Hi!  My name is Shirley Phillips.  I have been an active La Leche League
Leader since 1974.  I am an RN, IBCLC (1988) and worked for many years on a
combined care (mother-baby) maternity unit.  In 1994, I took the plunge and
went into independent LC practice and started the Winnipeg Breastfeeding
Clinic.  It's been slow going at times but is continuing to grow.  I have
done a lot of breastfeeding inservice education over the years. Currently, I
am also involved in two research projects; one as co-principal investigator
in three phase research-utilization project looking at the impact of a new
breastfeeding protocol (hospital) on breastfeeding longevity; and the other
as the study coordinator for a province wide infant feeding study focusing
on breastfeeding policies, implementation, and maternal experiences.  I have
been thoroughly enjoying learning on Lactnet since last October (somehow,
"lurking" just isn't the right word for me).  I have particularly
appreciated the commitment to breastfeeding and the sharing of information.
I hope you can help me solve this persistant thrush case.  Mother and the
two LCs (myself and another) are stymied.

To be as brief as possible - healthy term baby born 8 Mar.96, no vag.
infection during preg., no antibiotic Tx postpartum.  No significant Hx
other than long 2nd stage, epidural and forcep del. Saw mom initially, on PP
day 5, for positional sore nipples (started in hosp.) Nipples cracked,
scabbed but healed quickly with management and position changes.  By PP day
11, BFding going very well, baby gained 11oz. since D/C,  2 oz. over birth
weight.  At 2 wks, according to mom, baby very fussy, sliding down on
nipple, curling in bottom lip, taking up to 10 tries before effective latch
on.  Called a breastfeeding hotline, thrush diagnosed - mom Tx with
Mycostatin x4/day, baby's mouth painted with gentian violet x3 days.  Two
days after Tx begun, mom called - back to BFding well with some gassiness.
Mom called when I returned from holidays (Apr. 27,baby now 5 and a half
wks.). Baby had developed diaper rash - Tx with Clotrimaderm, and was now on
Nystatin oral susp. (break of approx. 3 days between gential violet and
Nystatin).  Mom had just switched from Mycostatin to Miconazole on the
nipples before and after feedings. Now c/o burning, darting deep breast
pain.  Started on oral fluconazole.  10 days later, nipples still tender but
no burning breast pain.  Continuing with topical nipple Tx.  Baby still has
patch on tongue and had just restarted Nystatin oral susp. after 5 day break
in Tx.  Mom called MD who started baby on oral fluconazole 15mg/day, one
dose per day.  Again, I was away for a week at a conference.  Mom called
yesterday - baby's diaper rash all cleared but white patch on tongue remains
and appears to be spreading.  Baby has been on oral fluconazole X 9 days.
Mom's nipples still very tender, she can see difference in areola between
those areas in contact and not in contact with baby's mouth.  MD took a swab
of baby's tongue patches on May 8th.  The other LC spoke to Jack Newman and
on his recommendation, mom switched to Kenacomb cream for nipples.  Mom has
not had any break in Tx since Mar. 22 but has used Nystatin, Miconazole and
now Kenacomb. Baby currently weighs 14.5 lbs. and does not suck his fingers
or thumb.  Also not on vitamins.

Between the other LC and myself, over many conversations, we have covered
diet including lactobacillus acidophillus, hygiene, laundry, importance of
no breaks in Tx, etc. etc.  - the whole of Candidiasis - Unit 18 of the LC
Series.  Mom deserves a room full of medals for her persistance but is
understandably FRUSTRATED!  My questions:  would the baby's two breaks in Tx
have caused this to drag on for so long or could we be dealing with a very
persistent strain?  Have there been too many changes in medications?  Is
combination Tx of oral systemic antifungal and topcial oral susp. or gel
ever used in the baby as it may be used in the mother (ie topical to
nipples, oral systemic)?  Should the infant fluconazole be given in divided
doses to the maximum daily amount so that there is more frequent contact
with the oral candida?

Looking forward to all your words of wisdom!  Mom is ready to try anything
to clear this up. You can email me privately or post - I'll be watching the
digests closely.  Many thanks!
Shirley Phillips, RN, IBCLC
Winnipeg Breastfeeding Clinic
Winnipeg, Manitoba