Dear Lisa and Lactnetters,
       It has been good to see some really useful suggestions/comments on the vexed issue of persistent thrush over the last day or so.  It would be great to see an update, later, on which treatments and management plans were the most help in the mother and baby whose case started the discussion.
      Lisa Marasco's suggestion of combining the Diflucan with a some non-pharmaceutical treatment makes sense.  When I see someone with persitent thrush, it is not unusual to find that there are more sites involved than the usual ones checked, and there may be more members of the family with fungal infections than just the mother and baby.
     Nailbed infections of the toes are something I've learnt to ask about, and I usually show some photographs from a drug company leaflet.  Sometimes this results in a look of recognition, off come the mother's shoes, and she tells me she's had several toes like this for a long time.  If there are older children (same bath and shower) she's likely to mention their feet, too.  Teatree oil is an antifungal.  (I first learnt about tea-tree oil from Jean Ridler, Cape Town.)  Using tea-tree oil drops in warm water as a footbath in the shower stall or bath not only helps treat the feet, but also treats the shower base or bath, so that the fungal infection doesn't pingpong.  It makes sense to combine this with other topical antifungal treatment round the toenails, e.g. clotrimazole, and keep it up for 10-14 days after it seems to have cleared.  Don't forget about fingernail infections, too.
    One Mum I saw recently responded to my questions about other sites/types of fungal infections by identifying a ringworm on her leg.  (Clotrimazole is marketed as a treatment of ringworm and tinea, among other fungal manifestations.)  Another mother had a brown fungal area (diagnosed as such previously by a HCP) on her back!  Occasionally I see the pinkish rash of intertrigo in the fold under the breasts - worth checking in any case, but particularly in a woman with heavy breasts during a long, hot, humid summer.  This is sometimes the case where there is no recent history of vaginal thrush, no redness round the baby's anal area.  It also doesn't hurt to check the mother's mouth, e.g. corners of the mouth for what may look like slight ulceration (angular chelitis) and also the tongue for white patches.
    I usually give the mother a leaflet with pictures to take home with her, so that she can discuss other sites, e.g. "jock itch", with her husband.  Identifying all other sites will be helpful when the client is talking with her family doctor.
    Another important issue I cover with the client is the "extra" hygiene needed.  Physicians often don't think to recommend scalding the 'bra cups, after hand washing, by running very hot water through the cup part of the 'bra, keeping the elastic part out of the scalding water.  Disposable breast pads, rather than washable ones.  Extra care with hand-washing before touching the baby's mouth or the breasts.  It is just so easy for her to touch her mouth unconsciously, or to brush her hand against the ringworm on her thigh, or to take off her shoes and socks, or to rub an itchy area under the breasts - and then touch her breasts or the baby's mouth as she starts to breastfeed.  Often she is not aware of these as fungal sites, and being aware can help her remember to wash her hands well.
     These comments are not being offered to replace the excellent comments on dosages of fluconazole and antibiotic therapy offered by other Lactnetters for that specific case of the mother with the highly resistent thrush and skin breakdown.  My comments are being offered as a reminder of the need to check out other sites, including some which don't readily come to mind, in other cases of persistent thrush.  And to treat both the feet and the shower or bath when feet or other body areas are involved.
                           
                      Virginia 
                      Virginia Thorley, OAM, IBCLC
                       in sunny Brisbane, Queensland, Australia
                       [log in to unmask]

             ***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html