Kathy Boggs, I sympathize.  The persistent pain following mastitis cases is
so hard to work with, because the mothers try everything and still it hurts.
In the case of your mother, receding chin is, in my opinion, an
under-appreciated cause of nipple truama.  And in fact, maybe what we are
seeing in some of these cases is that the infection (fungal and bacterial)
is gone, but what initially caused the nipples to break down and allow
invading organisms to penetrate skin in the first place is something the
BABY is doing while sucking.  Or perhaps it is connected to some underlying
hormonal condition of the mother.

For the chin:  Try positions that make baby really tip back the head in more
dramatic extension than normal to see if you can jam the chin in closer so
the lower jaw isn't closing on nipple shaft.  Be sure to check shape of the
nipple the sec. the baby comes off the breast for signs of tell-tale
creasing or indenting of the lower aspect of nipple shaft.

One of the mothers I've been working with who has the deep pain and very
irritated, pink nipples (6 weeks of tx with various antifungals including 3
weeks diflucan) did begin a course of abx.  Our plan was that we would try
ketoconazole as per Lisa Amir's advice after finishing the abx, but the mom
has had it.  5 days into the abx she is no better and has decided to wean.
Her baby has very weak facial tone and poor lip seal.  During my initial
evaluation, I suspected that in order to compensate for lack of ability to
create and sustain good negative pressure (suction) the baby was clamping
and exerting greater than normal amts of positive pressure with gums and
tongue.  However, 'resting' her on a good pump did not resolve the pain.
One other interesting thing about this mom that came out just recently is
that she had a dx testosterone elevation some years ago for which she was
tx.  Don't know what her levels are today.  She never brought in a full
supply of milk for this baby, and 6 wks of exclusively bfg had produced an
unhappy, skinny, rather weak baby, who plumped up nicely and got happy the
min. formula supps were begun.  Could the borderline low milk supply
(possibly explained by hormones out of whack) have also contributed to the
pain phenomenon by creating some sort of breast strain from baby trying and
pump trying to get milk that really wasn't there?

I've tried everything I can think of and come up empty on this one.  The
fact that the baby had 8 weeks of mostly breastmilk feeds is a big comfort
to the mother, and she has felt well supported by her care providers, just
disappointed that the support didn't fix the prob.

Barbara Wilson-Clay BSEd, IBCLC
Austin Lactation Associates
http://www.lactnews.com

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