I have the mother's permission to post this.

I had a rare and challenging opportunity in the last few days.
Ordinarily, I only see mothers at WIC during my 8-10 volunteer hours
weekly. But last year I had a young mother referred to me who had such
horrible memories of painful nipples from her first child that she sought
out information on prevention before anticipated conception of her second
child last spring. She wanted a savior- to be given instruction and
reassurance on how she could avoid ever having to go through such pain
again, almost to the degree of post traumatic shock.

Much history taking, empathetic opportunities for ventilation, and
physical assessment and instruction have taken place along the way. She
even took my suggestion to go to a dermatologist to rule out any unusual
kind of yeast or skin condition. Her breasts are a "B" cup size, nipples
and areola are just naturally bright reddish pink, small to medium sized,
well everted, with no functional retraction on compression. I even
explained  Raynaud's to her, and reiterated what she had learned about
positioning and latch during her attendance at LLL.

I encouraged her to negotiate with her OB to request that only a saline
lock be placed in case IV's became absolutely necessary, but to avoid IV
fluids if possible. I promised her I would try to come to the hospital
soon after her birth if the timing were convenient for me.

This week, 10 days before her due date, she went into a spontaneous 3
hour labor at 2 a.m. and needed only a local for a small repair. The
hospital staff has been extremely supportive. She had ample opportunity
for skin to skin contact and early, frequent nursing. I was able to visit
her when the baby was six hours old. She needed mostly moral support,
doing lots of skin to skin, a great cross cradle and "sandwiching" the
shape of the breast when he rooted. He was alert and a vigorous rooter
from the start. She was inspecting the shape of the nipple closely
whenever he released it, with some occasional "pinched" appearance, but
mostly rounded. Needless to say, I had taught her RPS and had asked her
to do it before feedings from early on, just on general principles to be
sure the areola was always as soft as possible and the MER's well
stimulated.

By my first visit, she was already feeling extreme tenderness in the
nipples, the left one especially. There appears to ge no discernible
difference in the two nipples as far as size or function, and the baby
has been held in cross cradle and football on both sides, so I don't
think it has to do with him moving his jaw/tongue differently when lying
on one side versus another.

After observing the latching and nursing, I investigated the baby's
mouth. No apparent problem with the lingual frenum or the lower labial
frenum. The upper labial frenum may be slightly problematic, but I am
probably stretching my imagination. I found what seems to be a normal
hard palate, but when I did a suck check, the tongue did not curl around
my finger nor extend over the jaw to cushion it, and felt uncoordinated
and "humped" in the rear as far as I was able to palpate without gagging
him.

I could clearly feel the firm compression of the jaws, and the angle was
never more than 90 degrees when he was nursing. I was unable to see how
flanged his lips were due to her "guarding" to cope with the pain of the
latch. Compressing the tongue and trying to lead it forward made no
apparent difference in the tongue action in the short run.

The best I was able to come up with was to compliment her on all her
effective efforts, and shift her attention to the baby's part, and the
possible effect of birth on the temperomandibular joint and overlapping
cranial bones on nerves to the tongue. She was crestfallen that she had
tried to do everything perfectly and kept asking helplessly what else
could be done then and there.

I explained a little about possibly training the tongue motion and
introduced the idea of cranio-sacral therapy as soon as she was released
from the hospital. She was unwilling at that point to try the football
hold, but the hospital LC assisted and persuaded her to try it later in
the day, and the latch seemed somewhat less painful. I talked over the
possibility of a shield with the LC to at least protect the integrity of
the skin, but when it was tried, he simply chomped down on the nipple
inside of it.

I advised her to ask for her motrin regularly and possibly use cold packs
over the well protected nipple for 20 minute periods between nursings to
help cut down on inflammation. I showed her that a hot washcloth, as hot
as she could tolerate on her inner wrist, applied right before latching,
did in fact raise her pain threshhold. When the subject of his blood
sugars was brought up, she negotiated with the staff for a foley cup and
expressed a small amount of colostrum and fed it to him once or twice,
though he didn't extend his tongue to take it, and he "passed" his next
blood sugar test.

By my second visit at 20 hours of age, the nipples were extremely
painful, and the tip of one was beginning to show skin damage. Her mother
had arrived to relieve her husband to go home and get some sleep. It had
been at least 32 hours since she herself had had a short nap the previous
day. She was feeling even more "shell-shocked" and crestfallen (and
prolactin saturated and sleep-deprived) that she had been unable to avoid
this, not saying the word "failure" but obviously thinking it, and asking
me even more helplessly what to do.

I had to be direct. I said I wished that I had some magic wand to cast a
spell over the situation, but I didn't. I told her that some mothers
would choose to tough it out despite the pain and damage, hoping for the
time the milk came in, and other mothers would choose to have the baby go
back to the nursery and try to get a few hours of sleep to avoid eventual
"crashing and burning." I quoted Rule #1, (that babies must be fed) and
said this was the point where some moms might ask that a little formula
be given. And that in the long run, she was the mom, this was her body,
her baby and her pain, and the choice was up to her. Her mom and I did
strongly encourage her to try to get some shut-eye herself, which she
eventually did later in the night.

Today, she seemed to be "taking hold" of her situation better, resting
more with lots of skin to skin, and stating that nursing was her first
priority, and not answering many of her phone calls, planning to limit
visitors at home, using football hold a little more often, and continuing
to assess the quality of latch by her own sensations. I encouraged her to
let me change the baby's diaper (large meconium stool!) and rock him
while she ate her lunch. He was beginning to cue hunger, and while she
hastily finished her meal, I used the opportunity to pacify him with my
clean finger and work with the tongue. Same incoordination, but within 5
minutes or less, my finger was actually beginning to hurt from the
strength of the clamping of his jaws!

I told her I expected her to notice a gradual increase in breast size and
supply starting within a few hours. She does not plan to go home till
Wednesday. I supplied her with more info about cranio-sacral and
suggested she have her husband check with their own chiropractor to see
if he does it, and if so, to try to stop by his office on the way home.
Since it is the eve of a holiday, I don't know if that will work out. But
I did emphasize that the longer the sucking habits went on, the longer it
sometimes takes to change them after the original problem is corrected.

Frankly, I yearned for the really old-fashioned kind of nipple shield
with the plexiglass base and long rubber nipple, both to protect her
skin, apply mild vacuum of the suckling for milk removal and possibly to
help encourage the grooving of the tongue. I just didn't happen to have
one in my stash of equipment, or I would have offered it to her. I saw
them work decades ago, and for a situation like this, I still think it
might be a good tool. I know they are available in Canada and in Japan.
Does anyone on LN still use them? Does anyone have any more suggestions
that I have missed? Or other approaches that might have been better from
the start?

Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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