Hi, 'netters!  I could use your collective experience and wisdom.  I have
been working with a mom of a 4 1/2-mo old who had previously nursed two
children (by another marriage) several years ago without problems.  Things
apparently went well initially, but at 3 months she was treated for
probably mastitis L breast with amoxicillin, got better but within two
weeks developed similar sx's on R breast, treated with amox again, got
better again but not as quickly.  Within a couple of days of stopping
amox, she developed severe pain in R nipple with burning, worse with
nursing, but very sensitive any time, and she had a white "bleb" at the
tip of that nipple.  She was referred to me by her local LC.

On examining
her and her little cherub (22lb obviously thriving!), I found that her
breasts were soft, no lumps, the nipples were not red, pink or shiny, just
the white bleb over one duct.  On hand expression, the milk coming from
that area was clearer than her regular milk.  Baby's nursing latch and
position OK, baby's palate a tad shallow, tongue came well over midline.
Baby was nursing q3hrs, in past 2-3 weeks was only taking 5 minutes per
side and occasionally did not go to other side (mother was not restricting
him, he was just done, apparently a very efficient little nurser).  After
going through all the archives on white blebs, I opened the bleb, could
not get any "milk thread", sent her home to nurse in all positions, no
bra, soak with epsom salts.  Initially she had improvement but bleb
re-formed a couple of times, pt reopened it herself.

She was getting
discouraged by persistent pain, finding it difficult to keep up the
soaking and nursing regimen in view of her older kids' schedules, etc (by
the way, hubby very supportive), was considering drying up the affected
side and just nursing on the R, which was just fine.  However, things
seemed to improve this week, and as long as she nursed on affected side
only in the football position and did soaks about 3x/d, it was bearable.
2 days ago, in the shower, the bleb came off "like dry skin off a
callous", and has not returned.

This a.m. she woke up with severe pain on
same side, which was much worse during nursing and then she noted blood
coming from that breast and on baby's mouth.  The pain persisted but no
more blood was seen.  The milk coming from all ducts including the
affected one was white and creamy.  She nursed again, it was excruciating
but no blood.  Later in the shower she noted her breast was red all over,
veins very prominent "like a road map", firm and hot to the touch.  She
was sl nauseous but no fever or flu-like sx's.  I called in Dicloxicillin
500 mg qid, recommended that she keep nursing, rest, use soaks, etc.  I
want to send her for an ultrasound to r/o an abscess but she has no
insurance. I will be examining her tomorrow.

I would appreciate any suggestions.  Of course, with the current sx's I
have to be concerned about an inflammatory Ca, and if the breast doesn't
improve promptly I will urge her to get it checked.  I had read about
recurrent plugs and use of lecithin, but it seems that except for the one
episode of ?mastitis on the other breast, all the trouble has been on this
one side, particularly this one duct.  If this mastitis clears and there
is no abscess or other lesion, any other ideas for the plugged duct? TIA,
Alicia Dermer, MD, IBCLC.