Nipple solutions 3: pumping

bottleIn addition to using a nipple shield, both the health visitor and the NCT helpline lady suggested I try expressing milk and feeding it from a bottle, to give my nipples a bit of a rest. C’s response to the shield was not encouraging, so using a breast pump was really the only option I had left if I wanted to carry on. So far I’d just about been able to put up with the pain: if I gritted my teeth through the initial agony, the remainder of the feed was just about bearable. The sight of my nipples, however, was really quite perturbing. The open wound on the outside edge of one was so deep it looked as if the nipple were in danger of detaching. The psychological effects of seeing this type of damage were considerably worse than the pain. I could only assume it was getting worse with each feed, and therefore that I was mutilating myself further.

Despite the obvious arguments for using a pump, and possessing one that was bought before C even arrived, it took me another couple of days to get around to using it. I don’t know quite why I was so reticent, but I think it had something to do with feeling guilty and inadequate not being able to get it right on my own. The turning point was speaking to my friend Zara. It turned out that she’d had exactly the same problem – right down to the fissures in the same place – and had pumped to help with the healing. She’d also had the same feelings of guilt and inadequacy, but had come through the other side and said that it made a massive difference. I wasn’t going to get any extra points for prolonging the pain, so I should just get on with it.

Some women find expressing milk easier than others. The key is prompting the letdown reflex – after that getting milk out is reasonably straight forward. Without your baby actually suckling, however, letdown isn’t always that easy to initiate. Looking at a picture of your baby (or indeed your baby herself) is one way of getting the vital oxytocin flowing. The solution for me was pumping from the really mangled left hand side, while C fed from the slightly less injured right hand side. For about four days, I expressed on the left and fed on the right, feeding C the expressed milk in a bottle if she was still hungry.

Using the pump and feeding simultaneously gave me an interesting way to monitor the extent to which the expressing helped. I had the same injury on both sides (albeit not as badly on the right), but only used the pump on one. It definitely provided me with some relief – expressing was much less painful than feeding – and the nipple did heal eventually, but the right side also healed completely, without any intervention. The healing actually occurred slightly faster on the right hand side, although this might be expected, as the injury wasn’t quite so serious. It seemed that the midwife who told me that things would eventually improve of their own accord was right after all. I think the problem for me was caused by the fact that my nipples weren’t quite the right shape initially (for C’s mouth at any rate – I don’t know if it would be different with another baby) and the skin broke so they could be stretched into a better one. Certainly, they now look quite different to how they did originally – pointy where they were once quite flat. When they healed, extra skin grew over the fissures where they’d stretched, rather than the skin knitting together at the point where it was originally joined, providing further evidence that my nipples were simply going through a (very painful!) transitional process.

Although it seems that both nipples would probably have recovered of their own accord if I’d continued feeding C as normal, I would strongly recommend using a pump if your nipples are suffering. It really helps to relieve the pain, and if you plan to bottle feed later on (whether with expressed milk or formula), introducing it early (and continuing regularly) means you should meet less resistance later on. Even if you take into account the constant pump dismantling, sterilizing and constructing, it’s a win-win situation!

Nipple solutions 2: shells and shields

shell

Although I’ve criticized the health service for their, ‘breastfeeding is easy as long as you do it right’ line (a criticism that I stand by), the health visitors and midwives I have spoken to have generally been sympathetic. They have also been willing to deviate from the official advice when it’s obvious that it isn’t working.

Faced with my mutilated nipples, two midwives suggested nipple shields.  A shield is a silicon or rubber teat that you hold over the nipple to protect it during a feed. It is shaped like a large nipple, with holes in the end for the milk to come through. Apparently, they can affect milk supply, so do not have NHS approval, although I have since discovered that this recommendation may be rather out of date (see the nipple shields research post). I didn’t have any luck with shields (C looked at me as if I were mad – she was going to put one of those in her mouth?!) but I have spoken to many women who found them useful.

