Expert: Sally Wendkos Olds - 11/16/2008

Question
QUESTION: Hi,

I have a 3mo/1wk old who has developed a pattern of tugging
at the nipple and sucking vigorously.  It has become
extremely painful to feed her now.  Her weight gain appears
normal and now she will not take the bottle to give me a
reprieve.  She has a constant nursing blister.  My nipples
have become quite stretched, sore, red, and creased.  Is
there anything you can suggest about the breastfeeding,
nipples (whether the damage is permanent), and getting her
on the bottle?

Thanks

ANSWER: Dear Rose,

I apologize for not answering your question sooner -- something got mixed up in the system, either mine or the website's.

Congratulations for giving your daughter the best start in life by breastfeeding her! Especially with the problems you're having now.

When your baby starts to tug, gently take her off the breast and when you put her back on, be sure she is latched on properly. Her nursing blister is not a problem -- one of my daughters developed one and kept it the entire time she was nursing, and then it disappeared when she started to take a bottle. And the soreness on your nipples is almost certainly not permanent.

As far as getting your daughter to take a bottle, you might try giving it to her after she has nursed and is not so hungry. Or try giving it to her when she is half asleep, either when she is just about to wake up or just about to fall asleep. Her sucking reflex may take over and she'll suck the rubber nipple before she knows what she's doing! You may also want to experiment with different types and sizes of nipples. She's still young enough to get used to a bottle.

The best thing for you to do is to consult a lactation consultant who can watch your daughter nursing and prescribe remedies. You can find one in your area by going to www.ilca.org (International Lactation Consultants Organization). It's a good investment.

I am attaching an excerpt from my book (see below) with various suggestions -- I hope that one or more of these can help you.

Good luck!

Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with Laura M. Marks, M.D.
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Dermatologist Donald A. Sharp, M.D., likens cracked nipples to chapped lips. If your lips get dry, you put on a cream to restore their internal moisture and you avoid surface wetness by not licking your lips. The same principle applies to nipples.
  If your nipple cracks, “moist wound healing” can accelerate the healing process, eliminate scab formation, and provide pain relief. It restores internal moisture by increasing the moisture content of the skin. To create the moist healing environment for sore, cracked nipples, apply pure, medical-grade, anhydrous lanolin (Lansinoh), which is soothing and will also lubricate the skin and help it retain its internal moisture. Pure lanolin does not need to be wiped off before feedings because it won’t harm your baby.
  You can also express a little bit of your breast milk and apply it to the affected areas. You will thus be taking advantage of the healing and antibacterial properties of human milk, as well as its moisturizing benefits. And of course, you don’t need to wipe it off your nipple before your baby nurses.
  Even if some blood appears in cracks in your nipple, you can continue to nurse; your blood won’t harm your baby. If you see blood in your baby’s spit-up, don’t be alarmed. The baby is fine – but if you’re bleeding, take immediate measures to heal your nipples.

