Heather asks for opinions about a sore on the nipple of a mother who has
been struggling for 6 weeks with a sore that won't heal.  It is barely
visible before a feed, but gapes to the size of a large pinhead afterwards.
Heather writes:
"To look at, her nipple was normal, though there was a tiny 'hole' about the
size of a pinprick, in the very centre. You would not notice it unless you
were peering at it.

The baby fed beautifully on this side and it was pain free.

Then, when the baby came off, this pinprick hole was gaping - it was now
about the size and depth of a large pin head and bright red raw. 
This part of the nipple was tender, but the rest of the nipple was fine.
It struck me that this was, indeed, a very slight inverted nipple of some
sort, and the inside bit lived happily enough tucked away, but when it came
to being put into a baby's mouth, it didn't have an epidermis to protect
it."

This is a very apt description of something I have seen several times.  The
most pronounced and memorable one was years ago and finally did resolve
after 3 months of lanolin and limpet shells, the latter being a folk remedy
for sore nipples with no evidence to support their use but widely used here,
even on my ward.  The nipples had a divide that looked like a smile before
feeding, and afterwards there was an area with no skin about the size of my
thumbnail.  The shells kept the lesion everted and exposed between feeds,
and the lanolin prevented crust or scab formation so the skin could
gradually cover the exposed area, which did take 3 months.  This mother went
on to breastfeed happily for about another year without problems.

At the moment I am following a similar sore but this woman has been treated
for two bouts of mastitis in the 7 weeks since baby was born, and had until
this week been doing her utmost to keep the lesion dry.  It does not look
infected to me.  It is about as large as the aforementioned one, but has
been forming a hard scab-like surface which gets torn off every time milk
flows through it.  Breastfeeding is the least painful option she has tried,
the others being breastfeeding with a shield, and pumping.  We are trying
moist healing now and I hope it improves soon because her endurance is
wearing thin.

I would try to get a culture taken from the sore, because sometimes there
are bugs there that prevent healing and she might benefit from a topical
antibacterial agent.  Meanwhile I would try to find something to keep the
sore exposed so that the surfaces don't get the chance to adhere to each
other between feeds, and keep using the lanolin with the same aim.

Rachel Myr
Kristiansand, Norway

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