Mastitis

Contents:

Best article on breast abscess: at breastfeeding.asn.au

Another account of breast abscess is here on Kelly Mom

I spent most of November 2001 in hospitals with my 6 week old baby. By the end of it I discovered that it could have been averted. So this page is here just in case someone else could be spared the anguish of being sick and helpless while trying to care for a baby in a busy hospital. Also to show that you can continue to breast feed even with a breast abscess the size of a cricket ball.

It must be said that most cases of Mastitis do clear up with minimal treatment. Also, I am not a doctor, or any sort of medico. My training is in Electrical Engineering. This information comes from experience and as far as I know it is accurate. If you have any comments I can be reached at veronica@brandt.id.au.

Blocked Ducts

It all started with blocked milk ducts. Milk ducts are the little passage ways from the glands that secrete milk to the nipple. If they get blocked then the milk banks up behind the blockage and gets thicker. This makes it harder to unblock, but not impossible.

You can spot a blocked duct by feel. Its a lump somewhere in the breast, sometimes right on the edge of the breast, sometimes up near the arm pit. Sometimes the skin over it looks a bit red. Sometimes it gets sore.

To unblock a duct there quite a few things to try.

  1. Feed the baby with the baby's chin pointing towards the blockage.
  2. Start each feed on the affected breast so the baby sucks more strongly at the blockage. It might stimulate your milk supply more on that side, but you can balance it back out once the lump is gone.
  3. Massage the lump gently before and during feeding.
  4. Use hot packs to warm the lump before a feed.
  5. Use cold packs or cabbage leaves after a feed to slow the production of milk.
  6. Express off any excess milk after a feed, either by hand or with a breast pump. NOTE: the baby is the best breast pump, now is not the time to stop breast feeding. You could try expressing before a feed so the pump takes of the loose milk and the baby is left with the stubborn milk.
  7. Become a healthy eater. Lot's of fruit and vegies. Plenty of water. Build up your immune system with Vitamin C. A glass of water at each feed is good, especially if there's someone who'll get it for you.
  8. Try Lecithin supplements, start about 6 weeks before the baby's due. You can get tablets to swallow or granules to sprinkle on your muesli. This has been discredited, but maybe has a placebo effect.
  9. Keep clean. Wash your hands with soap and water before feeding and all those other times you're supposed to wash. It might not help unblock the duct but it will help prevent mastitis.
It's worth contacting a lactation consultant if lumps are being persistent. They are trained in attaching the baby in different positions to help move the milk along.

Mastitis

Mastitis is inflammation of the breast. It's not necessarily infective.

If the milk sits around for too long there is an increased risk of infection. Look out for high fever and red streaks on the breast. Your doctor might prescribe Flucloxacillin or Keflex (or cephalexin). Remember to keep trying to clear the lump.

You may think, I'll just sit it out for a while and see if it goes away, its better not to use antibiotics for every little thing. That's what I thought too. Trouble is that's not what the infection thought. Mastitis is an incorrigible rogue of an infection. A double course is recommended because the bugs often come back otherwise.

You see, its not your average, everyday scratch that's got a bit dirty. The bugs are sitting in a pool of milk - excellent nutrition for bugs as well as for your baby. The milk is not refrigerated, rather its at a perfect temperature for bugs as well as for your baby. To cap it all your breasts are not on your arms or your legs, they're right up close to all the major organs. That's why the fever is often sudden and very high. Don't delay, see a doctor today!

Also, its worth bearing in mind that most doctors are not well informed and up to date on mastitis. Decades ago it was thought that infected milk was dangerous for babies, so the baby was put on the bottle and milk was expressed and discarded. Since then they've found that babies can cope with milk, even with bugs. My baby coped handsomely, though his motions were a bit strange. I thought they were smoky bacon flavoured for a while, most people people thought I was crazy (I was a bit crazy). Breast feeding is the best way to clear the milk ducts, so don't wean yet!

