I would be grateful for any suggestions on what to try with this mother.  Her second baby is just over a month old, a 4 kg boy born at term, feeds well at the breast and has done so pretty much since birth.  First baby was weaned to bottle by 14 days because of problems with attachment (and a grandmother whose support was misplaced, to put it politely).  This was such a source of grief to mother that she contacted me at 20 weeks gestation to discuss her need for help to be available when #2 was born.  I met her just post-weaning last time and she was not open to relactation, though with aftersight I feel I should have pressed her just a little.  Bf started naturally, initiated by baby, this time, and during her hospital stay no intervention was needed.
The problem: her nipples are on the large side and normally inverted at rest.  She developed what looked like open sores in the inverted part, most pronounced on one side, after less than a week, but had little or no discomfort and so we decided to wait it out.  Positioning and technique appeared correct, baby is thriving and mother was so pleased that bf was working that we didn't want to overemphasize what seemed to be a trivial problem that might well solve itself.  Well, it didn't.  She got an acute mastitis on that side after 10 days which was treated with antibiotics, can't recall which drug but bf continued throughout and the symptoms cleared.  (She didn't contact me until two days into the treatment, which was prescribed less than 6 hours after onset of fever, tenderness, swelling, redness and systemic aching.)  The sore on her left side is no better now than it was at the start, but now attachment is very uncomfortable, pain subsides while baby is drinking for the first 5 minutes or so, and then gradually increases again until she switches sides because of the pain.  She just  phoned me, she is very reluctant to "impose", and I am not able to see her until Wednesday, but she says the sores appear as they did the first few days, which was like hamburger in what I can only call the craters at her nipples that appear right after feedings (I couldn't believe she had so little discomfort then!).

She perceives the problem as follows: "I think my breasts aren't as open as most women's.  They are like flowers in the bud, and after I feed him, the flowers are forced open, but they don't stay that way."  In the meantime, she has tried air-drying, limpet shells (a traditional remedy which provides a dome of protection over the sore area, prevents nipple edema and promotes moist healing, not well documented but received with enthusiasm by most mothers here who try them) and something known here as Peru Balm, a plant extract which looks like tar, smells a little like podophyllin when applied and dries like varnish on the damaged skin, giving an intact membrane on the sore area.  None of these things have helped (these are suggestions she has gotten from a number of other people who were around while I was away on vacation).  Expressing milk by pump causes the same discomfort as feeding.  Besides, both pumping and manual expression raise the question of how to get milk into baby.  I should add that she is alone all day with baby and first child who is now 15 months old-- not the ideal situation for feeding systems which take time to use and clean, and she is wary of giving him milk by bottle after bad experience last time.

I am thinking this could be a bacterial infection which is taking advantage of mechanical tissue trauma to really take hold, it could be thrush, and it could be mechanical.  Any ideas?  Anyone seen anything like this?

Rachel Myr

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