I haven't been reading due to time constraints, but I need some help!

Have a first time mom, whose baby is 5 weeks old today.  Baby was born
vaginally, after a long labor and 3 hour second stage at 9 lbs 7 oz.  Mom
did have an epidural, late in labor, and thus lots of IV fluids, but no
other meds.  Baby was born spontaneously.  In the first 2 days, he was a
poor latcher, mostly seemed sleepy and discoordinated.  Later in the first
week, he would latch willingly to the left side, but often refused the right
side.  Mom had nipple pain with the right side almost from the beginning. 
Mom appears to have good anatomy, normal size nipples, not a lot of edema,
etc.  The baby has a slightly recessed chin, but appears to have a normal
palate, and no tongue tie.  He does, however, have an assymetric mouth
opening, with the left side of the gums appearing closer together when he
opens his mouth. 
By the end of the first week, the mom had developed a hole in the skin at
the base of the right nipple - about 3x9 mm.  We used APNO starting a day or
two after the initial crack appeared, and initially it seemed to get better,
but is still present and not improving.
I have had the opportunity to observe this baby at breast several times, as
had a colleague IBCLC.  Both the IBCLC and I were able to get the baby on
deeply with an assynmetric latch and the feeding was then relatively
pain-free.  Mom has not been able to replicate that, though.  She had pain
in the right nipple and breast, severe at latch, and also persisting
throughout the feeding, with occasional sharp stabbing pains in the breast
as well.  The left side was pain free after the first week.  When baby would
refuse the right side she would pump that side instead, and as she makes
plenty of milk, that milk was not given to the baby, but stored.
3 days ago, she called in tears to say that the right breast pain was so bad
that if it couldn't be fixed she would have to wean.  The IBCLC and I
thought that temporarily not nursing the baby on the right might help.  Mom
was to pump only on the right, nurse on the left, and give baby any pumped
milk if he seemed hungry by bottle (her choice, and she was shown paced
bottle feeding.)
Today, she called to report that the right breast was no better with the
temporary stop in breastfeeding, and now the left side is hurting as well,
pain deep in the breast and in the nipple, even thought their is no crack on
the left.  
She has pretty bad asthma and allergies, and uses both a steroid inhaler and
a steroid nasal spray, so yeast is a thought.  I saw baby about a week ago
and didn't notice any thrush then, but mom says on the phone that his tongue
appears whiter now (she has not actually seen thrush before, though and
isn't really sure what to look for.)
With all this, baby has gained weight well (was down to 8 lbs 11 oz at
hospital discharge and up to 10 lbs 13 oz at 4 weeks.)
I am sort of at a loss with this persisent pain and the non-healing crack on
the right breast, and this mom is sort of at the end of her rope.  Any good
ideas?

Jennifer Tieman
Family Physician
Mom to 4, including my nursling Caroline Rose, almost 3!

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