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Disclaimer: the case below is an amalgam of multiple cases that have presented to me, and is not derived from any specific or identifiable mother-baby pair who have seen me as patients. Needless to say, all names are fictional.

The third day of Leilani's life

On the third day, Sina and I exchange texts.

The baby is doing well, dialled down and suckling frequently. Leilani’s stool is turning yellow, and she is passing enough wet nappies. Sina reports that she fed overnight, on just one occasion using the shield.

She texts that the skin to her nipples remain somewhat pink. She can see the raised bumpy ridge that resulted from that one feed which really hurt at the end of the first day. When Leilani goes on it hurts, about a three or four on the painscale, but “once the baby is buried in it’s fine. We get to a zero or a one. There is some nipple pain about half the time. But generally going in the right direction,” she texts hopefully. She feels she doesn’t need me to visit.

“You’re doing amazingly!” I text. Women care so much about their babies, care so much about getting the breastfeeding right, and apply themselves with the formidable intelligence of the female brain to an embodied task that they know matters a great deal to their baby – and to themselves. Women are desperate to know what they need to do to protect from nipple damage.

I find out later that by the end of the third day, Sina’s nipple pain had become much more intense.

The fourth day of Leilani’s life

We have a brief phone consultation on day four.

“I switched to pumping only from two yesterday afternoon because the nipple pain was different and intense. I’ll try direct breastfeeding again once my nipples are healed. They are quite angry looking now, with cracks forming, some bleeding, and those white bubbly bits on the ridge have turned yellow and green. It was like they were saying: ‘Warning! Wrong way! Go back!’"

“There have been tears,” she says, in a while.

We talk about safe and gentle pumping, being sure the flange is the right size.

“Use a blob of Lansinoh on the breast pad if you need to, because we don’t want your nipples sticking to the breast pad and being further damaged. But try to get as much air exposure as you can.”

Sina asks about hydrogel.

“Hydrogel can cause softening and redness of the nipple and areola. So can Lansinoh really, or any application - Nursicare too. I’d suggest alternating between the Lansinoh and Hydrogel discs when you need to wear a bra or protect the breasts, and then having as much air exposure for your nipples as is sensibly possible. I'd suggest not wearing a bra to bed, for that reason, too.”

Sina plans to let the nipples heal and then try again next week, pumping in the meantime, and will contact me when and if she needs more help.

“So the fun thing about pumping,” she says, bravely trying to be upbeat, “is that I can measure the milk as it comes in! At two o'clock yesterday afternoon I got three millilitres of colostrum in total. It’s increased now because my milk came in overnight. I just pumped 40 ml in total! Leilani is sleeping very well and is very calm. Wees and poos are fine. So we’re all pretty chilled.”

Sina tells me that coincidentally, a friend of hers has had a baby at just the same time. She says: “My friend sits there happily breastfeeding and there is all this breast tissue drag, even I can see it! The positioning is awful – the baby is rolled away from her – but everything is going fine! Why? Why? It’s not fair!!” She is both laughing and maybe crying.

“I know,” I say. “It really doesn’t seem fair! ... If all is truly going well for that lucky mum and bub, no back arching and fussing, good weight gain, no nipple pain, then it ain’t broke, and we don’t need to fix it. ... But for some of us, there are challenges to deal with – and then we absolutely have to get the fit and hold right, to get us through.”

I think a bit more, then try to explain it better.

"There's lots of anatomic elements that affect the way a woman and her baby fit together. A woman's breast and body shapes and baby's face, mouth and oral tissues and tongue shape have enormous amounts of normal anatomic variability. It's as if some mother-baby pairs have a lot more buffer in their breastfeeding anatomic systems than others. The ones who have less buffer are the ones who really need to get the fit and hold as good as possible. Almost none of the research done on clinical breastfeeding support to date takes into account fit and hold, and the way it affects what happens in babies' mouths. So all the noise around breastfeeding and nipple pain, all the diagnoses and surgical and exercise treatments which try to help mothers and babies fit together better without pain or fussing, aren't evidence-based. But they risk side-effects, and they cost a lot of money. That's the space we're in, I'm afraid."

The ninth day of Leilani’s life

Sina texts.

“If you’re available, I’d love to see you this week some time. My boobs finally healed. I fed Leilani on both boobs (once each) yesterday and there was a lot less pain. I could hear swallowing and I know she fed well. But the nipples were still wedged at the end of each feed. There's no urgency. If you are able to come, that would be wonderful.”