A Short Introduction on Infant Growth
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Many families are worried about breastfeeding successfully and having a baby that flourishes and grows well. It can feel very overwhelming to have a small person so completely dependant on your care ( and breast), and it's common for parents to be concerned about weight gain as a sign of health. New parents often confuse frequent feeding as a sign that the baby is not being fed enough or well. In some instances the baby is simply having a growth spurt, in other situations the baby is truly not getting enough to eat, and the baby needs to be supplemented while breastmilk production is pulled upwards. In this post I’ll be talking about why it is important to be able to tell the difference between a healthy baby and a baby not getting enough milk. I will also provide 8 suggestions to correct the problem if your milk production is low. 
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What is normal weight gain for breastfeeding infants in the first place?
 
The average term infant will take about 10-14 days to get back to birth weight. This can be complicated by excessive weight loss in the first 3 days of life, jaundice ( sleepy nursing) and preterm infant feeding ( more sleepiness). If the baby has lost 10% or more from original birth weight, then it is reasonable that it might take the full 14 days or a few days longer to regain the weight.

After 2 weeks of life my expectation is that the baby should be able to gain 6-7oz (180-210 grams) per week if they have access to a full supply of breastmilk. If your baby is not gaining weight regularly, losing weight in a prolonged fashion ( still losing on day 5, or still under birth weight at 17 days of life) it’s important to figure out why, and correct the issue. Older babies may gain weight a little slower than infants in their first 8 weeks, but they should still be able to stay on their growth curve without falling off of it. 

How to Tell if Your Baby is Gaining Enough Weight

A baby that is gaining weight normally, will stay on their growth curve and grow accordingly. It is also important to watch head circumference as an indication that the baby is healthy and getting enough to eat. Their are percentile for head circumference growth, as well as a separate chart weight. If your baby is gradually dropping weight percentiles and has dropped two weight chart growth curves downwards; it’s time for corrective action. Important to early weight gain tracking is that infants in their first 5-8 weeks should be stooling at least twice a day to indicate that they are eating enough volume of breastmilk. You can’t count weight gain if the baby isn’t stooling appropriately, it might just be a backup of waste material vs real weight changes. A well hydrated infant will have 5-6 wets and 2-3 poops in a 24 hour period, after the age of 5 days old.

How Milk Production Works

Milk production is dependant on the signal to make more, which is effective removal from the breast. Breast emptiness triggers a faster speed of milk production, while staying full over a long period of time slows milk production through the mechanism of the “Off Switch”. The off switch in milk production is called the Feedback Inhibitor of lactation, a small protein that we call FIL for short. Its build up signals a slow down in milk production. This is why pumping after breastfeeding to get very empty helps drive up supply. An emptier breast makes milk faster! The first 5 weeks or so of breastfeeding, the milk is produced in a way that is offset by hormones. Between weeks 5-8 or so, the production of milk is slowly changed over to mechanical milk removal. This means that the baby has to be able to do the work if supply is going to stay up. For women that have oversupply it might be closer to around week 8-12 before they notice a drop in infant weight gain due to tongue tie. 

Why Isn’t the Baby Gaining Weight?

Babies that are failing to gain correctly will often have a structural reason for the issue; meaning possible tongue tie or lip tie. Sometimes tongue tie is assessed for by unknowledgeable healthcare providers and it is missed or dismissed, or a parent is told that the tongue tie is “little” or “unlikely to cause any problems”, and then the baby simply can’t get the milk out and no one can figure out why. Once this occurs, the mother’s body responds to the decreased mechanical milk removal, by making less milk. Milk production is dependant on milk removal. Supply follows the demand at the breast, so if the demand is not effective, supply goes down.

In general, a baby is not gaining weight well if the baby isn’t getting enough calories. Instead of focusing on the real reason some HCP will tell women that their milk is watery, low calorie or some other nonsense. When reviewed, there is little evidence to support such claims, and what can be seen is that a mother’s milk is perfectly made for her baby each time. The quantity that the baby is receiving is the usual issue. 

Slow Weight Gain Without Infant Tongue Tie

If the baby has been assessed by an International Board Certified Lactation Consult already and it has been determined that the baby has normal tongue and lip function, this section is for you. There is evidence that other health conditions in the mother may influence milk production, such as PCOS, breast hypoplasia, breast augmentation, breast surgery, hypothyroid, anemia, low prolactin levels, postpartum hemorrhage, and diabetes. For those with a low supply that refuses to increase despite these tips, please look into visiting a lactation consultant to make a custom plan of action to pull up milk production. You may also need specific lab work to rule out health problems; your LC can help you figure out what is the best choice for you.

