Enterovirus D68

A couple of months ago, while my husband and I were watching the news, a story came on about a scary new virus in the Midwest that was causing many children to be hospitalized. He turned to me and said "Your phones will be ringing off the hooks about this tomorrow."  He was right of course. Whenever the media widely circulates a story it is hard not to get concerned.

That virus now has been identified at Enterovirus D-68 and it has subsequently spread to most of the country. We do have cases here in California.

Every year, enteroviruses and rhinoviruses cause millions of respiratory illnesses in children. This year, EV-D68 has been one of the most common type of enterovirus identified, leading to increases in illnesses among children. It affects those with asthma most severely. This strain last circulated back in the 1960s so older adults already have some immunity.

Viruses can be frightening. Every year different ones make the rounds and infect millions of people. With most viruses, the majority of the people with the illness have mild or moderate cases, but unfortunately there are a number of people with severe cases. Fatalities do occur. These are the folks of course who make the news. Luckily we have vaccines developed to protect us from some common viruses such as Influenza. Alas there is no current vaccine for this strain of enterovirus. Because most patients with the most common viruses are untested and unreported, it is hard to get a full sense of the accurate numbers.

We likely have seen some cases in the office. We did in fact have a few patients that needed to be admitted with severe cases of wheezing that seemed a bit unusual. Luckily everyone has fully recovered.

In our office when we are suspicious about flu, we often do run the test because with a diagnosis in hand, we can offer a medication like Tamiflu that might shorten and ease the symptoms. Identifying the actual virus would eliminate any uncertainty but testing for this enterovirus would be of limited use; we don't really have anything to offer beyond supportive care.

Testing for the enterovirus has also not been simple. Unless someone was actually in the hospital, the CDC wouldn't run the test. We actually did try to test of few of our sicker children in the office but didn't succeed. Just this week however (October 14^th,) the CDC has started using a new and faster test. This new lab test will allow the CDC to rapidly process the more than 1,000 remaining specimens received since mid-September. As a result, the number of confirmed EV-D68 cases will likely increase substantially in the coming days. These increases will NOT reflect changes in real time or mean that the situation is getting worse.

The CDC expects that, as with other enteroviruses, EV-D68 infections will likely begin to decline by late fall.

The parameters for knowing when to be seen are the same as they are for any virus illness.

Dealing with colds and coughs 

There are some ways that you can be proactive. If your child has a history of wheezing, have a current asthma action plan that you are familiar with. Have unexpired medication on hand.

If you have a very young infant, avoid crowds. Politely ask anyone who has any signs of illness to "Please step away from my baby." Wash hands with soap and water and friction.

Alcohol hand sanitizers are a good start, but enterovirus is not as susceptible to those as it is to soap. Teach your kids a hand washing song that might help encourage them to take a bit longer with it.

Nurse Jen blogs about Keeping Play Dates Safe

A few years ago, my daughter (then 7) declined an invitation to play at her friend's house; a neighbor she had played with many, many times. In fact, they had just spent the day before together. I thought she was being moody, but she dug in her heels and refused to go. What I later found out was the friend had led a game of doctor the day before, complete with physical exams and my daughter as the patient. My daughter did not like it and I was proud of her for standing her ground and not returning the next day (although the true reason why didn't come out until much later.) When I spoke to the mom about the incident she respected my daughter's feelings but I got the sense that being naked was not such a big deal in their household. In fact, she confided that her younger son was often taking his clothes off in public places because he was so used to being naked at home. While my daughter was fine being naked in our home, she was less than pleased about nakedness at someone else's home!

This got me thinking about how we may think we know our friends and neighbors well, but we really don't know the intricacies of how they parent until we are faced with a real life situation....involving our own children.

Providing enough supervision to keep kids safe while also letting them have the chance to make mistakes and grow is one of our many jobs as parents. It's not an easy one. Local non-profit Kidpower offers some advice about setting up safe playdates for our kids, I've forwarded their recent newsletter below.

The fact of the matter is, your parenting style will never be exactly the same as your friends - even your best friend. I was reminded of this just last week when my best friend visited with her three kids. While I refused to allow my kids to ride in their camper van because there were no seatbelts, she refused to let the group of kids out of sight at a small town street festival. We explained to the kids that different families have different rules. I worry about car accidents, she frets about stranger abduction. Hopefully the "It takes a village" mindset will help keep all of our kids safe, I think the advice below is a great start.

