Consider bacterial infection, ductal thrush and reynaud's phenomenon.
Visualize the nipples/areolas for any flakes, crusts, redness.   Culture the
breastmilk after a few minutes of feeding. Check for reynauds, if you don't
see any change in nipple color  (white, red, blue) ,  look for any signs of
yeast in infant or mother.    Ask about a history of yeast in the mother.   I
have seen bacterial ductal infections with the only sign being a 1 mm honey
crusted flake on the areola.   Then give a trial of whatever seems most
likely  (yeast or bacteria).   Get her something stronger for pain  (Tylenol
with codeine perhaps--is she taking max doses of advil- 800 mg tid?).

My guess is that is is yeast--can cause the plugged ducts to begin with.

Christine  Betzold NP IBCLC

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