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From:
Sharon Knorr <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Tue, 11 Mar 2003 21:02:27 -0500
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After we have solved the mysteries of milk production, I would like someone to take on sore nipples.  We have determined quite definitely that poor latch and positioning can cause sore nipples and tissue damage, as can infection. There still remains the issue of initial soreness which resolves spontaneously, usually within the first two weeks, without intervention and with no decernible long-term effects on breastfeeding.  I think that some of it is due to hormonal changes - just as many women experience nipple soreness at different times during pregnancy, I think it is possible that a certain percentage will experience the same effect postpartum.  We have even had reports here on Lactnet of moms with actual tissue breakdown as well as soreness during pregnancy - this is not due to latch problems. We know that moms who experience unmedicated home births with babies who nurse well right away, can still experience sore nipples. I think that, like milk insufficiency, nipple soreness has multiple etiologies requiring multiple approaches.

While I agree that an obviously poor latch should be corrected as soon as possible, I am reluctant to intervene in a situation where the latch appears good, baby is nursing well, poops and pees are good and mom is coping with the initial latch pain which resolves rapidly as the feeding continues.  I have seen instances where mothers became quite upset when an LC continued to try to get the baby to latch perfectly.  I think this can also undermine the mother's confidence in her ability to breastfeed and the idea that the process should flow naturally between mother and baby.  There are even times when the nipples comes out looking quite squashed or strange, but mom reports little or no pain and breastfeeding goes very well with no complications.  And then there are the dyads that seem perfect in every way, and yet the pain is unremitting and the cause undetermined.  We just don't yet understand everything that is going on.

I think that pain with the very first feed is a big red flag.  Pain which continues throughout the feed or after the feed - also indicates need for intervention, as does pain which lasts for more than a week to ten days with no sign of abating.  I think that the longer the pain continues, the more risk you are taking for long-term problems, so the waiting game does have its limits and its risks.

Those who deal a lot with normal babies with few problems are more likely to wait a little too long for things to work out, thus precluding an early resolution to a problem.  Those who deal more with difficult cases are more prone to jump in early, maybe a little too quickly in some instances.  When working with new moms, I try to coach them to help their babies to achieve a nice, deep latch. I don't hesitate to suggest a relatch if things really don't look too good and it is cool to watch a moms face light up when baby goes from bad to good latch.  However,  I tend to let them go if baby latches pretty well and is nursing vigorously.  We do close follow-up and emphasize when to get help with sore nipples.

As one who works with her fair share of train wrecks, I empathize with Cathy's desire to get things right from the start.  I guess I just worry about the amount of unnecessary intervention which may go on if we push for a goal of absolutely no pain for all women.  I think that this is a little like the stool controversy - is stooling less than several times a day a pathological condition of some kind?  Is pain while  breastfeeding always indicative of a problem requiring intervention?  Or are both these things more of a bell curve type of thing with a range of normal, depending on a variety of factors unique to each mother and/or baby?

If I knew the answers to these questions I would be speaking in Sydney instead of trying to scrape together the money to go there and listen to other people speak.  Ah well, maybe next year.  Considering how many mothers stop breastfeeding because of nipple pain, we certainly need to continue to explore this topic and share our observations with our colleagues.
Warmly,
Sharon Knorr, BSMT, ASCP, IBCLC
Newark, NY (near Rochester on Lake Ontario)
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