From Kidpower (www.kidpower.org)

When setting up playdates with kids who we think will enjoy spending time together, we usually think of logistics such as what time and which house. Assuming that other parents will have the same standards about safety and respect that we do because they are nice people and have great kids is normal. At Kidpower, we call these assumptions: "The Illusion of Safety," because they can lull us into believing that everything is fine - until something suddenly goes wrong.

For each situation, make a realistic assessment of your child's ability to speak up or refuse if someone does something against your safety rules - and to get help if anything makes them uncomfortable. Make sure that your child knows how to reach you or another adult caregiver at all times.

Have a frank conversation with the other parents about your expectations and, before you accept responsibility for their child, insist that they do the same with you. These conversations might be uncomfortable - but, as we teach in Kidpower, your children's safety is more important than anyone's discomfort.

Here are 8 questions to ask yourself and other parents as you are setting up a playdate in someone else's home:

1. What is and is NOT okay with you? Sometimes there can be an issue due to a difference in culture. For example, families with young children might have very different ideas about kids playing naked in the water on a hot day - or seeing each other's private areas.  Sometimes there may be a difference in values - families have very different beliefs about teasing, for example, or what kinds of videos kids are allowed to watch. Sometimes there may be an issue due to a lack of understanding. For example, people who don't have allergies might have a hard time believing that one little bite of something your child is allergic to could cause a problem. Having a clear agreement about what is and is not okay ahead of time can prevent a great deal of unpleasantness.

2. Will my child spend any time around older children or other adults? Visiting children are sometimes harmed by their friend's older siblings, friends of those siblings, or neighbors -  who may tease them or who do something unsafe, such as locking them in the closet, taking them out of the yard without permission, or molesting them.

3. Will you be there and available the whole time? Some people think nothing of leaving their and your kids with someone else for "just a few minutes" while they go to the store - and you want to know who is going to be in charge of your children.

4. Are there places you let children go without you with them? Kids going alone to the park down the street might seem normal to this family - but you want to know and decide yourself if your child is ready to handle this kind of independence and be aware of the potential hazards.

5. Are there guns in your home? If so, what kinds of safeguards do you have so that children do not get hold of them? Too many tragic accidents have happened with kids playing with guns, so we want to be aware of this hazard.

6. Do you supervise all use of smart phones, computers and television so that you know what children are seeing? Letting kids go unsupervised with technology can be as dangerous as leaving them alone in any public area without adequate preparation.

7. Will you be taking the children anywhere? You want to know where your children are, who is with them, how they will get there, and what they are doing.

8. Is there a pool, hot tub or other water feature nearby?During summertime especially, many playdates involve playing in the pool, or even in cooler weather, sometimes a hot tub. Knowing if the children will be in or near a private or open body of water, and how they will be supervised around it, is important in order to avoid tragic accidents. Even children who are good swimmers can get injured or surprised and find themselves in trouble in the water - and therefore need close supervision.

A parent's response to your questions will help you to make the decision about whether or not playdates with this family will be in the best interests of your child.  Finally, check in with your child before and after each playdate to review the safety rules and find out what went well, what didn't, and how can you make things better.

Tech Time/ How much is too much?

See updated post on this topic February 2019

Dr. Schwanke is an avid reader who often sends me copies of articles that catch his eye. The other day, he sent me one about Steve Jobs being a low tech parent. Many of you may have seen it:

http://www.nytimes.com/2014/09/11/fashion/steve-jobs-apple-was-a-low-tech-parent.html?action=click&contentCollection=U.S.&module=MostEmailed&version=Full 

I realize that this is a topic that affects most of us.

There is no disputing that we live in an ever changing world. Those who try to ignore all the technology won't be able to keep up. As much as we may be tempted to wrap the Luddite cloak around our households, is that really fair to our kids?

On the other hand, I want kids outside playing, not inside glued to a screen (for the purpose of this post I am referring to screen time as anything computer, tv or video related.) I want my patients to know what it feels like to turn the pages of a real book, not just to swipe their fingers across an Ipad. I want them to know how to get messy with fingerpaints, not just how to create virtual art. I want them to interact with friends in person, not with avatars online. How can we find a balance?

