Dear all,

 

It would be wonderful to have any input or ideas on this case.

I have been helping this mother and babe for several weeks and have mum's
permission to post.

 

Mother had a c-section delivery at 42.5 weeks, after failure to progress.
Monitoring during labour had shown baby's heartbeat to not be fluctuating as
it should, and after breaking her waters thick meconium was evident in the
waters.  At delivery, baby girl not breathing well and had a lot of mucous,
but breathing well on her own within 5-10 minutes.  Low blood sugars for
next 3 days so baby received colostrum and formula top ups until her blood
sugars stabilised.

 

Breastfeeding and latch went well immediate post-natal period, however
nipple pain started despite what looked a good latch and then nipple damage.
LC seen at this time and referred for lingual and labial frenectomy release
by laser.  Mother both expressed and breastfed for a few days to relieve
painful nipples.

 

However nipple pain did not subside, let down became painful and dull deep
pains from armpit and upper back to breast became prominent.  A red patch on
left breast was noted one morning, with small pea shaped lump under it.
Back to LC who diagnosed as having thrush (nipples + baby's mouth + nappy
rash) and a breast abscess, Mother started antibiotics that day for abcess,
along with an antifungal cream on her nipples and gel in baby's mouth.  From
this point onwards mother exposed nipples to air as much as possible, took
acidophilous supplements and yoghurt, cut down on sugar and observed strict
hand hygeine and sterilisation of bottles, teats + breast pump etc.  She
changed breast pads frequently and began washing all laundry with
anti-fungal rinse.

 

1 week later Dr Newman's prescription for All Purpose Nipple Ointment was
given as no improvement in mother's thrush symptoms, although baby's mouth
had cleared.  10 days later breast abscess had gone (antibiotics finished)
but still no change in nipple pain (infact nipples becoming increasingly
painful to the point of being unable to wear any clothing on the torso) or
sharp pains in breasts and armpits - so a 3 week course of 100mg twice a day
of Fluconazole was started (starting with 400 mg on first day).

 

Improvement of thrush symptoms began within 3-4 days, with deep dull breast
pain disappearing.  After 6-7 days nipple tenderness eased slightly and
mother began breastfeeding (alternating with expressing) and building up to
full time breastfeeding.  Her latch was re-checked by LC and looked good,
although possible vasospasm diagnosed as needle like pains in nipples with
white to purple colour change up to 30 mins after a feed/expressing were
being experienced.  Oversupply also diagnosed as expressing for too long at
a time (producing 200ml + per double express sometimes).  

 

14 days into the 21 day course of Fluconazole, and nipple pain has increased
again after 3 days of full time breastfeeding.  There are no cracks or
grazes on the nipples.  When baby comes off breast there is no nipple
pinching, flattening.  Nipple is long and round, latch looks very good, baby
removing milk well. She is also experiencing all over breast tenderness, to
the point she cannot hold her baby to her chest to cuddle or carry.  Breasts
are not red.  Nipples pink and swollen, areolar are brown normal pigment but
swollen with whole breast tenderness, nil mastitis, nil blocked ducts, nil
lumps.

 

Mother is now expressing full time again (for 7 mins ev 3 hrs obtaining
approx. 120ml combined), taking ibuprofen 200mg six hourly + Fluconazole
200mg per day + acidophilus supplement.  Rinsing nipples post express or
feed with water and vinegar.  Baby is now 8 weeks old and mouth is still
clear of thrush, and no nappy rash.  Using formula to top up feeds where
necessary. Strict hand washing is being observed as well as sterilisation of
pump parts and bottle and teats.  Continues to use APNO 4 times per day.

 

No vaginal thrush experienced by mother during this time, although has had a
history of vaginal thrush every 3-4 years for past 12 years, and twice
within one year once (she thinks).

Breastmilk was sent for culture and came back negative.

 

My only thoughts going forward is that there is a residual bacterial
infection here.  This mum is very committed but the extreme on-going nipple
pain and breast tenderness is really getting her morale down.

 

Any thoughts and ideas would be greatly appreciated.

Many thanks

Claire Payn

IBCLC, RN

Helensville

Auckland 
New Zealand

 

 


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