So I was able to see the mother Saturday. The family is a good 50 miles away from me, so it's a time committment for sure. 
 
I never thought such a damaged nipple could exist without any signs of infection. Both nipples are actually cracked to the point of creating a flap across the top/outer half of the nipple. One is somewhat worse than the other, and the flap approaches 60% of the diameter of the nipple base. But the nipple, including the exposed tissue, is completely pink, without redness, drainage or swelling. 
 
The baby actually appears to be fine. He has been gaining weight all throughout these weeks. While his mouth and tongue are on the smaller side, he has full movement of his tongue and can reach his tongue forward over the gum ridge without problem. A bit more than average attention probably needs to be paid during latch, but nothing that can't be overcome with good technique.
 
The family had obtained a nipple sheild in the days prior to my visit, but they reported that he hated it, cried and was miserable. We discussed pump availability, costs and the logistics of obtaining one, but then after I saw the nipple, I wasn't quite sure that that was the best way to go regardless. Since I pump just applies suction, I was really concerned that it might just pull the flap out farther, and not really give it a chance to heal. Pair this with the pump related issues I mention below-and I figured that re-attempting the sheild was at least worth a try.
 
We were able to get the sheild on well, which both the midwife and mother stated was different/better than before. And we were able to get it on without causing pain. 
 
Technique. THERE was the problem. As the baby latched with the sheild he 'schlurped' onto the nipple while holding him facing 'up' as opposed to in toward her. And then he would lay on his side and nurse facing up toward the ceiling, pulling her nipple out. I was able to turn him into a more appropriate position, facing her, with his belly up to hers. The mother was Amazed at how well he could nurse without causing her pain. She was actually shocked that he was nursing and she wasn't hunched over in pain. And also, that he was nursing with the sheild, when he had previously just cried. 
 
So he happily nursed for quite a few minutes. I didn't hear any clicks (which the mother stated she did hear when he was nursing previously) and she had great milk transfer into the shield. After he was done nursing, her nipple was drawn well into the sheild, but the flap looked no worse than before the nursing, and the nipple was a nice round shape within the shield. 
 
The money, cleanliness, running water, electricity issues all compound an already tricky situation. While other families on such strict a budget might use public resources, this is not their 'way'. So they would pay full price on all pump parts and rental costs. But that isn't really such as big a problem as the cleanliness. The water needed to keep all pump parts truely washed and cleaned (plus a cup or other feeding instrument) is a big strain. For example, this family's water is stored in a Beverage cooler. Like one of the large Gatorade containers seen at athletic events. And I'm pretty sure it gets there from either a pump or a hose in the barn. 
 
Given all these issues, and the fact that we were able to get the sheild to work well for everyone, and nearly pain free for the mother (she stated that the pain is 5% with the sheild and good positioning than previously)-we are doing a shield trial and holding off on exclusivly pumping-if we can. The midwife and I both discussed that we are not 100% sure that this will be the cure. She will go back out to see the mother tomorrow or the next day, and I plan a return visit 1) if the nipple is not healing or gettting worse or 2) when the nipple is fully healed, so that we can attempt nursing without the shield. The mother stated that the nipple is flat and white when he was done nursing before. I don't know if this is because of just poor technique-or if it is a symptom of a bigger problem. So before she starts working off the shield, I want to assist her with a nursing so we don't end up right back here!
 
This mother is quite the trooper. She realizes that it may take a month or more to resolve this issue, but breastfeeding is very important to her. She didn't call anyone for help for 3 weeks because she 'felt like she wasn't doing her job' when it hurt to nurse. She thought she was being a wimp. Her husband actually called with midwife (and then myself) after she ignored his urges. 
 
I would like to add, I was a NICU nurse for ~6 years, handwashing is very important to me. Of course I always wash my hands before dealing with any mom/baby, even my friends. But after this weekend I realized the prudent thing to do is just to keep a gallon jug of tapwater in the back of my car! Then it'll always be there. Not all Amish are consertative to the point of not having plumbing, but these are. They also don't use zippers, snaps or buttons! Their nursing-wear is held together with straight pins. Ow!
 
 
Thanks everyone for all the ideas, and the natural remedies. I have been taking notes. I run into a lot of mothers/families who are not interested at all in any conventional or non-homeopathic remedies. I have another question coming too...
 
Deann Ragsdale RN, IBCLC



      

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