Nipple Wound Case Studies

This week on the Milk Minute, we’re talking all about nipples—specifically, nipple wounds and how they make breastfeeding wayy less enjoyable. Hear firsthand accounts from real parents who’ve experienced these challenges and get practical tips as we guide you through effective protocols for healing and prevention. Join Maureen & Heather for support, solutions, and a bit of reassurance on your breastfeeding journey!

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THANKS TO OUR NEW PATRONS: Slade Wilson, Gwyn Poblete, Ashley Haus, Chris John, Franziska Ronquillo,  Jennifer Raines,  Grace, Leigh Campbell, Erica Metzner, and Sid Conley.

Listener question: Do you work with clients in Europe?

Mentioned in this episode:
Ep. 202 - Breast Surgery and Breastfeeding: Interview with Dr. Katrina Mitchell
Physicianguidetobreastfeeding.org

Prefer to read the transcript? Click Here 

Transcript

Hey everybody, welcome back to the Milk Minute. Welcome, welcome. Do you have nipples? They ever been wounded? You want to talk about it? I got nipples, fucker. I feel like you're about to turn into old Greg.

You don't want to see my mixed up downstairs? You want to drink Bailey's from my shoe? You know you're a millennial, Lynn. Anyway, we are talking about nipples today. We are going to do, well, I'm, I'm asking Heather to present us with some case studies for complex nipple wounds that she's managed over the past couple years.

You know why Maureen doesn't manage nipple wounds very often? Because she sees her clients from the time they give birth and does all kinds of early intervention that prevents nipple wounds. Yeah, I pretty, most of my lactation clients are also just my birth clients these days. I still get occasional, like, stand-alone lactation clients, but yeah, I do not see the kind of ripped up nipples you do, girl.

I mean, there are sometimes people walk into my office and I'm like, what brings you here? And they just lift their shirt up and I'm like, Oh, God, sit down. Does it have to do with the blood on your shirt? Is that why you're here? Ha. Ha. Ha. So anyway if you are squeamish, I don't know, maybe not the episode for you, but I think most of y'all really love this stuff.

So I'm excited to hear some, some gory details and some up to date effective protocols. Yeah, can we get, let's get up to date. Yeah. Let's do it. Absolutely. Before we do that, I want to thank a couple of patrons from, again, from over the summer, sorry we are late, but we just needed a break. Okay. So big thank you to Slade Wilson, Gwynne Poblete, Ashley Haas.

Chris John, Francisca Ronquillo, Jennifer, Gracie Lee Campbell, Erica Metzner, and Sid Conley. Thanks, everybody. We really appreciate your continued support for this project and we're able to provide the most up to date evidence because of you. So, thank you so much. All right. Well, do we have a question before we proceed?

We do. We have a good question from one of our patrons. This is a question from Una D. Una says, Hi, Heather and Maureen. Are you happy to consult with a listener in Europe? Activate that I in IBCLC. I look forward to hearing from you. Una, first of all, sorry we didn't message you back sooner because we took our break.

Yeah. But also this is a question that we get quite often and the answer is yes, we will do international consults. Obviously, we can't take insurance internationally, cash pay, but we'll, we'll do cash pay. The hardest thing is time zones. So, you know, if you're willing to do the math and the mental effort of trying to figure out what time we're meeting, then we can absolutely make it work.

Actually, I've had the easiest ones I've had for internationally are actually Australians. I'm like, it's just a 12 hour difference. So I'll stay. Stay up a little late and you get up a little early and we'll make it work. Sometimes it's 13. Yeah. It's close. It's close. Okay. Well, we are going to take a really quick break and when we get back, let's get into the gory details of some wounded nipples.

All right. Welcome back everybody. So very important thing to start out with here is to remind everyone that nipple tissue is still tissue. It's not like this magical thing. thing that we're supposed to treat differently than other things. And we really learned this very succinctly from Dr. Katrina Mitchell in that interview.

And we can link that in the show notes if you're interested. She's a breast surgeon out on the West Coast who has the Physician's Guide to Breastfeeding online. So if you have not embarked upon the Physician's Guide to Breastfeeding journey yet and you are a lactation professional, you need to go there.

