For Dr. Cunningham,

It certainly sounds like the mother and child you are caring for have
developed yeast.  The nipple redness and the deep breast pain are very
suspicious.  The concern I would have is that the baby has not been noted to
have yeast on the buccal mucosa and that the mother seems to have unilateral
pain.  Perhaps you might take a swab of the baby's tongue to verify the
presence of yeast.  The differential of unilateral nipple and breast pain
would include vasospasm, fissuring, positioning and latch problems,
infection, eczema and other skin disorders.

If you elect to treat the couple for yeast, I have found miconazole cream
very effective when used after every nursing.  I use a little breastmilk to
wash it off before the next  nursing.  If I do not get a 50% reduction in
pain after one week of use, I turn to fluconazole (200 mg loading dose, 100
mg po OD for nine days).   For the infant, I have the mother apply the
nystatin suspension after every nursing using a swab to paint the oral
mucosa and tongue.  If this fails to be effective after one week, I turn to
fluconazole suspension for 10 days.   I have yet to have a failure from this
regimen.  It this doesn't fix things, you might want to review the initial
diagnosis.  The biggest draw back for fluconazole is the price, about $130
Can for the mother and $40 Can for the baby.

I recently needed to use fluconazole in both a breastfeeding mother and her
baby.  The mother did not respond to topical antifungals and the baby did
not respond to nystatin.  I had to do some estimating and I checked the
numbers with Dr. Tom Hale who has written a text on drugs in lactation.

I wanted to use 100 mg po OD for ten days for the mother and treat the baby
with 3 mg/kg for one week. I wanted to see if I would have to decrease the
infant's dose as the baby was also receiving fluconazole through the breast
milk.

Peak serum concentrations noted for 150 mg stat dose was reported at 6.4
ug/ml.
Using 100 mg, peak serum concentrations should be 2/3 of 6.4 or around 4.2
ug/ml.
Steady state concentrations are 2/3 of peak levels (I think).   2/3 x
4.2ug/ml = 2.8 ug/ml
The average M/P levels reported in Peds Inf D J March 1995 was .8
If the average baby takes in 900 ml of breast milk per day, 900 ml x 2.8
ug/ml x .8 = 2.01 mg per day.

To treat the baby, I needed 3 mg/kg.  This was a 8 kg baby so it appeared
the intake of fluconazole through breastmilk was not very significant.

By the way, it is wonderful to see other physicians interested in
breastfeeding!

Shirley Gross

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M. Shirley Gross M.D.,C.M., C.C.F.P., I.B.C.L.C.
Director, Edmonton Breastfeeding Clinic
Edmonton, Alberta, Canada
E mail at  <  [log in to unmask]  >
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