Hi All,
I was hoping you could provide some suggestions/insight to help this poor
mother I saw tonight, who gave permission to post. Mom reported she is
G2L2, delivered via C/S 8d ago. She has only exclusively pumped for both
babies. Mom had an overabundant milk supply with her first baby and seems
to have continued it with her new baby, pumping pints of milk in minutes
each time. She reported having occasional plugged ducts and mastitis with
her first baby but overall it was an uneventful lactation.
Mom is currently pumping with a Lactina and standard 24mm flanges. She
said that pumping for her first baby was never uncomfortable, but this
time it was painful, especially the first few minutes. Over the phone
this morning, I questioned the fit of her flanges but we were unable to
conclude whether her flanges fit properly. After further questioning, she
realized that she had been misunderstanding the way her pump worked and
actually had it set on the highest suction setting.
She also described how, since this baby’s birth, she has been able to peel
off a thick layer of tissue and debris from the face of her nipple every
few days. She has been taking Ampicillin 500mg qid for the past 48h for a
bladder infection.
Other than these details, she felt that everything was going well, until
last night. She was pumping her breasts before bedtime and noticed that
she had a firm lump directly behind her right nipple. Pumping was even
more painful in this breast, and she noticed she only expressed “about a
teaspoon” from the affected breast. She immediately contacted a lactation
counselor (not IBCLC) who helped her through the night with no relief.
By dawn when she called me, the pressure and pain was even more
excruciating in the breast, and mom received little more than a trickle
from the affected breast. I explained RPS, hoping it might shift the
swelling slightly, especially since she had been using such high suction
and for nearly an hour at a time. She wasn’t able to press on the areola
without going through the roof.
By the time we spoke, she had scheduled an appointment mid-morning with an
MD general practitioner. She had no fever yet, but the fatigue from lack
of sleep and pain made her feel very achey. Since she was adverse to
medication, I urged her to consider an offer for stronger antibiotics if
her HCP advised them. Until her appointment, I suggested moist heat,
massage, and frequent pumping on a comfortable setting. I also mentioned
that lecithin can be quite helpful for this condition.
Mom called immediately after the appointment and said doc didn’t feel she
had mastitis (yet) but prescribed her APNO. Doc had no other suggestions
for relief, despite the growing lumps and pressure in mom’s R breast. Mom
also reported that, by this time, lumps were starting to appear in her L
breast as well. I wasn’t able to see her until several hours later,
during which she had even tried cold compresses on the right nipple and
lecithin, with no relief.
When I got there, both of her nipples looked like Figure 154 in the
Breastfeeding Atlas (page 73): bacterial infection with pus. Both nipple
faces seemed to have a thick yellow callous with pus underneath that would
just not soften regardless of what mom tried. Her R nipple had a lump
directly behind it the size of a walnut but the L nipple was still
reasonably pliable. I’m guessing the severe trauma was caused by too
small of pump flanges coupled with too high of pump suction.
I fitted her with larger flanges on both sides (settled on 30mm for both)
and crossed my fingers that it would resolve all of her problems…but it
didn’t. She got little more than a trickle from the right and just a few
ounces from her left. The right breast was firm all the way to her chest
wall. I couldn’t even hand-express because of the excruciating lump
behind the nipple that stretched it to the size of a quarter. Every
gentle touch and palpation caused this mom to jump and the tears flowed.
She admitted she had been firmly committed to breastfeeding but this was
too much for her to take.
I looked up Ampicillin in M&MM, which said that a standard adult dose was
1,500 mg qid. This mom was receiving 500mg qid. I suggested she consult
with her HCP about either taking a higher dose or getting a stronger
antibiotic, as well as methods pain relief. I suggested a thin layer of
APNO on the nipple, followed by cabbage leaves (changed when wilted),
followed by supportive bra, followed by cold packs while lying on her back
to encourage drainage (20m on, 20m off). I gave her information on ways
of suppressing milk supply such as sage and peppermint. I reassured her
that, after her bladder infection and nipple infections and C/S incision
were all healed, which should be in a very short time, she could un-quit.
She was so relieved and thankful, although still in incredible pain and
very emotional.
Okay…what did I miss? What did I do wrong? Help!!
Humbly,
Debbie Gillespie, IBCLC, LLLL
Tempe, AZ
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