her anatomy more swollen.> 


To me this translates as interstitial fluid that has moved forward within the tissue under the skin as in my first paragraph. Did she in fact have IV fluids with this birth? If so, how many sacks before birth? More than 2 in any one 24 hour period? Did she receive any induction, augmentation or multiple hours of 3rd stage management with pitocin? If any of these, by postpartum day 2 (and following) they could be exacerbating any tendency for tissue swelling within the nipple and under its skin cells. Before and after photos would be helpful in sharing with someone in an "on-line" sort of a consult for detective opinions of the "clues".


<She said with her last child, these bumps would eventually fall off and leave an open wound that would bleed and cause more pain. She even said she had one of these bumps "rub off" during this pregnancy while she was in the shower.>


Many years ago when I did a prenatal nipple assessment on a (red-headed) first time mom at 32 weeks gestational age. She consented to serial close-up photos during the next 4 weeks because I discovered a thick layer of dried skin cells covering the entire top (face) of the nipple (a circle about half a centimeter in diameter at the tip) which apparently did not 'slough off' regularly. (I have a red-headed daughter with congenital ichthyosis so had a special interest in skin that did not slough regularly without special care. Not that that's necessarily connected to your mom's sitation, but there are special genetic differences in redheads, one of which is that they often require more general anesthetic to take full effect for surgeries. I digress.)


Knowing the probable questioning reaction of the hospital staff to the appearance of this nipple if it were still like this at birth, I sent a slide of sluffed off skin to the pathology lab to have some idea that there was nothing serious there (keratin cells with some few cells of an  uncommon variety of yeast, which I ignored. I might not do so today. So APNO sounds like a good thing to cover all bases.) I explained briefly and then encouraged her to use very gentle towel friction on the face of the nipple for just a minute or so after a shower, then apply some triple lanolin (the only form of purified lanolin I was aware of at the time. Olive oil might work just as well.)  She had no discomfort while the unsloughed skin cells were gradually leaving and her nipples then had a normal appearance. She went on to have a satisfactory nursing experience.


I get the impression you have seen this mother as a hospital employee, so I don't know whether you will be able to follow her up as I have suggested. But if she is still there for you to see, perhaps you can set up some sort of plan to either see her privately once or more within the next 7-10 days or perhaps give her your contact info to share with any LC that follows her?? Despite short hospital stays, continuity of care during this stage seems especially important for this mom. 


K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC     Dayton OH  (Currently visiting my sis in Columbia MO)

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