What You can Do to Correct Weight Gain

• For many mothers the first step is ensuring that the baby is eating a minimum of 8 times in 24 hours, with the knowledge that many babies who gain weight well eat about 12 times. If you have been sleep training it may be that the baby is not ready if they can’t continue to grow without feeds at night. 
• Start pumping after breastfeeding for about 10-15 minutes, both sides, in order to drive up milk supply. You should see some changes in about 4 days. 
• Reach out to a Lactation Consultant in your area to check your baby for tongue tie or lip tie. You can use a simple google search to find one in your area, or you can reach out to me directly.
• Rent a hospital grade breast pump to help drive up milk production. A regular single user breast pump will not work as good and is meant for an already established supply. This means a hospital grade medela Symphony or an Ameda Platinum, with a pump kit. 
• If you are already using a  breast pump, ask your LC to make sure that your pump fit is correct. Using the wrong flange size can decrease the amount that you remove.
• Use breast compressions while you are actively breastfeeding. This is a gentle breast squeeze where you meet your fingers through the breast in order to move the milk towards the nipple. Make sure you are far away from the areola so you don’t break your baby’s suction. 
• Make sure you are not taking any sudafed, or estrogen based medications. Also, large amounts of peppermint and sage may decrease milk production, be careful about using essential oils with cleary sage or peppermint.
• If you have hypothyroid avoid taking the herb fenugreek because it can alter the conversion of T3 and T4. Many people will report a reduction in supply if that have thyroid issues and take herbal supplements with fenugreek. One key factor is that many mother’s milk teas will have fenugreek, so make sure to read labels! 

Reaching out for Help When Your Baby Isn’t Gaining Weight Right

It’s really hard to have your feelings that something isn’t quite right listened to or validated. Well meaning family may dismiss your worry about your baby as first time mother’s nerves. If you know something isn’t right or you think your healthcare team should be paying more attention, you are probably right. In the field of medicine we are quick to dismiss what we don’t totally understand or agree with. If your baby has not been gaining any weight, or is losing weight its time to start looking for a Lactation Consultant. Before you add in a supplement, please take a moment to really make sure one is needed. Please talk your options over with your Lactation Consultant! If you are not sure how to find one, I wrote another blog post on finding a Lactation Consultant near you that might help you find one! 

Meeting Serena Meyer RN IBCLC for an Appointment
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If you have given some thought about your situation and you live in the San Francisco Bay Area you can reach out to me through my webpage to book an appt: https://www.bayareabreastfeedingsupport.com/contact-me.html

​If your baby is on an extended nursing strike, the Internet can be a disheartening place. There are plenty of stories out there, but longer the strike, the more likely the story is to end with: "Unfortunately, little so-and-so never nursed again."
 
This is not one of those stories. It took 40 days, but in the end, we made it from all bottles to all breastfeeding. It was Serena who coached us through. Without her guidance, I doubt we would have made it.
 
Our strike started on September 15, 2016, when my son was just over 10 months old. I nursed him when he woke up, then gave him his solids for breakfast as usual. Toward the end of the meal, he began crying and pulling at his lower lip, and I saw he'd bitten it slightly. He calmed down quickly, and I thought nothing of it.
 
A few hours later, I went to nurse him. He latched, sucked a few times, then pulled off, upset, and wouldn’t latch again. I pumped a feeding and gave it to him by bottle, then another, and another as he kept refusing to breastfeed. I figured he’d go back to nursing when his lip felt better. By the next day, however, he wouldn’t even try to latch when I offered. I’d always been home with him; the last time I'd pumped more than an occasional feeding had been just after my son was born, before we had tongue and lip ties released. I found myself struggling to keep up. I’d never had much fondness for my electric pump, so I was primarily using my hand pump. I’d offer a breast and then, when he refused, pump that feeding, no matter the time of day (or night). I had no freezer stash; I’d never needed it. I quickly began to worry about maintaining my supply, both to keep him fed and so there would be something for him to come back to.
 
The following day, I took my son to the pediatrician to rule out any medical problems. Nothing. Good news, of course, but it also meant there was no obvious factor causing the strike that we could address. I tried to nurse him to sleep for a nap after the appointment — something he usually liked and sometimes even required — but he wouldn’t latch. I emailed a retired lactation consultant acquaintance, who replied with the words I’d feared: “nursing strike."
 
