Hi,
 
     I have an interesting case.  Mom presents to me on postpartum day 5
with bright red breasts.  Both are hot to touch, angry red, with redness
about an inch beyond areola on top of breasts and extends to most of tissue
underneath breasts.  She had bilateral breast reduction 10 years prior,
periareolar incisions that then extended down breast tissue and underneath
breasts.  She has no fever, no chills and no noticeably hard lumps.  Breasts
feel fuller in some areas, but certainly not rock hard.  She is not leaking,
and milk is difficult to express.  The nipple/areolar complex is thick and
difficult for baby to latch onto.  The integrity of the nipple is becoming
compomised, as little tears are seen here and there.   I felt mom needed
antibiotics and pumping and nipple care that included washing with a diluted
baby soap 2xday and an APNO.  She had already been using a
bacitracin/polymycin mix; so was to continue that.  (at the time, I felt the
baby was doing the nipple damage due to shallow latch and taut nipple
structure)  I sent her to her OB, and they prescribed antibiotics as well.
Today I saw her again.  It's been 3 days.  (Friday to Monday)  She wants me
to see her nipples, as they look kinda "funny" to her.  Both nipples are
scabbed over, some a yellow crust, some a bloody crust.  (she has also been
wearing elastogel pads around the clock and applying lanolin prior to
pumping)  As I further inspect her nipples with gloved hands and a 4x4, much
of the scab lifts from the sides and healthy nipple tissue is seen below it.
So, and I should mention here that I am also a nurse, I get some sterile
suture removal scissors, and clip away the easily removed scab.  One nipple
looks much better when done, but the other is not ready to be "debrided".  I
have her pump, thinking that might soften things up some more, but it really
doesnt.  She barely gets out 1/2 an oz. combined.  (which is the amount she
has been pumping)  Her OB, whom she saw prior to seeing me, wants her to
pump less, but mom wants to give her breasts a fair shot at making milk and
understands the importance of stimulation.  She leaves me today pumping q3h
during the day and q4h during the night.  She is to continue to use the
cream, but I have her adding some biafine with it.  (its an emulsion cream
much like lanolin, and Dr. Hale didnt see why it wouldnt be ok)  My hopes
are that this will prevent it from scabbing.  She is to continue to use the
elastogel and continue to take her antibiotics.  I had already increased her
pump flange sizes, making sure the sides were not rubbing against the sides
too much.  They can both move freely within the flange. 
     I will be calling her tomorrow to see how things are going.  
     I guess the next step would be to have her nipples cultured, but wanted
to throw this out to y'all in hopes that you could give me further guidance!
(!!!!)
 
Appreciatively!
 
Linda Hill RN, IBCLC
Capital Pediatric Group
Austin, TX

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