• Lips tucked under—“grandpa lips”?

• Not opening wide enough and getting only nipple in mouth?

Poor latch

• Pull out lips.

• Wait for wide-open mouth; may need to get to baby before too awake and hungry to increase cooperation.

• Early days’ discomfort from baby’s vacuum suction?

• Any blanching?

Discomfort in first weeks vs high suckling pressure

• Lanolin
• Deep breathing

• Review of good latch

Blister-like lesions on breast?

Herpes

Avoid nursing on affected side.

• Pink-tinged nipples?
• Itching?

• Shooting pain in breast?

Candida infection

Simultaneous antifungal treatment of mother and baby (APNO not adequate)

• Does baby’s tongue extend beyond gums?

• Does baby’s tongue move up and sideways when you rub the gums?

Tongue-tie, other mouth abnormalities

If any suspicion, get a formal evaluation.

Shiny white dot on tip of nipple?

Bleb or milk blister

Topical steroid for softening. May need massaging. Best to leave alone but opening up may be needed with sterile needle in severe cases, high rate of reoccurrence.

• Dry, flaky rash?

• History of allergies or eczema?

Eczema or irritant dermatitis

• OTC hydrocortisone and if no improvement may need more potent version by prescription

• May have allergy to lanolin, detergents/bleach, soaps

• Sensitivity of nipples to cold or stimulation?

• Color change of nipple after nursing?

Vasospasm of nipple/ Raynaud disease

Needs evaluation; will likely need help with improving the latch, use of a heating pad immediately after nursing, and, possibly, a prescription for nifedipine.

• Plentiful milk supply?
• Baby pulls off with squirts of milk a few minutes into a nursing session?

• Blanching of the nipple?

Clamping down due to oversupply

Lean back with nursing because it affords baby better control of fast flow.

• Soreness beyond the nipple?
• Area of redness of breast?

• Fever?

Mastitis

Needs evaluation, will likely necessitate antibiotics