She is excellent and very, what's the word I'm looking for? Succinct. Succinct with how she puts her recommendations and explains things and there's pictures. I mean, she's, Extremely talented, both at her job and at communicating about it. Yeah. Which you don't always find, so we were so thankful for that.

And I recommend her website to every, like, family practice doc I talk to who, like, you know, finds themselves treating this to other IBCLCs, whatever. So yeah, go check out the Physician's Guide to Breastfeeding. She's got lots of really easy, like, troubleshooting information. And I assume then, you know, you took a lot of her guidance for some of these cases.

Absolutely. I mean, really, it's just like the mindset shift of like, nipples are just tissue, like everything else. We don't have to freak out and start doing other random stuff to them because they are nipples. So, anyway, just come at it from that lens when you're hearing these case studies. Obviously, I'm keeping this anonymous for patient privacy, but I think a lot of these scenarios are going to apply to a lot of people and we want to make sure that we cover all of it.

Yes, and we are sharing these cases, of course, with permission as well, but yeah, I'm excited because I, Heather didn't tell me about any of these. Yeah, it's gonna be a surprise. I get to react with you. All right. So our first case study is a newer mom that came to see me when baby was two weeks, almost two weeks.

And she reported that the baby was biting straight down on her nipples at first in the hospital. So they ended up doing a supplemental nursing system with a nipple shield and, you know, stuff and things. That's complicated and hard, and we're not going to get into all of that right now. But he was comfortably sucking with the supplemental nursing system using formula.

Okay. So then they moved on to exclusive pumping and bottle feeding because the pain was just too intense. So I'm like listening to this story and I'm like, okay, so we were doing formula, we had intense pain that early on and the pain just got worse. Alright, so she had seen a previous lactation consultant and the LC was able to latch the baby.

Like the L. C. latched the baby, but mom was not able to latch the baby herself, so then they went home, and that night was a complete disaster, and everybody was crying, and her nipples were in pain again, and so they ended up doing pumping and bottles again, and so she was like at her wits end, and like, Sitting on my couch, she was scoring like a 10 on the EPDS score, so like the Edinburgh Postpartum Depression Screener, you know, so it's not quite positive, but it's almost positive, and she's crying, and she's like, this is my last effort, she's, and I was like, Got it.

So I asked her what her goal was because that's always really important and she said her goal was to mostly exclusively direct breastfeed, but to do an occasional bottle. So she still wanted to keep a bottle in play. Great. Fine. So obviously I had to get a rundown of what's currently happening. So I was like, all right, just walk me through a regular day in the life of what's happening with feedings.

And so she said in 24 hours, she's only trying to breastfeed one time. And, you know, it's lasting 10 to 30 minutes, but then she has to break the latch because it's too painful. So somewhere between 10 and 30 minutes, it gets too painful and she pops the baby off. And I was like, okay. How many breast milk bottles?

She said, eight. Doing stuff like that. You know, about three ounces in each. And I said, okay, awesome. So baby's getting about 24 ounces a day so far, totally normal. And they were using the Phillips Avent natural bottle with a slow flow nipple. And I was like, okay, thank you. How about pumping? And she said that she is pumping nine times in 24 hours and she is expressing 48 ounces a day.

Oh, and she was. Okay. And I was like, You're like nine times. Maybe you don't need to be doing that. I was like, Oh. Okay. So she's using a 21 millimeter flange. Huh. Also. And she was using Earth Mama nipple cream. And babies Pooping five times a day, the color was yellow and brown, and seedy, but baby had horrendous diaper rash.

Hmm. And I was like, hmm, okay, sounds good. So you have an oversupply. Yeah. So she had, she already had hundreds of ounces in her freezer at this point. I'm sure you're like, you have a year's worth of breast milk in your freezer already. Yeah. So I said, let me see your nipples, you know, like whip them out.

Let's see what's going on here. And her nipples looked okay, actually. But her boobs were as hard as the desk my microphone is sitting on. And baby engorgement. Yes. Yes, she was so engorged, and I was like, oh honey, like this is, this is the problem right here, and so I look in the baby's mouth and he has no tongue tie, no lip tie, like he's doing great.

