Permission to post, sorry this is long. I’m been a silent member of Lactnet for several years.

I saw a client today with a several factors affecting one of her breasts, and I’m not sure exactly how to advise her.

For background, mom nursed baby #1 (now 2 years old) but had painful cracked nipples and developed severe mastitis in her left breast around 3 or 4 weeks postpartum, after which time baby completely rejected that breast. She tried to get baby back on that breast for two weeks after the mastitis resolved, but then gave up and nursed on only the non-mastitis breast until baby weaned herself around 9 months old. Mom also went back to work full time at six weeks postpartum and double pumped at work but only ever got drops from the mastitic breast, while the other breast produced 3-4 oz at each pumping session. (As a side note, an LC at that time suggested that baby #1 might have a tongue-tie, but the pediatrician said not so baby was never evaluated by a specialist. More on that later.)

Baby #2 is five days old and at first she felt he was nursing well on both sides, but by day 4 she felt that he was also rejecting the left breast. She also didn’t feel her milk “come in” on the left breast, although she did on the right. Yesterday she developed a some hard lumps and a red painful spot on her left breast, characteristic of a plugged duct or ducts. She can already pump 2+ oz from the right breast but again the left breast only produces drops from the pump (I observed her pumping with two different sized flanges and different suction levels and she got less than 1/4 of an oz from the left breast in 15 minutes of pumping). I wouldn’t say the left breast feels engorged, but there are definitely a number of hard spots that she winced when I palpated them and she doesn’t feel any relief after nursing or pumping.

The facts above seem like a pretty typical case to resolve with good BF management, but here’s where it gets confusing to me:

First of all, the nipple of the left breast appeared flat at first glance, then I noticed what looked like cracks, but mom doesn’t have any pain or bleeding this time. After the mom breastfed and pumped, I observed that the nipple wasn’t flat, it was the same size as the right nipple, maybe 1 cm in diameter and slightly less than 1 cm in length. It seems the left nipple is actually inverted into itself, not flat at all, with the cracks making a sort of cross shape that the nipple everts out from when stimulated.

Secondly, I know it’s difficult (impossible?) to count nipple pore openings with the naked eye, but when mom was hand expressing or pumping, I could only see milk coming from two spots on the nipple. I expressed milk from her breast myself and I moved my fingers all around to try and stimulate different areas of the breast, but again I really could only see the milk coming from those two spots, both of which were on the non-inverted part of the nipple (the nipple skin that’s always exposed, if that makes any sense at all). When I mentioned my observations to the mom, she asked if there’s a doctor she could see to evaluate her nipple & breast and I realized that I wouldn’t even know where to send her, other than to Australia to see Donna Geddes (we are on Long Island, New York; if there is a sonographer or doctor who evaluates this sort of thing in the tri-state area, I’d love to know). 

Is it possible that this mom has only two nipple pore openings in one of her breasts? If so, I have two possible theories: one is that she only ever had two nipple pore openings; the other is that maybe between the inversion of the nipple, and the cracks, bleeding, and mastitis she had with her first baby, some skin grew over her other nipple pores as her nipple was healing. Can you wise people in this group to comment on the likelihood that either of my theories is correct and if there’s some other possibility I haven’t considered?

The second and more pressing question for my client, is about management. She is understandably extremely afraid of getting mastitis again. Most of the techniques for preventing/treating plugged ducts and mastitis focus on effective emptying of the breast, which doesn’t seem possible for her, and she’s concerned that if she stimulates her breast a lot and the milk doesn’t come out, she’ll get mastitis again. (To go back to the tongue-tie issue, baby #2 does have some obvious signs of tongue-tie and upper lip tie, and I encouraged her to see a specialist this time around, but clearly her problems are not caused by this, though baby #1’s tongue tie might have been another factor in her developing cracked nipples and mastitis. Baby #2 nursed well at her right breast, taking in over 2 oz, and we later convinced him to nurse at the left breast by sliding him over so that he was in the same position as at the right breast but he only took in about 1/4 of an oz). 

I suggested lots of massage, breast compressesions while BF or pumping, warm compresses, pumping the left breast between feedings or while feeding on the right side. I also gave her a syringe she could slip into the corner of the baby’s mouth while nursing on the left side, to give him extra milk so he’ll be more willing to stay on that side. She already had a nipple shield so I showed her how to use it properly in case that would entice baby to nurse more on the left side, but it didn’t seem to make a difference. He nurses beautifully on the right side without a shield.

In addition to her fear of mastitis, mom is not sure how much effort she wants to put into trying to get the left side to produce more milk, since she also has a toddler to take care of and doesn’t feel she has time for extra pumping. On the other hand, she’s not sure she’s ready to give up and do single sided nursing again either.

I also thought of lecithin and castor oil compresses but again am not sure of their efficacy in the absence of effective breast drainage. Thoughts? What about cabbage leaves? She’s not engorged per se.

I’m not sure whether to encourage this mom to stimulate her left breast and try to drain it more, or to wean from it altogether. I’m also concerned about engorgement and/or mastitis if she stops nursing or pumping that breast. Would love some advice.

Thanks for reading this looooooooong post!

Jennifer Sokolow, IBCLC
New York
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