I continue to be seeing the occasional mother with really complex, extremely
painful, entrenched nipple pain. It's important to look at multiple possible
causes, some of which may co-exist. Often it's not all down to thrush, and
only thrush. To use a musical metaphor, it can be an orchestra, not a
violin solo. Some cases, especially where they have cropped up in previous
lactations and never been resolved, can remain mysteries, even if some
factors can be eliminated. If solved, it can take time and some lateral
thinking, too. This may come about by identifying other sites of infection
in the rest of the family, e.g. kids with fungal infections of toe-nails
(and guess who is drying their feet?).
Definitely sending this mother to a dermatologist is a very good idea. One
of the recent journal publications I find very useful when working with
mothers with persistent nipple pain is this, which I think I've cited on
Lactnet before:
Heller MM, et al. Caring for new mothers: diagnosis, management and
treatment of nipple dermatitis in breastfeeding mothers. International
Journal of Dermatology 2012; 51: 1149-1161.
Heller and colleagues look at a good deal more than nipple dermatitis. They
also cover: poor latch, psoriasis, eczema, white bleb, yeast infections
(thrush), bacterial infection, a herpes simplex virus lesion (very dangerous
for babies 0-3 months), Raynaud's phenomenon, and dermatitis. They also
discuss the difficulty of doing cultures. The colour photos are useful.
Indeed, the photo of psoriasis on the nipple and areola was identical to the
photo I took a couple of years ago of a puzzling case involving a mother of
an older baby. This article is well worth adding to one's resource files -
a good desk reference.
With an older baby, think of what changes may have happened as to what else
is going into the child's mouth as a possible cause of contact dermatitis.
For instance, tomatoes or other acidic fruit? A colleagues of mine
identified the (recently begun) use of baby toothpaste to clean the new
teeth, as causing a rash on the mother's nipple/areola area. The baby was
too young to rinse and spit after tooth cleaning.
Virginia
Dr Virginia Thorley, OAM, PhD, IBCLC, FILCA, GD Couns
Honorary Research Fellow
School of History, Philosophy, Religion & Classics
The University of Queensland, QLD 4072
Australia
----- Original Message -----
From: "Alison Keating" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, November 21, 2013 5:35 AM
Subject: Nipple pain
> PTP. A mom nurses first baby for 22 months, no issues, no nipple pain,
> ever. The baby developed a cold with congestion at 22 months, and had
> difficulty nursing. He was treated with motrin and benadryl, both of
> which
> mom states he has had before. No other changes in his diet. At the same
> time, mom developed extremely sore nipples. She lives an hour away but we
> met and I looked at them... angry red and dry, not shiny. Raised, puffy
> plaque of irritation ending almost at the edge of the areola with very
> clear borders... no satellite lesions. Crescent shaped cracks at the base
> of each nipple with yellow crusting. She said this developed almost
> overnight. No radiating pain into the breast, during or between feedings.
> She saw the PA at her OB practice who prescribed Diflucan and an APNO
> ointment with an anti fungal, cortisone, antibacterial, and analgesic
> component. After 2 weeks there was a small improvement and some healing
> of
> the wounds, so the PA continued Diflucan for another week. Mom stated a
> 90%
> improvement in how they felt and the healing of the cracks. As soon as she
> stopped the Diflucan after this additional week, all symptoms returned
> within 24 hours. My thoughts: Get a dermatologist to take a look, since it
> seems confined to the skin and not throughout the breast. Mom made an
> appointment for Monday. Would more Diflucan make a difference? Is there
> something in the baby's diet that is causing an eczema or contact
> dermatitis? Would an oral antibiotic help?
> I would appreciate any thoughts. Thanks!
> Alison Keating RN, BSN, IBCLC, LLL
> --
> Alison Keating
> 3004 2nd Avenue
> Altoona, PA 16602
> 814-946-7061
> 814-934-0466 cell
>
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