G6P2 woman with history of severe asthma. 5 days postpartum she developed shooting breast pain with nursing. She complained that she was having breast pain on day 5 and was told that it was, “NORMAL”. Over the next two days not only did the breast pain worsen but it became accompanied by the development of nipple scabs and bloody milk. Postpartum day 8 Mom stops nursing due to pain that even Vicodan does not control. Not surprisingly, she developed 101 degree fever and bilateral breast redness and induration overnight. She presented Monday afternoon; ready to give up nursing her baby girl.
Below is her treatment plan and course.
She was immediately given a shot of Toradol 60 mg IM. 30 minutes later baby was placed on the breast to nurse to prevent breast abscess, decrease engorgement pain and to hasten recovery. Baby observed nursing well with lots of swallowing. Latch-on adequate.
Mom instructed to take Vicodan ES and alternate with Motrin 800 mg around the clock.
Diflucan 400 mg stat and then 200 mg daily for at least 2 weeks was prescribed for DUCTAL THRUSH.
EES 333 mg PO tid for 10 days was given for the bilateral mastitis (Mom is PCN allergic with respiratory distress).
Mycolog II ointment was given for application to nipples post nursing to control pain and treat nipple thrush.
Pure lanolin prior to nursing to protect scab formation.
Symptomatic treatment and comfort measures encouraged to promote healing and to help with breast and nipple pain. These included recommendations such as; applying heat, massaging breasts, warm showers, keeping nipples open to air, and the use of breast shells. Encouraged frequent nursing.
Infant diagnosed with thrush. Mom given choice of treatment gentian violet, Diflucan or oral Nystatin. Mom chose oral Nystatin. Both to take acidophilus tabs. Mother informed about the infant benefits of breastfeeding specifically the research showing less asthma in breastfed infants.
Mom called two days later frantic because her supply had dropped dramatically. Minimal swallowing heard and baby crying post feeds. The breast pain and redness had improved. Mom instructed to obtain a hospital grade pump and to start rebuilding milk supply. Feed baby at breast then supplement post nursing as needed. Pump bilateral for 5-25 minutes at least 8 times a day after or in between breastfeeding. Encouraged lots of skin to skin contact and rest; feed baby expressed breastmilk along with adequate amounts of formula. Replace formula with breastmilk as supply increases. To assist the relactation process, Mom started on Reglan 10 mg tid, Fenugreek 2 capsules tid and Blessed Thistle 2 capsules tid. Mom's morale was low, so the physician was asked to call Mom to validate the importance of her efforts and to bolster her spirits. (It was extremely effective.)
One week later Mom was pumping up to 12 oz in a 24 hour period in between feedings. Baby is gaining weight well. Continued weight checks. Mastitis resolved. Still some ductal thrush symptoms, Mom to continue Diflucan for one more week. Pain was in control. Discontinued Mycolog II ointment. Will attempt to wean off Reglan when full supply established. Mom was pleased with her progress.
10 days later Mother had extra milk and was no longer using formula. Mom was encouraged to give extra milk to the infant’s sibling who was not yet two, so that he may also share in the benefits of breastfeeding. (She was unable to breastfeed him.) At this time, Mom expressed her gratitude for my help.
Mom was planning on ceasing nursing when returning to part-work because she works irregular shifts and she could not count on management to give her a routine break. A work note was written stating that she must be given a break every 4 hours. If this fails, she made aware she could opt to be placed on four hour days. What she opted to do was to change jobs within the company. She now has a very supportive boss, who’s wife is still nursing their two year old.
Unfortunately, once she stopped her Diflucan the ductal thrush reoccurred and she and the infant needed a total of about 6 weeks treatment.
This woman overcame other adversities during her breastfeeding relationship with this child. They included a hospitalization with severe asthma and nurses who wouldn’t bring her a pump until the physician went out and spoke to them. She was on high dose steroids but was reassured by the physician that it would only make her baby “chubbier”.
In addition, she initially pumped at work in a public toilet stall, plugging her pump in over a sink. Moreover, twice the infant went on a nursing strike/breast refusal. Lastly, she was unable to maintain a milk supply without the Reglan and took it for at least a year.
The infant self-weaned a 13 months.
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