Re: a very challenging case - please advise

April 10, 2008

but again - why from the first latch??

Observation from years of experience: did she have color changes in her nipple/areola during pregnancy? I've found that women who have very pink nipples/areola and who burn, don't tan, and who have difficulty with much breast play during lovemaking (it starts feeling ... noodgy ...) and have tenderness during pregnancy and periods, can have a really tough time with breastfeeding and nipple pain.

It isn't sexual abuse -- it is just like a red-head can't go out in the sun without getting sunburned.

The melanin which is what causes the nipples and areola to get brown also "toughens" up the nipples in preparation for breastfeeding. I've never believed in the "bulls-eye" theory -- as I rarely see a newborn approach the breast with eyes open.

No, you won't find this in the literature. It is my opinion (and I know there are probably 14 red-heads on this list that will tell me their nipples never changed, they always burn, and they never had one iota of discomfort with breastfeeding. To you I say -- God Bless You. Would it be that all your sisters have the same experience.)

Not seeing this mom, I don't know, of course. She could have had lots of nipple changes during pregnancy, tans with the best of them, and adores hours of breast play. But when I read your post, that was my hunch.

Unfortunately, I don't have any good suggestions. Most moms have been able to gut it out -- but this sounds beyond what most of my moms have had.

I'd stop all treatments. I think they are probably making things worse. I suspect the Raynaud like symptoms she is experiencing now is vasospasm brought on by hunching over the baby and breast to try and protect herself when the baby latches because it is so very painful.

This might be one time I might wonder if a nipple shield would help -- or make it worse.

Jan BargerMy blog Year of the MC Planning your summer road trip? Check out AOL Travel Guides.

April 10, 2008

Lyla,Yikes! What a challenge you have!A few thoughts. First of all - it sounds like mom is being treated, but not baby. If there is thrush involved, even if there is no visible yeast in the baby's mouth, both mother and baby need to be treated simultaneously

Also, you mentioned she had the same experience with first baby. Nipple damage and subsequent thrush can be caused by a posterior tongue tie - a congenital condition, often siblings have similar ties. Mom would need to see a specialist (ENT, dental surgeon, etc) who is both an expert on those difficult ties, and also familiar with how the tie can effect breastfeeding.

Vasospasm, thrush, release of suction, poor weight gain, etc, could all indicate a tongue tie. In my experience many ties cause the flattening of the nipple, but sometimes it does not.Take a look at the Coryllos, Genna article on tongue ties, especially look at checklist on

page 3www.aap.org/breastfeeding/8-27%20newsletter.pdfHope this helps. Good luck helping this mom!

greetings!

i have a client for whom we seem to have tried everything.

brief history - " horrible " breastfeeding experience with first baby, damaged nipples, excrutiating pain from first latch, weight loss, and abandonment of breastfeeding early on -(i didn't see her for this baby).

this baby - she came in for a prenatal to try to get everything off to the righ start. no medical history pertinent to breastfeeding problems.

baby born at a watebirth center, my partner saw her within a few hours of the delivery, because it hurt to breastfeed almost immediately.

oral anatomy normal, no indications for cranial sacral, normal birth, normal breasts and nipples, and NO COMPRESSION of the nipple upon nursing. and yet pain. terrible horrible pain.

i saw her a few days later, and her nipples were pink, and she had some yeasty symptoms, so she started candida protocols.

no improvement.

a week or so later she started nifedipene (she had already been taking omega 3s, vitamins, using APNO, etc. etc.

the nifedipine seemed to help a little bit, but she still was writing me several times a week saying she was in terrible pain. the in between pain seemed to fade but hte nursing pain was still ominpresent. the only visable symptom is/was bright pink nipples.

she made an appointment with a derm with whom we've had good success treating hard pain cases. here is what he prescribed/recommended, in her words:

© On Mon. March 18th, saw Dr. Gasch (Dermatology). He diagnosed dermatitis of the nipple and mastitis; in association with dry skin (which was allowing bacteria to enter the nipple through cracks in the skin). He recommended discontinuing the Nifedipine and beginning a new treatment plan: 600mg of Advil every 6-8 hours (to reduce inflammation), washing with CeraVe Hydrating Cleanser, applying Alcortin to the nipple in the AM & PM, and applying Plastabase to the nipple before and after nursing. I began this treatment plan that afternoon.

© For the next week, I continued to take my final week of Nifedipine (since it appeared to be helping – I was hesitant to not finish the dosage) along with following the new regime to treat the dermatitis/mastitis.

© On Wed. March 26th, I took my final dose of my 1-month Nifedipine – while continuing the skin-care regime. During the next week, my nipples began to feel "itchy/scratchy" during feeds and relatively painless between feeds (though still extremely sensitive).

© On Wed. April 2nd, _____ began to "click/smack" on the breast (frequently breaking the suction). I tried to change her position, but she continued this behavior at every feed (and throughout the feed). This continued for about 3 additional days.