You are still in charge of how much screen time your child gets.

I think that there is absolute value in getting some. Technology offers a vast array of education and entertainment. We can learn so much from computers. The games are fun. Television has some nice programs. Having some down time while you get something else done and your child is happily engaged can be very helpful. How many of you have been in the position when you want to strangle your partner because they voiced the "no computer or videos for you ALL week!" as a consequence for some errant behavior. Some of you need that down time more than the kids!

The key is figuring out how much is too much. This is a plan that each family should discuss and create. Some families will allow more than others. Your own family should be the only one to make rules that make sense to you, but please, set some sensible limits that apply to all of you. Don't sabotage each other. If you have a partner, figure out the rules that you both feel comfortable with. Make a plan and be consistent. If your kids figure out that the rules are meaningless, you have significantly weakened your credibility.

At my solid foods class when I discuss "safe eating" I tell parents that they need to set a good example. If you shovel food in your mouth and talk with your mouth full, why would your child learn to eat any other way? Put in a small piece of food, chew and swallow. Set the standard.

When it comes to being a role model, technology is no different.

If you are always looking at a screen, if your forms of relaxation are all technology related, consider making some small changes.

My goal is for your child to have a healthy relationship with technology. Learning how to use it at a young age will keep them on the level playing field with others. Let them enjoy their allotment of tech time, but focus on opportunities where they can have just as much fun reading a book, or doing other things that don't have a screen involved. There are so many options:

http://nursejudynvp.blogspot.com/2013/12/the-best-present-is-your-presence.html 

Having a no TV/ no computer environment is not something that I recommend. When your child emerges from that protective bubble, they may feel a bit like Alice in Wonderland. Back in the "olden days" when my kids were young, our screen was simply the TV. They had friends come for play dates who were not allowed any television at home. If I allowed it, the only thing those kids wanted to do was watch tv because it was such a treat for them. They had no balance.

Extra screen time (still with limits) can be a commodity that can be earned for good behavior. But because I don't want it elevated to the most important thing in their lives, I would rather make the rewards that they work towards be special non-tech activities with you.

Make sure you put some child control limits on your device:

http://hintmama.com/2014/07/16/todays-hint-the-iphone-feature-all-parents-should-know-about/ 

There are lots of apps out there, with more being developed all the time. Some can help you make sure that all the sites that your child can access are safe and appropriate, others can help you limit the time allowed.

As your child gets older, it becomes much trickier. It is reasonable for rules to be renegotiated with each age. Have your child be part of the discussion and verbalize understanding of the family rules. Until they are a certain age, many experts agree that all computing should be done in a common room.

  

May the force be with you...this is a tough one. 

Pacifiers - Friend of Foe

There are plenty of differing opinions out there when the subject is pacifiers. My thoughts are as follows. If used with a few common sense rules, a pacifier can be a useful tool, and what parent doesn't need all the tools they can get?

The main benefit is that it satisfies the baby's need to suck. Sure, a finger works, but a pacifier can offer a little peace and free up your hands so you can get something else done while the baby is content. If your baby is fussing and you are fairly certain they are not hungry, a pacifier may help them calm right down. Trust me, if they are looking for milk and you offer a pacifier instead of a meal, they will NOT simply happily suck. I also want to protect mom's tender nipples. It is not so good for a baby to linger on mom's nipple long after the feeding is done just because they are enjoying the sucking. A little extra sucking is fine, of course, but some kids will never sign off.

If I have my way though, I would counsel that you keep the pacifier out of the crib. Certainly it is fine if your baby drifts off to sleep occasionally when they have a pacifier in their mouth, but make it the exception, not the rule. Take it out before you put them in the bed. The cornerstone of my sleep advice is that you let your baby learn to fall asleep without too much assistance from you. Don't PUT them to sleep. Don't SNEAK them into their beds. If they learn that a pacifier is an essential part of their sleep routine, then they are dependant on you to replace it every time it falls out. I have plenty of families who are ruing the fact that they didn't heed that advice. Some of my patients now go to sleep with a dozen pacifiers scattered around the crib in the hopes that they will be able to find one and replace it themselves rather than waking up mom or dad every few hours.

