I have permission to post.  I am working with a mom (P1, G1) and her  baby, 
born 3 Jan.  Baby was TXFR for surgery at birth to repair an  imperforate anus. 
 Surgery was uncomplicated and baby was discharged home  at one week of age.  
Mom had a C/S and so was unable to see baby until she  was d/c'd.  Mom was 
able to breastfeed baby but nursing staff pushed  formula and baby received 
numerous bottles while hospitalized.
Mom contacted me day 10 of life.  Baby is gaining well, stooling  frequently 
and hydrated.  Mom is in a lot of pain while nursing.  I  saw her on a home 
visit.  Extreme pain while latching, but mom could  tolerate the later 
discomfort after initial latch and has been "nursing through  the pain".  Nipple was 
compressed.  Worked on a deep asymmetrical  latch and mom was able to latch and 
nurse without pain.  Nursed in  cross cradle and lying down with baby flat on 
mom's stomach (mom had C/S and  incision was opening again).  Both worked well.
Saw mom a few days later and left nipple is now open and baby drew  blood 
with one quick latch on and off.  Mom has not nursed on that  side since and has 
pumped with PIS, milk supply is going down.   Nursing on right still leaves 
compressed nipple and now (10 days after  initial consult) has opened a wound. 
Oral digital exam is normal, tongue  protrudes well past bottom lip, palate 
seems normal, baby sucks with tongue  under finger and does not bit or mash often 
(I think when she realizes my purple  gloves don't have milk!!).  
Several days ago I did another home visit and mom was able  to nurse well in 
side lying position and cross-cradle.  Baby  seemed to have thrush although 
mom had asked PEDI at appt. 48 hours prior about  it and he said it was "milk 
residue".  Advised mom to start  Nystatin.
Yesterday contacted mom and she said that right nipple now is VERY  painful 
and she is to the point of not being able to nurse without extreme pain  on 
either side, she is also starting to feel the yeast on her breasts (has  started 
Nystatin for her as well).  I reluctantly suggested that  we try nipple 
shields to attempt to give her nipples a chance to heal  while not removing baby 
from breast completely.  Mom came to my house  with shields.  Baby does not like 
the shield and although she nursed  well at my house she refused to nurse with 
them last night.
Also advised mom to start gentian violet and if no relief for  her and/or 
baby in 24 hours to get RX for Diflucan.
She started fenugreek yesterday to increase milk supply on left.  She  is 
insurance pumping with shields.  
Even when the latch was deep and comfortable for mom the nipple still  
emerged compressed; both in cross cradle and football.  Ensured baby's  hips were 
flexed and a few times I put baby onto the breast as mom is hesitant  to pull 
baby on firmly due to pain with most latch attempts.
I am feeling at a loss as to what to do for this mom and baby at this  point. 
 I am concerned about the open skin on the nipple and have suggested  that 
she get a RX for Newman's all purpose nipple ointment.  She is  getting Newman's 
book and I think that may help convince her to be  a bit more aggressive with 
this.  I am concerned about the yeast  getting worse and mastitis.
Through all this the baby is happy (while latched and after a good  feed) and 
gaining.  Mom is really determined to get this right.  She  and her husband 
will be moving in April and I would like her to  feel REALLY good about 
breastfeeding prior to moving (actually, I would  like her to feel good about it 
today...)
Any suggestions or things I have missed or misadvised...feeling out of  sorts 
about this one.
Thanks in advance.
 
Christie Pillado 
El Paso, TX 


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