Hi All,
 
    Remember a while back when I wrote needing a LC in Japan?  Thanks to all
who replied.  I was able to find someone for them by using the ILCA website.
They are now in Austin and I am trying
to help them.  I need some suggestions.  Here is a quick synopsis:
Baby girl born 6 wks ago, vaginal birth, uncomplicated, tho had manual
extraction of placenta.
I first heard from them when baby was 11 days old and mom was screaming when
she put baby to breast because her nipples were so torn up.  Her husband
sent me some pictures via the internet.  They were blood red, looked like
the shaft of the nipple had been circumcised, leaving the tip intact.  My
instructions to her were to keep baby away from them and to only manually
express to keep herself comfortable.  They were too bad even for a pump,
IMO.  I also told her she needed oral antibiotics and an antibiotic cream
for her nipples.  She got started on some medication in Japan, but was not
able to figure out if it was the
right stuff for what I had suggested.  (dicloxicillin and APNO)  Her father
in law is a doctor in the states, and sent her what I had suggested.  Her
nipples started to heal.  She was able to rent a symhony pump and was able
to tolerate the pumping.  She got to the states when baby was 5 1/2 weeks
old, this is when I saw her for first time.  By then she had just finished
the antibiotics, was still using APNO and pumping, but only getting 30-50 ml
8xday.  Of course she has wide spaced breasts with one noticeably smaller
than the other.  argh!  So, we talk about that and its possible affect on
supply.  I worry about still using the APNO this long as the hydrocortisone
can cause tissue breakdown with longterm use.  SO, I suggest she stop that
cream and try just bactroban and elastogel pads.  I send her to an OB in
town.  I fax a letter to the doc along with a copy of the ABM protocol for
treatment of mastitis.  She does not have symptoms, but can certainly
develop into this or worse.  Protocol suggests milk being cultured. I am
just SURE she has MRSA! (nonhealing wound...)  But, 3 days later, no growth!
NOthing!  HOw could this be?  She still had some postpartum bleeding of
bright red, but OB checked her and said uterus and cervix were fine and
normal amount of blood.  (this is a very good OB)   
     Now mom is also dealing with Raynauds, which I know is normal having
gone thru all this nipple trauma.  So, the gel pads that we started are
stopped, as they make her nipples cold.  She keeps doing the bactroban and
placing a soft dry cloth over her nipples. I don't want to do the grapefruit
seed extract along with bactroban, so don't make that suggestion.  (wool is
suggested, but she doesnt have any, nor do I)  I find out she has been
pumping on MAX strength because it doesnt hurt and she gets more out.  I
told her this is probably too strong and her "pain" concept is probably all
out of distortion with all she has gone thru, so instruct her to not pump
higher than 1/2 strength.  She sets on minimum and content with that.
States it does feel better.  (by the way, the pump flanges are standard size
but not rubbing near wounds at all.  We try other flanges and standard are
most comfortable)   
     Few days later, nipple wounds are now purple, and one nipple wound
seems to be spreading.  So, if you can picture this:  remember the above
circumcised description?  With the meds, some of that skin healed, so the
wounds had areas that were closed but still gapped in other areas.  Now
those closed areas seem to be reopening.  
     So now I'm trying to find a wound care specialist in Austin and reading
about wound care.  We do have silvadene here which is commonly used for
burns.  It helps wounds heal and takes away the pain.  We decide to try some
of that on the wounds.  Mom still pumping only, getting about 300ml/day.  
     Silvadene was started twice a day on 8/28.  Using lanolin on wound
prior to pumping.  Wearing breast shells now, which states feels better.  It
has been 4 days of this and mom initially thought it was getting better, but
now states her nipples remain unchanged.  Still not healing.
 
   Ok, so much for brief!  If you have read all of this, bless you!  
   Here is what I am thinking....... the purple is the nipple healing.  As
long as the nipple wound is closed, we are good.  Other than that, the only
other thing I can think of is having the nipple wound cultured (not sure why
we didnt do that in the first place) or having her slowly wean, as maybe
only stopping is going to heal the nipples.  This morning she is encouraged
that the nipples are no worse, and she is pumping onlhy 5x day for about
250ml total. (supplementing with formula, of course)
 
   Any suggestions????
 
Linda Hill RN, IBCLC
Austin,TX

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