Dear Lactnetters,
I am in need of your collective wisdom. I have a challenging case and I
know all this wonderful knowledge on lactnet will be able to help me
out. I have been working with this client for several weeks. She
contacted me initially for persistent sore nipples and help with thrush.
Baby is now 8 weeks old. Baby had thrush and she had pain in breasts and
nipples but no outward signs of thrush. Her OB doctor told her that he
did not believe in ductal yeast and would not treat her. She desired
info to take to OB or primary care provider so she could get treated. I
provided her with info from Breastfeeding and Human Lactation, Ruth
Lawrence's book and Kay Hoover's information sheet. She was able to get
the baby treated and initially was told to use the baby's oral nystatin
on her nipples---Aarrrgghhh!!! Nothing like putting pure sugar on your
yeasty nipples. Oral nystatin has 30% sucrose.
She did not get better with this treatment and when I initially talked
with her she really wanted to try Diflucan instead of topical nystatin.
The nurse midwive group that I work with is only able to treat by their
protocols which only allows for a one time dose of 150 mg of Diflucan.
She received this treatment and did not have much improvement. I
provided her with information on Diflucan-- Thanks Dr. Jack and Dr.
Hale.
She took this to her primary care provider to receive a 2 week course of
Diflucan    (400 mg loading dose and 200 mg daily). She really felt that
she had some latch on problems but did not want to come in for a consult
until her nipples were feeling a little better. Latch on was
excrutiating and some feeds she just pumped and fed expressed
breastmilk. I saw her for consultation on 3/25/99. Baby does not always
open wide and has a very tight upper labial frenulum that does not allow
baby to flange upper lip. I helped her adjust her positioning she
admitted to using some pretty unusual and probably not great positioning
when her nipples were so sore. She couldn't tolerate the baby brushing
up against her nipples. We used various positions to try to improve
latch on. We used compression technique to keep baby drinking at the
breast-- baby would make a lot of clicking noises and not consistently
drink with an open-pause-close type of pattern and not consistent
audible swallows.  Compression technique and clutch hold helped some
with latch on but she still had some pain of nipple. Nipple also had a
crease across it so I know that we still have work to do with latch on
and we still have a portal for infection/yeast entry. She has been on
Diflucan for a full 2 weeks and was able to get a continuation of her
prescription for another 2 weeks. She states that she is 70-80% better
but still has pain more generalized now throughout breasts, some
shooting and sharp pain and continued nipple pain. Pain lasts throughout
feeding and continues between feeds. She says that the pain is worse at
night.  Both sides are affected but the left is more painful than the
right side. What am I missing? What if anything can be done for the
tight labial frenulum? Anything I can try with postioning to improve
latch on? Should she continue on Diflucan for a full 4 weeks? This still
screams yeast to me but could it be something else? She has made dietary
changes, she tried doing rinses with vinegar but said that it made her
nipples worse. Should she be evaluated by another doctor? Please send
responses to my private e-mail as well as to the list as I am hopelessly
behind on my lactnet posts. Sorry for the length of this post.
Thanks to all, I just love this forum. Happy Easter and Happpy
Passover!!!
Jodi Smart RN, IBCLC
Port St. Lucie, Florida
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