I went straight to Google to read everything I could find about nursing strikes and how to end them. Most were said to last 2-5 days, maybe a week at the outer limit. We could make it until then, I thought. The following day, I started trying everything I could to get my son to nurse. I held him for a nap and offered as he woke up — no luck. We took a bath together, and I offered there — no luck. I offered after he was drowsy from his pre-bed bottle — no luck. He would snuggle up and happily take a bottle or suck his thumb, but he’d freak out if I so much as moved to offer a breast.
 
I was shocked by how heartbreaking it was for me. I’d recently gone through a sudden divorce, moving cross-country and in with my parents, and the thought of what would quite possibly be my only baby, whom I'd planned to let self-wean, never nursing again was crushing. It felt so final; he was so adamant it freaked me out. I just kept thinking that the last time he’d nursed, I’d probably been browsing Facebook on my phone. I hadn’t even been paying attention. I swore if he’d come back, I’d never use my phone while nursing again. I told myself not to panic for at least a few more days; it was early still.
 
The house I’d recently purchased was ready for us to move in, but I put off the move, afraid that making any major changes might prolong the strike. Instead, over the next days, I kept trying different ideas. I got my son to take one feeding from an open cup in case using a bottle was keeping him on strike, but by the second feeding, he’d had enough and refused. I tried to teach him to drink from a straw for the same reason, but he didn’t catch on. I got him a couple of learner cups, all of which he rejected. I switched to a slow-flow nipple instead of the “age-appropriate” one we’d been using. We did skin-to-skin when we could, but it was hard while sharing a living space with others. One time, he started to latch before pulling away. Another time, he bit rather than latching. He fell asleep with a bottle, and it broke my heart that he was so comfortable with that imposter breast. I rocked him to sleep with the breast nearest his face out. We tried different positions and places to no avail. I called the lactation consultant associated with our pediatrician’s office, but she didn’t have any more ideas.
 
I noticed he seemed to be pigging out on solids, eating way more than he had been even a few days earlier, and I got worried I wasn’t producing enough milk for him. I rented a Medela Symphony and started power pumping. I even managed to get a feeding ahead.
 
I posted in several Facebook groups, including Serena’s, looking for advice. Through one of these groups, a mom with a similarly aged baby who was also on strike contacted me, and we struck (no pun intended) up a kind of friendship, brought together by the strange and stressful situation we found ourselves sharing. It helped immensely having someone to talk to who knew what this felt like.
 
A week into the strike, I noticed something white on the inside of my son’s top lip. It looked a bit like blisters to me. Someone said thrush; someone else suggested hand, foot, & mouth. Back to the pediatrician we went, where we figured out the lip was torn up from the shape of the bottle we’d been using, the friction of teeth against lip against bottle wearing tooth-shaped patches. He didn't seem to be in pain, but the doctor warned I would need to switch to a faster flow bottle soon to avoid things getting worse. I went out and bought another brand of bottle, hoping a different nipple shape would alleviate the problem, and it seemed to help.
 
A couple of days later, my son started letting me express milk into his mouth now and then, which I hoped was a good sign, and occasionally he’d let the very tip of a nipple touch his lip. It didn’t feel like much progress, though. I reached out to local LLLI leaders who, though kind, didn’t have any more ideas for me to try. I knew the people around me were wondering why I didn’t throw in the towel, especially given everything else we were dealing with. But in a way, it was because of all that that I needed to keep going with what I believed was right for us. I needed us to beat this thing.
 
Thirteen days into the strike, I talked to Serena. She had me send a video of me offering to nurse my son and immediately labeled his refusal as behavioral, not caused by pain or discomfort. Though the strike may have started from mouth pain, in the days that followed he had decided not to nurse, that he preferred a bottle. She had a plan, and I was so relieved to feel like I was taking actual steps toward a resolution.
 
Serena had several suggestions right off the bat. She wanted me to focus on increasing my supply so that I was pumping several ounces more than what my son was eating each day. That way, there would be plenty of milk ready and waiting if/when he decided to latch, not to mention a little bit of a freezer stash just in case. We were to switch gradually from our current bottles (Avent Natural) to Dr. Brown’s, starting with a faster flow nipple and moving to progressively slower ones every few feedings until we were using preemie nipples. I stopped offering to nurse. Instead, I gave my son his bottle in nursing position, with the bottle held in my armpit, and gradually worked on having the corresponding breast out during the feeding. As he got more comfortable, I started holding the back of his head as I always had to help him latch, making sure he could see the bottle as I did so to keep him from thinking I was going to make him nurse. Soon enough, he was comfortable taking his bottle like he was breastfeeding, breast out and everything -- though he would look around for the bottle to make sure it was there.
 
