>------------------------------
>
>Date:    Mon, 15 Feb 1999 11:05:45 -0200
>From:    Sherry Hartenbower <"[log in to unmask]"@EROLS.COM>
>Subject: Re: sore nipples
>
>Sherry Hartenbower wrote:
>>
>> I have a patient who called me when her baby was five days of age
>with
>> extremely sore and fissured nipples.  Three LC's had previously
>observed
>> a feeding and found baby latched appropriately (or so they thought).
> By
>> the time the mom sought my advice, she could not bear to put baby to
>> breast because of the level of pain.  She has been pumping for 72
>hours
>> plus, using lanolin between feedings, etc. and her nipples have not
>> appreciably improved.  What might I suggest?
>
Sherry

These are just a few things I want to contribute. I'm sure others will
have additional ones.

My first suggestion is: STOP ALL VACUUM FORCES on the nipple tissue till
healed completely 1) The pump  2) the baby.

Suction does not pull on the milk directly. It PULLS ON FLESH, including
the capillaries attempting to heal and the skin cells trying to fill in
the wound. Continue moist wound healing principles.

Reassure, reassure, reassure the mother that you will help her overcome
this detour and find a new route around the pain.
Whenever it seems needed, use a small, wrapped hot compress (tested first
on the inside of her wrist, and laid on the outside of her bra for now).
This is often helpful prior to expression of milk. It seems to raise the
pain threshhold. This will then be especially comforting to know she can
get  "relief in advance" when the day finally comes that her skin and her
spirit are again ready to attempt a latch.

Teach her gentle digital and manual expression Teach her all the
relaxation tricks you know to help her learn to elicit MER in this
exceedingly vulnerable period. If she is sometimes too sleepy, consider
checking with her if it's alright to teach her husband or her mother to
gently massage some milk forward to relieve milk tension at least 8-12
times or more a day.

And as Coach Linda says "Rule # 1: Feed the baby." See if the family can
help some of the time to get the milk, (EBM, or as a last resort, ABM)
into the baby without a rubber nipple so that she may overcome and avoid
severe sleep deprivation. Saps the joy out of life, and the hope and
spirit of a new mom (and a family)!

Check the baby's mouth closely, especially the frenulum, even it this has
already been done. I have seen pictures of the craters on nipples that
anykyloglossia can sometimes cause. If it needs to be clipped, find
someone in your area that does it. Hopefully, it will be a dentist, not
an oral surgeon or someone else who might make a big deal of anesthetic,
etc.

By the time her tissues are ready to resume latching, her postpartum
fluid balance will have removed much of the possible edema that may have
contributed subareolar tissue resistance.
This resistance is often enough to interferes with the inner, invisible
mechanics of a good latch, no matter what it looks like from the outside.
To be on the safe side, have her use deep digital extraction of a 360
degree area of the areola each time before the first few latch attempts.

In the first few days back at breast, encourage her to break the suction
a few times during the feeding (no, not by the clock...just in the time
it takes a disc jockey to play a song or two, or an egg-timer to have
been turned over once or twice).

This allows her to check the shape and color of the nipple immediately
after suction release, letting its shape return to normal if needed, and
allows the capillary circulation to replenish the nipple tissue, in case
something is still a little faulty about the latch.

Burp the baby and switch to another position on the same breast at these
"timeouts for circulation." If the latch is still causing a tiny bit of
stress on the newly healed skin cells, this will at least transfer the
stress to another area.

I realize my approach may be controversial, based on my biases. I hope
this gives some help. I would like feedback on her progress.

K. Jean Cotterman RNC, IBCLC
Dayton, Ohio

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