I saw an interesting mom and baby this week.  Mom delivered this baby on
2/11, with a different OB provider, and takes her children to a different
pediatric provider, but ended up in my office for a consult since her good
friend is my office manager and she had such bad luck in the past getting
breastfeeding help from her own docs.  This little guy was her fourth child,
born vaginally, induced with pitocin due to social reasons.  He was 39 1/2
weeks, 7.5 lbs.  Mom described to me that he "latched well" and nursed
frequently from birth.  She stated that she nursed her 1st child for 8 mos
really mostly without difficulty except some mild sore nipples in the start.
 The next 2, however, she describes having very sore, damaged nipples, and
that she thought her nipples had become inverted.  With the third child, she
also had several illnesses at the end of pregnancy requiring antibiotics and
received IV antibiotics in labor.  That child she reported also having oral
thrush, yeasty diaper rash, and she had nipple scabs that never healed and
she weaned at 6 weeks of age (she and the baby were never both treated for
yeast with any regimen together.  Baby received "a few days" of nystatin
suspension.)

She came to the office on the 15th (5th day of life) with the babe, having
not put him to breast in 12 hours.  She described her nipples as being
terribly sore at latch and for about the first 10 minutes of a feeding, and
just when she was getting comfortable, she was then switching to the other
side.  She described the right as much more sore than the left, and stated
she could not now even stand to pump on that side.  Also, her breasts were
very full and tight, and she had aching pain under her armpits.  She called
the office asking for an emergency visit in the morning, and we had her use
cabbage and hand express until she could get there in the afternoon.
On exam, the baby was noticed to have a somewhat recessed chin ("My last 3
kids all have dad's chin!")  He had no tongue tie at all, and was able to
maintain his tongue forward in his mouth if encouraged to extend the head.
Mom refused to put him to breast as she was in so much pain, so I had to
demonstrate positioning theoretically!

Mom's breasts were engorged and leaking.  She reported this was actually
much better since starting the cabbage and expressing a little milk.  Her
nipples were in fact not inverted, but the nipples themselves were broad and
had indentations in the nipple surface.  The right nipple was scabbed and
very tender.

She was in tears thinking her breastfeeding relationship would be over.
Since she was in so much pain she did not want to put the baby to breast in
the office.  I taught her cross cradle and football hold to allow the baby's
head to be extended, gave her a prescription for APNO, recommended she hand
express instead of pumping since I'm sure her pump flanges were too small
given her nipple size (she had a Medela mini-electric with standard
flanges,) and gave her the LLL handout on hand expression.  I asked her to
"finish the first breast first" and not to switch the baby at some arbitrary
time.

The next day I called her and she was acheiving a comfortable latch on the
left and expressing the right and bottlefeeding top-ups of EBM.  She
desribed the APNO as a miracle, though, and said the right was healing
already.  Two days later, she was back to exclusive breastfeeding on both
sides, with a little residual soreness as she was still healing, but
thrilled that her breastfeeding relationship had been saved.

Two questions:  One - What causes these indentations in the nipple surface?
 The nipple surface itself is concave, and difficult to heal probably due to
folding on itself?  Is there a way to fix that?

And Two - all this has happened before her pediatrician had even scheduled
them for a first post-discharge visit at 2 weeks.  This ped prefers not to
see babies before 2 weeks, and has even told moms who call with
breastfeeding issues to just wait until 2 weeks to be seen.  Any good
references for encouraging her to see babies sooner, or at least give some
resources for breastfeeding help to her patients?  This mom came because my
office manager is her friend and told her she was sure I could help her
(which after that billing I'm glad I could!) but many others I know of have
just given up before 2 weeks.
Jennifer Tieman
Family Physician
Mom to 4, including my toddler nursling Caroline Rose

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