Breast shells, on the other hand, did prove to be a hit. In contrast to shields, you use shells in between feeds, to protect sore nipples or draw flat ones out (they apply a small amount of suction). They consist of a silicon disk with a hole in the middle for your nipple, topped off with a half a clear plastic tennis ball that acts as a protective bubble around your nipple and stops the fabric of your clothes coming into contact with it. The plastic bit also has holes in, to allow air to circulate. The instructions said to always make sure these were facing upwards, an instruction that I initially failed to heed. What difference would the direction of the holes make? I discovered the answer to this when I noticed a substantial wet patch on my t-shirt. A significant amount of milk can collect in them if you have them on for any period of time, and this milk will naturally leak out of any holes it finds. If you can motivate yourself to sterilize the shells regularly, you can store this milk for later use, but it wasn’t really a priority for me at that point. In the end, I put a breast pad in each shell to soak up any rogue milk (making sure the holes pointed upwards, of course.) Although this will have hindered the air flow a little, the shells still proved very effective in preventing discomfort, and seemed to allow my nipples to heal more easily. I say ‘seemed’ because the effect may have been psychological – when using the shell, my nipple looked less mangled, and I thus assumed it was improving.

I should probably mention, however, that I didn’t exactly use the shells as specified on the box. The instructions state that you shouldn’t use them for more than a couple of hours at a time, as they can cause blocked ducts. I weighed up the potential for blocked ducts against the possibility of my nipples healing a bit faster, and decided the chance of the latter made it reasonable to risk the former. This meant, in practice, that I ended up using them all the time, including at night. Fortunately I didn’t suffer any blocked ducts, although I did end up stretching a rather expensive Elle McPherson nursing bra (and looking like Madonna during her pointy cone bra period unless I dressed very carefully).  To date, there has been very little clinical research investigating the effectiveness (or not) of breast shells (see breast shells: preserving your modesty), but they seemed to help me get through a difficult time. If you want to take the pressure off your nipples – and are willing to risk increasing it on your milk ducts – they may be worth a try.

Nipple solutions 1: doing nothing

creamMy nipple fissures weren’t showing any signs of improving, so after a day of deliberation, I phoned the National Childbirth Trust. I was starting to realise that the fact that there were helplines (and whole charities, in the case of La Leche League) dedicated to solving breastfeeding problems should probably have served as a warning that it might not be that easy. The counsellor who answered the phone was helpful, if a little abrupt. She asked me which direction my nipples pointed (!) and when I said it was slightly outwards, rather than directly forwards, she said that they were probably getting bent backwards in C’s mouth when I was holding her in the cradle feeding position. She suggested using a different position to feed her (such as the rugby/football hold, where C’s mouth would approach the nipple from the opposite direction) while I waited for them to heal. This seemed sensible advice, and after a few goes, C and I managed to perfect some new feeding positions. Although I can’t say it was definitely less painful, the knowledge that C’s mouth probably wasn’t putting pressure on my nipples in the same way seemed to help at least psychologically.

The NCT counsellor, like every midwife I spoke to, also recommended I use Lansinoh cream – ‘absolutely loads of it, as a barrier’ – to protect my nipples. I had been religiously applying it since the bleeding had started, and following advice, continued to do so as the state of my nipples got worse. After a few more days, I stopped to think about this: the state of my nipples was getting worse…

Up to now, still in a post-birth haze, I’d been relying on the NHS resources, reading the leaflets and speaking to midwives and health visitors. They’d been very understanding and sympathetic, but things weren’t really improving, and I was getting desperate. I decided to start Googling in earnest, searching for things like ‘nipple fissures’, and going beyond the first page – sometimes even as far as the fifth! What I ended up with was quite a lot of hits for ‘anal fissures’ (not terribly useful), but in amongst these and the general parenting advice sites, was a scientific paper looking at treatments for cracked nipples1.

The study compared using lanolin cream (like Lansinoh) with using breast milk, and leaving nipples untreated. A short summary of the results goes as follows: the women who used breast milk on their nipples, or who did nothing at all, recovered significantly faster than the ones using lanolin (for a longer discussion see the is lanolin cream a waste of money? post).

Armed with this knowledge, I dumped the Lansinoh, and within only a few hours, things seemed to improve. I can’t be sure whether this was as a direct consequence of not applying the cream, but it seemed to be working, and I decided to stick with it.

  1. Saudi Med J. 2005 Aug; 26(8):1231-4
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