Other disadvantages of a pacifier if you don't set limits is that you could end up with a Maggie Simpson on your hands. For the few of you who may not get that reference, Maggie is a cartoon character who is actively sucking on a pacifier 100% of the time. Pacifiers are also potential germ minefields. It is important to clean them well, especially after any illness. The dishwasher is fine for this.

Pacifiers can also be safety issues if they are worn down. If you have a brand that your baby is attached to, make sure you have several, and throw away any damaged ones immediately.

Typically the oral stage should be ending around 12 months. This is also an age when the mouth is about to go through some major growth changes. Ideally try to lose the pacifier habit well before that.

Dr David Rothman, who was my children's dentist says that he is often  able to guess the brand of the pacifier by the shape of the roof of the mouth. They do have an impact! Some forceful frequent sucking on a pacifier can generate more force than an orthodontic appliance. When I asked him his opinion about which is the least heinous type, he told me the better ones are probably the Playtex natural nurser and the evenflo. He says the worst offenders are the NUK and "orthodontic" type pacifiers.

Dr Claudia Masouredis, another popular local pediatric dentist says that she doesn't have any strong opinions on pacifiers. She admits to having had a daughter who used one and feels they provide comfort to some children, so she is not militant about forbidding their use. She adds that they can cause bite issues if used frequently. These malocclusions may self-correct when the habit stops.

Nurse Charity says that pacifiers can be  linked to early weaning. She prefers that folks use round ones for the least impact. She is fine with limited use.  As she says, "use them for a purpose, don't just shove them in!"

One of Dr Anne's twins enjoyed the pacifier while the other rejected them right off the bat. Every baby is different. She stopped offering the pacifier around 4 months.

My older daughter Lauren loved her pacifier. I don't even know what brand it was. It was pink and plastic and luckily she seems to have survived having that habit without any long term repercussions. She referred to it as her "powell" which was probably the garbled way she would have said "pacifier" if she didn't have it in her mouth. At the time, I didn't know enough to set any pacifier limits and it became clear that if we didn't intervene, this was a habit she was in no hurry to break. When she was older than two, we ultimately made the rule that she could only have it when she was at home and she had to deposit it in a little bowl when we were leaving the house. Eventually we staged an intervention and "gave them away" to a new baby that a friend had just had. She plaintively asked for her powell for about a week before she moved on.

Dr Kaplan sent her little guy's pacifier up to the pacifier fairy by tying it to the end of some helium balloons. "Bye bye pacifier"

Bottom line, if your baby likes it, use a pacifier for occasional sucking needs during the day and for the first year only (but try to get rid of it before 6 months unless it is essential to your peace of mind.) If you follow these guidelines, you shouldn't have to worry about breaking a difficult habit later.

Hepatitis B/Your first vaccination opportunity

Deciding whether or not to vaccinate your child is a decision that some parents struggle with.

It can be hard to find a balanced discussion. The internet is full of one sided rhetoric (both pro vaccine and the anti vaccine factions are guilty of this). Can vaccinations have some side effects? Absolutely. Do they always work? Of course not. That being said, I personally believe that vaccinations save lives and that the benefits overwhelmingly outweigh the concerns.

Our office puts an enormous amount of thought into the vaccination schedule that we follow.

We don't just blindly follow the rules. In past years there were times that we were doing our schedule a little differently than other offices as we tried to minimize the amount of shots during one visit.

When the Pentacel combination vaccine was introduced, our schedule finally shifted around and now we follow the standard immunization recommendations. It appears that Dr. Sears seems comfortable with this vaccine schedule as well; so many of the parents who were trying to spread things around no longer feel the need to do so.

The first immunization that is given to many babies is the Hepatitis B vaccine. There are different forms of Hepatitis. The B strain is mostly contracted through blood exposure or sexual activity.

Hepatitis B is no joke. It is 100 times more contagious than HIV. It can lead to liver cancer and death. In Britain where babies currently do not routinely get the Hep B at birth, the cases of Hepatitis B have doubled in the last decade. The Hepatitis B vaccine was approved in 1981 and has over 30 years of proven safety. It was actually the first cancer preventing vaccine.

