Just a word from a fledgling prescriber, humble in the presence of greatness, daring to venture a comment: Because the prescription oral antifungals are marketed directly to the public (ostensibly so that the patients/clients can advocate for their own treatment options) it is easy to imagine that they are pretty benign substances. But there are some serious things to think about concerning oral fluconazole and her sister antifungals. One is impairment of liver function, so the prescriber has to consider monitoring liver function tests, wondering if baseline info is available. The prescriber might also be starting to wonder what kind of yeast is really involved and whether a culture of the milk will yield valuable information. Then he/she wonders whether the foremilk or the hind milk would be the stuff to culture, and lacking clear guidelines, figures maybe we need to culture both. The prescriber wonders what kind of yeast is involved because there are other antifungals to consider, such as ketoconazole which is indicated for mucosal candidiasis and candiduria. The poor prescriber searches every where for something to tell him/her specifically about ductal yeast infections and comes up with not much more than Dr. Newman's article. Maybe something from Tom Hale. But seeing the cautions about fatal arrhythmias associated with oral antifungals and worrying about creating resistant strains with incorrect prescribing.....this is all hard on the poor prescriber who definitely can't digest all this in a 15 minute office visit or in a 5 minute phone call. I don't for one minute say that Dr. Newman's suggestions aren't perfectly correct. He has taken the time to explore the subject and come up with well-thought out plans. But there are limitations inherent in being a lone voice in the wilderness. Very few prescribers are going to risk their licenses and malpractice records on the exhortations of the one lone voice. If a patient gets hurt, juries are notoriously unimpressed with that kind of justification for treatment. That's just the way things are in medicine today. So I don't blame the doctor involved one bit. I wish he or she DID feel comfortable with Dr. Newman's suggestions but I can't blame the poor thing. I'm sorry you had to be the target of the doctor's frustration with trying to prescribe in an environment where drug companies enlist the help of patients/clients to sell their wares and then insurance companies stomp on any treatments that seem to be outside the norm. Talk about being between a rock and a hard place! Is there an adult/women's health nurse practitioner IBCLC in your area? She would be the one for your client to go to. I am going to be just such a person but not until June 2001 when I sit for my exams and begin practice here in the Boston area. I would love to be in contact with other NP-IBCLCs out there, especially to know how they handle ductal yeast. Maybe I could put together the case reports for my master's thesis! That's what we really need, more journal published articles on this subject. That is what would reassure the doctor in question. Maybe Dr. Newman's article has been published in a journal already and if so, that is what should be brought to the attention of the doctors. Anyone with input is welcome to reply to me privately, since I will be out of the country NOMAIL until July 12. Loni, I hope you will let me know how it finally works out. Thank you for sharing this with us and I hope you will forgive me for piping up like this. Bonny Nothern, RN, IBCLC MSN-nurse practitioner candidate, adult primary care and women's health Massachusetts General Hospital, Institute of Health Professions Private practice LC 1993-1998, at which point I lost my mind and started graduate school full-time, having three teenage children, and a husband working 80 hours a week for an internet start-up (MotherNature.com)........I really need this vacation.............. *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html