© By Thurs. April 3rd, my left breast began to become increasingly sore, with an increasing burning sensation and extreme sensitivity. The pain/sensitivity continued to increase (in the right breast as well) over the next 4 days. During this time, I noticed that the nipples were both continuing to blanch after feedings (bright white to a dark maroon color).

© On Tues. April 8th, I saw Dr. Gasch – as the pain in my left breast was becoming nearly intolerable. He reconfirmed a diagnosis of nipple dermatitis and a possible yeast infection. He prescribed continuing the application of Alcortin to the nipple in the AM & PM, applying Plastabase to the nipple after every feeding, and washing with CeraVe cleanser. He also added to the treatment a 150mg tablet of Fluconazole taken daily for 10 days along with 600mg of Advil daily. If I didn't see improvement in 2 weeks, I cold replace the Advil with Prednisone: two 20 mg tablets taken for three days, then one 20 mg tablet taken for three days, followed by one 10 mg tablet taken for three days. He commented that the "itchy/scratchy' feeling I had experienced the prior week likely a histamine response, but did not suggest an antihistamine at this time. He suggested a follow-up visit in one month, but I scheduled for two weeks out. After the intensity of the pain increased over the afternoon, I decided to start taking the Prednisone immediately in lieu of continuing the Advil. For the remainder of the day and through the night I always started to feed ___on the right breast – as the left beast was too painful to nurse.

I am not sure where things are at right now, but pretty much where they were two days ago, i'd imagine. this is not a mechanical compression issue - there is NO nipple malformation. i honestly do NOT know how to help this lady and would love any advice or feedback or experience.

thanks in advance!

warmly, Lyla

Lyla@...

www.beyondbirthservices.com

-- Levine, Lactation Consultant, BFA, RLC, IBCLCDon't think of it as a mother's right to breastfeed - think of it as a baby's right to eat!http://rachismom.googlepages.com/

April 11, 2008

baby did get probiotics, and i am very familiar with simultaneous treatment - but the diflucan and all the other yeast approaches did not improve the mom's pain AT ALL, which makes it seem very doubtful that it is yeast, or only yeast. baby may have actually had nystatin - i am not remembering now...

i am also very familiar with posterior and submucousal tongue tie - i believe (according to notes from my partner about this mom's previous baby) that the first baby might have had this before we really knew what it was.

this baby, however, definitely has full tongue mobility. AND -mom has NO nipple damage or compression, fine weight gain. trust me - i think i "overdiagnose" tongue tie if anyhting - i seem them around every bend....

her nipples are just bright pink and in pain. and blanching and shooting. yeasty/raynaud's type symptoms, but with inadequate relief from a month of nifedipine. i am going to suggest she do the third course of nifedipine, as jack newman suggests, if needed, but that still doesn't explain the bright pink nipples. and it doesn't explain why the very first latch hurt....

and sue - to answer your question - i need to look at her file about the mastitis - i think she did briefly have mastitis, in between visits with us, and took antibiotics (may be mistaken about that) but i dont' understand the derm's mention of that either - she did n ot report mastitis to me this week....

i was wondering if anyone has ever seen a bacterial infection cause these symptoms with no nipple damange - would culturing of the nipple tissue be worthwhile? perhaps if she did have an antibiotic, it wasn't targeted toward the correct strain of bacteria...

but again - why from the first latch??

Lyla Wolfenstein, B.S., IBCLC, RLCOwner, Lactation Consultant, Parent Educator

Zenana Spa & Wellness Center, LLC and Beyond Birth Lactation Services503.238.mama (6262) or 504.232.baby (2229)mobile fax 503.473-8047 email Lyla@... web www.BeyondBirthServices.com and www.Zenana-Spa.com----- Original Message -----

From: Levine

To:

Sent: Thursday, April 10, 2008 1:24 PM

Subject: [sPAM]Re: a very challenging case - please advise

Lyla,Yikes! What a challenge you have!A few thoughts. First of all - it sounds like mom is being treated, but not baby. If there is thrush involved, even if there is no visible yeast in the baby's mouth, both mother and baby need to be treated simultaneouslyAlso, you mentioned she had the same experience with first baby. Nipple damage and subsequent thrush can be caused by a posterior tongue tie - a congenital condition, often siblings have similar ties. Mom would need to see a specialist (ENT, dental surgeon, etc) who is both an expert on those difficult ties, and also familiar with how the tie can effect breastfeeding.Vasospasm, thrush, release of suction, poor weight gain, etc, could all indicate a tongue tie. In my experience many ties cause the flattening of the nipple, but sometimes it does not.Take a look at the Coryllos, Genna article on tongue ties, especially look at checklist on page 3www.aap.org/breastfeeding/8-27%20newsletter.pdfHope this helps. Good luck helping this mom!

On Thu, Apr 10, 2008 at 11:31 AM, Lyla Wolfenstein <lylawcomcast (DOT) net> wrote:

greetings!

i have a client for whom we seem to have tried everything.

brief history - "horrible" breastfeeding experience with first baby, damaged nipples, excrutiating pain from first latch, weight loss, and abandonment of breastfeeding early on -(i didn't see her for this baby).