My name is Deborah Ehrhardt and I've been an IBCLC since 1989.  I've been in
private practice since 1992 and an LLLL since 1982.  I have a challenging
case and I need some help from my friends on LACTNET.

Mom is G2P2.  First child, now 2 years, breastfed for 1 year.  Second child
was a home birth on 1-6-96.  Mom and Dad are committed to breastfeeding.  Dad
is active duty military.  They use the military health care providers, but
are open to seeking civilian care, too.

First consult when baby was 5 days old.  Mom experiencing sore nipples, scabs
on both nipple tips, and bruising in the 3 o'clock position on the left
areola.  Baby's frenulum was attached to the tip of her tongue and the tip of
her tongue stayed at the lower alveolar ridge during sucking.  Referral
through their pediatrician was made to an Ear, Nose, and Throat physician who
recommended pumping and bottle feeding and waiting to do a frenotomy because
of the baby's age.  A second opinion was obtained from a civilian dentist and
a frenotomy was performed at age 9 days.  Baby was immediately placed at
mother's breast and mom reported "it feels normal."

At one month of age,  both children had yeast diaper rashes.  Pediatrician
prescribed Nystatin cream.  Mom was still experiencing sore nipples
  Pediatrician prescribed hydrocortisone cream for her nipples.  After
several days of "no worse, no better," pediatrician prescribed Nystatin cream
for her nipples and Nystatin oral for baby.

Mom called after several days of above treatment.  She reported that diaper
rash was clearing, but she felt pain in her breasts now.  She switched to
Monistat and began using Advil OTC for 48 hours.  The next day she reported
her nipples were still tender and she still had pain in her breasts.  The
pain was "not excruciating," but like an "irritation."  She was considering
weaning.

Second consult on 2-12-96 (baby age 4 1/2 weeks old.)  On Nystatin - no
change.  On Monistat - no change.  On 2-11-96 she added hydrocortisone cream
to Monistat - no change.  She now felt shooting pains in her breasts most of
the time.  She said the baby's tongue hurt the underside of her nipples with
nursing.  Her nipples were still bright pink.  I referred her back to her
health care provider for further evalution.  We discussed referral to a
pediatric OT to assist with baby's sucking pattern.

On 2-15-95, Nurse Practioner recommended discontinuing all mediations for mom
and baby.  NP also recommended renting a pump and expressing her milk for the
baby.  Mom rented pump and fed baby by bottle.  Mom returned the pump several
days later and said she found the pump to be as uncomfortable as nursing.
 Mom continues to feel shooting pains in her breasts, although she continues
to breastfeed.

Dermatologist was seen and said he was not familiar with ductal yeast.  He
did take the Kay Hoover yeast information sheet and said he would look up the
research.  Pediatrician B prescribed Diflucan for mom and Nystatin for baby.
 Since mom's breasts were also tender, prescribed Augmentin for possible
breast infection to be taken simultaneously with Diflucan.

On 2-29-96 after seven days of Diflucan and Augmentin, mom is experiencing
more shooting pains in her breasts than before.  Her breasts and nipples are
less tender. Her nipples are less pink.  Baby sleeps all night and mom does
not feel pains in breasts at night.  The shooting pains she feels are between
breastfeedings.  Baby was fussy today and didn't want to nurse.  Mom's
nipples feel numb after she nurses and appear white and creased.  Is this
vasospasm?  Mom is really ready to quit breastfeeding now as nothing has
worked to relieve her pain.

I appreciate any comments you might have.

Sincerely,

Deborah Ehrhardt, IBCLC
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