Betsy, you wrote
< I inquired about why a particular person was unable to nurse.  She said
that her nipple kept separating from her areola.)

I have a special interest in the anatomy of the nipple-areolar complex.
Your report intrigues me. I would like to know more about the
circumstances, especially what she remembers about her nipples while
nursing the first child.

Would the mother be willing, and is there anyone you know that could do
close-up photography from all angles, tipping the nipple this way and
that, having a millimeter ruler or a U.S. coin in the picture for size
comparison?

Without any further information, the only possible thing that matches my
experience is that I saw one mother years ago with cracks at several
places and stages of healing at the base of both (medium-sized) nipples,
right where they joined the areola.

This mother too, had nursed a daughter, a "gentle nurser" for 13 months
without problems. The 6 week old baby boy was a vigorous nurser, and had
a relatively shallow latch, and "yanked" at the nipple frequently during
the feeding.

(I cannot remember if I knew at that time that such yanking might
sometimes be a sign of overactive let-down from oversupply, and the baby
might somehow be trying to cope by interfering with the rapid flow. What
I thought more likely then was that the baby was impatient and "yanking"
to stimulate a let-down, much like a calf or a kid goat would butt its
mother's udder to make the milk flow faster.)

The mother, in for a routine WIC visit, told the RD that it felt as if
the baby were going to tear the "buttons off her chest", and indeed,
that's precisely what it looked like. I have "before" pictures, before I
showed her how to trigger the let-down in advance, rotate to various
positions to avoid damaged areas, taught her to insist he keep a deeper
latch and the way to break suction correctly, and furnished her with some
postpartum Hobbit shells to allow air to get to the cracks. But I failed
to get "after" pictures 48 hours later when much healing had already
taken place.

The main thing I remember about the mother's reaction was that when the
pain became unbearable, she quickly backed the baby off from her breast,
placing sudden traction right on the areola while trying to get the
nipple out in what she instinctively felt was the fastest possible way.

I have seen this happen with other mothers who have gritted their teeth
and put up with excruciating pain till they just couldn't tolerate one
more second of it and reflexively pushed suddenly inward on the areola to
jerk the nipple out of the baby's mouth without taking a second to draw
the baby close and properly break the suction first.

I refer to that particular injury process by the nickname of "spraining
the nipple". (Of course, it bears no anatomical resemblance to a wrist
sprain, but the internal process is much the same, I think.) In this
general area, due to a lack of fatty tissue there, the skin is very close
to the underlying connective tissue between the ducts converging there.
The nerves from the rest of the breast also converge there on their way
to meet and spiral around each of the tiny ducts that will exit through
the center of the nipple.

The pain from internal bruising here, or even actual skin breakage here,
can last throughout the entire feeding and be one of the most
excruciating kinds of nipple pain I have seen mothers experience. This
area is what I labeled "Zone 3" in a short article I wrote last year:
(Anyone interested in a copy, please e-mail me privately.)
Cotterman KJ, "Zone Model" Tool for Assessing Early Nipple Discomfort:
Part 2: The Assessment Process, Lactation Currents, Florida Lactation
Consultant Association Newsletter, September, 2002, p. 5-9.
The only two things that I can think of at this time to explain it are
both caused by undue traction:
1) either the mother allows the baby to put traction on the area as above
(which sometimes also happens when the baby reaches the curiosity stage
and hangs on to the nipple for dear life while jerking his head around to
follow an interesting sight), or
2) by the mother allowing the breast to sag, ending up with a very
shallow latch because the baby is trying as hard as he can to maintain
what he can, and/or by her putting sudden traction on the skin where the
nipple base joins the areola, in a reflex attempt to sever the baby's
latch ASAP.
Of course, this could also be a great "set-up" for thrush, which can also
cause an excruciating pain, and perhaps by its appearance, lead the
mother to conclude what you described in your post! But with each of six
children?? Not a likely explanation.
Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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