I have received permission from my client to post this information and 
request advice.

My client has 3 children. The first pregnancy resulted in twins and she 
pumped for 7 months. She said breastfeeding was too painful and difficult, 
but even pumping caused breast/nipple pain-though she persisted because of 
the benefits. She did not seek help with her first babies. Now she has a 4 
month old and when I first saw her a couple of months ago she reported 
nipple pain. Observation at that time revealed nipple compression and with 
better positioning, deeper latch that improved. However, she recently 
contacted me again and said that even though the compression is gone, she 
still has severe pain in her nipples and breast when nursing, primarily 
during MER. I saw her again and observed her baby feeding-deep latch, no 
compression. Nipple and breast look healthy, no s/sx of yeast, infection, 
plugged ducts, etc.. She described the pain as most severe in the very 
center of her nipple and thinking she may have a plug, I asked her to 
express milk and noticed that she seems to only have ducts exiting in the 
very center (maybe 20% of the total area), nowhere else. It occurred to me 
that perhaps she has a very forceful MER AND very little exit room which 
combines for excruiating pain (Increase flow pressure with smaller 
diameter) We discussed this possibility and she said that it does feel 
like there's a lot of pressure with MER and until it stops, she has severe 
pain. Because she pumped so much with her first babies, she lets down just 
as forcefully with the pump, so it's no better. She really wants to 
continue nursing for a year, but is very uncomfortable. Does anyone have 
experience with this and are there any suggestions for relieving it?

Tricia Soliz, RN, MSN, IBCLC

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