I'm a LLL leader living in Germany and working with mostly American
military-connected women.  I've been reading this forum for almost a year and
have already accessed the archives on this topic.  Still, I'm really stumped
and need some help and direction from you lactation-savvy people.

 21 yr old mother exclusively bfing her 2nd baby (4 mos.-old) has had 5 bouts
of mastitis (left side 2x; right side 3x) and 6 courses of antibiotics
(dilligently taken for prescribed length of time) and has had no separations
from baby.  She has given me permission to share the details of her situation.
 Her long history follows.

1st baby:  Mom received IV antibiotics during labor for Group B strep.  Nursed
one week, stopping due to excruciatingly painful and traumatized nipples.
IBCLC diagnosed highly-arched palate and thrush.  Pumped & used Haberman
feeder.  Both Mom & baby treated with several rounds of different medications,
including gentian violet.  Nipples remained deeply cracked (she still has
visible scars), never completely healed even though she complied w/ meds,
sterilized pump parts, bottles, nipples, etc. daily.   Attempted nursing even
with pain but baby refused to latch.  During this time she had one case of
mastitis w/ fever of 104* F.  Only after she quit pumping at 4 months did
thrush finally go away.  (She described peeling off dried bits of white stuff
from her nipples.)  Milk supply abundant--enough frozen milk to last another 2
months!

2nd baby (born 2 yrs after 1st):  Mom again received IV antibiotics for Group
B strep.  Treated for vaginal yeast infection at 2 wks pp.  Baby nursed well
and gained rapidly (birth wt: 6lbs 6oz; 2 mos: 11lbs).
1st Mastitis at 5wks pp:  High fever, flu-like symptoms with painful, red
lump; 24 hrs of home care not helpful.  Velosef (Cephradine) and Ibuprofin
prescribed, relief w/in 24 hrs but on day 5 (still taking antibiotic)
developed...
2nd mastitis on other side:  Med changed to Dicloxacillin (250 mg qid), 10 day
course, sx subsided.
Baby about 2 months developed nasal stuffiness & the next day high fever
lasting 6 days--Drs unsure of diagnosis despite numerous tests; nasal
stuffiness continues to present (along with some excess tearing of the eyes)
and since this time baby often has refused to nurse well during daytime waking
hours; mother pumped to prevent engorgement; baby fussy when hungry yet only
nurses briefly; cries himself to sleep, at which time he will nurse fairly
well; nurses moderately throughout night; sleeps with mom.
3rd Mastitis:  One wk after finishing previous med, developed fever, achiness,
and breast pain.  Dicloxacillin (increased to 500mg qid) prescribed.  Sx
disappeared.  10 day course.
4th Mastitis:  48 hrs after finishing med, sx began again.  Same med, same
dosage repeated.  Sx disappear.  Following this bout, began prophylactic dose
of Dicloxacillin (250 mg 1xdaily).
5th Mastitis:  On day 9 of prophylactic, sx reappeared and Dicloxacillin upped
to 500mg qid for 14 days.

Based on information she has received from me and others, mom had anemia ruled
out, her milk cultured (which showed both staph & strep), and finally, after
much insistence, the baby's nose & throat cultured (which also showed staph &
strep, but also pseudomonas about which the Health Care Provider was very
concerned--said it could be life-threatening to baby if it entered blood
stream--prescribed antibiotic [Cephalexin]for baby).  3 wks ago, mom began
taking lecithin caps (19 gr. tid), Vitamin C (500mg daily), Echinacea, garlic
& calcium.  Has been taking prenatal vitamins, throughout.  Ultrasound 2 wks
ago--negative for abscess.

A 6th course of antibiotics (Dicloxacillin 500mg qid, 10 days) was prescribed
for mom due to results of a second milk culture (still positive for staph and
strep).  Immediate weaning ordered by 3 different HCP's involved due their
reluctance to prescribe antibiotics ad infinitum.  (No IBCLCs employed in this
overseas military community!)

Complicating factors:  Mom has history of migraines (not currently on meds for
this),  frequency increasing during last 2 mos;  is highly allergic to certain
foods (apples cause airways to swell), was consuming lots of milk and cheese
(until she stopped dairy 3 wks ago--thought it might be contributing to baby's
nasal stuffiness).  Has also stopped other likely allergens including peanut
butter, eggs, sugary items.

Baby had 4 month well-baby check-up this week.  Had only gained 8oz in last 6
weeks!  His current wt is 13lbs 13oz.  (Dr not concerned because his ranking
on the wt percentile charts is still ok.)  Mom notes she no longer feels
overly full even though baby still often refusing nursing during day; baby
fussy and frantic when hungry, gnaws on his fist, wants to suck, but often
won't latch on or lets go quickly.  Still nursing pretty well at night.
Last weekend, mom developed plugged duct on one side, then the other; neither
progressed further and both resolved with home care.  Mom waiting for results
of 3rd milk culture and for a referral to a Dr whose specialty is infectious
diseases.
It has now been 9 days since mom finished last round of antibiotics.  Mom
reports yesterday and today baby is completely refusing to nurse unless
sleeping.  When she offers the breast (and she offers before he gets frantic),
he turns his head away and cries.  For the short term, I've suggested lots of
skin-to-skin contact, having bare breast available without actually offering
it, keeping close track of wet diapers (and other signs of dehydration),
pumping, and feeding baby using an alternative feeding method if necessary.

I have numerous questions including (but not limited to) the following:

***What is causing recurrent mastitis? Scarring from nipple trauma with first
baby?  Scarring in ducts from repeat mastitis?  (Any way to determine
extensive internal scarring?)  Initial oversupply?  Undiagnosed yeast in milk
ducts?  Bacteria (causing illness in baby and mastitis in Mom) being passed
back and forth?. . . Why has it not responded to antibiotics?  Do cultures of
mom's milk and baby's  mouth provide useful information?
***What is causing baby's refusal?  an initial oversupply?, nasal stuffiness
(possible allergy)?   Undiagnosed bacterial infection in baby?  Forceful let
down?  Yeast?
***What is recommended treatment course for mom?  continued prophylactic use
of antibiotics? (what is the effect of long-term antibiotic use?)  Prophylatic
use of vitamins, herbal/homeopathic remedies or other alternative therapies?
***What are recommendations for baby?  Suggestions for baby to more readily
accept the breast? How does current low wt gain factor into mother's continued
BFing?  Any suggestions for prophylactics (alternative or otherwise) with a
4-month old?
***What are recommendations to her HCPs?  They are currently recommending
weaning; being stationed outside of the US, mom has little recourse for other
opinions without causing a financial strain for her.  Any studies citing
various tx options which INCLUDE continued BFing would be beneficial.

Any responses to the aforementioned questions or other pertinent suggestions
would be greatly appreciated.

Elizabeth Malone, LLL Leader
Mehlbach, Germany