In this country, most hospitals will automatically give this within a day or so of birth unless you tell them otherwise. If mom is Hepatitis B positive (It is important to know your Hepatitis B status, check with your OB if you don't) it is essential for the baby to get the protection as soon as possible.

If mom is not a Hepatitis B carrier, then I am perfectly comfortable if you decide to hold off from getting it before you leave the hospital.  The official recommendation is to get that first one over with in the hospital and there is no down side, but if you are feeling overwhelmed with things and want a bit more time before jumping into the immunization program, I have no issues with my patients delaying that hospital dose, but don't delay too long. I would suggest getting started with it at the one month visit if you put off that immediate new-born dose.

Is your young child high risk? Probably not. But before you decide to waive the protection altogether please consider this. Hepatitis B can survive outside of the body for at least several hours.

I know of more than one case in this city where an unsuspecting child found a syringe in a playground. Living in an urban environment means it is not zero risk for exposure. Currently most day-cares and schools require the series before admission so most likely (unless you sign a vaccine waiver) your child will get need to get the Hep B series within the first few years of life.  It is much easier on your child to get this shot added to the rounds of shots that we give that first year of life. A few extra  shots makes no difference to them. Once they are over 18 months they are much more aware of every poke and trust me, you will be glad that you got these over with. Certainly all children should get the Hepatitis B series before they are teenagers, even if you sign a waiver to delay it when they are young. This vaccination is a three part series.

The Hepatitis vaccine seems to be quite safe and I usually do not see any obvious vaccine reaction to it. For more information, the CDC Hepatitis B vaccine information sheet can be viewed at the following link:

http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html 

Infant Acne

 

Infant acne is a very common affliction and one that we get a LOT of calls about. Although the timing can vary, it typically shows up between 3 and 6 weeks of age and is usually gone in a couple of months. Your previously flawless infant is suddenly covered with pimples. This will include whiteheads, pinkish pimples and red, rough patches of skin. The rash can spread beyond just the face and move to areas all over the chest and the head. The situation seems to get aggravated and redder when the baby is warm. The cause of the infant acne is thought to be a combination of maternal hormones and baby sweat glands starting to work

Infant acne drives parents crazy, but usually doesn't bother the baby at all. Of course, not all rashes are infant acne. Little white pimples called milia are also quite common and may be present at birth. Some babies may be sensitive to detergents, soaps or something in a breast feeding mom's diet. As with any rash, if the baby seems bothered by it (they may be rubbing at their face as if they are itchy) if they seem unusually fussy ( probably unrelated, but.....) or the rash seems oozy or crusty, schedule an appointment to have the baby evaluated. Any distinct large pustule should be checked out to make sure it isn't Staph. 

Infant acne loves to show up when the grandparents are about to meet the baby for the first time or you are ready for a photo shoot (this is what Photoshop is made for. My generation wasn't so lucky!)

There is no standard treatment. Simply wash the areas with gentle soap and water. Some folks say that applying breast milk or Calendula cream  directly to the rashy area seems to help calm it down.

While the rash on your baby's face  is very likely infant acne, I understand if you feel the need to check in anyway by sending a photo or giving us a call. Trust me, I get it. In my own case, when my first born Lauren suddenly resembled a teenager with horrible acne, I broke down and made that very first call to the pediatrician.

Nurse Charity blogs about thrush

Breastfeeding and Thrush

or

All that Burns is not Yeast

Summer is here (although in our foggy part of the world, some days it feels like a long cold winter) and this means a plethora of rashes, bug bites, and minor injuries.  For breastfeeding moms of new babies, it means a lot of diaper rashes (both bacterial, and fungal), and *possible* nipple thrush.  Candida albicans loves warm, dark places- like the mouth, the warm folds of skin covered by a diaper, and the damp inside of a supportive bra.  It is a part of our everyday human flora, held to manageable numbers by competing microorganisms; the addition of a bit more moisture, a more alkaline environment, and warmer weather are just the resources yeast has been looking for to begin !world domination! (starting with your nipples).  

Because breastfeeding involves both moms and babies- it is doubly hard to treat.   I will focus on Moms first, (because we tend to put ourselves last).