Treating Sore Nipples
• Be sure your baby is properly positioned for nursing, with her chest facing yours, her face and nose facing your breast, and her mouth covering all or part of your areola, as described in Chapter 6. Be sure that your nipple is well into your baby’s mouth and that her gums are compressing the milk ducts under the areola. If she is not properly positioned, carefully take her off the breast (breaking the suction with your finger in the corner of her mouth) and bring her back to it. If you are in any doubt about your nursing technique, consult a lactation specialist.
• Never let your baby chew on your nipple. If you feel this happening, carefully take him off the breast as above and bring him back. If he keeps doing it, end this feeding session.
• Express a little milk manually before putting your baby to the breast; this will start your milk flowing, help your let-down reflex operate more quickly, and lubricate your nipple.
• Practice a relaxation technique just before nursing (see the box on page tk, Chapter 7).
• Nurse your baby more frequently, but for shorter periods of time. Your breasts are less likely to overfill and your baby is more likely to suckle gently.
• Offer the less sore breast first most of the time. This will give your milk a chance to let down from the sore nipple, and your baby won’t be suckling as hard by the time he gets around to his second course.
• Change your position at each feeding. Lie down, sit up, hold your baby in different positions so that you can change the position of your baby’s jaws on your breast. If you have a crack in your nipple, it’s especially important to position your baby so his mouth clamps down elsewhere.
• If a scab forms on your nipple during early nursing, leave it alone.
• Avoid all irritating and drying substances. Never use soap, alcohol, tincture of benzoin, or witch hazel on your nipples.
• Don’t wipe away milk left on your breast after a nursing. In fact, you can express a few drops of your milk and rub that gently onto your nipples. As we said earlier, mothers around the world treat their children’s irritations and infections with human milk. Your milk’s curative powers can help you, too.
• Soothe the soreness with a cream prescribed by your doctor or with pure lanolin. Lansinoh for Breastfeeding Mothers® can be purchased from your local pharmacy or supermarket, or online. It’s hypoallergenic and thus safe even for people who are allergic to wool, and it does not need to be wiped off before your baby nurses. Be very cautious about using other over-the-counter nipple creams; one widely marketed cream was recently taken off the market after the FDA determined that it had ingredients that could harm babies.
* Wear hydrogel pads inside your bra, and keep them in refrigerator or freezer when not in use. Prices vary considerably for the different brands, as do the amounts of time they can be worn. Popular brands include Ameda ComfortGels, Medela, Soothies Gel Pads, LilyPadz, and Blossumz (see Resource Appendix).
• Ask a lactation consultant about the advisability of wearing an ultrathin silicone breast shield and use it only under her direction.
* If you’re using a breast pump, be careful of excessive suction or vigor. An electric pump is the most nipple-friendly. If your nipple soreness seems related to your pumping sessions, call the pump’s manufacturer for help (see Resource Appendix).
• If only one nipple is sore, breastfeed only on the other side and pump (with an electric pump) from the sore side. If nipples on both breasts are sore, consult with your lactation specialist. You may need to stop nursing completely for a couple of days, during which time you can pump or express your milk. (Using an electric pump is usually less irritating than your baby’s suckling might be.)
• Keep your nipples free of surface wetness:
--If you wear breast pads to catch leaking milk, change them when they get wet. Don’t use the kind with plastic liners.
--Wear an all-cotton bra, not one made of a synthetic fabric. Change it every day.
--If you wear breast shells (milk cups) to bring out inverted nipples, empty them often.
--Walk around the house with your nipples uncovered when you can. If the air in your home is very dry (as in an overheated apartment), use a humidifier or keep a pan of water on the radiator.
--If it’s too painful to have clothing touch your nipples, apply a light coating of lanolin and insert into your bra small mesh tea strainers from the hardware store, from which you have removed the handles; or silicone breast shields (described in Chapter 4).
• If your nipples are tender after showering, apply a coating of lanolin before you take your shower.
* Try seashells. Seashells? Yes, Scandinavian mothers have worn them over their nipples between feedings for thousands of years. If you can’t go beach-combing yourself, you can buy them online. Air-dry your nipple area before you put seashells over your nipples, and boil them between uses. One  mom said, “I liked the notion of having this potent feminine energy from the ocean and the tides at my breasts.”
• Occasionally take a mild pain reliever to ease your discomfort.
• Sore nipples are sometimes caused by thrush, a fungus infection, which may be affecting both you and your baby. See next section.
• If, as happens in rare cases, your soreness continues to worsen until your nipple cracks and bleeds and is absolutely too painful to nurse from, take your baby off the affected nipple for twenty-four to forty-eight hours. Nurse him often on the other breast. If necessary, give him expressed milk or formula. Express or pump your milk from the affected breast every three hours, or every time you would ordinarily be nursing.
  Gradually resume nursing on the breast with the sore nipple, starting twice a day. Continue to pump milk from the sore breast at other feeding times until your nipple is healed enough to work up to the full nursing schedule. Apply pure lanolin to heal the nipple fissures.
• If you have a persistent rash around your nipples that does not clear up, see your own doctor to rule out any underlying problem.  




---------- FOLLOW-UP ----------

QUESTION: Thank you Sally for your response.  It was very helpful.  I
am wondering if my daughter may have Thrush because of the
burning sensation I feel and the creases in my nipples.  I
do not, however, see any signs in her other than her
refusal to take the soother and bottle when she used to.  
If it is Thrush, can I still breastfeed and use the frozen
milk?  Also, how do you deal best with the constant wetness
from leakage.  Confusingly, when I am very full, my
daughter nurses rather calmly.  When I am not so full and I
suspect she is not getting the milk as quickly, she tugs,
fidgets, and pushes on her legs.  This is what confuses me
about what I am dealing with.  I have started Nystatin out
of a precaution until my daughter's culture comes back.  Is
it okay for her ingestion of this and for it to be in the
pumped milk?

Sorry for the several questions.  I am quite desperate
because it is so necessary to feed her and impossible when
she will not take a bottle.  I am trying to see a lactation
consultant but getting an appt is very diffiult as there is
always a delay.

