Hi, all: I have recently gotten involved in helping a mother of a
6-week-old who was apparently having a fairly uneventful nursing
experience until she started developing sore nipples and a very fussy baby
about a week ago. I had not worked with her until then. She is a
resident in my program and I had seen her about 2 weeks postpartum at a
reception at which time she said the baby was thriving and she was doing
well. Last week she called me and said that her nipples were sore during
nursing and that the baby tended to pull off or "chew" on her nipples and
was very fussy. Further questioning led to a few relevant facts,
including a C/section, 3 weeks of painful nipples postpartum (purportedly
due to large breasts and "flat nipples" per hospital staff, recent efforts
to pump and introduce bottle and pacifier in anticipation of return to
work this coming week. I suspected thrush and oversupply issues,
recommended that she cut back on pumping and try one-side-per feeding and
to come in to see me for a check on thrush (she said her nipples were
pinkish). When she came in, she had just developed mastitis, her breast
was very red and hot diffusely and she had flu-like symptoms, so I advised
frequent nursing (baby anatomy and latch-on were good), antibiotics (they
got dicloxacillin 500 mg qid from their pcp later that day, and gentian
violet qd. There was improvement initially, with the fever and achiness
resolving and the redness of the breast relieving within a couple of days.
However, on further follow-up there was still a lot of engorgement of the
breast, possibly exacerbated by the mother trying to attend some residency
functions and also missing a couple of doses of the antibiotic. I
re-evaluated her and found that there were a couple of quadrants of the
breast that were still red and warm. There was no mass palpable in
the breast. With "creative positioning" we got the baby to drain the
affected areas, which got soft and less red. Both nipples were sore and
still pinkish, but she had not obtained the gv until the night before I
saw her, so I had her continue that and keep on nursing frequently. At
this point, she said that pumping really didn't work on that breast (she
had been able to get only 1 ml out of the affected breast compared with
3ml from the other side -- the affected breast had previously been the
high producing breast). Of interest, the milk coming out of that breast
was very thick and creamy in appearance, very different from the other
side. After one day of following the recommendations, things actually got
worse, with increased pain in both nipples (both during and after nursing)
and shooting pains into the breasts, as well as a decrease in the
effectiveness of the nursing to drain the breast, with persistent redness
and engorgement. I recommended a culturing of the milk, an ultrasound to
rule out an abscess, and diflucan. The pcp was reluctant to start
diflucan and wanted to empirically switch from diclox to keflex
(cephalexin). She also wanted to wait on the ultrasound until the keflex
was given a chance. The mother, by the way, does not currently have a
fever or achiness.
The reason I am writing (sorry it's been this long), is to ask for
people's experiences with regards to the decrease in the baby's ability to
drain the breast adequately and what other suggestions might be helpful
here. I thought that there might have been a latch on problem all
along but I feel that's been ruled out (although the mother's
current engorgement may be aggravating the situation for the baby)
I've thought about ultrasound treatment but I'm not sure
about doing ultrasound until an abscess has been ruled out. Any and all
suggestions would be greatly appreciated. TIA, Alicia Dermer, MD, IBCLC.
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