I have permission from a Mother that I've been assisting to pose her scenario to the group to elicit some input: 

23 yo second time mother.  First breastfeeding experience, 3 years ago,  was unsuccessful in that she never achieved baby feeding well from the breast so she pumped and bottle fed  for a few months.  She got cracked nipples and  mastitis in the left breast. Now with second baby she wants to not only succeed with breastfeeding but avoid mastitis.  A complicating factor with this Mom is that at age 18 she had bilateral breast implants placed, with a periareolar incision, and then the implants were removed about 2 years later (she said she didn't like them).  She called me to see if I would help her with getting a better latch with her two-week old baby.    Latch is painful ("not intolerable" ) and she has deep breast pain only on the left.  She says the nipple and deep breast pain is especially acute at latch on but persists throughout the feeding.  She describes the pain as sharp or like severe stretching.  She also says she has some tenderness even between feedings (" if I touch my breast they feel bruised").  She says since the surgery her breasts feel alittle numb but is aware of having at least 1-2 letdowns per feeding.   Baby does soften the breast comfortably with most feedings.   Baby is gaining weight (3 oz over birth weight at 2 weeks, I don't know what weight went down to) and having greater than 4 yellow stools and 6 wet diapers/24 hours.  I noted latch on the left to appear ok but when nipple came out of babes mouth Mom had a compression ridge across the tip.  I instructed her on assymetrical latch and she said immediately it felt better.   Thinking that her deep breast pain was possibly due to retained milk in that breast (since latch wasn't as good as it could be) in conjunction with scar tissue or adhesions in that breast from the surgery.  She has no hard painful segments or reddened areas in that breast.  Nipple doesn't appear particularly red and tissue appears to be intact.  Mom is aware of signs/symptoms of mastitis and denies feeling like that.   I recommended she massage both but especially left breast prior to feedings and if baby falls asleep too soon and the breast isn't softened with feedings  to use breast massage and compression to keep feeding going.  Also, I recommended to her that if baby doesn't eat enough to soften the breast every feeding to express (or pump) enough to soften the breast for comfort.  She denies having any problems with breastfeeding on the right.  Now it's 48 hours later and she called me again.  She says the latch problem seems to be resolved although she says when baby gets relaxed toward the end of the feeding he tends to relax and slip off the breast to the nipple-she knows not to let him continue feeding like that.  She does say the deep breast pain is persisting though and she has been sure her breasts are soft after each feeding.  She asked me if it could be thrush and I told her it could or it may still be pain from possible adhesions/scar tissue.  She was going to contact her Dr to see if she would consider yeast treatment to "test" the situation and if it gets better on diflucan she would know that's what it is-this was all her idea.  I think she just called me to see what I thought.  I told her it sounded reasonable.  
Thought I would see what some "experts" think about this.  

Thanks.
Sally Myer RN, BSN, ICCE, CLC
McCook, NE

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