Hi Kika!







I think we are missing the details on why the surgical trauma to the left nipple/areolar complex is less than that of the right... it sounds like both sides had peri-areolar incisions but the left additionally had been incised completely around the base of the nipple in order to be re-positioned. That last put the ducts at risk, but you are reporting that once MER occurs, the baby is able to extract milk well from that side. I am curious as to whether a pre-post feed weight was taken to document the relative removal of milk from each side? I know you said "great milk transfer."







On eliciting MER with latch on the left... I am wondering if the nipple-repositioning created some scar tissue and nerve irritation that makes that whole side more sensitive and prone to stretching pain. Such noxious stimuli, and/or the anticipation of it, can certainly inhibit the letdown reflex. The fact that once MER is stimulated from the other side the left side can be fed on comfortably is telling. Do you happen to know if touching/pulling/stretching of the left nipple is uncomfortable vs the right? Does she have equal sensitivity to touch (no numbness) of each nipple?







In the meantime, you've hit on the best strategy- get MER going by an alternate method. Perhaps a little light massage, stretching and expressing of the left side to get milk flowing first would also be helpful. Alternatively, she could keep doing what you tried- start on the right then switch quickly to the left.







I suspect that once you've both settled on a successful strategy, that conditioning will set in and she will start to have the common experience of anticipatory letdown prior to latch that should also help this along.







Let me know which of this resonates and which does not!  I love a good challenge. 😊







Lisa Marasco











>>My client had breast augmentation surgery 15 years ago. She had no problem breastfeeding her older child 8 years ago. Last year, in february (just before first major pandemic lockdown) she had a new breast surgery, to replace the implants as the old ones had begun to leak. A couple of months later she became pregnant.



Her current consultation is with her second child, a 3 week-old infant.



Mother reports intense pain in left nipple upon latching and during feed.



Also, for the past few days, baby has been irritable and stools have turned green (not all, but a few each day).







Birth was normal, with immediate skin to skin contact; milk came in on the evening of the second day. Mother reports feeling her let-down reflex as a tingling sensation. Baby has had good weight gain, regaining birth weigh on day 10, albeit a bit slower gain this last week (21 gr per day).







Upon examination, infant is looking good (no asymmetries, no ties, normal development for age), mother has periareolar scars from surgery. The scar on the left nipple goes completely around it (mother explains that nipple position was corrected during latest surgery) and periareolar scar on left breast goes from 3 o'clock to 9 o´clock.







Feed: mother is proficient at helping her baby latch with a good cradle position, baby latches onto left breast and starts stimulating with a fast suckle - which gets faster and stronger and painful and milk ejection reflex is not forthcoming. Baby is very insistent and does not give up and mother remarks that this is what has been happening, this very vigorous suckling but no MER that she can feel.







I ask mother to begin hand expression simultaneously on the other breast (she is a fast learner!) thinking to activate her MER this way, but even though she expresses milk from the right breast while baby suckles on left, there is no MER. So I suggest she switch baby to right breast to see if that will elicit MER - and it does. When left breast starts to leak profusely, we switch baby back to left breast, where she maintains a deep, effective suckle with great milk transfer - and no pain.







Mother does this several times during the feed - we´re trying to make sure baby gets all that rich milk that MERs provide, thinking that this lack of MER activation on the left breast may be responsible for her green stools, irritability and slight fall in weight gain.







I thought this was a very interesting case, had never had a similar one.



I´m kind of surprised that the areola that suffered less surgical trauma is the one that is neurologically affected, but it is clearly the case. I guess the right breast nerves have regenerated faster. Outwardly, the scar tissue was minimal on both breasts, no atypical or excess scarring at all.<<



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