Nikki thought my answer to her might be of interest to others on LN. She wrote: <Is it really true? That even when a nipple is grievously damaged, correcting the latch will enable a mother to nurse without pain? I haven't had that experience. Usually when the nipple is exquisitely painful, the mother instinctively flinches away when attempting to latch. There is no point continuing then; so pump and cup or bottle feed until she feels ready to try again. I am very patient about that. What do you all think?> I can't truthfully say I have had that experience too much. Maybe because I have concluded that any vacuum applied to damaged tissue has the potential to have some adverse effect on newly healing skin cells. (After all, which of us would apply vacuum to, say, a cigarette burn or other wound?) So when I have a mom whose nipple damage and her impression of the pain involved is such to cause her to cringe, I usually go in favor of efficient fingertip expression (so many don't know the most effective way to do it, a la the Marmet method.) If a pump is used, I believe it will reduce the potential to delay healing if: 1) The MER is hand triggered 3-5 minutes in advance of the pumping. (RPS is even better at triggering MER than fingerfip expression for some moms, especially if they find expression itself painful.) 2) The lowest possible vacuum is used, for the shortest possible time at one sitting, but maybe a little oftener than 3 hours. 3) Mid-pumping breaks are taken for thorough forward massage and re-MERing, and "circulatory restbreak for the wound." I have a theory, a conceptual design for an assessment tool I have been using for years, and am just beginning to think about writing it up. I've cut and pasted from a previous e-mail to someone: <I developed this idea (my "Zone theory" of assessing pain in the nipple-areolar complex) in working with mothers in the hospital or within the first 7-14 days postpartum and I do not feel it is particularly helpful for yeast etc. or later problems after the sinuses have developed more elasticity. My conceptual model of various nipple zones: (More later on assessment.) Zone 1 - the surface skin of the tip and sides of the nipple, including nerves, blood vessels and the openings of milk pores. Visualize a thimble, and this is what I am including. Zone 2 - the "meat" of the nipple, (like the finger inside a thimble), including nerves, blood vessels, muscle and connective tissue, and the tubings (variously known as collecting ducts, or galactophores or ampulla) that travel through the "button" of the nipple to the milk pore openings. Zone 3 - the very base of the nipple where it connects to the subareolar tissue, including both the skin, the galactophores and the deep internal layers of this small zone. (the root of the nipple, so to speak) Zone 4 - the walls of the individual milk sinuses deeper inside the areola, about 2-4 cm. behind zone 3.> <Now we come to the pain assessment part. I have found it helpful to do the assessment immediately before the feed for a more accurate idea of what has been going on in previous feedings. Of course, if desired, it could be repeated afterward too, but is usually quite different for an hour or so after a feed. If possible, I like to do it myself the first time, taking it slowly, till the mother proves to herself how the subjective experience can be separated out into a more objective observation. But I have taught it sight unseen over the phone to savvy mothers, and it has been very helpful in choosing where and how to intervene. Zone 1-brush a fingertip lightly over the tip and sides of the nipple button, asking the mother to rate the pain on a 0-10 scale, describing it as from "no discomfort ranging up to the worst pain you can imagine" or some such explanation. (despite the appearance of damage during this time period, which usually leads everyone to conclude that's the source of all the pain, I, and the mothers I've tried it on, have usually found the pain to be in the range of 0-2.) Zone 2-gently pinch the meat of the nipple button with the thumb and first finger, and watch the mom's body language for signs of flinching, etc., release pressure and then recompress several times, increasing the pressure somewhat more according to her response. Have her choose again from 0-10. (Elevated pain here is due to bruising/inflammation of the muscular/connective tissue inside, due to misapplied compression of the jaws and/or the tongue against the hard palate. If ice packs are comfortable, between feedings they can help resolve inflammation. However, immediate relief often comes from saturating a clean folded washcloth with the hottest water a mother can comfortably tolerate on the skin of her inner wrist, and holding it to the nipple and areola till it cools somewhat. It seems to elevate the pain threshhold, and according to some radiology texts on performing ultrasound ductography, presumably relaxes the muscles in the nipple. This area should normally experience only extrusion from behind. If the source of this trauma goes on long enough, I suspect it can eventually be part of the etiology of Raynaud's syndrome of the nipple.) Zone 3-gently grasp the base of the nipple where it meets the areolar skin and slowly begin to tug and twist and increase traction as you watch the mother's body language, and have her rate it. (Extreme guarding, exquisite tenderness ranging upward to 6-7 or higher is often a sign that traction has "sprained" this area of tissue, causing internal bruising and/or tearing.) Also, look closely at the skin at the junction of the nipple and areola, tilting the nipple this way and that, as it may even cause external skin tears there. At this stage, it is almost always due to severe traction due to the mother's fearful, self-preservation urge, grit-your-teeth, rapid but incorrect suction breaking, and it only gets worse the oftener she breaks the suction. Or it could be perhaps partially due to the weight of a poorly supported breast dragging the nipple from the baby's mouth. There should be absolutely no traction, ever, on the mother's breast. There should also be no significant compression in this area either, except for that part of the ripple of the middle of the tongue during the extrusion process. IME, this pain, when present, is excruciating, lasting through practically the whole feeding, unless the mother can reposition the baby's mouth at least 1 cm. beyond the "sprained" area. I have found Australian (or prone) position helpful in maintaining this deeper placement of the baby's jaws and tongue. I have had a few mothers who found this type of pain resolved only by 24-48 hours of resting the nipple base, without even the traction of vacuum either, using fingertip expression to maintain supply and avoid engorgement. A few weeks down the pike, (at the beginning of the "curiosity" stage) it can be due to the baby's slipping and then jerking the head with the tip of the nipple held firmly between the jaws, perhaps while attempting to follow someone or something with his eyes. Zone 4-Visualizing the nipple as the center of a clock, place "C" shaped thumb and fingertips, with first knuckle bent, at 12 and 6 o'clock, about 2-4 cm. away from the base of the nipple. First, press deep straight inward, maintain that pressure, and begin to close the fingertips into an "O" shape over the "belly" of several milk sinuses, and have the mother rate it. This often rates a 6 or 7 from mothers where overdistention of the sinuses is present. IME, as much as 50-75% of supposed "nipple pain" is really occurring in the walls of the milk sinuses due to sudden compression exerted on the overdistended walls at their thinnest, most tightly stretched area (Think of the relative thinness of rubber in various areas of a balloon, or the sensation you get when someone suddenly applies the brakes, which causes your seatbelt to forcefully compress your full bladder!) Gentle slow removal of 5-10 drops causes the pain to subside, and co-incidentally often triggers MER. If the mother's body/verbal language indicates pain, I go at it more easily, slowly, and tell her to let me know when the pain goes away. She gets an incredulous look of relief on her face 30-60 seconds later and says "Why, it's gone!" Of course, 90 degrees around, in the opposite quadrants, the same thing can be expected to happen, because each outer wall of each milk sinus is prone to overdistention, even prenatally, but especially during this time period while elasticity is being established.> I have since realized that if the Zone 4 test demonstrates pain for the assessment purposes, and subsequent relief of pain with expression of 4-5 drops, (to show the mother), then I can avoid the pain in the opposite quadrants by using RPS to decompress those sinuses somewhat. Let me know what you think if you use it on any moms, mainly in the first 10-14 days. The more feedback, negative or positive, the better I like it, so I'll know if it's just a bias of mine, or whether it's a tool worth submitting to a journal. 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