Hi everyone,

I need your collective wisdom once again...

I saw a mom (permission to post) 2 days ago who is having nipple pain with an 7+ month old. Hx: nursed first child and at 1 yr 8 month, began having tiny cracks and irritation and extreme pain in both nipples. Treated with Augmentin (didn't work) and limped along nursing another four months until 2 yrs (her minimum goal) and weaned. Now with second baby, at 4 months, same type of thing; diflucan for 10 days (Rx by OB before she saw me) and improved some, but now, again, at almost 8 months, it's back. Mother describes situation and pain as the "same" as with first child.

I saw her Monday afternoon. Both nipples reddened; small cracks at base (not exactly lining up with placement of baby's upper lip); one had reddened puffiness extending into areola (size a bit larger than a nickel); the other had some faint raised red "dots" extending into areola. Nipple faces don't look eroded or injured; no scabbing anywhere.

She had her 4 y.o. with her, so I checked her mouth: she has a labial frenulum (though it is not that thick at this point, nor is it that short) going into gum ridge with a gap between her two front baby teeth. Current nursling also has a labial frenulum: short, thick and tight. Additionally, both s had/have acid reflux; first went undiagnosed until toddlerhood (don't recall when) and current baby on Prevcid since 2 months. Mom notes increased discomfort to baby when she does not give meds.

My approach was (is) this could be individual to this baby, or it could be due to some factor that both babies share. These are the possible situation I thought might be going on:

1. Subclinical infection?--suggested she have it cultured and treated with appropriate antibiotic 

2. Dermatitis--maybe an allergic reaction to some food in baby is eating? maybe some kind of reaction to the acid in baby's saliva? 

3. Yeast--frequently accompanied by infection; treat with yeast meds plus appropriate Abx; APNO

4. chronic injury due to labial frenulum

Since mom is having s very hard time tolerating nursing, my approach with was to get the nipples as healed as possible (saline rinses, APNO, Abx if needed, making an effort to get baby to open wide and latch from below, wiping inside of baby's mouth after she eats solids) and hopefully the reason why this is happening will become clearer.

Mom went to derm yesterday, who, despite repeatedly questioning mom's desire to keep nursing (and this is a derm who is currently breastfeeding her 2 month old!), Rxed the APNO and cultured the nipple surface. Derm say my care plan, which included my thoughts as above and spend the whole consult focused on "this is nipple trauma due to baby's frenulum and will keep happening over and over again".

Update from mom this morning: APNO seems to be making a huge difference, along with withholding nursing somewhat (nursed at 3 pm yesterday, to put baby to sleep and then at 4 am when baby woke again; uncomfortably full after 2 am). Puffiness on areola is starting to go down and smooth out and pain has lessened to tolerable. She is asking me if I think APNO will be enough, to which I think, NO. At this point, I think that Abx is needed.

My questions to you wise ladies are:

1. Does it seem like I'm on track? What else comes to mind here? 

2. I don't have a lot of experience with the culturing process; what if the culture shows "nothing" and derm doesn't want to Rx Abx? My Plan B is to go to OB then. 

3. I've told the mom to try to keep the idea that the frenulum is the culprit on the back-burner for now; her experience nursing both kids has been pain-free and pleasant except for these distinct episodes of pain/inflammation/cracking. It has been my experience (personal and also with several moms I've worked with) that when a tight labial frenulum is causing the mother discomfort it is chronic, with peaks during cutting of the upper teeth. This has not been the case with her. Ultimately, the frenulum might need to be dealt with, but I am hesitant to go there right now. Thoughts?

Thanks so much for whatever insights you can offer. 

Happy belated Mother's Day to all!

Ana

Ana Estorino Uribasterra, IBCLC
www.lovingstartlactationservices.com
 
  

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