Step 1:Look for the most obvious culprit of nipple pain- LATCH!

Many books and online articles will leap immediately to yeast as a culprit for burning nipple pain- I mean why not? that stuff is everywhere, and in the warm-up phase, it is easy to treat over the counter with some inexpensive cream.  As a lactation consultant in practice for many years, I have learned the hard way that most pain, burning or otherwise, is usually caused by ~bad latch~.   It is a sad, sad fact that no amount of cream can cover.  So the first stop for any burning pain is a quick trip to a friendly lactation consultant to have a look at the latch.  Many stellar, comfortable, milk transferring, latches change over time, as babies get bigger and bigger, they start looming over the breast, tucking the chin to the chest to nurse, and not getting a wide open mouth- ouch PINCHY!!  

Step 2: Look for bacterial infection-

Yeast is very hard to grow out in culture.  The most comprehensive study of burning pain and relation to nipple thrush actually implicated low level BACTERIAL infection (meaning when we went hunting around- we found a lot more bacterial causes).  Most antifungals will also treat bacterial (not as well, but will kill off some- often enough to let the body put down the uprising).  So If I see a crusty, goopy nipple with "white stuff."  It is usually bacterial in nature, and matching the cause with the treatment means you get a faster, better solution to your nipple pain.

Step 3:  Ok- lets look for yeast-

Fungal infections of the skin (because they are not a mucous membrane) usually do not put out a lot of white stuff.  Mostly what I see is BRIGHT red/pink, and looks tight and shiny.  Sometimes it looks dry and cracked. Unfortunately, many other skin conditions also look like that:  Eczema on the nipples, contact dermatitis from soap,  etc, etc etc.  So forays into yeast treatment are experimental.  Ductal yeast (an infection on the inside of the breast  we cannot even see) usually feels like glass under the skin- very painful latch- feels like tiny cuts with glass shards, and then a very painful burning.

We came, we saw- now we want to conquer!

Try an over the counter antifungal-

Low level yeast, or probable yeast (no one is ever quite sure) can be treated with an over the counter vaginal yeast cream (clotrimazole, miconazole, that little tube of external cream that came with your vaginal yeast suppositories- it all works)  Just put it on in a thin layer after feeding or pumping.  And now I am going to shock you.  *Don't wash it off* before your next nursing.  A little bit of cream will not hurt your baby in the slightest- while the friction, and soap residue from washing your nipples compulsively every feed will definitely give you sore nipples.

Get rid of the warm, moist, alkaline environment-

Leave the nipples open to air as much as possible.  Wear a clean bra everyday, put some vinegar in the rinse water to kill yeasty bits hanging out there in the fabric.  Ditch the disposable breast pads (they have a plastic backing- holding in moisture- and they are very alkaline).  Try cotton ones, or my favorite WOOL (change them 3-4x per day).  If you like the idea of a vinegar rinse, I like a very dilute vinegar and water mix in a spray bottle (one tablespoon of vinegar, white or apple cider to one cup of water). Do not be tempted to make it stronger- too much acidity will cause dryness, burning, and nipple cracks- all signs of yeast.  Sometimes we use coconut oil on the nipples, reputed to be naturally antifungal and definitely supportive to dry looking skin (no one has done the actual research, but it seems like a good theory).  

Check the baby's mouth-

Most white tongue is actually milk tongue not yeast.  Even low level oral candida albicans usually requires no treatment, we just let it go. If your nipples, and breastfeeding start to suffer, however, we often treat the baby as well.  When I first started at Noe Valley Pediatrics, the oral Nystatin worked pretty well for most cases.  We still use it, it requires a trip into the office, so the Docs can have a look at the mouth! Probiotics cant hurt, might help.  For oral thrush, I like a powdered probiotic, ¼ teaspoon, dampen a finger roll it around in the powder, then put the finger in the babies mouth 1 time per day. Pro tip- Can also be dusted on the nipples.

I did everything you told me, now where is my relief?

Sorry Moms- sometimes even if you did all that, we need to do more:-(  Sad Story.  