So what was hurting her? The fact that he, positioning, number one, so we were not getting the posterior arm out of the way. Yeah, that's, that's always hard to do. And she was always breastfeeding in cradle. Okay. And so, you know, whenever we have like, essentially, baby couldn't get a deep enough latch because the breast was too hard.

Right, was there any recess to that? No, thank God Yeah. That's why she didn't have damage. Right. You know, like, and I kind of, I chuckled a little bit and I looked at her and I was like, I know this seems like a him problem. And it probably was in the first couple of days, but now this turned into a bit of a you problem.

It was like, in the best way possible, that's good because we can fix it. Yeah. We can fix it. This is a much easier fix. Then I originally was anticipating. I thought we were going to have tongue tie. Sure. When you hear all that, you're like They're like, okay, we're going to look in this kid's mouth. It's going to open two millimeters, like, and we're going to have a lot of work ahead of us.

No, no. He actually ended up having a very, very strong suck. And so, but the bottles, so she's also exhausted and the bottles are taking 30 minutes for three ounces. And, and so I'm like, all right, we got a couple of things to work on here. So we latched the baby and he's. We get him on deep and we get him in an upright position.

Yeah. So we change the positioning on the nipple to change the suction pattern on the nipple. So I wanted her to have a couple more positions in her arsenal to make sure that we're rotating that high suction pattern on the different areas of the areola especially. And so that upright position was really important.

I also got him latched in sideline and I had her husband come over and make sure he could get the baby latched in sideline position. And I always, when I do these more alternative positions, take pictures. Of the baby in that position so they can try to recreate it later at home and because of her experience with the LC being the one that latched the baby, I was very hands off and I just tried to, tried to cue her verbally so she could do it herself and encouraged her along the way.

And so she, I could see it happening. And of course we've got towels everywhere because the opposite breast is just like spilling. And she's like, Oh my God, I'm so sorry. Don't worry about it. Don't worry about it. Yeah. So anyway, what we ended up doing, was no HACA. Okay. No pumping. Other than I gave her an out.

I always give people a life raft because we were earlier on, we're like at 10 day or something. Yes. I said you can do one full drainage every 24 hours where you hook up to your double electric pump and you literally pump to empty just once a day. But other than that, we're going to block feed in four hour blocks.

So that sounds. Easy, but that math is actually kind of hard. Oh, it's, it's really hard, especially going from her pumping schedule to that. Yeah. So what I, and she was kind of confused. So like, if you do like, because of sleeping, sleep throws it off. So it's like, okay, but I only fed the baby once on the left breast and then Went to sleep and then now it's time to do the right breast, but then the right breast got more breastfeeds than the other one.

So what I always tell people is like, this is a guideline. The goal is to keep the pressure in the breast to decrease the milk supply, basically. The pressure is going to kill those milk making cells. So if you have a question between, do I feed on this breast or do I end this block and switch boobs? You always want to go with.

the one that's going to be the longer time. Yeah, you if you can, you would go for the over instead of the under. Yeah. Does that make sense? Do you usually recommend ibuprofen when you're doing this? Oh yes. So we, she also had a second degree tear. So like she was already kind of doing that anyway, but 800 milligrams of ibuprofen every eight hours.

We also did some hydrocortisone on the tips of the nipples with hydrogels. Just to kind of keep everything from rubbing the, her shirt, keep her shirt from rubbing. I did tell her that to save her sanity, she could put the Haka ladybug on the other breast, but don't put any suction on it. Yeah, I've had some people do that with the regular Haka, and just like, I'm like, wear a pumping bra.

Mm hmm. Stuff the flange in there like you would for a pumping bra, but don't, like, depress the bulb, and just catch milk in it, you know? Yeah, she was having, her baby was actually really big, too, so whenever she was using the haka, he would kick it and it would hurt her. So, the ladybug is a nice option that you can put suction on or not.

Yeah, or any of those breast saver shells, like any, Any of that shape. Yeah. Object. So I told her like, we have to be realistic. Your nipples are still going to be sore for the first few days. It takes like three or four days. Yeah. How much did her nipple pain persist? So it, it got better with the ibuprofen and the hydrocortisone and the hydrogels.

