Hi Debra

Thank you SO MUCH for your long and helpful response.  I always
appreciate your thorough posts, and am so thrilled to be the
beneficiary of one myself now :-)

Yes, thrush seems so likely, doesn't it?  I have no way of knowing yet
whether it's been tested for, but I had presumed that would be part of
the procedure.  I know that the nipple's mere appearance does not
always indicate the level of pain a mum might be experiencing, and I
admit that I might not have seen it in the best light.  I loved your
story about your hearing-impaired client and the revelations after
moving from a dimly lit sitting room to the brightly lit dining room.
So true that families like to keep their lights dim - not great for
ageing LC eyes!  Lessons indeed for home-visits (and social occasions,
ha ha).  How frustrating that your client did not receive good medical
help to clear thrush from her and the baby simultaneously.

In this particular case, the baby has not been to the breast, so I
feel that I have no case for suggesting that the baby is treated.
However I've already said to the mother that she deserves to have
resolution for her pain, and I will follow up as long as she will
allow. Others have suggested that the mother be referred to a
dermatologist now.

The other side of the equation - the baby.  I agree that finger
feeding can be extremely helpful when transitioning from bottle to
breast, but most particularly when the baby is younger.  This case
will be a challenge, but I know there are precedents for older babies
learning to breastfeed.  So much to explore when the mother is
actually comfortable enough to hold the baby skin to skin.

Your messages about motor learning and sensory conditioning have
always been inspirational to me, so thank you for the link to Carolyn
Rovee-Collier's article.

I will keep you posted on how this mother goes.

Best wishes, and many thanks.

Jacquie Nutt


Hi Jacquie,

I would first suspect thrush due to the mother's description of a raw
and burning sensation, even though her nipples were everted, intact,
and with no visible damage when you met her.  Were the areolae also
nonreddened and intact?  Paget's can be bilateral, but is usually
unilateral.
https://www.cancer.gov/types/breast/paget-breast-fact-sheet

During a consult on a winter evening about 8 years ago, I observed a
feed in a family's living room.  One living room lamp was on, and the
room was dimly lit by that one lamp.  The feeding was in progress when
I arrived.  Baby was beautifully positioned in the cradle hold without
my assistance, and he displayed a wide open gape with a deep latch.
The consult was for weeks of maternal nipple pain, and the baby's oral
exam was unremarkable for TOT or visible thrush (I used my penlight
for part of the baby's oral exam).  The mother was hearing impaired
and used verbal language as well as American Sign Language (ASL) to
communicate, with her husband providing some ASL translation when I
didn't understand some of the verbal conversation.  In the dim
lighting of the living room, the mother's nipples and areolae appeared
nonreddened and intact, although I didn't use my penlight during that
portion of the mother's exam.  When baby went to the second breast, he
opened wide and quickly displayed a deep oral grasp.

This recollection is at least 8 years old, but I remember a powerful
lesson from that consult.  After the baby finished nursing, the mother
asked if I would show her how to use her new and not-yet-used high-end
retail pump.  She wanted to have the pump demo in her dining room, and
placed her pump on the dining room table.  In contrast to the living
room, the dining room was brightly lit with a chandelier directly over
the center of the table.  I demonstrated how to assemble and clean the
pump parts, discussed milk storage guidelines, provided and reviewed
handouts, and asked the mother if she would like to practice with her
pump.  When I began to assist the mother in using her pump, her
nipple-areolar anatomy under the bright lights of her dining room
revealed clinical signs consistent with a profound case of thrush that
included both nipples and much of her areolae.  When asked to describe
the type of nipple pain, she said verbally and in ASL, "It burns," and
she confirmed that the burning sensation occurred during and between
feeds.  If memory serves, babe had no visible signs of thrush in the
diaper area.  I provided extensive teaching on the rationale for
treating both mother and baby for thrush, regardless of whether the
baby had visible signs of thrush, pointing out this recommendation on
print teaching material.  Teaching also included how to clean pump
parts and nursing bras during a thrush outbreak, etc.

During all my years of inpatient practice, it was an old habit to
routinely ask for permission to increase the lighting at the bedside
when I entered a room that was dark, nearly dark, or dimly lit.  The
nearly-missed clinical signs consistent with maternal thrush during
that home consult took me by surprise.

Lesson learned:  When consulted for nipple pain, immediately utilize
one's penlight or other small flashlight to examine the nipple-areolar
anatomy, unless already in a distinctly brightly lit room.  In
telephone follow-up with my patient, she continued to have burning
nipple pain, and reported that the pediatrician said that her baby
didn't have thrush.  It was a challenge to again emphasize that both
mother and baby needed to be simultaneously treated for recurrent or
unresolved thrush, regardless of whether the baby has visible signs of
thrush, in order to resolve the mother's inflammation.  Yeast spores
likely travel readily from the nipple-areolar complex into the baby's
mouth, then back again to the nipple-areolar complex many times a day,
and the thrush-dance continues until it is adequately treated in both
members of the dyad.

In recurrent vaginal candidiasis, a partner can also be treated to
help hasten recovery from that inflammation.  And presumably there
isn't sexual contact at least 8 to 12 times daily between partners
during the vaginal candidiasis outbreak.  Nearly all young infants
need to nurse at least 8 to 12 times every 24 hours for adequate
growth, and during a thrush outbreak, that's presumably a lot of
transfer of yeast spores, even if the inflammation of yeast overgrowth
isn't yet visible in the infant.