It was around this time that I decided to move into the new house. Maintaining the status quo wasn't breaking the strike, so perhaps novelty would. We would have less practical support after the move, but there would be more baby-friendly areas where I could let my son play while I pumped, and with our own space, walking around topless (another common piece of strike advice!) was actually possible (not that it helped in our case).
 
After a few days of “armpit boob,” Serena gave us the ok to try using a nipple shield, which would feel more like a bottle nipple to my son. I tried taking the bottle away mid-feeding and offering a breast with a shield full of expressed milk and a letdown I’d stimulated with a hand pump. He got upset and refused, but I suspected it was more at having his feeding interrupted than about the breast itself. We finished the feeding by bottle. A couple of times he fell asleep with the bottle for a nap, and I’d offer a breast with the shield when he woke up. Both times, he just cried until he found his thumb. I even tried offering once in the middle of the night after I’d rocked him back to sleep, but he didn’t even acknowledge that I was tickling his lip with a nipple shield. He never was a dream feeder, and if he wanted to suck, he’d find his thumb.
 
On day 20, I got my son to latch twice with a full shield. He gave a few sucks each time before pulling away and refusing to try again. The third time I tried, he flat-out refused. Serena reassured me that it was progress and that the process might take weeks. When I asked her to tell me when it was time to be discouraged, she replied: "I am never discouraged because all things are possible."
 
The next day, my son nursed twice, and I was ecstatic. We used the shield, and I had to do breast compressions the whole time, but he nursed! It seemed miraculous. The biggest issue was that he was biting like crazy. He’d go to latch, then clamp down on my nipple for what felt like an eternity before finally relaxing into nursing. Without the shield as a kind of buffer, I’m not sure our efforts would’ve been sustainable. He was biting all kinds of things at the time — furniture, my legs, stuffed animals — so I wondered if maybe he was teething or something. I tried ibuprofen the next day, but it didn’t seem to lessen the biting. We did get a couple more nursing sessions in, with lots more biting. He started opening his mouth to relatch after letting go mid-feeding instead of sucking his thumb, which was a tiny step in the right direction. When he refused to breastfeed, or when my nipples were too sore to try, we’d do a bottle.
 
I started to worry that continuing to let him bite and not unlatching him when he did (since waiting out the bite was the only way to get him nursing) would turn into a habit. After a few days of letting him bite, I started taking him off each time he clamped down. I’d offer an ounce of milk by bottle, then try to latch again. That didn’t work, and I was afraid he'd either develop negative associations with the nipple shield if I kept offering and then removing him or decide biting was a way to get a bottle. We went back to bottles full time. It felt like such a setback, coming on the heels of what has seemed like great progress. I reached out to everyone I could think of about the biting, but no one had ideas beyond teething. I think by this point, most people I knew thought I was well and truly crazy for not having given up by now. But still, I just couldn’t. I knew I wasn’t ready to be done breastfeeding, and I believed my son wasn’t, either.
 
After a few days’ break, I offered a breast without the shield, just to see what would happen. My son started to latch, then bit me. I tried giving half-feeding bottles to take the edge off of his hunger, then offering with a shield. He wasn’t having it. Serena advised us to go back to armpit boob for a day so that he didn’t start rejecting breastfeeding altogether. "Go slower," she said. I was afraid each feeding by bottle would carry us further away from breastfeeding, but Serena's logic made sense.
 
Four weeks into the strike, I had to cancel plans I'd been looking forward to for reasons unrelated to the strike. With that disappointment added to the discouragement of the past few days, I was feeling particularly low. It was a beautiful fall day, unseasonably warm, so I decided to take my son out into the backyard. We sat together on a blanket, looking at birds and leaves and reading books together. It felt like a connection that had been strained during the strike was strengthened. At one point, when I had him on my lap, he turned toward me and almost rooted for a breast. Back inside, we put on some music and danced around our living room together, something he loved. Then I donned the shield and offered…and he latched without biting! It was evening, and my supply was low, so there wasn’t much milk at the ready. He quickly became frustrated and let go. But oh, it was progress.
 