It got down to like a four instead of a seven and the position switching. Then it went, brought it down to a three. However, yeah. When I saw her again, four days later, she was still, she never did a full drainage. She used two Hakkas instead and only took off an extra six ounces. So she went hard into the like down regulation.

And so I said, buddy. Seriously, it's okay. You can do the double electric pump. Yeah, we actually want you to do that. It's fine. We don't want that status. Right. So she listened to what I said and then a week later she was like so much better. Yeah. She was so much better. Baby was actually able to get a deeper latch.

Her breast was softening up. And, and she felt confident because she could breastfeed him in multiple positions. And his butt got better with some of the magic Dermaceta cream from the crazy pharmacy in Clarksburg and her Edinburgh went down to a four because pain is a huge determinant for anxiety and depression.

And then we were actually able to stop block feeding and we were able to go back to alternating breasts. But it took, I would say to go back to the alternating, it took about 10 days. Do you feel like her like Persistent engorgement then was the, like, essentially the sole cause of all this issues. Yeah. I do.

And she is dead ass lucky that he did not have a tongue tie because, or torticollis or anything that would have made the latch even more shallow. Sure. Because otherwise her nipples would have been completely destroyed. And I think a lot of the pain was really coming from also the wrong flange size. Heh.

So she was using a size flange that was a little bit too small. And you know, just that pumping nine times a day with a flange, it's a little bit too small and nursing a baby who's got a really strong suck on a boob that is really big and sore. Yeah. She's also one of those people that had like A cups to begin with and then went to like a D in two seconds.

So that tissue was just screaming. Yeah, but she's all better now. That's wonderful. Good job. Yeah, I mean, I don't need you to say good job at the end of all these. I'll keep saying good job because I love you. But it is nice. It's nice. If this episode is only to give you affirmations, like I'm here for it.

You're going to listen to the Snoop Dogg affirmations on YouTube. If you haven't, by the way, please go do that. They're great. I've been listening to them. Alright, case two. Are we ready to move into that one? Yeah, absolutely. I'm excited. So, case two was a patient who mastitis in the breast. Which, of course, she got on vacation.

She, yes, she had used ice, but she had also used a vibrating toothbrush, dangle feeding, additional pumping, because it was really hurting, which she believed resolved it at the time. So the extra pumping really helped. You know, she did see it go away. So when it came back on the opposite breast, she went even harder on the extra pumping and harder on the vibration using a massager.

She was also using the mom cozy wearable pump. So she could do the more pumping. Do you know how many times I've seen mastitis? Those, like, in brow pumps. I cannot. She has been using the size 24 millimeter flange, but she's pretty sure her nipples are a 20, but she's not sure. And she said the highest that she goes on her Spectra vacuum is a 12.

Still pretty high. So that's the highest. Yeah, it's pretty high. That's like the highest. It's like, I don't, girl, I don't think it goes to 11. Like, you can't, you can't turn it up anymore. It's like spinal tap. We gotta tone it up to 11. Yeah, so we went over the new mastitis protocol and she was laughing at herself because of course she's also a medical professional.

I mean, but man, like when that first came out, we were skeptical. Remember? We were like, okay, whatever, I guess we'll try it. And now it works so great. Totally. And now, now I feel like half the time I don't have to see people in person. I'm like, try this for 24 hours and call me back and they're fine. Right.

So often. Well, my, my first question to her was. You know, how long does it take you to finish pumping, right? And she was like, eight minutes. And I said, so you don't really need it to go up to a 12. You're just trying to hurry up. And she like cracks this half smile. And she's like, yeah, you know, she was back to work at that point.

Which I totally understand, but we also like can't just abuse our tissues. Right. So she was like, if I just increase the suction, she's like, well, I went up on the suction slowly. And I was like, yeah, but also like eight minutes is awesome. And if you can do an eight minute pump without hurting yourself.

Please do it. But most of the time to be safe, it's going to be better to stay in more of a mid-range, take a 15 to 20 minute break to actually pump and be kind to your nipple tissue. And cause she also had reported that previously she'd had some little clear blisters on the tips of her nipples. Yeah.

And I was like, okay, yeah, those are suction blisters from the pump. And she's like, oh. Also, the mom cozy, like you have to be really careful because if you're going all the way up to a 12 on your spectra, and then if you put that high, high, high suction on the mom cozy, and it hits that long pole, what is it will that long pole?

