I would appreciate your insights with a mother I saw some time back who is
still having problems. It's a complicated case, and I won't take the time to
provide all the details here. I originally saw the mom for pain with feeding
(which seemed to be improved with better latch) and low supply (which
improved slightly but never caught up despite mother's use of herbal
galactagogues and domperidone, frequent feeding and pumping, etc.) Baby was
also treated for posterior tongue tie, which made only small improvements in
latch.

I saw mother for a follow-up visit and baby latched well, wide gape, mother
reported pain during feed, but there was no nipple compression after feed.
The mother's nipples and part of the areola were noticeably red. Baby also
made strange breathing sounds during swallowing (but not stridor). Baby
sometimes leaks milk at the breast and often with a bottle. I suggested
mother see a dermatologist, but the doctor she saw said the nipples looked
normal to her (!?). Mother's pain with feeding increased, and I reviewed
treatment options for thrush; mother and doctor chose to treat with
diflucan. Original dosing was not optimal, but mother went back to doctor
and got appropriate dosing. She did one course (loading dose, two weeks at
200mg/day, then four weeks of a once weekly dose of 200mg) and was pain-free
in a few days. However, the pain returned when she went to the weekly dose.
Another doctor at the practice then prescribed 200 mg/day for four weeks
(not sure if there was a loading dose again). Mother again felt better
quickly. Through this time the nipples remain very red.

Any suggestions for what might be going on? Why would pain improve with
diflucan, but redness remain? What else might it be? Should she try to see
another dermatologist?

Lisa Mandell, MBA, IBCLC
Havertown, PA  USA

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