The next day, day 29, my son nursed once in the morning, using the shield but without biting. I was ecstatic. The second feeding, though, he played around and then bit. Serena told me to slow down. She assigned us one week of only trying to nurse for the first feeding of the day, with the shield, and doing the rest by bottle. After five days of successful single morning nursing sessions, Serena let us go up to two nursing sessions a day. At first the second one was iffy, but after a couple of days it became routine.
 
On day 40, after a week of successfully nursing twice a day and doing the rest of the feedings by bottle, Serena bumped us up to four feedings. They went so well the first day that she told me to pull all bottles and see what happened. He kept nursing! That first bedtime nursing in six weeks, he went for a whole hour, like he was reveling in this familiar ritual we’d almost lost. I was reveling, too.
 
He was a different baby — taking his time, playing, stopping to babble or look around — but he was breastfeeding. And it made sense. It had been a month and a half, and he was more like a toddler now at almost a year old than the baby he’d been when the strike began. He now got excited when he saw the hand pump I still used to stimulate letdown, like he used to get excited when he saw a bottle, and the change made me so happy.
 
The road was not completely smooth from then on. At times, it was like he had forgotten how to nurse. He’d latch happily, then lie there for 30 or 40 minutes not really sucking. Several times he bumped his mouth while playing, and I went into complete panic mode, terrified he would go back on strike from the pain. The biting came back sometimes, a hard, long, clamping chomp that he used on breast and toy and furniture alike. I continued to pump, first to decrease the oversupply I’d intentionally built during the strike and then to supplement what he was getting from breastfeeding, as I suspected he continued to struggle. There was a period a few weeks after the strike ended that we were back down to a single breastfeeding session per day; the rest of his feedings he took by straw cup after refusing a breast.
 
Finally, I contacted a local craniosacral therapist about the biting, which I suspected was somehow linked to the ongoing breastfeeding challenges. My son had had problems with face and neck tension that had affected his latch around five months of age, which we’d resolved with the help of a CST where we lived at the time. The new one we saw took one look at my son, tried to do one short exercise with his mouth (which led to him crying and cowering away from her for the remaining 45 minutes of the session), and referred us to a feeding therapist. This, it turned out, was exactly what my son needed. Over the months since, through weekly sessions and daily exercises that we do at home, he has gradually released a huge amount of tension from his jaw and face and developed movement patterns and muscles that allow him to nurse comfortably as well as eat solids and drink from a straw so much more effectively. The difference is staggering; it's easy to see how much wider he can open his mouth and how much better he can manage food as he chews, not to mention the improvement in breastfeeding. I have not pumped since a month into therapy. And according to our therapist, uncovering and working on these issues now will avert food aversions and even speech problems down the road. I don’t believe it was these issues that caused the strike in the first place, but I do believe they made it harder for us to get back on track, especially once the strike was over. They also explain why, months before the strike began, the Baby-Led Weaning approach to introducing solids was a spectacular failure for us.
 
My son is now 16 months old. Our breastfeeding looks different from what it did before the strike, and not just because he's older. We still use a shield; the one time I tried without it, he bit me. He also stopped asking to nurse when the strike began, and he has never started again. I offer five times a day, based on when he wakes up, naps, and goes to bed on a particular day, and that seems to work for us. And nice as that first hour-long bedtime session was, he has since cut back to a more manageable 10-15 minutes most of the time.
 
Oh, and my promise not to use my phone while breastfeeding? Still going strong. Some things are too precious to miss, and it took losing one of them for a time for me to realize that.

Welcome to my Clinical Lactation Support blog. I like to tuck away some of my thoughts and treatments Ideas here.

Mastitis is associated with a fever over 100.4 and a red area on the breast that is very painful. Because of the associated fever keep replacing fluids and supporting immune system health. You can treat a fever with either Ibuprofen or Tylenol safely while breastfeeding.

Start dose of ibuprofen at 800, then once fever is down, can alternate Tylenol and ibuprofen at much lower doses until pain and infection is resolved.

Ibuprofen every 8 hours (400 mg- 800 mg). Good to keep the max dose over 24 hours at or under 3000mg
Tylenol every 4-6 (325 mg-650 mg). Good to keep the max dose over 24 hours at or under 3000mg

If your fever is still high when using one of these, you can take both types of medications at once if needed. Watch your top maximum dose over 24 hours with Tylenol in particular since it is metabolized in the liver. A single dose should not go over 650 every 4-5 hours at the highest. Do not take the ibuprofen on an empty stomach.
 