I got beef with the long pole, too. I am not playing. I'm, I, I just, I don't know. Is that how a baby eats? No. They actually sent us an email a while ago asking about collaboration. I know, they send one like every month, and I'm like, I can't. Yeah, I'm like, I just don't know, y'all. Maybe if you fix your pump. I mean, it just doesn't make sense to me because it's not anything the way a baby eats.

No. I don't know what the philosophy is behind it. I don't know. But anyway, we changed the way she pumps and we put her on the anti-inflammatory protocol. And I did an ultrasound on her breast because her wedge of inflammation actually went all the way down into her nipple. Do you think? therapeutic ultrasound or imaging?

Therapeutic ultrasound with the one megahertz. And we did a five minute treatment, moving it in a continuous circular fashion over the affected area. And it was fine. So she's actually totally better. And she is pumping much more normally. And she, you know, the whole purpose of her, the whole reason she got mastitis in the first place wasn't because of oversupply.

She makes about six extra ounces a day on top of what baby eats. So, not crazy. It is an oversupply, but it's not a crazy clinical oversupply. Yeah, it's not one that you usually see causing issues. This was for sure a vacation problem, where she got off schedule, she was eating differently, drinking differently.

Nourishing her body and her body was like, I got extra. Yeah, exactly. Yeah, different bacteria, all kinds of stuff. Yep, so that's kind of what happened there. So we did the Lactea for 30 days to prevent any future mastitis from coming up and now she understands the assignment. So if it ever happens again, she calls me and she starts the anti-inflammatory protocol immediately.

Yes. Good. Alright, so there's that one. Let's take a quick break because when we come back, I've got a doozy of a case for you. Yes. I'm gonna get gory. I'm so excited for this one. Yeah. Alright, welcome back, Heather. Hit me with it. I want to hear it. I've been waiting for this one the whole episode. Okay, so this girl came in hot to my clinic.

She was like ready to just launch off my couch. She was in so much pain and she had clearly been in so much pain for so long that her energy was just like, it was hard to sit too close to her. You know, it was just like, she was a donkey on the edge. And she's, so I said, tell me your story. And she said, okay, I've been dealing with severe nipple injury since he was about six weeks old.

How old is he then? Four and a half months. Oh my God. She was told by her OBGYN that it was not going to heal until she stops breastfeeding. What? But she did not want to stop. Okay. So she attended some breastfeeding support groups through WIC. I'm so nervous already. Yes. And the LCO, also back up, the pediatrician is not happy with the baby's weight.

So baby was born in the 89th percentile. And When I saw him, he was in the less than first percentile. So, you know, I do give some wiggle room, by the way, with those babies that are born in like craziest percentiles that are like giant babies. They do have to have some kind of a catching down phase. Yeah.

I just had to have that talk with somebody where I'm like, okay, your baby is this size and we might see more weight loss than we're used to. And we also might see their percentiles dropping and we will just. Keep watching right and but usually they find their equilibrium around two months and this baby just did not right kept going so now she's stuck between a push pull between You know breastfeeding support groups online WIC and her pediatrician who's like, I want you to start doing formula.

They're all telling her something different. Yes, she's getting different things from everybody. Her OBGYN is clearly out of their depth and they're just like, quit breastfeeding. Because all the while, like we were all focused on the baby because the baby is losing weight. We're not losing weight but losing percentiles.

And all the while her nipples are like, rotting off her body. So she keeps getting all purpose nipple ointment. Oh no. And putting that on every day for months. Oh no, no, no. We've talked about this before, but if you're new here, AP PNO because it's a topical steroid cream and an antibiotic and an antifungal, it just keeps thinning out the tissue that you put it on.

Yeah. and that is not a long-term solution. Yeah. You know, she said that she feeds on demand when she's at home and she only pumps when she's at work. And she's just been gritting and burying it through the pain. I'm sure she's a very strong person. Yeah, she said the only moderately comfortable position is football.

Okay. And so that's also, like, not sustainable for, like, a four and a half month old. It's, like, really Yeah, they start to get so long, too, that you're, like I'm like boosting myself to the edge of the chair just so your butt can fit back there. Yeah, so when I saw him, he was only getting one scoop of formula in every bottle of breast milk per day, but he was only getting three bottles of breast milk per day of three and a half ounces each, which is fine, but not for him probably.

