Dear Lactnet colleagues, HELP!!!!  I am stumped.  Following is a case
history as complete as I know.  If you need additional info, let me know.

Infant girl 7#4oz at birth.  Vaginal birth at home with midwife.  No
medications.  Low heart tones detected during labor, all was well at birth.
Baby placed on abdomen.  First feed was uncomfortable, felt as though baby
was "biting".  Began using Lansinoh liberally at 24h.  Saw OB at 1 week for
severe blistering of nipples.  OB Dx breast infection, prescribed
dicloxicillin x 10 days.  Twelve days later, a second round of
dicloxicillin.  Mom began taking acidophilus at 3 weeks.  At 3 weeks saw
another LC (who has a reputation for making anything that breathes suck
right). LC Dx poor latch on, gave positioning tips, recommended OB prescribe
7 more days of dicloxicillin.  Two days after LC visit, mom took baby off of
breast because it was too sore too feed.  Mother had surgery in 1987 to
reconstruct and inverted nipple on R breast, reports that half of the ducts
were cut in the surgery.  Decided to pump L breast to feed baby and dry up R
breast because she felt it would continue to have infections.  Contacted me
by phone 9/5/95, baby was 5 weeks.  Mother described nipples as having open
wounds, and not healing after baby was off breast x 2 weeks.  I suggested
she see a dermatologist.  Mother has a Hx of sensitivity to wool, I
suggested she stop using the Lansinoh.
Dermatologist Dx Staphylococcus aurilius, Rx erythromycin x 10 days.  Second
culture came back with klebsilla pneumoniae, Rx septra x 10 days.
Dermatologist recommended weaning infant because bacteria could be dangerous
to infant.  Day 6 of septra mother began having hives as an allergic
reaction to septra.  Mother is nearly indigent and could not afford another
office call to dermatologist.  Called our ACCCHS (public health care) office
who assigned her to a family practice physician.  Dermatologist refused to
release records.  Family Practice doc Rx Keflex x 7 days.  Saw 1st LC again
a couple of days later when nipples appeared nearly healed.  LC used a
nipple shield to help baby back to breast, one feed with nipple shield
caused severe blistering.  Mother discontinued nipple shields immediately.
Family practice doc recultured nipple, Rx ampicillin.  Mother did not take.
Culture came back with enterococus.  Fam practice doc gave 1g Rocephin
(ceftriaxone) by injection on Tuesday and again Thursday.  Mother put back
on R breast Tuesday using SNS and pumped milk.  When R breast began to
blister mother used 1/2 hydrogen peroxide 1/2 water solution on nipples
after nursing which she felt helped.  I saw the mother for the first time
last Monday.  Baby is now 12#.  Nipples have a yellow, oozy, crust.  Baby
latches well onto breast but slides down to tip q 15 - 30 sec.  Oral cavity
seems normal on digital examination, tongue can extend well beyond lips,
tongue motion waves normally most of the time with occasional disorganized
sucks.  Suggested she use counter pressure against baby's chin to keep baby
from sliding down nipple.  It seems to work if baby is not extremely hungry
or fussy, if baby is not cooperative, counter pressure does not work.
A couple of other things, mom perspires profusely during breastfeeding as
well as other times.  Mother indicates baby's father is last possible
exposure to HIV.  HIV test in March was negative.  Reports that since
Thursday, milk is smelling like grass.  Mother asked family practice doc if
it was baby infecting her or poor sucking causing the sore nipples, he
replied for the next baby she will have to toughen her nipples by rubbing
them with rough cloths since babies suck really hard.
Where do I go from here?  I am wondering about culturing the baby to see if
she is passing these germs to mom.  What about a referral to a speech
therapist?  Any other ideas?  Very frankly, with all of the problems this
mom has had, if she were my kid, I think I would have weaned by now!  As
long as this mom wants to try, I want to help her.  Any ideas you could send
me would be appreciated.  She has a follow up with the Family practice doc
tomorrow.

Thanks in Advance,


Linda Pohl, IBCLC
Phoenix, Arizona USA
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