Please contact your primary healthcare provider if you have a sustained temp over 100.4 it is likely time to add in one of these antibiotics. All are compatable with breastfeeding. 
There is a fantastic evidence based article available that says this: 
Nursing mothersOutpatient treatment
Outpatient options includes the following:

• Dicloxacillin 500 mg PO QID for 10-14 days or
• Cephalexin 500 mg PO QID for 10-14 days or
• Amoxicillin-clavulanate 500 mg PO TID or 875 mg PO BID for 10-14 days

If beta-lactam allergy:

• Clarithromycin 500 mg PO BID for 10-14 days (or see following section)

If suspected community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection:

• Clindamycin 300 mg PO TID for 10-14 days or
• Trimethoprim-sulfamethoxazole 1 DS tablet PO BID for 10-14 days [4] (caution if nursing preterm infant or child with known or suspected glucose-6-phosphate dehydrogenase [G6PD] deficiency) or 
• Doxycycline 100 mg PO BID for 10-14 days (pregnancy Category D and secreted in breast milk; do not use in pregnancy or if breastfeeding)  "

Full Article here: http://emedicine.medscape.com/article/2028354-overview

For a more holistic treatment of mastitis you will want to use vigorous massage prior to breastfeeding with a oil carrier of at least I teaspoon to one drop of essential lavender oil, and a breast poultice of sliced or grated potato placed directly on the breast. Heat the breast before breastfeeding and cool it down afterwards. 

There is good evidence cited here:  http://cid.oxfordjournals.org/content/50/12/1551.full that says treatment with probiotics L. fermentum CECT5716 or L. salivarius CECT5713 will help resolve mastitis.

The key probiotic strains are sold, but not together. I looked for a bottle that had both but I could not find one. http://www.swansonvitamins.com/swanson-ultra-femflora-feminine-probiotic-formula-60-caps and this one: http://www.swansonvitamins.com/swanson-probiotics-dr-stephen-langers-ultimate-16-strain-probioticwith-fos-60-veg-caps
Take both of these each day along with 4800mg of sunflower lecithin to prevent any future blocked ducts.
So lets start with those, add garlic into your diet for immune system support, make sure you are eating enough iron rich foods, and also consider a dilute amount of oil of Oregano. Be sure that you never offer an Essential oil to a baby.

Consider reading over my article on mastitis: http://nativemothering.com/2011/10/what-are-some-of-the-predictors-and-solutions-for-mastitis/

-Serena Meyer RN IBCLC

THE “ALL-PURPOSE NIPPLE OINTMENT” OR APNO

We call our nipple ointment “all purpose” since it contains ingredients that help deal with multiple causes or aggravating factors of sore nipples. Breastfeeding parents with sore nipples don’t have time to try out different treatments that may or may not work, so we have combined various treatments in one ointment. Of course, preventing sore nipples in the first place is the best treatment and adjusting how the baby takes the breast can do more than anything to decrease and eliminate the breastfeeding parent’s nipple soreness. Please note that the “all-purpose nipple ointment” is a stop gap measure only and that the definitive treatment of sore nipples is to help the baby latch on as well as possible.


See these other information sheets: Sore Nipples, Latching and Feeding Management.


THE APNO CONTAINS:

1. Mupirocin 2% ointment. Mupirocin (Bactroban is the trade name) is an antibiotic that is effective against many bacteria, including Staphylococcus aureus including MRSA (methicillin resistantStaphylococcus aureus). Staphylococcus aureus is commonly found growing in abrasions or cracks in the nipples. Mupirocin apparently has some effect against Candida albicans (commonly called “thrush” or “yeast”). Treatment of sore nipples with an antibiotic alone sometimes seems to work, but we feel that the antibiotic works best in combination with the other ingredients discussed below. Although some mupirocin is absorbed from the gut when taken by mouth, it is so quickly metabolized in the body that it is destroyed before blood levels can be measured. Most of it gets stuck to the skin so that very little is taken in by the baby.
2. Betamethasone 0.1% ointment. Betamethasone is a corticosteroid which decreases inflammation. By decreasing the inflammation, the APNO also decreases the pain the breastfeeding parent feels. Most of the betamethasone in the ointment is absorbed into the skin by the parent, so that the baby takes in very little.
3. Miconazole powder to a final concentration of 2%. Miconazole is an antifungal agent, very effective against Candida albicans. Because it is added as a powder, the concentration of miconazole can be increased to 3% or even 4% or decreased to less than 2%. We feel 2% is the best concentration for most situations. Fluconazole powder to 2% may be substituted for miconazole and so can clotrimazole powder to 2%, but I believe that clotrimazole (Canesten) irritates more than the other drugs in the same family. Miconazole cream or gel cannot be substituted for miconazole powder as the compound will usually separate. Where miconazole or any of the above mentioned drugs (fluconazole, clotrimazole) are not easily available as powders, it is better to use only the mupirocin and betamethasone ointments mixed together than add a cream or gel or nystatin ointment for example. By using a powder, the concentration of the other two ingredients is not as decreased as they would be if another ointment were used for the anti-fungal agent (for example, nystatin ointment). Thus, in the above preparation the concentration of the betamethasone becomes 0.05% (due to combination withthe mupirocin) and the mupirocin concentration is decreased to 1%.