Yeah, It's like, it's borderline, like, those cases are so hard where you're like, objectively, a lot of this looks okay, but I look at this kid and it's not adding up to be okay for him. Right. So I, I asked her like, have you ever done a weighted feed? And she said, yes, I've done a weighted feed. And he transferred an ounce and a half.

And I was like, well, not really where you want a four month old to be. Yeah. So this was around two months that they did a weighted feed, but still, I'm like, still Okay, if that's the smaller feeds you get, not okay if that's the bigger feeds you get. And you have to look at the overall picture. Yeah. So then I asked about pumping and she said that she's pumping four times in 24 hours and she's getting six to eight ounces total.

in that time period. So she's getting one and a half to two ounces total. So this kid is like trying his damnedest to get the milk out of the breast that's available to him. He also had a bunch of siblings that were distracting him while he's nursing. Of course, because when you're sucking on a boob that only has an ounce and a half to two ounces in it and you have to work really hard and then your funny sibling comes over, it's very easy to give that boob up.

It's harder to give up a boob that's like full of milk and you're actively chugging, you know, like even now, Marty will pop off, but like milk will be spraying and then she'll be like, Oh, wait, I forgot what I was doing. She'll get back on. It's not like that repetitive nip lash that people get when the baby's kind of like.

over it. So, all right. Then I, I look at the baby, of course. He's got an extremely high palate. He has partial lateralization, so he can't move his tongue to the left or right very well. He has a slight cleft in the tip of his tongue. His lingual frenulum, so the one under the tongue, is short, and it's attached directly to the gum ridge.

And then, In my opinion, yeah, he had low muscle tone for his age, right? So he was technically meeting developmental milestones, but he was very weak. And I just knew that, like, if that kid had enough protein in his body, he'd be building some muscle. You know, he was just real skinny. So I also measured her nipples cause we had to make sure that we got the right flange size.

Oh, and the baby was diagnosed failure to thrive. Yeah. Hey, have you started using arm circumference? Okay, so I, tangential, but was just watching like a conference presentation about failure to thrive and like standardizing measurements for that since they're kind of all over the place. And the presenter was talking about how, Upper arm circumference is one of the more accurate ways to assess that now versus weight, length, length for weight, head, etc.

Because the arm assesses muscle, essentially. We're assessing how much muscle that kid can pack on. And it was, it was, I don't know that I've ever seen a provider measure that. And I was like, where do I even get growth charts for arm circumference? But it might be a good thing to kind of add into your assessment.

Yeah, at least for the failure to thrive babies, you know and just kind of get an idea. I think there are like charts for it, too, that you can get, but anyway. He also had a lip time, by the way. Of course he did. Yeah, sorry, this is a little out of order. So, yes, we reveal, we reveal the nips. We reveal the nipples.

And we see. And we see. I'm like, holy, for the love of God, you poor thing. Yeah. Her right nipple was completely cratered. So I measured it and it was about, it was over seven millimeters in diameter. In the very tip of her nipple, the whole center of it was eaten out. So it was all bright red tissue. There was blood, obviously.

It wasn't like. oozing blood. I mean, it wasn't dripping blood, but it was oozing blood into her nipple pads. So she had to wear pads in her bra all the time. That one was the worst. Her left nipple had a two millimeter fissure in the tip of the nipple. So that one wasn't cratered, but it was a straight up fissure, and it would be eventually.

And so I was like, Oh my God. She goes, Yeah, so yeah. And I said, all right, tell me what you've tried already. So she said that she had tried the silverettes. She has tried keeping them dry. She's tried keeping them moist. She tried sideline nursing. She used APNO for four weeks at a time and then would take a break and then do it for another four weeks.

She said that she doesn't think the nipple injury affects the baby's ability to get full because the baby always seems satisfied after nursing directly, which of course we can talk about later. She works most days and will pump twice while she's there. And she uses a mom cozy. and the spectra and she does not ever get enough to replace the bottles but she Supplements with formula in the bottle.

