I have permission to post and request your feedback on this case.



First baby, 3 months old. Mother hx of preeclampsia and endometritis.
Severe nipple pain, including nipple blistering, abrasions, bleeding and
painful blanching.  Saw another lactation consultant who felt nipple pain
was due to “resistant yeast.” Past treatment of candidiasis with
probiotics, echinacea, 2 courses of fluconazole, nystatin, gentian violet,
APNO, and topical vinegar. Mother has been breastfeeding 2-3 times per day,
and otherwise pumping and bottle-feeding to allow nipples to heal. Baby
received formula supplementation after birth for hypoglycemia, now
exclusively receiving breast milk. Baby latches on both breasts, but
becomes fussy after feeding for a few minutes. Nipples are pink with
pinpoint areas of excoriation on tips. Painful blanching of the left nipple
noted after breastfeeding. Baby with normal oral anatomy, no TOTs. No
evidence of candidiasis in mouth. Mild diaper rash that does not appear to
be due to yeast. Baby latched on both breasts, and fed for approximately 15
minutes per side. Initially latched deeply, but tends to slide off breast
during feeds. Test weight showed intake of approximately 3 oz. during
feeding.



I felt that the candidiasis was resolving, and felt that mother’s nipple
pain may be due to Raynaud’s phenomenon, and recommended that she discuss
treatment with Nifedipine with her doctor. We also discussed other measures
to treat the Raynaud’s such as latching deeply, applying warmth to nipples
after breastfeeding, and taking Ibuprofen. I recommended she obtain inserts
for her Medela pump to reduce the diameter to fit her small nipples, and
recommended continuing to use APNO until nipple pain resolved. We worked on
positioning to help baby maintain a deep asymmetrical latch and not slide
back onto the nipple.



It has now been a month since my initial visit. I have been contacting mom
periodically, but so far no in-person follow up. Baby continues to be fussy
at breast, and nipple pain continues despite treatment measures and
Nifedipine for Raynaud’s. Baby’s stools have been green, especially when
mom breastfeeds directly versus giving expressed breastmilk by bottle. Her
nipple pain is unresolved.



What would you recommend at this point? What am I missing?



Thanks so much,

Christy Van Orman, RN, IBCLC

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