Hi - I'm a Registered Dietitian and previously did a lot of work and
training as a lactation educator.  It's been a couple of years since I've
been very active in breastfeeding issues - now I'm in Bogota Colombia with a
mom that I'm not sure how to advise.  Any help would be greatly appreciated

Mom came to me with a healthy 3 month old, nursing every 3 hours for
15min/side.  She has been using a nipple shield since birth due to a poor
latch and tongue tied.  Mom c/o chronic plugged ducts and "borderline
mastitis".  Mom is a speech pathologist with experience working with bf babies.

Within the first session, baby was latching well without the shield and mom
reported feeling that her breasts were more drained than ever before.  Latch
on the right side was not as good as the left, right breast is larger and
baby did not seem to be able to handle it as well, although definitely
better than he had with the shield.  

For the next 3 days baby continued to latch well, mom felt like latch
continued to improve each time.  Stool went from green, slimy and stinky to
normal yellow stool.  On night 3, baby refused to nurse without shield.  The
next morning mom c/o plugged ducts, hard/ red/hot breast, pain.  I enc her
to nurse as often as possible, adequate fluids,  massage, bedrest, cabbage,
ibuprofen.  

Day 4 redness was increasing, mom had fever, aches, nausea, etc.  Referred
her to MD for antibiotics.  MD prescribe 3 days Keflex with 1 refill if she
needed it..  He stated he would be willing to lance the breast if infection
did not resolve.

Days 5-7 she felt like things were improving slightly, but not
significantly.  Day 8 redness is gone, breast is still very painful.  I
watched baby nurse and latch looks very good.  Breast is quite swollen,
plugged ducts are palpable from nipple back 3 - 4 inches.  No significant
softening after feeding.  Dad tried to help out, no softening after that either.

My questions - should duct still be that plugged after 8 days?  Is 3 days
Keflex adequate?  I've recommended start lecithin, have discussed ultrasound
(mom is worried that it might spread infection - I don't know?) and am
working on finding someone to do u/s treatment, mom back to MD.  Is there
anything else I should look for/recommend?  Mom and I are both a bit
uncomfortable with MD, as he is NOT very familiar with BF issues,
unfortunately he's the MD provided through her hubby's employment and BF is
pretty rare here among locals.  Any help appreciated!

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