I saw a mom in support group today who has been nursing a 5 week old baby.
She is complaining of a pain that she describes as sharp and shooting, more
so in one breast over the other. She says that the pain occurs when the baby
is feeding, at the beginning and often throughout the feeding. She says that
warm compresses before feeding make it worse. When she pumps, she does not
experience the pain.
I observed the baby, who has a long, flexible tongue that extends well over
the gumline. I watched the baby latch, and after several attempts where mom
removed her (correctly by breaking the seal) when she felt that the latch was
not deep enough, the baby got on well, with a real wide angle between top and
bottom lips. Lips were nicely flanged; I could not see if the tongue was
coming forward well without disrupting the baby. Swallowing was evident, with
an episode about 10 minutes into the feeding where you could see that the MER
had given the baby a big burst of milk, to which the baby pulled off, and
then relatched.
Mom's nipples have intact skin without any visible cracking; you might say
they were a little pink, (but not cherry red) but mom did not feel that they
were reddened unusually when I questioned her. There are no signs of visible
thrush in the baby's mouth, nor on the nipples. No itching of the nipples. No
diaper rash. No vaginal itch nor cheesy discharge noted by the mom. Mom did
have the usual antibiotic IV right after c/section, but baby has not had any
antibiotics. When asked, mom says that occasionally the baby bites down, mom
feels it is in response to a good letdown, but this is only occasional. There
was no nipple blanching after the feeding.
When mom called her doctor's office about the soreness, she was told that she
should be wearing her bra all of the time (she was not) b/c it might be due
to muscle pain. The breast is larger than the baby's head, which is my
guideline for telling moms that they need to give good support to the breast,
with a bra, hand support and maybe a washcloth roll placed "in the crease"
under the breast.
Impressions:
1). Possible ductal thrush, evidenced by the sharp, shooting pains and hx of
antibiotic
However, with no other signs in mom or baby, the doc is not likely to give
her a dose of Diflucan unless I can convince them (any references??)
2). Baby biting due to forceful MER, but would that cause shooting pains?
3). Muscle spasms in the ductal system (but then why would warm compresses
bother this--I would think the response would be elicited more with cold).
We talked about position options as she always holds baby in cradle hold,
leaning forward (she says that when she leans back, the pain is worse). Also
breast support options, using her hand under to support breast along with
nursing bra and the washcloth roll. We talked about watching for s/s further
indicating thrush and considering asking for the Diflucan 150 mg for one dose
to see if it helps (my gut feeling is thrush, but will her docs see it this
way??) We also talked about taking a break if she needed by pumping (rather
than quitting) and that most pain in bf is temporary.
What am I missing???
Thanks,
Kathy Rubin in NJ
IBCLC, RN, BC (Maternal/Infant), APN, C (Family Nurse Practitioner)
PhD student hopng to study lactation issues someday
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