Hi Jacquie,

I would first suspect thrush due to the mother's description of a raw and burning sensation, even though her nipples were everted, intact, and with no visible damage when you met her.  Were the areolae also nonreddened and intact?  Paget's can be bilateral, but is usually unilateral.  

https://www.cancer.gov/types/breast/paget-breast-fact-sheet

During a consult on a winter evening about 8 years ago, I observed a feed in a family's living room.  One living room lamp was on, and the room was dimly lit by that one lamp.  The feeding was in progress when I arrived.  Baby was beautifully positioned in the cradle hold without my assistance, and he displayed a wide open gape with a deep latch.  The consult was for weeks of maternal nipple pain, and the baby's oral exam was unremarkable for TOT or visible thrush (I used my penlight for part of the baby's oral exam).  The mother was hearing impaired and used verbal language as well as American Sign Language (ASL) to communicate, with her husband providing some ASL translation when I didn't understand some of the verbal conversation.  In the dim lighting of the living room, the mother's nipples and areolae appeared nonreddened and intact, although I didn't use my penlight during that portion of the mother's exam.  When baby went to the second breast, he opened wide and quickly displayed a deep oral grasp.     

This recollection is at least 8 years old, but I remember a powerful lesson from that consult.  After the baby finished nursing, the mother asked if I would show her how to use her new and not-yet-used high-end retail pump.  She wanted to have the pump demo in her dining room, and placed her pump on the dining room table.  In contrast to the living room, the dining room was brightly lit with a chandelier directly over the center of the table.  I demonstrated how to assemble and clean the pump parts, discussed milk storage guidelines, provided and reviewed handouts, and asked the mother if she would like to practice with her pump.  When I began to assist the mother in using her pump, her nipple-areolar anatomy under the bright lights of her dining room revealed clinical signs consistent with a profound case of thrush that included both nipples and much of her areolae.  When asked to describe the type of nipple pain, she said verbally and in ASL, "It burns," and she confirmed that the burning sensation occurred during and between feeds.  If memory serves, babe had no visible signs of thrush in the diaper area.  I provided extensive teaching on the rationale for treating both mother and baby for thrush, regardless of whether the baby had visible signs of thrush, pointing out this recommendation on print teaching material.  Teaching also included how to clean pump parts and nursing bras during a thrush outbreak, etc.  

During all my years of inpatient practice, it was an old habit to routinely ask for permission to increase the lighting at the bedside when I entered a room that was dark, nearly dark, or dimly lit.  The nearly-missed clinical signs consistent with maternal thrush during that home consult took me by surprise.  

Lesson learned:  When consulted for nipple pain, immediately utilize one's penlight or other small flashlight to examine the nipple-areolar anatomy, unless already in a distinctly brightly lit room.  In telephone follow-up with my patient, she continued to have burning nipple pain, and reported that the pediatrician said that her baby didn't have thrush.  It was a challenge to again emphasize that both mother and baby needed to be simultaneously treated for recurrent or unresolved thrush, regardless of whether the baby has visible signs of thrush, in order to resolve the mother's inflammation.  Yeast spores likely travel readily from the nipple-areolar complex into the baby's mouth, then back again to the nipple-areolar complex many times a day, and the thrush-dance continues until it is adequately treated in both members of the dyad.

In recurrent vaginal candidiasis, a partner can also be treated to help hasten recovery from that inflammation.  And presumably there isn't sexual contact at least 8 to 12 times daily between partners during the vaginal candidiasis outbreak.  Nearly all young infants need to nurse at least 8 to 12 times every 24 hours for adequate growth, and during a thrush outbreak, that's presumably a lot of transfer of yeast spores, even if the inflammation of yeast overgrowth isn't yet visible in the infant.  

I continued to follow up with the mother by telephone.  During one phone conversation, the mother said she hoped to stop direct breastfeeding soon - - by 8 months - - because she could not imagine continuing to breastfeed for at least the first year with constant nipple pain for so long.  She hoped that by stopping direct breastfeeding and continuing to express her milk, the burning nipple pain would resolve, and we discussed her perception of this.  It was a sad professional experience to continue to advise her to follow-up with her HCP as well as her baby's HCP, when she may have been expecting the pediatrician to once again say, "No thrush here."  I wonder if she thought her IBCLC sounded like a broken record with that ongoing recommendation for simultaneous treatment of both members of the nursing dyad for what appeared to be consistent with maternal thrush.  Whatever the cause of burning nipple-areolar pain, it needs to be investigated toward actual resolution.        