She does give up breast milk. She puts a scoop of formula in begrudgingly. Yeah. She has used tons of coconut oil that she uses every single time she pumps. She uses a 19 millimeter flange. She's also tried a 21 millimeter flange. But she, but with that one, the base of her nipple was turning white. So she thought it was too big.

Yeah. So I was like, okay, all right. So I had her, when I measured, I told her you're swollen right now because of the injury. So this could potentially change because nipples are just tissue like everything else. So I 24 millimeter flange on the right and a 21 on the left That was the size we needed to make clearance on the base of the nipple.

And I told her, no more Mom Cozy until this is completely healed. Because that long pull is too scary and also we need to be able to see. Yeah, and honestly, like, you know, even with the Mom Cozy, like sometimes that tunnel's really short for how far your nipple goes in. And if it's just like hitting the back with that kind of injury.

Mm hmm. Yeah, and I really needed her to sit down and focus when she was pumping and to like really be in her body as much as possible because she had so many kids running around that if you put the mom cozy and you, you know, grit and bear it and you just like don't pay attention as much. And I could not, risk her getting any worse.

So one thing I also did, I was, she said, should you culture this? She said, the lady at WIC said, maybe you should culture this. And I said, I don't need to culture that. I know there's staff in it. It's been open so long that like, we definitely have staff. So I went ahead and ordered her antibiotics. I was like, I can stick a swab in the tip of that nipple, but that's going to hurt.

And I think it's better at this point to just go ahead and take a total full 10 day course of Dicloxacillin. So we did that. We discontinued the use of the silverettes because when she took them off in my office, I could see that it was actually choking out the tissue. I've seen that. So I also said, and she fought me a little bit on this one, I said, I need you to discontinue using coconut oil completely.

Yeah. And she was like, why? And I said, long term use of the coconut oil can cause Well, and it's just, it's not working and we have better options. Right. If that's not working for you. And I told her to completely discontinue the use of the all-purpose nipple ointment. And she was like, Oh, are you sure?

That's what makes it feel better. And I said, Yes. Yep. We're sure. We discontinued the Mom Cozy. We switched the flange size, like I said. And I told her the new plan is going to be with that. While these wounds are actually open, we're going to use the Polymem wound dressing. We're going to put a small bit of hydrocortisone ointment, just like the over the counter hydrocortisone ointment, on the tip of the nipple.

Right. And cover it with the Polymem. And then every other time, you do Medi honey instead of the hydrocortisone, just to kind of break it up a little bit. And so you keep using the same Polyneme dressing until it's saturated. So, I mean, they are kind of expensive. So, and it's big enough that you can move it around and you can, probably every few days, depending on the wound, you can switch it out.

And so, I had to have the Come to Jesus meeting with her about the fact that this is not going to be healed tomorrow, that this is probably going to take about a month. And she looked at me and I said, we can do it. Like we can continue breastfeeding. At that point, like she's already had it for four months.

I know. So it's kind of like either if you want to keep breastfeeding, it's going to be a month of healing, or it's not going to heal at all, or you can stop breastfeeding. And it's still going to be two weeks till you have, so Well, and she also wanted to boost her supply. And I said, we need to table that for right now.

I said, we cannot, we don't have nipples that are available for supply boosting. Like, we can't tolerate power pumping. We can't ask you to pump any more than you're already pumping. So, no. I said, your baby does need more food. So, let's give your baby some food. We have donor milk in the freezer. Or we can do formula.

He's already tolerating formula really well, so whatever you want to do. But we got to feed this baby a little bit more. She said, okay, like, so we increased the formula. So I had her do one to one and a half ounces of formula after the last four or five breastfeeds of the day, just because her milk supply would really drop off in the afternoon to get him closer to 24 ounces a day.

I also wanted her to offer one to one and a half ounces after breastfeeding and keep the bottles at three to three and a half ounces. Just because it's hard if you increase the bottle size, but then your breast milk isn't increasing. It makes them not want to nurse on the breast as much. So, keeping those bottles the same, but just feeding a little bit more each time after.

I told her to use the pitcher method for making formula in the morning because she's got a lot of kids and I said, you don't have time. I got her scheduled with a pediatric dentist to get the tongue and the lip tie revised because I was like, as long as we don't have a working mouth, we're going to be at risk for more nipple wounds.

