Ruth wrote:

<I have came across an interesting situation i need help with. a 35 year
old
G3 P1 woman presented at 28 weeks antenatally to day with 'crusty
colostrum'
like substance 'scabbed thickly' over the end of both nipples. (that is
the
best way i can describe it). she identified that she would like to
breastfeed this baby "if she can". on further assessment she had
breastfeed
her first baby (now 5 years old) for six weeks but never "had enough
milk"
so put the "poor starving" baby on formula.>

<she revealed that the thick  colostrum
like scabby substance had always been present on her nipples since a
teen. . . .the crusty stuff comes off in the shower and she can scrape it
off any time with no problem or nipple soreness.>
<the substance really  almost looks like crystalysed colostrum and I am
wondering if there
is such condition where the colostrum or milk is 'crystalised' instead of
sticky and flowing.>

I had such a mother once, whose case I have described before on LN, in
response to someone else observing this in a mom. They described the
entire tip of the nipple as "covered with firm yellowish scales".

I discovered the condition at 28 weeks g.a. and by 35 weeks, we had it
cleared up (so as not to "freak out" the nursery personnel!) The "crust"
seemed fully 1/16 to 1/8 inch thick, and I was afraid to make any attempt
to rub or scratch it off in the clinic because it was so thick and firm.
First and only case of "tough nipples" I've ever seen!

My clue came because I have a red-haired daughter with mild congenital
keratosis, noticeable on arms and legs since about age 2 or 3. She keeps
the condition under control with leisurely baths, gentle friction
(loofahs, bath gloves, etc.) to the areas that do not desquamate easily,
and habitual moisture barrier skin hygiene. This is what I believe you
might be seeing.

I followed my client with close-up photography. I had her soak for a
short while in her baths, and gently towel herself off all over (not too
vigorous on the nipples). I had her apply Triple Lanolin to the tips of
the nipples immediately after bathing as a moisture barrier. (That was
years ago before Lansinoh or Purelan were on the market.)

At about 32 weeks, when about half of it was gone,
I had her gently catch some of the cells that peeled off, and put them
between microscope slides and sent them to a pathologist. He identified
what he found as keratin, with some few yeast cells of a type he did not
name, but if it had been candida, I'm sure he would have said so.)

As for her future breastfeeding success, I think such clearing up as I
described might give her self-image, her morale and her general
confidence a boost. But I don't think the crust itself had anything to do
with her poor breastfeeding experience. I imagine bits and pieces of it
fell off in the baby's mouth during feeding, so that the nipple tip was
probably entirely clear early in the actual 6 weeks of nursing. Who
knows? It might even have protected her from cracked nipples!!

I would see as one good place to intervene: making sure that she
understands that it is the frequency and thoroughness of milk removal
that drives the milk making process.

I would emphasize that breastfeeding a lot oftener than she ever thought
to during the other experience, including 10-12+ times during the first
24 hours, would go a long way in giving her breasts better signals.

You can also remind her this is a new placenta, which is stimulating her
body to rebuild the inner breast with brand new milk making cells, like
new leaves on the trees every spring. (Catherine Fetherston can give you
a delightful explanation.)

There was also a recent Lancet article, I believe, that in general, one
can assure second time mothers that they will make more milk than they
did the first time around.

And certainly, I would give her some anticipatory guidance on the
importance of a good off-center latch from the beginning, and teach her
to the way to hand express according to the Marmet method, partly so that
she knows where the milk sinuses lie, and where the tongue must compress
to get milk out.

I would also try to give her a complete understanding that the MER is the
most important force in the milk transfer process. I would try to empower
her by explaining how to stimulate that by hand expression, massage,
breast compression and/or plain nipple stimulation, so that she feels she
has much more control over the process of her breastfeeding experience.

Good luck. Keep us posted. I think this condition occurs more often than
we hear of.

Jean
*******************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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