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Lactation Information and Discussion <[log in to unmask]>
Date:
Sun, 20 Dec 1998 20:24:05 -0500
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Dear Ms. Miller,

Your symptoms seem quite compatible with a Candidal infection of the
nipples.  Seeing as things have gone on so long, here is what I would do.  I
would use gentian violet 1% solution (available without prescription).  You
use it as follows (check also website below under Gentian Violet):

First I combine its use with "all purpose nipple ointment".  The gentian
violet is used once a day.  The "all purpose nipple ointment" (see website
below) after all other feeds.  Three possibilities:

1. The mother's pain disappears after 3 or 4 days.  Great.  Stop gentian
violet, decrease "all purpose nipple ointment" over a week or so.

2. The mother's pain is unchanged after 3 or 4 days, or aaargh! *worse*,
stop gentian violet, continue "all purpose nipple ointment" and call.
Consider possibility that Candida is not the cause.

3. The mother's pain is improved after 3 or 4 days, but not gone.  She
continues both gv and "apno".  The gv for a week *should* be enough and she
should stop it after 7 days.  If pain not gone, continue with "apno" and
then call.

4. If mother's pain is gone, but baby still has thrush, use gv once or twice
more, but if stubbornly refuses to go, stop gv and see what happens. Usually
mother's pain will not return (usually).

The "all purpose nipple ointment" is below (unfortunately requires a
prescription).  Check information on sheet called Treatments for Problems on
website below:

mupirocin 2% ointment (5 grams)
nystatin 100,000 unit/ml ointment (5 grams)
clotrimazole 10% (vaginal cream) (5 grams)
betamethasone 0.1% ointment (5 grams)

The pharmacist mixes it all together and it is applied sparingly after each
feeding (except the feeding you use the gentian violet).  Do not wash or
wipe it off.

Information about fluconazole (Diflucan) which I would only have used if
gentian violet and the apno did not work, needs to be used in larger doses.
Indeed, I now prescribe 400 mg loading, and then 100 mg twice daily (or 200
mg daily) until the mother is pain free for a week.  This may require 2 or
more weeks of treatment.  Under treatment leads only to resistant organisms.
If that happens, I use Itraconazole (same dose as fluconazole).

Hope this helps.

Jack Newman, MD, FRCPC

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