Although I have lurked for years and learned much from the communal wisdom of everyone on this list, I've never posted before.  However recently, I've worked with a mother of a 2 year old that I am having a really difficult time finding answers for and wondered if anyone here might have encountered a similar situation or could share more perspectives.  I have the mother's permission to post:  Mother has had sore nipples since child's birth.  Birth was to be a planned homebirth which resulted in an emergency c-sec after many hours of pushing.  Child was diagnosed with a posterior tongue tie which was clipped at 5 months.  Mother used a nipple shield until the child was a year old.  Mother states she has had nipple pain for most of the child's 2 years, although it was much less when she was using the shield.  She states her pain is an 8 on a 1-10 scale.   Mother is now 15 weeks pregnant.   She has been treated for yeast before the pregnancy and treatment has included a 2 week course of Diflucan (200 mgs.), Gentian Violet and APNO.  She only felt slight relief while on the Diflucan.  She feels the pain is worse on the right and mostly when latching.  She describes the latch pain as "feeling like sandpaper is rubbing her nipples" and then the pain progresses to a pinching feeling.  She does not feel the pain in between nursings.  The child nurses around 3-4 times a day and she finds it the least painful to nurse lying down with her child on top of her.   She has never had any cracks or abrasions on her nipples and they appear normal in color, have no triphasic color change, and have a slight crease after nursing.  I examined the child's tongue and palate and observed that the tongue, although clipped, still has a heart shape and though child is able to extend tongue, has some restriction with elevation.  What really threw me was the child's palate (although, admittedly I don't get much of a chance to evaluate many 2 year olds) which was somewhat high but had more of a ridge instead of an indentation in the middle of the palate.  Again, I don't have much experience with the palates of toddlers, except my own children, and they are now way past toddler age, but this seemed unusual.   Mother stated her milk supply was always ample and never had any milk transfer issues as child had great weight during the time she was exclusively breastfed and continued beyond.  Of course, her supply is diminishing now due to the pregnancy.  Mom's goals are to tandem nurse when the new baby arrives until the older child weans naturally and she is very concerned how she can continue nursing both if this nipple pain continues.  She has seen a number of lactation consultants but has never figured out exactly the cause of her nipple pain.   My feeling is that this is not related to yeast, although I discussed trying Grapefruit Seed Extract since she hasn't tried that yet.  I am wondering about the possibility of this being staph related but since she has had this since the beginning with no real resolution of pain and it is confined to when the child latches and during nursing feel it is more related to tongue/palate issues.  We have discussed how the pregnancy may cause her to have sore nipples but she doesn't feel the pain has become worse during the pregnancy and she doesn't have symptoms of Reynaud's.  I would really like to help her reach her goals, especially since she is getting many opinions to just wean the child, and that is not in line with what she feels is best for her child and herself.   What am I missing?  I would appreciate any and all thoughts on this siutation!  

Carolyn Hose, IBCLC
Northern VA 

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