Note that nystatin ointment, which we used to use and which decreases the concentration of the other ingredients, is far inferior to miconazole and also tastes bad.


I write the prescription this way.
1. Mupirocin ointment 2%: 15 grams
2. Betamethasone ointment 0.1%: 15 grams
3. To which is added miconazole powder to a concentration of 2% miconazole
Total: about 30 grams combinedApply sparingly after each feeding. Do not wash or wipe off.
NO SUBSTITUTIONS


If possible, it is best to get the prescription filled at a compounding pharmacy. You can find a list of compounding pharmacies by going to http://www.pccarx.com/. Click “Find a compounder” at the top, then add relevant information.


HOW TO USE THE OINTMENT:

1. Apply sparingly after each feeding. “Sparingly” means that the quantity of the ointment used is just enough to make the nipples and areola glossy or shiny.
2. Do not wash it off or wipe it off, even if the baby comes back to the breast earlier than expected.


HOW LONG SHOULD THE OINTMENT BE USED?

Any drug should be used for the shortest period of time necessary and the same is true for our ointment. If the breastfeeding parent still needs the ointment after two or three weeks, or the pain returns after the breastfeeding parent has stopped the ointment, the parent should get “hands on” help again to find out why the ointment is still necessary. The most important step for decreasing nipple pain is still getting the “best latch possible.” Sometimes a tongue tie has not been noticed and is a reason for continued pain.


Some pharmacists have told breastfeeding parents that the steroid in the ointment will cause thinning of the skin if used for too long. While this is a concern with any steroid applied to the skin, we have not seen this happen even when breastfeeding parents have used it for months.


Updated February 2017


The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.


This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!


Questions or concerns?  Email Dr. Jack Newman (read the page carefully, and answer the listed questions).
Make an appointment at the Newman Breastfeeding Clinic.

​

 ​PREVENTION OF SORE NIPPLES: To prevent sore nipples, ensure a large amount of areola enters baby’s mouth! Do not coat a thrush infected nipple with expressed milk for healing- it actually feeds the yeast and makes it worse. A simple rinse will do.
  
PROBIOTICS: You want the fancy “Women’s Health Probiotics” ; the one I like most is call Raw vaginal Care by Garden of Life. These are for the mother to take.

THRUSH: TREATMENT OF Candida Infection NIPPLES will need the care of your OBGYN for APNO ointment for signs of Thrush. Wipe off excess. The following link is a sheet to print out for your Dr.
http://www.breastfeedinginc.ca/content.php?pagename=doc-APNO but if that link is not working you can link my directions for healthcare providers for APNO found on my blog.
This will have dosing directions but typically you apply a shin sheen over the nipple and areola each time after nursing. This means use a ½ pea sized amount and rub your fingers together until it disappears, then use it on your nipples. In this amount it is compatable with breastfeeding.
 
 If the APNO does not resolve the thrush alone:
“Persistant Pain” Academy of Breastfeeding Medicine 2016,
 "Oral fluconazole (200 mg once, then 100 mg daily for 7–10 days) may be used for resistant cases.  Before prescribing fluconazole, review all maternal medications and assess for drug interactions. Do not use fluconazole in combination with domperidone or erythromycin due to concern of prolonged QT intervals.”

Evidence of Pediatric Thrush:
If the Baby has a small amount of light white on the tongue that will not wipe off, Contact the Pediatrician so the infant and the mother get concurrent treatment and do not pass it back and forth. Remember the goal with oral nystatin is to paint the inside of the babies mouth, vs put it alongside one cheek just to be swallowed. Spread it around!