Your help is greatly appreciated.  Rose

ANSWER: Dear Rose,

I'm attaching an excerpt from the next edition of my book (see below) about thrush. I hope it's helpful.

Yes, you can continue to breastfeed and use the frozen milk. And the nystatin should not hurt the baby. On the leakage, I suggest that you wear cotton bras and breast pads (and change both often) and print or dark tops that won't show the leakage. While you're waiting to see the lactation consultant, can you call your pediatrician? She or he may also be helpful.

I hope the following helps a little.

Good luck!

Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.
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Thrush
Thrush, a yeast infection caused by the fungus Candida albicans, loves milk and places where milk goes. It isn’t serious, but it can be very painful. If your baby has it in her mouth, it may hurt her to nurse. If you have it on your nipples, it may hurt you to breastfeed. If one of you has it, you’ll probably pass it to the other.
  To check your baby, look inside her mouth for milky white spots or a coating on her tongue, gums, or on the insides of her cheeks. She may also have a diaper rash. Or she may have no symptoms at all. You may have pink, flaky, crusty, itchy, or burning nipples; a burning pain inside your breasts during or soon after feedings (which signals an infection in the milk ducts), and you may also have a vaginal yeast infection. Thrush sometimes develops after antibiotic treatment in mother or baby; also, women with diabetes are more prone to develop thrush. If you suspect thrush, see the suggestions below.
• Continue to breastfeed, in short, frequent feedings, on the least sore side first. Be sure to break the suction of baby’s mouth before taking her off the breast.
• Call your doctor, who will probably prescribe either nystatin or fluconazole. If you start with nystatin, the baby will get a liquid form for her mouth, and you may get the same formulation for your nipples, which doesn’t have to be wiped off. Or you may get a cream to put on your nipples, which does have to be gently wiped off.  If you started with nystatin but it doesn’t work, you’ll probably get a prescription for fluconazole (Diflucan), which is given orally to both mom and baby.
• Follow the treatment for both of you for two weeks or longer, even though your symptoms may clear up in a couple of days. Some women need to take Diflucan as long as a month or more, in a high dose (higher than for a vaginal yeast infection).
• While your baby’s infection is clearing up, wash your nipples after every nursing in a solution of one teaspoon of baking soda or one tablespoon of vinegar to one cup of boiled warm water. Dry your nipples gently.
• Try probiotics (good bacteria -- see page tk in Chapter 10 for an explanation), like yogurt with active cultures, or supplements of lactobacillus acidophilus, like Culturelle, especially if you have recently taken or are currently taking antibiotics.
* If you’re especially susceptible to this kind of infection because you’re diabetic or have an immune system dysfunction, limit your intake of sugars. Do this in conjunction with the treatment your doctor ordered. Over-the-counter or alternative remedies sometimes do nothing for a yeast infection and can even make it worse. Treat yourself only if you have previously been diagnosed and treated by a professional for a yeast infection, and then only if you’re absolutely certain about your symptoms.
• To prevent reinfection, wash your hands and your baby’s hands often, and dry them with soft paper towels that you discard after one use.
• Don’t give your baby any milk expressed and frozen during the thrush outbreak.
• Thoroughly wash anything that goes into your baby’s mouth. Boil rubber nipples, pacifiers, teethers, and toys for twenty minutes once a day and discard them after a week. Boil breast pump parts. Wash nonboilable toys and breast pump parts thoroughly with warm soapy water. Sterilize bottles after every use.
* After the bout of thrush clears up, buy new nipples, pacifiers, etc.
• Change your nursing pads after each feeding, and wear a clean bra every day.
• If thrush recurs after two courses of treatment, include all family members in the treatment plan. Thrush can be transmitted during sexual relations, and children tandem nursing or sharing toys can pass it to each other.



---------- FOLLOW-UP ----------

QUESTION: Sorry Sally,

Last question.  You said it was ok to give my daughter the
pumped or frozen milk I produce during the Thrush outbreak.  
However, your book said the following:

Which is the advice I should follow?
Thanks.  You've been very helpful.

• Don’t give your baby any milk expressed and frozen during
the thrush outbreak.

Answer
Hi Rose.

Here's the message I received from the expert on thrush I had been trying to reach:

"Giving the milk pumped during a yeast outbreak later, when there isn't an overgrowth, is controversial.  What I generally suggest is not giving that milk feed after feed after feed, but to mix it up with "non yeast" milk.  It kills me to tell a mother to discard her milk."

I agree with the sentiment in this last sentence! Still, check with your doctor.

Regards, Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.