I'd like to ask for some advice for a tough case of painful nipples.  I have permission to post.  First baby of 29 year old mom.  She is a resident at our hospital.  I saw her early for latch issues.  Baby had frenotomy while still in hospital, but continued to have difficulty latching.  He had a somewhat narrow jaw and high arched palate.  After a couple of weeks, they had a really nice week of good latch, good volume and only slight tenderness on the nipples occasionally.  Last week she called me about burning nipple pain that was preventing her from latching the baby on.  He has been taking expressed milk for the past week or so.  She appeared to have some thrush on her nipples, which I treated with gentian violet.  (She apparently has a difficult time when she has yeast infections--even fluconazole doesn't work).   

At any rate, that pain improved and then she developed small painful "vesicles".  These were not visible to me today, though the nipples were still painful--too painful for even the consideration of latching.  She also reports some deep breast pain after pumping.  I did culture her nipple and milk today, but I'm stumped.  Is it eczema?  Could it be bacterial?

I'd appreciate any thoughts.  Thank you!

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