Hello fellow Lactneters,

Permission to post.  I saw a mother of 6 month old twins today (for the first time) who is pumping and feeding her babies milk from a bottle.  She has a full supply for her babies and is committed to providing human milk for them.  Babies were born at 37 weeks but one was IUGR, and she has structural issues (strabismus and is in PT for problems with her arm and shoulder) and has never latched well.  Mom reports bleeding nipples for first 2 weeks, early formula supplementation by bottle, and gradual transition to bottle feeding pumped milk.  The "good" breastfeeder still breastfeeds 2 times at night (at one point 6 times/day).  From about 1-3 months pp, her nipple soreness had resolved and pumping/breastfeeding were comfortable.  

At 3 months, the mother developed mastitis and went on antibiotics (she thinks it was dicloxacillin).  Within 4-5 days she developed very sore inflamed nipples and went to her OB, who diagnosed thrush.  She went on Diflucan (was told to take it only every other day) and her nipples got even more inflamed. She went back to her OB, who told her to take the Diflucan every day and started her on APNO.  This did not help, so the OB said it might be Reynaud's (mom has always had cold hands and toes).  She was prescribed Nifedipine, which did not help the nipple pain and she reports it lowered her supply (rebounded after she discontinued it).  She stopped that and went to a dermatologist, who told her she just has irritated skin and to stop the APNO, and just use steroid cream.  The mother did ask her OB whether it could be a bacterial infection and she said no.  The OB also asked her colleagues their opinion and they had no suggestions.

Starting when her nipple pain began about 3 months ago, the mother reports that her letdown is not the same as it was.  She used to pump for 20 minutes and empty well, and now it takes 30-45 minutes, at a higher suction, and constant massage/compression with her hands to get the milk to come (she's using a Symphony, changing pumps has not improved things).  Flange fit looks good, she is doing everything to the "t", but like she said I observed a very slow letdown, with 10 minutes passing before milk started to flow.  She reports a pain level of 6-7 out of 10 when pumping.  She also reports deep breast pain during and after pumping.  She also attempted breastfeeding with both babies and the better feeder latched for about 1 minute and then refused to latch again. Interestingly, though, she did let down quickly for her baby, as she was swallowing every 1-2 sucks in 30 seconds. The other baby refused to even look at her breasts on either side.  

Upon examination, her nipples are bright pink, and she says she sometimes has satellite flat pink patches dotting her surrounding skin on her breasts. I suspect that this mom has a bacterial infection in her nipples and breast.  Considering the antibiotic she went on was narrow-spectrum, do you think this is possible...that the antibiotic cleared the way for a resistant strain to set up shop?  I also think that the letdown problem is related to the pain.  She reports that she has "numbed" to the pain, which to me says that the sensory pathway for oxytocin response is also dulled.  I think it also might be useful to check her thyroid levels, as milk ejection has been shown to suffer with thyroid disease.  This is a zebra in this situation, though, in my opinion.

I would greatly appreciate any input as to the cause of this poor mother's pain and letdown problems.  Three months is a long time to endure this pain!  And she is sad to be sitting at the pump instead of engaging with/breastfeeding her babies.  I am suggesting osteopathic treatment for her baby with structural issues and we are discussing her long-term breastfeeding goals.  She is heading back to work in a month so getting back to breastfeeding seems futile from her perspective.  I would also like any information you may have about fennel and any evidence that it helps with milk ejection.

Many thanks!
Tanya Powell, IBCLC
SF Bay Area

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