<This is ONE DETERMINED momma, and she continues to nurse this sweet baby on
demand notwithstanding VERY formidable cracks at the base of each of her
nipples. She reports that the pain is manageable after the initial latch
(which is clearly quite exquisite), but this is coming from someone I know
to have a VERY HIGH pain threshold. ANY insights about how we might achieve
healing of these cracks which appear to be on scar tissue would be VERY
welcome.>
Aimee,
Virginia Thorley once published an article on the mother's body reflex
response to nipple pain, and I hope she will supply the citation because I
have not kept my master bibliography up to date.
I myself have been fascinated with histologic, embryologic and surgical
explanations of nipple anatomy for over 3 decades. I would be interested in
your pictures, particularly to see the cracks and at what area of a
clock-face superimposed on the nipples those cracks might be, or if they are
completely around the base. This would suggest a pump flange that is too
small and/or vacuum too strong, IME.
My first thought would be to avoid redamaging (in addition to any other
actual topical aids to healing).I would give special attention to observing
a whole feeding to detect any possible tension or traction at this location
which I call Zone 3, Watch the way in which she breaks suction, if she does
so.
I would also suggest using baby-prone position exclusively for a while, with
breast compression if necessary, so that there is no "drag" on this area. I
would suggest hand expression rather than vacuum if milk removal is desired.
If any pumping is, however, being done, soften the areola thoroughly first
with RPS or HE, and be sure the diameter of the flange tunnel is large
enough to allow the circumference to fall at least 1-2 cm. beyond the
junction of the base of the nipple with the areola, and of course, use the
lowest vacuum setting that will give results, for the shortest time period,
plus speed the removal with breast compression simultaneously with pumping.
Some of my ideas, from Cotterman KJ, “Zone Model” Tool for Assessing Early
Nipple Discomfort: Part 2: The Assessment Process, *Lactation Currents,
Florida Lactation Consultant Association Newsletter,* September, 2002, p.
5-9.:
*<Zone 3-gently grasp the base of the nipple where it meets the areolar skin
and slowly begin to tug and twist, and increase traction as you watch the
mother’s body language.* Have her rate any discomfort. This area is
relatively devoid of fatty tissue to cushion trauma. Extreme guarding,
exquisite tenderness ranging upward to 6-7 or higher is often a sign that
traction has “sprained” this area of tissue, causing internal bruising
and/or tearing. There should be absolutely no traction on the nipple. Also
look closely at the skin at the junction of the nipple and areola, tilting
the nipple this way and that, as traction/tension may even cause external
skin tears there.
During the learning period, discomfort in this zone is almost always due to
severe traction at the base of the nipple caused by the mother’s fearful,
self-preservation urge, grit-your-teeth, ‘*get-it-out-of-his-mouth!’*,
rapid-but-incorrect suction breaking. The more often it’s done, the worse it
may become. In addition, this kind of discomfort may also be partially due
to the weight of a poorly supported breast dragging the nipple from the
baby's mouth, or from too small a pump flange, perhaps combined with too
strong a vacuum. There should be no significant compression in this area
either, except for the ripple of the middle of the tongue during the
extrusion process. This pain, when present, is excruciating, lasting through
practically the whole feeding, unless the mother can reposition the baby’s
mouth at least 1 cm. beyond the “sprained” area. I have found baby-prone
nursing position helps maintain this deeper placement of the baby’s jaws and
tongue.
I have had a few mothers who found this type of pain resolved only by 24-48
hours of resting the nipple base, especially if skin tears exist. This
includes even the traction of vacuum, instead using frequent fingertip
expression Ľ-1/2” further back on the areola beyond the tender area, to
maintain supply and avoid engorgement. A few weeks later (at the beginning
of the “curiosity stage”) it can occur due to the baby’s allowing the nipple
to slip and then jerking the head with the tip of the nipple held firmly
between the jaws, perhaps while attempting to follow someone or something
with his eyes.>
K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC
Dayton OH
**
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