I continued to follow up with the mother by telephone.  During one
phone conversation, the mother said she hoped to stop direct
breastfeeding soon - - by 8 months - - because she could not imagine
continuing to breastfeed for at least the first year with constant
nipple pain for so long.  She hoped that by stopping direct
breastfeeding and continuing to express her milk, the burning nipple
pain would resolve, and we discussed her perception of this.  It was a
sad professional experience to continue to advise her to follow-up
with her HCP as well as her baby's HCP, when she may have been
expecting the pediatrician to once again say, "No thrush here."  I
wonder if she thought her IBCLC sounded like a broken record with that
ongoing recommendation for simultaneous treatment of both members of
the nursing dyad for what appeared to be consistent with maternal
thrush.  Whatever the cause of burning nipple-areolar pain, it needs
to be investigated toward actual resolution.

In regard to your patient, her recent course of an antifungal may not
have been effective against thrush, since she was also given a course
of antibiotics with the antifungal.  If she had received a course of
antibiotics while in the hospital for her baby's birth, that may well
have created the beginning of the candida imbalance.

Am including these links for anyone new to the field:
https://kellymom.com/bf/concerns/child/thrush-resources/
https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/26-persistent-pain-protocol-english.pdf

This mother needs to be followed up until her symptoms of burning pain
fully resolve.

Finger-feeding may help her baby transfer his learning from bottle to
breast, in the manner of associative learning, but there will likely
be a performance plateau for a period of time in favor of
bottle-feeding skills, due to the length of time spent by her infant
in learning and performing bottle-feeding skills, which builds robust
motor memory for bottle-feeding skills (the primitive survival
reflexes are often more heavily weighted toward the more recently
learned milk-feeding method).  Finger-feeding in a very young newborn,
such as the Day 2 or Day 3 infant, typically helps such young infants
with a much faster transfer of learning from bottle to breast, or
pacifier to breast, or nipple shield to no nipple shield, reflecting
the exuberant learning of infancy (the younger we are, the faster the
learning).  Furthermore, the younger we are, the faster the
forgetting, as evidenced in motor forgetting/skill decay for
breastfeeding skills after an early learning experience with an
artificial nipple.

Like you, many thousands of IBCLCs (including myself) would recommend
skin to skin contact to help the baby learn to associate the smell,
touch, and taste of his mother's skin with sucking and receiving milk
from the breast, but it's critical that the mother's burning symptoms
are resolved, so that this mother can enjoy holding her baby in STS
contact, whether or not the baby eventually learns how to transfer his
learning from bottle-feeding skills to breastfeeding skills.  Many
babies benefit from adequate clinical guidance that is needed beyond
one or 2 consults, because 1) motor learning is complex, and 2) motor
learning is particularly complex when competent task-switching is
expected of the infant from breast to bottle, or bottle to breast,
particularly during early learning, when memories (including motor
memories) are particularly fragile.

Sensory-perceptual learning can be taking place during a performance
plateau, and thus the critical recommendation for skin to skin contact
ad lib until baby outwardly learns how to transfer learning from
bottle-feeding skills to the breast (sensory-perceptual-motor
learning).

A definition of performance plateau from the field of kinesiology -
the study of human movement, motor learning, and motor control:

Performance plateau:  A period of time during the learning process in
which no overt changes in performance occur.

IBCLCs observe performance plateaus in infant feeding skills with
great frequency, particularly in non-Baby Friendly settings.  It's
part of being human:  we may practice and practice a hoped-for skill,
such as learning how to ride a bike or play a particular piece of
music on a specific instrument, without immediately seeing the
hoped-for improvement in skill.  The repetition of task-specific
practice is critical for effective learning, as each individual
movement in a movement sequence gradually becomes more integrated,
smooth, and controlled.  When the primitive survival reflexes are
involved in motor learning, these reflexes are often more heavily
weighted toward the more recently learned feeding method.  When the
most recently learned milk-feeding method is bottle-feeding, we often
observe that many babies no longer reflexively lunge toward the
breast; many babies no longer open the mouth into a wide gape; many
babies no longer utilize greater excursion of the mandible, and no
longer utilize peristaltic motion of the tongue, etc.

A definition of associative learning from the cognitive sciences,
including kinesiology:

Associative learning:  A type of learning in which an association is
formed between two or more stimuli (such as the smell/touch/taste of
mother's skin and her milk during finger-feeding), between a stimulus
and a response, or between a response and its consequence.  For infant
milk-feeding skills and any feeding skill across the lifespan,
learning how to transfer milk is the consequence of our actions, which
also reflects reinforcement learning and reward-based learning, all of
which are heavily studied in the cognitive sciences.

A 2010 article on the exuberant learning of infancy from the late
developmental psychologist, Carolyn Rovee Collier (1942 - 2014), who
is considered the founder of the field of infant long-term memory
research:

Title:  Why a neuromaturational model of memory fails:  The exuberant
learning of infancy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2823839/pdf/nihms161955.pdf


Please keep us posted in regard to how this mother recovers from her
experience with burning nipple pain, and how her little one progresses
with a transfer of learning from bottle-feeding skills to
breastfeeding skills.

Debbie

Debra Swank, RN BSN IBCLC
Program Director
More Than Reflexes Education
Ocala, Florida 34481http://www.morethanreflexes.org/webinars

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