At 01:47 PM 10/11/00 -0500, you wrote:

>Denise, it sounds like the pulling, or stretching of the nipple/areola may
>be  a common denominator in the pain.

Thanks for your very thoughtful reply Carla - I really appreciate it and
will certainly followup with the mother what you have suggested.


>   I'm assuming here that the improved
>manual expression added a bit more of a forward tug than what the mom was
>doing on her own

Hmmmm yes, maybe.  She was doing the usual fiddle around about an inch back
from the nipple with a bit of a sweep towards the nipple.  My technique is
very similar to the marmet technique which involves that backwards pressure
after the fingers are positioned, which could be stretching the areola
backwards, but still a stretch.  I seem to recall it was more on the
compression (my technique is just directly finger to thumb, rather than the
'roll' that marmet does) that she felt the pain - again it would still be
stretching the areola.

>It hurts when the babies suckle and it hurts when she pumps both of which
>have forward tug.  It doesn't sound like compression is a common factor (it
>hurts while pumping and there is no compression there).

Yes - I thought about this point too.  I've been trying to visualise those
sucking ultrasounds.  What does the nipple do when the baby stops sucking,
but negative pressure of good latch is still maintained.  I recall there is
some backwards and forwards movement of the nipple during suckling, so
obviously it must be a slightly backwards more relaxed state when the
infant pauses.


>If your optimizing the positioning meant the teaching the asymmetric latch
>then I'm guessing less stretch and more compression took place.

That's a very good point!  I do teach asymmetric latch though not quite the
same as Jack's.  I line the baby up with the baby's mouth directly opposite
the nipple (from my recollection Jack's method has the baby slightly
inferior to the nipple).  BUT then I tilt the nipple right up the baby's
nose and keep it there until the chin has been brought in firmly against
the breast, then roll the nipple into the mouth.  So it does end up
asymmetrical.  This is a la the Sue Cox video Mother and Baby: Getting it
Right available from NMAA.  BTW I was personally taught by Sue, not just
the video ;-)

>thicker than usual areola is tight, it makes sense that stretch might hurt.
>I find moms who use the asymmetric latch have less of that initial
>nipple/areolar stretch pain that normally quickly fades; the phenomena we
>call "normal nipple tenderness at latch on".  Maybe not so normal if the
>latch is optimized.

Yes - that's an excellent observation.  Mother's do comment right from the
first suck using that latch that it is more comfortable.

>I just reviewed a little book I have called "Solving the Mystery of Breast
>Pain" by Judy C Kneece <snip>She mentions musculoskeletal referred pain
><snip> "The pain starts at the nipple and shoots (stabs!)
>laterally on the left side of both breasts to the central chest wall on the
>right breast and the underarm on the left breast - only there, no where
>else."  While that is not just one side, it is interestingly enough in just
>one direction. I think chiropractic evaluation is in order. <snip>

I'll suggest this option to her.  I also found it interesting that it was
on the inner aspect of one breast and the outer aspect of the other.  I
always thought of breasts as being mirror-images of each other, allowing
for differences in size, and minor anatomical differences.  So, if I were
to anticipate this pain I would have anticipated it would be both outer or
both inner.

>  Another thing
>this book mentions is costochondritis, which originates in the area of the
>breastbone and is an inflammation of the cartilage of the ribs.

Well I guess we'll never know - it really was a gentle birth, but yes, you
never can tell what effort she may have used pulling herself to standing,
or whatever.  Why would the pain be as it is though - are you suggesting
nerve involvement again?

Once again thank you Carla - if you have no objection I'll pass your email
on to the mother.

Renate thank you for your comments too.  I thought about the narrow ducts
too - but it isn't in the 'mirror' position that you'd expect for an
anatomical problem, but more that it occurred immediately the baby closed
his mouth (you know what I mean!) so I don't know that there was much
pressure on the ducts that quickly.  And different positions didn't make
any difference ... if it were narrow ducts, would it ... perhaps not
because good latch would see that the pressure within the ducts was the
same in every position anyway (just thinking aloud here).  So yes that is a
possibility - but wouldn't you expect it to be constantly painful once her
milk supply increased with lact II and the ducts were distended with
milk.  There were no lumps distal to the area affected which would indicate
narrow ducts not emptying the alveoli very well.

I'll keep you informed.

Denise

*************************************************
Denise Fisher BN, RN, RM, IBCLC
BreastEd Online Lactation Studies
++++++ earn 120 L CERPs +++++++++
mailto:[log in to unmask]
http://www.BreastEd.com.au

*************************************************

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