Martha, thanks for your vote of confidence in me. Sorry to be 3 days
late-rarely do I miss LN that long but mucho car problems etc. in last
few days. I'll try to work off of the comments that raised pictures in my
mind.

<some pitocin after protracted labor at home. >

OT has antidiuretic effect, competing for some of the vasopressin binding
sites, so I imagine this may have intensified the engorgement period, and
cause swelling to take up to 14 days to resolve completely.

< Within 2 days, she had stripes
across both nipple tips>

Positional sore nipples as described 50+ years ago by Mavis Gunther. The
direction of the stripe (began with "blood blisters")  corresponds with
the plane of the baby's hard palate junction with the middle of the
tongue during suckling at the time the damage occurred.

This thin stripe was the only area of skin exposed to vacuum. The rest of
the nipple was so far forward it was pressed completely between the
tongue and hard palate. Most of the perceived nipple pain is not
necessarily always emanating from the damaged area though. Part could
well be from the trauma to the "meat" of the inside of the nipple.

At the very least, I would advise "circulation breaks" for the nipple to
replensh O2 and take away metabolic waste products whenever the baby
stops active drinking (release vacuum for several minutes till nipple
resumes normal color and regains shape, or maybe just switch breasts
frequently), and using different positions each feeding so that at least,
the site of maximum vacuum would not always be in exactly the same plane
if latch can't be optimized.

<Baby's tongue extends past the gumline, although it is a
bit short, and has a dimpled, slightly heart-shaped tip.>

I'm not any expert on tongues, but that description raises at least a
pink flag to me. I hope someone more knowledgeable in this area chimes
in.

<  Nipples are
large,  breast tissue is stretchy but somewhat thick around areolae.>

Sort of falls into the category near "latch-defying nipple". All this,
plus the edema component of engorgement, creates an extra degree of
subareolar tissue resistance, making it harder for the baby to get a deep
latch. In addition, it  often distorts the nipple somewhat to a larger
circumference, therefore shorter depth of shank. (See "ampoulla" below.)

Babies with vigorous jaw power may overcome excess subareolar tissue
resistance to get more milk out. But chance of damage seems higher.
Weaker jaws may not end up with as much chance of association with
damage, but not as efficient in milk transfer process.

This is a situation where I would use Reverse Pressure Softening before
each feed till 2 weeks, or less if the problem resolves earlier. I will
send you an attachment in a separate post, and will also send one to
anyone who contacts me personally.

<mom was developing fissures
around the base of one nipple, and decided she wanted to use a nipple
shield to mitigate pain during feeds.>

How well I remember this agony personally. I can't blame her, if it felt
better. I have observed that "pain in the nipple" is not always solely in
the nipple, nor even in the injured areas. Overdistended milk sinuses can
be very, very painful if compressed right over the belly of the sinuses.

In addition, it has been my experience that fissures at the base of the
nipple are often associated with sudden traction focused on an area that
seems to be thinner and more vulnerable because of less underlying
connective tissue at that small circumference.

When mothers are "gritting their teeth" bearing pain by sheer will power
or dreading attempts at detachment, I have often seen them come to a
sudden decision "That's it! I've got to stop this, "n*o*w!"

Whereupon they make a quick attempt to break suction and withdraw all in
the same motion. If the baby doesn't cooperate with the suction break,
this puts a very strong traction on this area, and even if not visually
damaged on the outside, is no doubt traumatized, even bruised on the
inside. It makes it exquisitely painful. (I have referred to it as "like
spraining the nipple" to evoke a mental picture for moms.)

This area is "Zone 3" of my conceptual nipple pain assessment tool.
(another story for another day. Simply, Zone 1-skin, Zone 2-"meat" of the
nipple, Zone 3, attachment area of base of nipple to areola/subareolar
tissue, Zone 4, walls of milk sinuses.)

I would watch carefully to see that breast is well supported with a
rolled towel beneath so there is no "drag" of the breast on the baby's
jaw. Also, when breaking suction, see that mom holds baby very close,
moves finger all the way on top of the tongue to actually cover the front
of the nipple and only after suction is on her knuckle, move baby away.
(Older babies can cause this by yanking or hanging on for dear life while
they crane their necks.)

<Today, things are worse.  Both nipples have fissures around the base
(stripes across nipple tips are healing).  Feeding is painful even with
the shield, and mom notes nipples are still wedge-shaped after baby comes
off.  Also she weighed baby Saturday and today, and he has lost 2 oz.
(milk was coming in when I left Friday, mom reports highest fullness
Sunday). We are considering a couple days of pumping to let her nipples
heal.>

If latch cannot be "planted" beyond this area, I have often advised 24-48
hours of rest from all traction, suckling, and particularly avoiding
vacuum. Fingertip expression is much better for regular milk removal in
this case IME, to avoid any traction on Zone 3.

This is how I imagine "lipstick latch" nipples get their shape by the end
of feedings. The ducts passing through the nipple area are lined with the
same kind of cells as the outside skin, a single layer of squamous
epithelial cells.

While I am still trying to learn more about how this effects the suckling
process, I am presuming that there is less elasticity to these than the
double layer of 2 different kinds of cells lining ducts that begin at the
level of the milk sinuses (cuboidal epthelial inside, myoepithelial
outside). (Yes, I do believe in them, just not bicycle spoke
distribution.)

There is an abrupt demarcation under the microscope between the aquamous
epithelial cells lining the ampoulla  (which in one nomenclature system
is of the name of the ducts passing through the nipple) and the types of
cells in the double layer beginning with the sinuses.

An off center latch places the upper jaw at a less distended portion near
the front of the sinus and the tongue and lower jaw beyond the belly of
the sinus further toward the less distended area of the proximal end of
the sinus (closer to the chest wall.)
I view this as the reason for sudden contrast in disappearance of latch
pain when the "latch is gotten right".

As I visualize it, when the sinuses are tightly distended, cells
stretched thin in the center, and the jaws/tongue impact them squarely
over the "thinned layer of the belly of the sinuses", the double layer of
cells in the overdistended sinuses needs to "borrow some emergency
stretch" and "tugs" on the ampoulla lining connected to them.

As I visualize it, the upper jaw serves mostly to supply resistance, and
the lower jaw, since it is movable, puts the stronger compression effect
on the belly of the sinus, if an efficient off-center latch has not been
attained.

With a latch where the lower jaw/tongue is centered on the belly of the
sinuses, it pulls that part of the nipple experiencing the most inward
tug, in a shearing pattern.

This is because of the combination of opposite forces of the vacuum
effect and the compression effect. The "lipstick" leading wedge (forming
less than a right angle) is the corner of the resulting rhomboid shape
that shearing causes. (per the second hand high school physics text I
happened across in the thrift store one day.)




This is why I like RPS and/or fingertip extraction before latching during
the first 2 weeks. When the sinuses are not distended, they are easier
for the tongue to "ripple" with less resistance, they do not seem to tug
on the ampoullae to misshape the nipple, they are not painful, and milk
passes through them more quickly and easily the less distended they are,
partly because of the MER that gets triggered in advance of the latch.

More than you probably ever wanted to know. (RPS attachment to follow
personally.)

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

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