at journal club last month we discussed dr. livingstone's article at great
length. we talked about some of the aspects of her study that have caused me
to make slight changes in what i do. whenever i see a mother that has any
kind of nipple pain, i advise her to use the approximation of the APNO which
is cortisone cream, antibiotic cream and lanolin, and the antifungal (OTC) if
there is even a hint of possible yeast problems. until i can get someone to
prescribe it that's the closest i can get.

when i think someone has thrush, i offer them gentian violet if they want to
try that first, and if not, recommend to their HCP that they be prescribed
diflucan. the reason i go to that next is that nystatin doesn't seem to help
most of the mothers i see (some have already been treated unsuccessfully). if
they use GV and it helps some but does not completely eliminate the thrush, i
also recommend diflucan or flucanozole or something "more" than nystatin.

or, if the patient and doctor want to use nystatin, i just make sure they
know that there is another level to go to.

at journal club we discussed the troubling fact that some of the sx. we
previously associated with thrush seem to be indicative of a bacterial
infection! we confronted the fact that thrush tends to be a catch all
diagnosis loosely based on sx. which i am guilty of, too. i feel like it is
so common (well, and it is) that if nothing else looks likely, i am sometimes
willing to treat it as thrush and see what happens. so now i think i am going
to be more interested in some history to go with the diagnosis of thrush if
it doesn't "look" like thrush. obviously, if the baby has a horribly yeasty
diaper rash (once a mother did too), there is a history of antibiotic use,
history of prior yeast problems, etc., its probably thrush.

but, given the statistics in the article, it also seemed pretty reasonable to
treat a case as something needing antibiotics (unless there were a more clear
cut reason to suspect thrush). some ideas on approach included: treat with
antibiotics AND antifungals. culture for both, while beginning treatment with
antibiotics while waiting for culture results. culture for both, treat with
APNO (its not big around here, i seem to be the only person who has both
heard of jack newman AND actually incorporates his ideas into my practice).

some of what i asked our resident docs about (we now have at least three that
come to journal club regularly) is cost and getting doctors to go for various
procedures. around here i was told that antibiotics are cheap, cultures are
easy to do and cheap, nystatin is cheap, and the other treatments for thrush
are VERY expensive. so, a doctor constrained by the requirements of insurance
is likely to go for a culture and a round of antibiotics while waiting for
some results (or further development of sx) to treat for thrush with anything
more than nystatin.

i, too, hate to think of causing thrush by giving antibiotics. i would
certainly never make a blanket treatment plan of antibiotics for nipple pain
(that was considered a possibility by some). we discussed using soap and
water cleaning once a day for nipple care, and this is certainly part of the
standard treatment for other similar surface injuries or damage. given that
we will expect the mother to be using lanolin or APNO constantly, the idea of
recommending soap and water cleansing once a day is not likely to cause
further damage by drying the skin, and should offer a bit more protection
against worsening the possible infection.

also i was looking at things on medscape and came across an article
"inflammatory breast lesions and their surgical management" edwin b.
buchanan, md, facs, elizabeth a. bender, md. spyros d. kominos, scd, mercy
hospital of pittsburgh. i printed it out and didn't bookmark the web address,
sorry.

this turned out to be a somewhat different article than i had thought and
very useful in considered livingstone's article. i have been thinking for
some time that i need to know more about "other" (outside pregnancy and
lactation) causes of breast disease and problems. this article discusses
various causes for breast problems, several of which i had not heard of
before.

some interesting points include: cancer may present as tender or inflamed
masses often with overlying skin redness, but culture fails to grow any
bacteria.

they refer to nipple and areolar skin as being more prone to admitting
infectious agents, being more porous than normal skin.

they discuss mastitits and state "the best treatment for milk stasis is
emptying of the breast by nursing or hand expression." yeah! i am so glad
there was not a ghostly reincarnation of the wean immediately type of advice.

some cases of mastitis have been shown to be caused by pseudomonas aeruginosa
caused by exposure to inadequate chlorinated pools and hot tubs. i don't know
about other places, but hot tubs are extremely common  in my area, so this
ought to be at least a local consideration for me.

their discussion is good, including a recommendation for both anaerobic as
well as aerobic cultures. their article includes color picture, so now that
this has turned out to be a more useful article than i thought, i am going to
go back and take a look.

also (drumroll here) i vaguely recall once sarcastically saying "tuberculosis
of the breast?!?!?! are you kidding?!?!?" about some report that a mother was
told that she had that problem. i couldn't find anyone who had ever heard of
it.

I WAS WRONG (okay, print it out, you nonbelievers). this article describes
tuberculosis of the breast, which they say occurs almost exclusively in
australia.

to add to my original comments about livingstone's article, i would look at
seeing some exudate or other signs of infection to try to distinguish between
thrush and "everything else."

carol brussel IBCLC
wishing for the magic detector to use in these cases

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