Martha, thanks for your vote of confidence in me. Sorry to be 3 days late-rarely do I miss LN that long but mucho car problems etc. in last few days. I'll try to work off of the comments that raised pictures in my mind. <some pitocin after protracted labor at home. > OT has antidiuretic effect, competing for some of the vasopressin binding sites, so I imagine this may have intensified the engorgement period, and cause swelling to take up to 14 days to resolve completely. < Within 2 days, she had stripes across both nipple tips> Positional sore nipples as described 50+ years ago by Mavis Gunther. The direction of the stripe (began with "blood blisters") corresponds with the plane of the baby's hard palate junction with the middle of the tongue during suckling at the time the damage occurred. This thin stripe was the only area of skin exposed to vacuum. The rest of the nipple was so far forward it was pressed completely between the tongue and hard palate. Most of the perceived nipple pain is not necessarily always emanating from the damaged area though. Part could well be from the trauma to the "meat" of the inside of the nipple. At the very least, I would advise "circulation breaks" for the nipple to replensh O2 and take away metabolic waste products whenever the baby stops active drinking (release vacuum for several minutes till nipple resumes normal color and regains shape, or maybe just switch breasts frequently), and using different positions each feeding so that at least, the site of maximum vacuum would not always be in exactly the same plane if latch can't be optimized. <Baby's tongue extends past the gumline, although it is a bit short, and has a dimpled, slightly heart-shaped tip.> I'm not any expert on tongues, but that description raises at least a pink flag to me. I hope someone more knowledgeable in this area chimes in. < Nipples are large, breast tissue is stretchy but somewhat thick around areolae.> Sort of falls into the category near "latch-defying nipple". All this, plus the edema component of engorgement, creates an extra degree of subareolar tissue resistance, making it harder for the baby to get a deep latch. In addition, it often distorts the nipple somewhat to a larger circumference, therefore shorter depth of shank. (See "ampoulla" below.) Babies with vigorous jaw power may overcome excess subareolar tissue resistance to get more milk out. But chance of damage seems higher. Weaker jaws may not end up with as much chance of association with damage, but not as efficient in milk transfer process. This is a situation where I would use Reverse Pressure Softening before each feed till 2 weeks, or less if the problem resolves earlier. I will send you an attachment in a separate post, and will also send one to anyone who contacts me personally. <mom was developing fissures around the base of one nipple, and decided she wanted to use a nipple shield to mitigate pain during feeds.> How well I remember this agony personally. I can't blame her, if it felt better. I have observed that "pain in the nipple" is not always solely in the nipple, nor even in the injured areas. Overdistended milk sinuses can be very, very painful if compressed right over the belly of the sinuses. In addition, it has been my experience that fissures at the base of the nipple are often associated with sudden traction focused on an area that seems to be thinner and more vulnerable because of less underlying connective tissue at that small circumference. When mothers are "gritting their teeth" bearing pain by sheer will power or dreading attempts at detachment, I have often seen them come to a sudden decision "That's it! I've got to stop this, "n*o*w!" Whereupon they make a quick attempt to break suction and withdraw all in the same motion. If the baby doesn't cooperate with the suction break, this puts a very strong traction on this area, and even if not visually damaged on the outside, is no doubt traumatized, even bruised on the inside. It makes it exquisitely painful. (I have referred to it as "like spraining the nipple" to evoke a mental picture for moms.) This area is "Zone 3" of my conceptual nipple pain assessment tool. (another story for another day. Simply, Zone 1-skin, Zone 2-"meat" of the nipple, Zone 3, attachment area of base of nipple to areola/subareolar tissue, Zone 4, walls of milk sinuses.) I would watch carefully to see that breast is well supported with a rolled towel beneath so there is no "drag" of the breast on the baby's jaw. Also, when breaking suction, see that mom holds baby very close, moves finger all the way on top of the tongue to actually cover the front of the nipple and only after suction is on her knuckle, move baby away. (Older babies can cause this by yanking or hanging on for dear life while they crane their necks.) <Today, things are worse. Both nipples have fissures around the base (stripes across nipple tips are healing). Feeding is painful even with the shield, and mom notes nipples are still wedge-shaped after baby comes off. Also she weighed baby Saturday and today, and he has lost 2 oz. (milk was coming in when I left Friday, mom reports highest fullness Sunday). We are considering a couple days of pumping to let her nipples heal.> If latch cannot be "planted" beyond this area, I have often advised 24-48 hours of rest from all traction, suckling, and particularly avoiding vacuum. Fingertip expression is much better for regular milk removal in this case IME, to avoid any traction on Zone 3. This is how I imagine "lipstick latch" nipples get their shape by the end of feedings. The ducts passing through the nipple area are lined with the same kind of cells as the outside skin, a single layer of squamous epithelial cells. While I am still trying to learn more about how this effects the suckling process, I am presuming that there is less elasticity to these than the double layer of 2 different kinds of cells lining ducts that begin at the level of the milk sinuses (cuboidal epthelial inside, myoepithelial outside). (Yes, I do believe in them, just not bicycle spoke distribution.) There is an abrupt demarcation under the microscope between the aquamous epithelial cells lining the ampoulla (which in one nomenclature system is of the name of the ducts passing through the nipple) and the types of cells in the double layer beginning with the sinuses. An off center latch places the upper jaw at a less distended portion near the front of the sinus and the tongue and lower jaw beyond the belly of the sinus further toward the less distended area of the proximal end of the sinus (closer to the chest wall.) I view this as the reason for sudden contrast in disappearance of latch pain when the "latch is gotten right". As I visualize it, when the sinuses are tightly distended, cells stretched thin in the center, and the jaws/tongue impact them squarely over the "thinned layer of the belly of the sinuses", the double layer of cells in the overdistended sinuses needs to "borrow some emergency stretch" and "tugs" on the ampoulla lining connected to them. As I visualize it, the upper jaw serves mostly to supply resistance, and the lower jaw, since it is movable, puts the stronger compression effect on the belly of the sinus, if an efficient off-center latch has not been attained. With a latch where the lower jaw/tongue is centered on the belly of the sinuses, it pulls that part of the nipple experiencing the most inward tug, in a shearing pattern. This is because of the combination of opposite forces of the vacuum effect and the compression effect. The "lipstick" leading wedge (forming less than a right angle) is the corner of the resulting rhomboid shape that shearing causes. (per the second hand high school physics text I happened across in the thrift store one day.) This is why I like RPS and/or fingertip extraction before latching during the first 2 weeks. When the sinuses are not distended, they are easier for the tongue to "ripple" with less resistance, they do not seem to tug on the ampoullae to misshape the nipple, they are not painful, and milk passes through them more quickly and easily the less distended they are, partly because of the MER that gets triggered in advance of the latch. More than you probably ever wanted to know. (RPS attachment to follow personally.) Jean ************** K. Jean Cotterman RNC, IBCLC Dayton, Ohio USA *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html