In regard to your patient, her recent course of an antifungal may not have been effective against thrush, since she was also given a course of antibiotics with the antifungal.  If she had received a course of antibiotics while in the hospital for her baby's birth, that may well have created the beginning of the candida imbalance. 
 
Am including these links for anyone new to the field:  

https://kellymom.com/bf/concerns/child/thrush-resources/

https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/26-persistent-pain-protocol-english.pdf

This mother needs to be followed up until her symptoms of burning pain fully resolve.  

Finger-feeding may help her baby transfer his learning from bottle to breast, in the manner of associative learning, but there will likely be a performance plateau for a period of time in favor of bottle-feeding skills, due to the length of time spent by her infant in learning and performing bottle-feeding skills, which builds robust motor memory for bottle-feeding skills (the primitive survival reflexes are often more heavily weighted toward the more recently learned milk-feeding method).  Finger-feeding in a very young newborn, such as the Day 2 or Day 3 infant, typically helps such young infants with a much faster transfer of learning from bottle to breast, or pacifier to breast, or nipple shield to no nipple shield, reflecting the exuberant learning of infancy (the younger we are, the faster the learning).  Furthermore, the younger we are, the faster the forgetting, as evidenced in motor forgetting/skill decay for breastfeeding skills after an early learning experience with an artificial nipple.    

Like you, many thousands of IBCLCs (including myself) would recommend skin to skin contact to help the baby learn to associate the smell, touch, and taste of his mother's skin with sucking and receiving milk from the breast, but it's critical that the mother's burning symptoms are resolved, so that this mother can enjoy holding her baby in STS contact, whether or not the baby eventually learns how to transfer his learning from bottle-feeding skills to breastfeeding skills.  Many babies benefit from adequate clinical guidance that is needed beyond one or 2 consults, because 1) motor learning is complex, and 2) motor learning is particularly complex when competent task-switching is expected of the infant from breast to bottle, or bottle to breast, particularly during early learning, when memories (including motor memories) are particularly fragile.     

Sensory-perceptual learning can be taking place during a performance plateau, and thus the critical recommendation for skin to skin contact ad lib until baby outwardly learns how to transfer learning from bottle-feeding skills to the breast (sensory-perceptual-motor learning).  

A definition of performance plateau from the field of kinesiology - the study of human movement, motor learning, and motor control:

Performance plateau:  A period of time during the learning process in which no overt changes in performance occur.  

IBCLCs observe performance plateaus in infant feeding skills with great frequency, particularly in non-Baby Friendly settings.  It's part of being human:  we may practice and practice a hoped-for skill, such as learning how to ride a bike or play a particular piece of music on a specific instrument, without immediately seeing the hoped-for improvement in skill.  The repetition of task-specific practice is critical for effective learning, as each individual movement in a movement sequence gradually becomes more integrated, smooth, and controlled.  When the primitive survival reflexes are involved in motor learning, these reflexes are often more heavily weighted toward the more recently learned feeding method.  When the most recently learned milk-feeding method is bottle-feeding, we often observe that many babies no longer reflexively lunge toward the breast; many babies no longer open the mouth into a wide gape; many babies no longer utilize greater excursion of the mandible, and no longer utilize peristaltic motion of the tongue, etc.      

A definition of associative learning from the cognitive sciences, including kinesiology: 

Associative learning:  A type of learning in which an association is formed between two or more stimuli (such as the smell/touch/taste of mother's skin and her milk during finger-feeding), between a stimulus and a response, or between a response and its consequence.  For infant milk-feeding skills and any feeding skill across the lifespan, learning how to transfer milk is the consequence of our actions, which also reflects reinforcement learning and reward-based learning, all of which are heavily studied in the cognitive sciences.  

A 2010 article on the exuberant learning of infancy from the late developmental psychologist, Carolyn Rovee Collier (1942 - 2014), who is considered the founder of the field of infant long-term memory research:  

Title:  Why a neuromaturational model of memory fails:  The exuberant learning of infancy.  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2823839/pdf/nihms161955.pdf


Please keep us posted in regard to how this mother recovers from her experience with burning nipple pain, and how her little one progresses with a transfer of learning from bottle-feeding skills to breastfeeding skills.  

Debbie

Debra Swank, RN BSN IBCLC
Program Director
More Than Reflexes Education
Ocala, Florida 34481
http://www.morethanreflexes.org/webinars
  

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome