OK...I'm stumped!  With mom's permission, I'm asking for your input...Oh
wise ones!

Mom came to see me, has been to 4 LCs - very knowledgeable ones, that I
know.
Baby is 3 months old, but since birth, mom has been experiencing painful
nipples.  

My oral assessment of the baby found no abnormalities in the palate -
ruggae were a bit pronounced in the anterior palate, but no bony
protrusions anywhere, no white tongue or plaques anywhere, tongue free and
easily extended well over the lower gum.

The tongue moved erratically - lots of side to side movements, and it took
a while to get the baby to take my finger in deeply enough so I could feel
good front to back peristaltic movement of the tongue and a release in the
tip of the finger.  Mom reported she has felt that the baby was "bending"
her nipple inside the mouth.

Nipples are very pink and mother reports very painful, and burning when
breastfeeding and when pumping.  Her nipples hurt when exposed to
temperature changes - but also when not having temperature changes, she
observes that they suddenly become very erect (she says she could be
feeling hot and this happens) and painful - no always showing any color
changes. 

Mom has been taught good latching techniques, but I still observed a lot of
thrusting by the baby, so we worked on this, either by holding baby and
breast (think sandwich hold) more firmly so that more breast goes deeply
into the mouth, or removing baby and re-attaching to again get deep latch. 
Mom has been in pain for so long that I had a hard time telling when she
was feeling pain - she just doesn't show it!  But whenever I asked, she
reported pain, burning, etc.  

The pain is on the nipple - not deep breast pain.  And the nipple pain
occurs when using a good double-electric breast pump.  She has even been
given a new shell from Medela to try, which is soft but does not collapse
on the nipple as the nipple tunnel is hard.  She finds no difference -
painful.

Mom's milk supply had been down, but she noticed a great deal of increase
in milk supply after just 24 hours of fennugreek. 

Now, she has seen so many people and has done so much that I'm listing them
here:
1. LCs had already taught better, deeper, more asymetrical latch.  

She was also referred to MDs for:
1. 7-day course of diflucan, stopped for 2 days, then a 14 day course of
diflucan - no relief
2. oral nifedipine - three times a day - she has seen very little changes,
the MD told her she could take 2 pills three times a day, but she's
concerned about how this would affect her baby.
3. Apno cream - she found it "felt better" when she put it on, but no
long-term relief, has used it for a week, but stopped, again concerned
about baby's oral intake.
4. nystatin AND gentian violet have also been tried with no relief.
5. She has also tried OTC antifungal treaments - also relief was temporary,
for a few minutes after application, then pain returned.

I observed the nipples become erect and pink, never saw the changes to
white or blue - and she reported sometimes they do become blanched, but not
blue. 

Sooo, when I was talking to her by phone, I had recommended she see a
dermatologist, but to tell you the truth, after seeing her,  the skin of
the nipples, despite all these treatments and pain, does not appear broken
down...but the color is very pink then they become erect and painful.  

One person suggested she was allergic to baby's saliva, another said "some
women just can't breastfeed."  

She's at the end of her rope - and I really spent a good amount of time
today praising her, reassuring her that crying does not reduce milk supply
(the current events on top of the loss of the dream of breastfeeding her
baby as she had hoped has her down), and praising her to High Heaven for
sticking it out this long!

What to do next?  I did try a nipple shield to try to stabilize the baby's
tongue and to give the skin of the nipple some relief from the friction of
the tongue.  Mom reported this was more comfortable, but I don't think it
will be a solution...after a day or so, I fear it will be as painful as
pumping or breastfeeding. 

Jeanette Panchula, BSW, RN, PHN, IBCLC
Vacaville, CA

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