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Subject:
From:
Camilla Aviss <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Thu, 4 Nov 2010 23:29:01 -0400
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Hello,

I'm turning to you all for some clarification, ideas, questions, etc. 

A client was just referred to me after seeing many, many IBCLC's over the past 4 1/2 months with severe nipple trauma, tissue breakdown. I have her permission to post. It's a very long post, but I'm hoping that with all the details some of you can confirm what I'm leaning towards or point me in a new direction.

Some History:
1st baby, born at 41 weeks via c/s due to outbreak of vaginal herpes lesions (appears to be herpes simplex virus 1, not 2 but not confirmed, swab was lost by lab!) Mom has history cold sores on mouth prior to pregnancy, but never had vaginal outbreak until just before delivery. Midwife referred to OB/GYN who confirmed he thought it was herpes based upon appearance and c/s was scheduled. Swab taken at time and lost, so cannot confirm. Client stated it took approx. 3-4 weeks for all the lesions to heal, disappear. Otherwise no other health concerns during pregnancy, mom has no other significant health history. 
Has had sore, cracked nipples from very beginning. Told baby was tongue tied and frenectomy was performed, subsequently at 7 weeks postpartum developed mastitis and treated with antibiotics (client could not recall name of antibiotic prescribed), then following this received treatment for Candida for the ongoing nipple pain. Has also been told she has vasospasm, although I saw no visual signs of this when I examined her. She has been using Dr. Jack Newman's APNO recipe for over 4 months with little effect, has done gentian violet, grapefruit seed extract, omega 3 fish oil, probiotics. She also has been using mepilex (a type of hydrogel dressing is the best way I can describe it) for months and has spent over $600 buying this and cutting it into squares (with her regular unsterile scissors) and putting it over her nipples to "help heal them". She did quit nursing for one month because she "couldn't take the pain any longer" but when I ask her if it helped her heal, she said "a little, not much". She decided to try and put the baby back to breast again and luckily he did so with no hesitation. 

Basically if it has been suggested to this mom she has tried it. 

When I met with her the other day for the first time, it was because she was told the lingual frenulum had reattached (which it had based on my exam) and the labial frenulum was "tight" and should have been clipped as well. 
When I examined her breasts/nipples she had very, very deep nipple fissures on both nipple faces basically right down to the dermal layer with some serous drainage.

Baby is thriving as mom has an ++abundant supply, which I think may be one of the reasons baby is still clamping down and "chewing" to cope with her OAL. Postural tips, herbals for slowly decreasing supply have been discussed/suggested. 
Basic deep asymmetrical latching techniques have been shown, but even so baby is still chewing and still seems to slip right back up. Baby did undergo another lingual & labial frenetomy was done as well earlier this week, post frenectomy oral exercises are being done several times/daily with baby. Cranial Sacral Therapy would perhaps help, but I cannot find anyone in my area with this area of expertise. 

I suggested to mom that she HAD to see her MD to get nipple swabs & EBM samples done for C&S, which she did do, and to discontinue using the mepilex dressings and just use sterile 2x2's. 

She received her results yesterday: Breast Milk & Nipple swabs showed a moderate growth of Staphylococcus epidermidis, Rare Gram Positive Cocci

Doctor did prescribe 30g of Fucidin Cream (Fusidic acid cream 2%) topical antibiotic which she said she was applying and wiping off before feeds. Today she said it was causing burning and had to discontinue it. Doctor didn't prescribe anything else and told her to wait to see a dermatologist. (Can't see her waiting, who could blame her?)

From what I can tell looking on-line, in journals etc. it appears that Staphyrococcus epidermidis infections are becoming one of those resistant organisms like MRSA and difficult to treat when it causes an infection. (Tell me if I understand it wrong please)

Any suggestions for what medications would work best to treat this? She has started to pump and feed a few times today with a bottle because the pain is so severe.

Thank you in advance for any help/suggestions!
Camilla Aviss RN,BHSc(N),CCCE,IBCLC
www.multiplereasons.com

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