I have a client who has given me permission to post. Her baby is 8 months old and I first saw them about 6 weeks ago. This is her second baby, and she had terrible difficulty breastfeeding her first baby as well. Both were home births, but the first baby experienced hospitalization at a couple of weeks of age. With this baby, she experienced pain from the beginning and has never stopped being in pain. She has had so many different symptoms over time that is has been difficult to determine the cause(es), especially in hindsight. It is important to note that her midwife taught her to shove the older baby onto the breast and she was cracked and bleeding from the very beginning. She was taught the same way w/ the 2nd baby and suffered again from the beginning, but after a couple of months ran into an LLLL friend who taught her to use asymmetric latch, after which she experienced improvement. She saw her midwife and LC many times during this period. She says the midwife ruled out thrush (don’t know how) and that the LC gave her bactroban, which she used for many weeks (perhaps months). She has vasospasms and has suffered from damaged nipples and severe pain. She thinks she probably had them with the first baby, but is uncertain. She has weaned from the left breast (more painful than the right) at various times, and has used a nipple shield in the first couple of months, The nipple shield caused increased pain, although I do not know if it was used properly. She saw a CST for the baby, but from my observations I would guess that the CST was not skilled in treating infants as she missed many problems. She also saw a PT for ultrasound due to repeated plugged ducts, but. does not feel it helped at all. 

As for possible thrush--mom did continue to bf the older child after he had severe thrush from ABX in hospital. She also has a history of vaginal yeast infections and UTI's, although not in the past couple of years. She consumes very large amounts of cow milk products and craves them. She eats a lot of carbs as well. She has a long history of poor gut health and her older child has allergies. OTOH, the older child was primarily fed soy artificial infant milk. Mom has been prescribed EFA's by a therapist for pp depression.and is also taking other supplements. The baby was previously not stooling even once per day but with the addition of a probiotic, the baby is stooling 2-3x per day.

Some other interesting points--mom has vasospasms even when she hand-expresses and it also stings.

The baby fights coming on far, but isn't pulling at the nipples as much as she did. The baby just got two front teeth—mom was even more sore during teething, but now is like before..barely tolerable. 

Mom almost always lays down to nurse (moms' choice--most comfortable) or straddles the baby on her leg--sitting up. Mom has to guide baby more on left side than right to get a decent latch. Her tissue is very friable on left--much worse than on the right. Mom is currently nursing approx 2x on the left and otherwise hand expresses and nurses on the right the rest of the time. Mom says it is much easier to nurse on the left when breast is very, very full—then it is "almost comfortable". 

I referred this baby for CST and mom started treatment for thrush. I was not certain that thrush was the culprit, especially as the baby was doing significant damage b/c of structural problems that caused misalignment and over-development of the musculature in her neck, beneath her chin. In other words, she was pulling the nipple up behind her top alveolar ridge and bending it in her mouth, then using the muscles in her neck to feed in a compensatory manner. She was not using her tongue properly and did not have the normal bf chubby cheeks. She said that when she used APNO (was also using GSE) there was some improvement. She also tried gentian violet and it caused trauma to her nipples (only 2-3 applications over 2-3 days). This made me wonder if there was a bacterial infection and I referred her to a family practitioner who felt the symptoms were more indicative of thrush and prescribed diflucan according to Jack’s protocol. There was no improvement.

I still wonder about a bacterial infection or even excema. I wonder about low milk supply (the left breast is only comfortable when full--maybe the baby is pulling to get milk), but weight gain is okay and baby also gets some solids. I have talked to this mom about success and failure and their innate subjecticity. her pain is so constant that I do not feel i can encourage her to continue to bf, nor will i discourage. I simply suppot thwrrever she is in the moment. Right now, she is open to ideas. What would you try?
Jennifer Tow, IBCLC, CT, USA