I'm working with a mother of a 3 week old who has got me stumped to find a
way to help solve her continuing areolar pain.  I have the mother's
permission to post.

Mother is 30 year old primip, healthy baby boy was born vaginally in an
unmedicated birth.  Mother was referred to me with nipple trauma and concerns
about feeding frequency.

Visual exam of breasts at first visit:  remarkable number of Montgomery
tubules, at least 30 per areola, scattered from the 9 o'clock to 3 o'clock
position.  Nipples have an unusual shape.  They are about 3/8" wide, approx.
1/2 and 5/8" long. They are bottle-shaped, being about an 1/8" wider at the
bottom than at the top.   There is a crack and bruising on the left nipple at
the 12 o'clock position.

Visual exam of baby at first visit:  somewhat jaundiced (yellow to navel),
sucking blister on upper lip, sleepy, mother reported it was difficult to
keep awake during a feed.

On the first visit, we concentrated on positioning and attachment issues,
including flanging lips and rousing techniques.  Baby tends to "chew" at the
beginning of the feed, clamping down a bit during sucking.  Mother is
practicing suck training with infant to try to correct this pattern and
inefficient tongue use (up in back, behind jawline).

3 days later, crack and bruising are healing nicely and attachment is better,
but still not flawless. (Mother tends to bring breast to baby rather than
vice versa, and has difficulty getting comfortable to feed.) She uses only
the cross cradle position.

At the follow up visit, the mother complained of pain on the outside edge
both areolae corresponding to the position of the corner of the baby's mouth.
 She has several Montgomery tubules in this area on each areola, and I
thought that there might be some irritation, but changing positions to
cradle,  football and side lying produced no improvement.  Various
configurations of pillows, washcloth and other supports for baby and breast
also did not help.  Mother reports that as the feed progresses, the pain
lessens, but never entirely disappears.  She had no predisposing factors for
thrush.  Frenulum and tongue are normal.

Could this pain be caused by the baby's tongue being up in back and the
biting down?  Any ideas?  Thanks.

Barbara Ash, IBCLC
Canberra, Australia

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