<Is is ever "supposed to" hurt?  I am on a list for moms who pump, and
there
was a discussion about how "those nipples have to toughen up" the first
couple of days, so "be prepared to be sore".  This is in regard to
pumping
as well as breastfeeding>

< Anyway, I got shot down, told it
was "normal" to have sensitivity and soreness as the nipples got "used
to"
the baby or pump. >

Common, yes. Normal, no.

Here's my impression:
Whenever anything in the central outer portion of the breast is painful,
it is often assumed that it is the mammilla, or nipple "button" proper
that is hurting. It's hard to be objective about something so subjective!
There is much more to the nipple-areolar complex than the mammilla or
it's skin.

I have created a conceptual model I use to assess pain more objectively
and separate out which zone or zones are involved. However, this is only
for initial traumatic type pain, and it does not apply to yeast pain,
which seems to be "a horse of a different color".

Zone 1: The skin at the tip and sides of the nipple button. Think of a
thimble-shape area of tissue.

Zone 2: The flesh, that is the interior muscle and connective tissue and
galactophores (milk tubings) inside the nipple button. Think of the
finger inside the thimble.

Zone 3: The thin delicate skin and tubings that connect the nipple button
proper with the areola and the deeper subareolar tissues and milk
sinuses.

Zone 4: The walls of the milk sinuses themselves. (I agree with the newer
Australian research that says there is no "bicycle spoke" distribution of
the milk sinuses as we are accustomed to see them illustrated on
diagrams. But I have palpated so many of them that I KNOW that there are
such things as milk sinuses buried in the subareolar tissue at varying
levels, sort of like flowers in a bouquet.)

But if a mom complains of pain, here's how one can gently test, (best
done before a feeding to decide on possible interventions) or instruct
the mom to test, even over the phone, and have her rate discomfort on a
scale of 1 (least) to ten (very severe.):

Zone 1: Gently brush the fingertip over the tips and sides of the nipple
skin. Most moms seldom rate this higher before a feeding than a 2 or 3
whether damaged or not.

Zone 2: Gently squeeze the nipple button between thumb and forefinger for
a second and observe mom's body language. If there is not much
tenderness, squeeze it a few more times, gradually increasing the
firmness, and have mom rate the intensity of this pain. Depending on
whether the tongue/jaws have been traumatizing the nipple severely, most
moms might rate this from 0-5 or so.

Zone 3: Grasp the nipple shaft near the base of the nipple and gently
twist and tug, increasing the torsion slightly if the mom's body language
indicates it's ok. This area can be EXQUISITELY tender if mom has been
breaking suction by just pulling on the areola till the nipple comes out
of the baby's mouth, which can happen almost by reflex, even producing
minute skin tears if she has "steeled" herself to go on nursing when Zone
2 hurts continuously, and she suddenly reaches a point where she "just
can't stand it a moment longer".

I call this a "sprained nipple". This can also start later if a slightly
older baby has slipped down and hung on for dear life, yanking while
pivoting the head to pay attention to something interesting. Rating can
be upwards of 6-7 or more. I think using the pump with too small a flange
and on maximum vacuum at the beginning could produce too much traction
and torsion on this zone and have this same effect.

Zone 4: Place the thumb and curved fingertips in a "C" shape about 2-3
cm. from the base of the nipple, push inward and hold while starting to
compress the thumb and fingertips together over the sinuses. If the
fingers are right over the "belly" of the distended milk sinuses, this
can be very painful, 6-7 and up. In my experience, 50-75% of the initial
latch or pumping pain can come from this source.

(Think for a moment. Have you ever been in a car with a seatbelt on and
bladder becoming distended, and someone suddenly jams on the brakes?
Hurts, doesn't it!)

If simple fingertip expression is used to slowly and gently begin
deflating the sinuses, the pain in this zone magically disappears within
less than a minute as soon as the particular walls being compressed are
no longer overdistended. One has to move 90 degrees around to the
remainder of the sinuses to do the same thing, or the other overdistended
sinuses will still hurt when compressed.

Cessation of pain is especially noticeable if the MER is stimulated by
the testing. Or if gentle fingertip expression even seems too painful,
discomfort can be avoided entirely by using Reverse Pressure Softening,
which applies pressure longitudinally on the sinuses to move some of the
milk back upward temporarily into the contributing ducts.

I suspect that Zone 4  pain may be a frequent cause of initial latch or
pump pain if compression occurs right over the "belly" of the sinus at
the thinnest area of the wall. (The "off-center" latch does not compress
the "belly" of the sinus. The top jaw falls near the distal end and the
rippling of the tongue starts beyond the proximal [closest to the body
end] of the sinus, producing a more longitudinal compression pattern!)

I do not think it is a matter of the nipple "toughening", but of the
subareolar tissue becoming less swollen, or walls of the sinuses less
overdistended and becoming somewhat more elastic, which usually happens
in a week or two.

Jean
*********************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA (Currently in Phoenix to visit kids - 80 degrees and
sunny!)

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