Denise, it sounds like the pulling, or stretching of the nipple/areola may
be  a common denominator in the pain.  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 (mom's way didn't cause pain but also wasn't effective).
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).

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

I just reviewed a little book I have called "Solving the Mystery of Breast
Pain" by Judy C Kneece and it mentions a few other causes of breast pain
than those we usually think of.  She mentions musculoskeletal referred pain
is most often caused by a pinched nerve in the back but feels that would
usually involve only one breast.  I found your description of the pain
interesting.  You said "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.  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.  This occurs
after heavy lifting or activities that stretch the upper body (like a
natural birth with some contortions of posture??).  Anti-inflammatory
medications on a regular schedule are recommended and are usually effective
in 24 to 48 hours.  I have had more than one mom come out of birth with a
musculoskeletal injury and they more commonly have been unmedicated births.
Perhaps these moms were not properly adequately, physically supported during
labor. (This is a plea for better physical support during labor, not
medication.) There are many other causes of noncyclic and cyclic breast pain
mentioned, but these two were the most relevant to your case.  I find this a
valuable and inexpensive little book.  I believe someone else mentioned it
on Lactnet before.  I ordered it from Amazon.com.

You said the mom feels better already, if she doesn't continue to improve
after the 48 hour course of anti-inflammatory meds and with your super
excellent latch technique :-) I'd see if she would be willing to get some
adjustments.    Oh, and the book mentions if it is costochondritis it may
recur if the cartilage is reinjured (like lifting twins) so if I'm at all on
track here, she could probably benefit from some healthy back teaching even
if she presently feels better.

Carla

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