And then also I told her that while we are healing, we need to really, really work on anti-inflammatory stuff and get some sleep. So that means at least a four hour block, which she was absolutely not getting because of the pain. So I have her doing 800 of ibuprofen every eight hours and 650 of Tylenol in between those times just to make sure that her pain is covered all day so she can maintain this and it took 27 seven days before they were spot on.

Yep. Before they were completely closed up. And as soon as they were closed, they were still a little bit tender, just like bruised. She said we switched to hydrogel. Okay. Yeah. Yeah. So as soon as we, and she said she tried several different brands. She likes the lactation hub brand. She said she felt like the Medela brand had an extra film on it that made it like weird.

Yeah. And the Lansinoh was too gummy and sticky that when she would pull it off, she felt like it hurt to pull off. So that's, I've not used them personally, so that's just some feedback from her. Good to know though, because I usually use the Medela ones. Like I just keep them in the office to send people home with if we need them, so.

He did get his tongue in his lip tie, and he had buckle ties as well. Did he do OT? Yeah. He did. Yes. And chiropractic. So he did all the things. She did all the things. She was actually able to come down a little bit on her antidepressant. Oh nice. Because of the pain. Love that. Love that. Yep. And now let me tell you baby's weight now.

So when I first saw him, he was 12 pounds, eight ounces. He was in the less than first percentile. And a month later, he's 14 pounds, 13 ounces in the sixth percentile. Awesome. So he's doing so much better. And now we're finally ready to trial power pumping. Yeah. And boosting supply. And I said, I don't know what's going to happen, but guess what?

He can start solids. Right. Because now he's at 12. Yeah, that's really good. Good work on that. Yeah, so I just want to make sure all of you have those three case studies in your pocket. Yeah. Because the interventions are basically the same. And you can kind of see how my brain works and how I work through the processes and like weighing what the patient can actually tolerate.

And also, I really wanted to highlight that pain and mental health were super linked. Absolutely. Absolutely. I thought maybe at some point later in the season we could bring in another case study episode too and see if we have any other interesting ones. But yeah, it was fun. It was fun. I think we should do a postpartum insomnia case study.

Next up we are always down for you giving us episode recommendations, by the way, we got a lot of really good ones over the break and we put them all on our list and we are trying to knock them out one at a time. So we are always excited to hear what you want to hear. Yeah, absolutely, and I, I mean, we can be really easily excited about, like, anything, so and if you have any guests you want to see on here, if you think you're a good guest, you know, we have a form on our website for that.

Please let us know. We'd love to have you. Would you like to do an award in the alcove? Well, I have an award that's a little bit unusual for us today. But, this award goes to Tina. She's a client that I worked with who had a very challenging situation with breastfeeding and with her baby. And She did not meet her breastfeeding goals the first time, so she was very, very, very, very determined to do it this time.

And when it wasn't working again, for many reasons, she came to me and she said, at two weeks, she said, I'm ready to stop, and I don't want to do this long term again, because that made me miserable. And I said, wonderful. Let's do that, Tina. And a week later, I have never seen someone look so happy. Oh, thank God.

She was so happy, her baby was so happy, and I was so proud of her for scaling back her goals and speaking up to me. In our appointments and saying, Hey, actually, I want to change my goal and I don't want to do this anymore. That's awesome. I want more than anything else in life for peaceful feeding experiences.

Yes. We're going for peace, you guys. Life is too short. Well, I have a great award name. You just, you inspired me to change it. We're giving her the Peace of Mind Award. Ooh. For knowing her own mind, knowing her own limitations, and knowing what is best for her and her baby. All right, only you guys know what's best for you.

So thank you for standing in your power and thank you for listening to another episode of the Milk Minute. The way we change this big healthcare system that is not made to really help us in the way that we need it is by educating ourselves, our friends, our family members, and sometimes our healthcare providers.

If you found value in the episode that we produced for you today and you've maybe even used some of our recommendations, let us know. You can email us at MilkMinutePodcast at Gmail. com or you can hit us up on our Patreon at Patreon. com slash MilkMinutePodcast and help support the show. And we will see you next week.

Thank you for listening. Buh bye.