Hi, all: I have recently gotten involved in helping a mother of a 6-week-old who was apparently having a fairly uneventful nursing experience until she started developing sore nipples and a very fussy baby about a week ago. I had not worked with her until then. She is a resident in my program and I had seen her about 2 weeks postpartum at a reception at which time she said the baby was thriving and she was doing well. Last week she called me and said that her nipples were sore during nursing and that the baby tended to pull off or "chew" on her nipples and was very fussy. Further questioning led to a few relevant facts, including a C/section, 3 weeks of painful nipples postpartum (purportedly due to large breasts and "flat nipples" per hospital staff, recent efforts to pump and introduce bottle and pacifier in anticipation of return to work this coming week. I suspected thrush and oversupply issues, recommended that she cut back on pumping and try one-side-per feeding and to come in to see me for a check on thrush (she said her nipples were pinkish). When she came in, she had just developed mastitis, her breast was very red and hot diffusely and she had flu-like symptoms, so I advised frequent nursing (baby anatomy and latch-on were good), antibiotics (they got dicloxacillin 500 mg qid from their pcp later that day, and gentian violet qd. There was improvement initially, with the fever and achiness resolving and the redness of the breast relieving within a couple of days. However, on further follow-up there was still a lot of engorgement of the breast, possibly exacerbated by the mother trying to attend some residency functions and also missing a couple of doses of the antibiotic. I re-evaluated her and found that there were a couple of quadrants of the breast that were still red and warm. There was no mass palpable in the breast. With "creative positioning" we got the baby to drain the affected areas, which got soft and less red. Both nipples were sore and still pinkish, but she had not obtained the gv until the night before I saw her, so I had her continue that and keep on nursing frequently. At this point, she said that pumping really didn't work on that breast (she had been able to get only 1 ml out of the affected breast compared with 3ml from the other side -- the affected breast had previously been the high producing breast). Of interest, the milk coming out of that breast was very thick and creamy in appearance, very different from the other side. After one day of following the recommendations, things actually got worse, with increased pain in both nipples (both during and after nursing) and shooting pains into the breasts, as well as a decrease in the effectiveness of the nursing to drain the breast, with persistent redness and engorgement. I recommended a culturing of the milk, an ultrasound to rule out an abscess, and diflucan. The pcp was reluctant to start diflucan and wanted to empirically switch from diclox to keflex (cephalexin). She also wanted to wait on the ultrasound until the keflex was given a chance. The mother, by the way, does not currently have a fever or achiness. The reason I am writing (sorry it's been this long), is to ask for people's experiences with regards to the decrease in the baby's ability to drain the breast adequately and what other suggestions might be helpful here. I thought that there might have been a latch on problem all along but I feel that's been ruled out (although the mother's current engorgement may be aggravating the situation for the baby) I've thought about ultrasound treatment but I'm not sure about doing ultrasound until an abscess has been ruled out. Any and all suggestions would be greatly appreciated. TIA, Alicia Dermer, MD, IBCLC. *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html