Oceans of potions-    

All Purpose Nipple Ointment (APNO)- When we are not quite sure, we tend to throw this concoction at it.  It is RX, is expensive (if not covered by your insurance, most current plans DO, but the pharmacy may call you to check)  and needs to be compounded.  The Walgreens near our office stocks the stuff for us (bless them!) but otherwise it needs to be filled at a compounding pharmacy (Like Four-Fifty Sutter downtown, or The Rexall in the Sunset).  It is an antibacterial, an antifungal, and has a corticosteroid.  We also use it for stubborn diaper rashes  on occasion, so some of you have tubes at home.  Directions: Thin layer after each nursing/pumping.  *don't wash it off.* Follow-up if it does not work in 7-10 days, don't just keep using it.  

Gentian violet- It is a purple, dye, clings well in tincture form to skin, STAINS!  This is sold over the counter at the 20th and Mission walgreens in the "latino" section (that is what the Walgreens calls the section- sometimes they will tell you they don't carry it at all- ask for the latino section, and have a look- it is usually there- in spite of what the staff says).  Like many medicines, it can be toxic in large quantities.  In the level we are using it, probably non-harmful.  It does WORK reliably, as it treats both the nipple and the baby!!.  New and improved Directions: Applied one time a day!!  I recommend at night.  Strip down mom and baby.  Put some aquaphor, or cream around, not in the babies mouth to minimize staining.  Open the tincture, put in a clean q-tip, then put that q-tip inside the babies mouth and let them suck on it.  I find trying to paint the white parts is messier than just the q-tip in the mouth.  It coats well, and as a q-tip does not actually hold very much tincture, they will not swallow much of anything (usually just saliva).  Throw that q-tip away, get out a new one, and use it to paint your nipple and areola. (do not double dip the baby q-tip, get your own clean one).  Air dry the nipples.  Now you have two purple nipples, and a purple mouth baby.  The baby will start off looking like a member of Kiss, by the am, they will look like you are a terrible parent, and are feeding your baby purple otter pops.  By the afternoon, they look slightly cyanotic.  Then you will repeat for 5 days THEN STOP.  If there is no improvement in 3 days, please give us a call.  IF it is mostly better but not all clear at the five day mark you can go to 7 days, THEN STOP.  If in doubt, please call us!  Weird sores?  STOP and call (has never happened on my watch, but before my time, there was such a case).

Thanks to our model Shannon for showing off her purple mouth in the photo 

Grapefruit seed extract GSE- (lifted, with permission, from Jack Newman) Use instead of vinegar and water spritz.  Mix very well 5- 10 drops in 30 ml (1 ounce) of water.  Use cotton swab to apply on both nipples and areolas after the feeding. Let dry a few seconds, and then apply "all purpose nipple ointment". If also using Gentian Violet, do not use GSE on that particular feed but use after all other feeds. Use until pain is gone and then wean down slowly over the period of at least a week. If pain is not significantly improving after two to three days, increase the concentration by 5 drops per 30 ml (ounce) of water. Can continue increasing concentration until 25 drops/ 30 ml of water.

Diflucan- This is for Mom for ductal yeast, (after we have ruled out other more rare causes like Raynauds, and bad latch).  We prefer you go through your PCP or OB/GYN. The dosage is listed here because some HCP use the one time vaginal yeast protocol (which does not work) Diflucan (generic is just fine) 400mg loading dose on day 1, then 200 mg day 2-day 14 until you are PAIN FREE, can be repeated. We sometimes use this in conjunction with gentian violet or nystatin for the baby.  

For those moms who are yeasty people

Sometimes women with stubborn yeast are just really, really good yeast growers.  They tend to get oral thrush, and vaginal thrush at the drop of a hat, or with any antibiotics.  You know who you are.  I am one of this group; It really, really sucks.  For these folks, we go heavy hitting early (gentian violet, and APNO and diflucan) and we also recommend some stuff to cut down on yeast in your home environment.  It is labor intensive, so not every mom with a yeast problem needs to do these things!  Use your towel once, and only once.  Wear a new nightgown or pajamas, sleep bra etc every night, change your sheets every 5 days. Add vinegar to every rinse of your laundry.  Cut down on simple carbohydrates, and sugars.  

So that's it!

THRUSH, may you never have to do battle,

but if you do-  Go prepared! 

Update 2023..The world health organization does not list gentian violet on their approved list of treatments.