LAUNDRY: when you have thrush will need Grapefruit seed extract and it into your wash to help kill candida on clothes.  Dry on hot, or sun dry. Bleach if you need to. Be aware that anything that touches your breast may hold onto the spores, so separate the towels; you get your own. Boil things that go into your baby’s mouth or steam them in a sterilizer bag (Bottle nipples, chewwies, pacis, pump flanges) I think a steamer bag is easier than boiling everything. Please carefully reconsider the instructions from anyone to apply grapefruit seed extract to your nipple neat- it is a great way to chemically burn your nipple.

NONE OF THAT WORKING? TRY GENTIAN VIOLET PER DR. NEWMAN:

“We believe that gentian violet (combined with “all purpose nipple ointment”, see the information sheet Candida Protocol) is a good treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it often works even when used alone (though we don’t recommend this, see first paragraph), and relief is rapid. It is messy, and will stain clothing (actually, it will usually wash out eventually or may be removed from clothing with rubbing alcohol), but not skin. The baby's lips will turn purple, but the purple will disappear after a few days. Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it. If you are in the US: gentian violet seems to be sold commonly as a 2% solution rather than a 1% solution. This is too strong a concentration and probably accounts for the mouth ulcers that some babies get after being treated with it. The pharmacist should dilute it for you. It’s easy to do on your own: just add an equal amount of water to the gentian violet 2% and you have gentian violet 1%.
 
1. About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment.
2. Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up. Gentian violet is messy.
3. Your baby will be less purple if, before you apply gentian violet, you rub some olive oil into the baby’s cheeks and around his mouth.
4. Dip a clean ear swab (Q-tip) into the gentian violet.
5. Paint one of your nipples and the areola and let dry for a few seconds.
6. Put the baby to the breast. In this way, both the baby's mouth and your nipple are treated.
7. When baby is finished on that side, touch up the gentian violet on the nipple if necessary, place a breast pad over top, and cover up that side.
8. Repeat for the other side
9. If, at the end of the feeding, you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with the ear swab and the gentian violet. In this way, the treatment is finished in one go.
10. A cotton pad can then be used to wipe the excess gentian violet from baby’s face
11. 11. Repeat the treatment each day for at least three or four days t see if it is working and then continue for the rest of the week if it is seen to be working (see the Candida Protocol information sheet for how long to use gentian violet).
12. There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it already has to other antifungal agents. Of course, there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. However, if your pain is virtually gone after three or four days, but not completely, you can use gentian violet a few more days if necessary.
13. All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet, or rinsed in a solution with grapefruit seed extract. Consider stopping artificial nipples. Artificial nipples can interfere with the way the baby latches on and may contribute to your pain.
14. There is no need to treat just because the baby has thrush in his mouth. The reason to treat is the mother's and/or the baby's discomfort. Babies, however, only very occasionally seem to be bothered by thrush.
15. Uncommonly, babies who are treated with gentian violet develop sores in the mouth that may cause them to reject the breast. If this occurs, or if the baby is irritable while nursing, stop the gentian violet immediately, and contact the clinic. The sores clear up within 24 hours and the baby returns to feeding.
16. It is advisable that a mother with a recurring infection take probiotics orally for a few weeks and or grapefruit seed extract orally for at least 2 weeks. In this case, the baby should probably be treated with probiotics as well (see the Candida Protocol information sheet).
 
If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of re-infection should be sought out. The source may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), or from artificial nipples the baby puts in his mouth. See the Candida Protocol information sheet.
 
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.
 
To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.
 
 Gentian Violet, Revised 2009
 Written and Revised by Jack Newman, MD, FRCPC 1995-2005
 Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2009
  
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY context that violates the
WHO International Code on the Marketing of Breastmilk Substitutes (1981)
and subsequent World Health Assembly resolutions.”
 
Here is where to get it: https://www.walgreens.com/store/c/de-la-cruz-gentian-violet-first-aid-antiseptic-liquid/ID=prod1550372-product#        
 
 
The Thrush Plan:

1. Use the APNO
2. Take the probiotics (Garden of Life Raw Vaginal Care)
3. Call Dr  for Nystatin tx for your baby
4. Ask your Dr about whether you are a good candidate for oral Diflucan
5. Use Gentian Violet

 
 
                                                                                                                                      
Serena Meyer, RN, IBCLC, RLC