Okay my Lactnet peers I am stumped again and need your help.  I have a
client who has been trying to nurse her 2nd baby after abruptly weaning for
similar reasons with the first baby. In short she has extremely sore
nipples.
Here is the course of events: (posted with mom's permission of course!)
Baby born 4/21/15, per mom-- uncomplicated vaginal delivery with skin to
skin immediately after delivery and nursed. Mom describes hospital course
as "latching sometimes better than others" but increasing soreness.  Before
discharge the pediatrician told parents that the baby was 'tongue tied' and
with their permission clipped the tie.  I  thought WOW because usually in
our area (rural WV) you are hard pressed to get even an ENT doc to clip.
Mom still had concerns so I saw them immediately after they got home (they
delivered a couple hours away from here at another community hospital).
Mom sore, but no open wounds, some compression (&bruise) noted on one
side.  Baby's tongue is coming out over lower lip and lip is indeed not
tied. Latch more comfortable with correction of lower lip ("untucking" it),
worked with mom on positioning, baby led latching and breast care.
By day  4 milk was in but mom was much more sore even though she felt he
was latching better.  She was using ice packs just prior to feeds and pain
meds (ibuprofen or tylenol) and 'lanolin nipple ointment'  I went to see
her again and nipples red and tender but no open areas. Again, we worked on
latch and suggested she use only expressed milk on her nipples instead of
the "tons of lanolin ointment" she had been using.
Day 5 she was engorged I suggested hand expression but she ended up pumping
small amounts.  Some clogged ducts noted.  By day 6 she reported latch was
much better and that her nipples were healing.
May 1st (day 10) mom reports baby 'chomping down while nursing'  she had
been using a pacifier up to that point and was convinced it was the kind of
pacifier they were using (the shape of it ) and were trying several other
kinds"  I reminded her that it was more likely the latch and to hold off on
pacifier -period- for now and discussed possibility of oversupply/forceful
letdown which seemed to be at least part of the problem.  I saw her the
next day and latch was painful, improved some with positioning and work on
latch but nipples very tender.
the next day (day 12/May 3) after baby nursing a lot over night (and no
pacifier and no pumping) and stools that were yellow went back to green.  I
encouraged her to nurse one side at a time (modified block nursing) both to
temper down supply a bit and to give nipples a rest.   This helped for a
couple of days until he started cluster feeding and the healing that had
taken place turned to sore nipples again.  With work on latch stools
returned to normal and soreness improved.
5/10/15 (Day 24) mom reports being diagnosed with thrush by pediatrician --
it is unclear as to whether she described symptoms to them or they actually
saw her.  Both mom and baby started on nystatin.
5/12/15 mom spiked a fever of 102 and had already seen family physician who
diagnosed mastitis and prescribed antibiotic and pumping.  I recommended
that instead she should nurse as much as possible and rest a lot(though she
has a 2 year old) We discussed Jack Newman protocol for thrush and also
breast/nipple pain.  She already by that point had prescription for APNO.
We came up with a schedule for antibiotic, probiotic, grapefruit seed
extract (topical) and APNO -- she did not want to do gentian violet.
Day 28 May 14 she reported that the grapefruit seed  extract solution
seemed to be helping
Day 29 May 15 reports that she thinks mastitis is better but thrush/nipple
irritation is really painful especially the 'little bumps on areola'.   Can
nurse about 10 minutes before it becomes too painful. Baby's # of stools
have decreased.  I suggested pumping after feeding and either cup or
carefully bottle feeding expressed milk -- this helped.  I saw them again
on 5/18/15 and nipples are red and tender appearing but appears thrush has
resolved.  Nipples seem to be very irritated. Encouraged her to go back to
expressed milk or APNO only on  breasts.
5/19 still complains of the 'soreness around the edges of areola and
inflamed 'bumps' on the areola.
5/21 able to nurse for periods of time before becoming too sore and having
to give it a rest and pump.  Re-evaluated for other causes of nipple
pain/tenderness.  Denies extreme sensitivity to hot/cold, baby's mouth &
tongue extension and suck do not appear to be problematic.
5/28 pain no better, no worse. Mom asking questions about weaning.
5/29 mom rallied with stronger resolve to 'fix' problem, got new batch of
APNO this time with ibuprofen in the ointment.
6/1 no improvement mom feeling that this has all become too much.  I
encouraged SLOW wean of the pumping that she has been doing in order to
give her more time to acclimate
6/3 since she is only pumping mom has 'healed' and is wondering about
trying to nurse but very apprehensive
6/5 supply is still good (and has been this entire ordeal!) mom gets
plugged ducts if she tries to go more than 6 hours between pumping.  I
encouraged her to continue pumping but she now stated that her nipples are
staying "bruised and purple" from the pump (Ameda) -- this was new news as
she had not reported this before.  Mom tried another style pump (Medela
pump and style advanced) but it was not any more comfortable.  We AGAIN
discussed the possibility of vasospasm.
6/10 Mom is nursing again.  after reading about vasospasm (resources I
provided her) she sent me pics of her nipple pre and post feed (OH the joy
of technology today!!)  There is definitely a color difference -- dark and
purply to pink. But also nipple tissue still looks irritated and fryable.
I am at a loss here as to exactly what this is (or combination of things it
is).  This has been really hard because even though I've done many home
visits and worked on latch I did not personally make the thrush or mastitis
diagnosis.  Mom is very savvy and searches the internet in between
contacting me.  HELP!!



Molly Scarborough McMillion RN, BSN, IBCLC, CCE, CPST
Lactation Consultant, Childbirth Educator
Special Projects Consultant - West Virginia Perinatal Partnership
Right from the Start - Direct Care Coordinator
304.667.4362   www.babylovegbv.com

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