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

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