a very challenging case - please advise

[Guest guest]

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

[Guest guest]

As requested, here is my first email.

Ghislaine

[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).

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

Lylabeyondbirthservices

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/