Hello, Jan.
       It does sound like possible ductal yeast to me.  The use of
antibiotics just adds to the history here that makes this possible, along with the
history of vaginal yeast.  And the single dose of diflucan for the vaginal yeast
would do nothing for the ductal yeast.
       I've worked with numerous moms who have a white bleb on the nipple.
Many times, they would open it (sterile needle, or soak in warm water and let
baby's suction pull it open), have baby nurse, and then the nipple would look
fine.  But a few feedings later, the white spot would be back.  I know you said
the mother you are working with does not have a bleb on the nipple now, but
perhaps the following suggestion would still be useful.
       Sometimes, I think the "bleb" was never truly gone.  My suspicion is
that, in many cases, the milk got stuck behind the epidermal layer that covered
the nipple pore.  That milk then got thick as the water was reabsorbed as it
sat in the duct.  So when baby nursed after the skin was initially opened, he
pulled out the thickened milk at the very front of the duct, so the nipple
*looked* better.  But I think the thickened milk actually filled a large portion
of the duct, and does not move down and out the duct very well, because it is
so thick.  As baby nurses during the next few feeds, he gradually moves the
thickened milk that was farther back in the duct down to the nipple opening
where it can be seen, so now mom thinks "it's back," but in reality it was never
really all gone!  Because the milk is thick and slow-moving, the milk that
forms behind it also cannot get out easily, so it begins to thicken as well, and
we end up with a vicious cycle.
       I have had good luck in many of these instances by suggesting that,
after she has opened the skin and the baby has removed the white part she can
see at the front of the duct, (this is often best done when dad or someone else
is around to watch the baby and any other children), she get in the tub. Have
her fill the tub with enough warm water so that she can sort of comfortably
lean over and submerge her breasts.  She should soak the breasts for 3-4 minutes
to let the heat widen the ductwork as much as possible.  Then she should
start just behind the nipple, and massage and try to express out a strip about an
inch wide (from base of nipple back one inch, and all the way around the
breast).  She may get out some more stringy thick milk.  Then she should move back
another inch and massage and express that strip.  She may or may not see any
thickened milk come out while she is in the tub.  Warn the mother that she may
see this thickened milk, so she doesn't freak out if she sees it.  But
reassure her that if she doesn't see it, but her massaging loosens it so it might
come out the next time the baby nurses, it won't harm her baby.  It's just milk
that has lost some of its water, but still has all its nutrients, antibodies,
etc.  Some mothers need to do massage in the tub like this several times before
the problem resolves.  After I started suggesting this procedure to moms with
"blebs," I have seen much fewer recurrences.
       Dee

Dee Kassing, BS, MLS, IBCLC
Collinsville, Illinois, in central USA

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