>Subject: Help! Breast Pain (very Long)

>Hello all,

>I have a lady that I am working with.  She has had a LOT of breast pain over
>the last 9 - 10 months.  I have seen her, another IBCLC (who is IMO, VERY
>qualified) has seen her, a Chiropracter has seen her and several doctors
>have seen her.  None of us can figure this out.  Please help.  I had her
>give me as complete of a history as she could recall, I have reprinted it
>below, replacing the other LC's name with VP (I did not ask permission to
>use her name on line.)

This sounds to me as if could be a fairly resistant yeast infection that
will need diflucan treatment at least for her and maybe also for her baby.
The pain sounds like yeast related pain and may be present with very little
or no nipple skin changes. Sometimes nystatin and gention violet are not
enough especially with a very long history like this.

I will repost something another physician (Shirley Gross) posted to me
about treating resistant yeast infections in both moms and babies.

Start quote:
"I turn to fluconazole (200 mg loading dose, 100mg po OD for nine days).
For the infant, I have the mother apply the nystatin suspension after every
nursing using a swab to paint the oral mucosa and tongue.  If this fails to
be effective after one week, I turn to fluconazole suspension for 10 days.
I have yet to have a failure from this regimen.

I recently needed to use fluconazole in both a breastfeeding mother and her
baby.  The mother did not respond to topical antifungals and the baby did
not respond to nystatin.  I had to do some estimating and I checked the
numbers with Dr. Tom Hale who has written a text on drugs in lactation.

I wanted to use 100 mg po OD for ten days for the mother and treat the baby
with 3 mg/kg for one week. I wanted to see if I would have to decrease the
infant's dose as the baby was also receiving fluconazole through the breast
milk.

Peak serum concentrations noted for 150 mg stat dose was reported at 6.4
ug/ml.
Using 100 mg, peak serum concentrations should be 2/3 of 6.4 or around 4.2
ug/ml.
Steady state concentrations are 2/3 of peak levels (I think).   2/3 x
4.2ug/ml = 2.8 ug/ml
The average M/P levels reported in Peds Inf D J March 1995 was .8
If the average baby takes in 900 ml of breast milk per day, 900 ml x 2.8
ug/ml x .8 = 2.01 mg per day.

To treat the baby, I needed 3 mg/kg.  This was a 8 kg baby so it appeared
the intake of fluconazole through breastmilk was not very significant. "

End of quote (Thanks Shirley!)

I tried this with one of my patients and had success with treating the
mom's yeast breast pain. The babe still has mouth thrush as mom ran into a
mastitis at the very end of the diflucan and went on a very short
antibiotic course which seemed to immediately bring back the babies yeast.
However mom has not had any further breast pain.

Second point. Is she feeding it any milk expressed and frozen during this
time period? If this is yeast she could be reinfecting the baby feeding it
this milk.

I hope this helps.

Karen Cunningham M.D. C.C.F.P.
London Ontario Canada
Email : [log in to unmask]
(My husbands address)