Dear Dawn,

This is when you need to sit down, take a deep breath, and re-evaluate everything that has been done.  Let's go through it all, based on your post.

Hypothyroid and hyperprolactin:  How has this been determined?  Lab tests?  Is she being treated?  Usually women who are hyperthyroid have decreased milk production, not increased.

You state that the problems started at 3 weeks pp.  What was happening before this?  Are you saying that there was absolutely no problems with pain or nipple damage before 3 weeks of age?  If this is so, then it makes it more likely that an infection has started the cycle.  However, there are other possibilities.  It could be that the mom's oversupply/OALD has masked a sucking problem which has come to light now that the milk flow has slowed somewhat.  Now that baby has to work a little harder to get the milk, he may be sucking in such a way that he is constantly damaging her nipples.  You say that the baby has a good latch.  Looks can be very deceiving.  Have you had the baby suck on your finger?  Have you looked inside this baby's mouth to evaluate palate, frenulum, etc.  For example, a baby with a short frenulum or palate anomaly may do well initially with a fast flow of milk - open wide, in comes the milk.  Later, when he has to actually start to latch well and compress the sinuses, he finds that the only way to maintain a good latch and get any milk is to suck really hard, since the other issue is preventing a truly good latch from happening.  This kind of "vacuum" sucking can produce the kind of nipples that you describe, including the blanching, as can other sucking disturbances.  There is also the possibility that the mom is exhibiting some type of contact dermatitis reaction - has there been any change in type of clothing, bra, or breast pad material or laundry detergent or even deodorant which may have triggered a reaction?

Yeast:  You state that mom has been treated with gentian violet, nystatin and diflucan; baby with gentian violet.  Was there any relied with the gentian violet?  Generally, if it is yeast, there will be immediate relief within a few days of beginning these treatments - the infection will come back if the treatment does not last long enough and/or does not involve both mom and baby.  If she had no real relief with any of these measures (a little relief after 8 days of diflucan does not cut it in my opinion), I would have to question whether or not you are dealing with yeast here.  If she is getting immediate relief with a return of symptoms after treatment has ended, then she may need a much longer treatment cycle - at least one week past the disappearance of all symptoms.  Have you tried Dr. Newmans APNO on her nipples?  This will hit at bacterial as well as fungal infections, with a little bit of steroids to knock down the inflammation.  This could be used in conjunction with the diflucan.

Breast pain:  If this mom still has an oversupply, then constant distention of the milk ducts can cause the kind of pain that she is describing.  She needs to continue to work on the oversupply issue.  You might also want to review carefully her posture and positioning during breastfeeding to see if this is contributing to her problems.  Bra fit may be a consideration here as well.

Nipple pain:  Aside from correcting latch and suck, mom needs to work on pain relief in the nipples.  If there is a touch of Raynaud's playing into this, then warm compresses applied to the nipple right after feeding may help with the pain associated with the blanching and many women report lessening of pain with warm soaks anyways; apply compresses for about 10 minutes, pat nipples dry.  If treating for infection or using lanolin, apply ointment and then use a breast shell with a wide base to keep the bra off of the nipple and allow good air circulation (care must be take here if she leaks easily - pressure from the shell may induce leaking - a larger bra may keep this to a minimum).  Another option is the use of a glycerin-based gel product such as Soothies - many moms find these to feel quite wonderful. Probably don't need to add that frequent, shorter feeds with a baby who is not ravenouly hungry should be less painful and traumatic to the nipples than longer, less frequent feeds by a very hungry child.

Raynaud's:  If this is the problem, then there are treatments out there, besides warm compresses.  Most commonly used are Vitamin B6 and nifedipine - see the archives for more info on this.  These treatments can give dramatic relief, so don't be too quick to dismiss this as a possibility.  If the vasospasms are being triggered by suck problems or yeast, then treatment can often be discontinued once the root causes have been dealt with.

General health:  If mom is run down, everything will feel worse and healing will take longer.  Anemia can be a factor.  Encourage her to eat well and take vitamin or other supplements which may give her a boost at this time.

This is when things can get discouraging.  Mom is beginning to lose hope and the LC is running out of suggestions.  Again, re-evaluation of all aspects is crucial.  You are getting into the "kitchen sink" stage here - as in, everything but. Try to put together a plan of action that is as simple as possible while addressing her most major concerns at this time.

Hope this helps. Good luck.

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