As a historical note, mastitis used to be known as Milk Fever and women often died of it. Don't worry, now antibiotics are saving lives all over the place. Also, I found it interesting that cows get mastitis too. The vet has to give them local injections of antibiotics in the udder.

Breast Abscess

If the infection goes untreated for too long there is a risk of breast abscess. If the blockage is not complete you may find pus coming out of the nipple. Pus is yellowy green and also can be very painful to force out of the nipple. That means its obviously an abscess.

No need to stop breastfeeding.

The other way to tell if its an abscess is by ultrasound. The ultrasonic waves can also help to loosen the blockage so get one if you can. In my case the image they got was inconclusive. If this is the case with you ask for a biopsy. It will show for certain whether its an abscess or just inflamed tissue and it may ease the pain.

If its an abscess there's a remote chance it will resolve itself, but realistically there are two options: incision and drainage or fine needle aspiration. Small abscesses (20mL or less) have been successfully treated just by fine needle aspiration. Larger abscesses need the full operation.

Cellulitis, Nipple Damage, Engorgement, Vasospasms and other unpleasant things

If a breast abscess goes unrelieved for too long then it can cause all sorts of trouble. The abscess keeps getting bigger because milk is still being produced and is still collecting in the cavity. Also the pressure from the swollen duct can cause other ducts to block up and because the infection is still around - even when you're on antibiotics - they can quickly become infected and make another abscess.

Engorgement is usually referring to the swelling that you get when you first start breastfeeding. I guess the swelling from an abscess is not quite the same, but the effects are. It is jolly difficult to attach a baby to an engorged breast. The baby has to have a wide open mouth and take as much of the areola as possible. Good help is important here. You can easily get demoralised and as long as the baby is getting something to drink it doesn't matter if it hurts like blazes and the nipple is bleeding again. You just want to sleep.

Nevertheless it is important to attach the baby correctly. Bleeding nipples are just the tip of the iceberg. Detached nipples are much worse. The best way is to relieve the pressure by draining the lump. Even just using a syringe.

Cellulitis is damage to the cell structure of the skin over the abscess. It can happen in other abscesses too. The skin thickens and gets leathery. This can make it very difficult to attach the baby if the areola is affected. The areola needs to be supple so the baby can draw back the nipple to the back of the mouth. Cellulitis is treated by intravenous antibiotics.

It is possible to breastfeed a baby with canulas in your arms. Canulas are the little needles they leave in you arms when you're on IV medication. You need to experiment with different positions to avoid knocking the canulas. The other thing is to keep the baby from pulling at them. Carrying the baby, changing nappies are also difficult with canulas. Its good to find someone to help you who can stay with you as much as possible. Draining the lump promptly helps avoid long periods of trying to look after the baby while you're disabled by canulas.

Vasospasms can occur independently from abscesses and such, but I found they were only a problem when the lump was large. Vasospasms are related to bad circulation. The blood flow to the nipple stops for some reason and it goes white and kind of throbs for a while too. Treatment is usually keeping the nipple warm, especially just after a feed. There are special lambs wool nipple warmers available from Mothers Direct through the Australian Breastfeeding Association. I haven't tried them, but they look like a good idea.

Fine Needle Aspiration

This is a simple little operation any doctor can do. The doctor just uses a syringe to draw out whatever's collected in the cavity. In treating abscesses you might go for aspiration every couple of days or even daily. You'd want to discuss this with a breast surgeon. You can also have it done under ultrasound, but this isn't necessary (but it is fun watching the cavity collapse). Also another thing to watch is you can easily get scratched inside which makes the next lot of liquid to be removed look a bit brown because of the left over blood. Its not too serious (or serous hee, hee, silly joke, don't worry, been hanging around hospitals too long) just don't panic, its not necessarily a returned infection.

Incision and Drainage

This is also a simple operation. Surgeons are familiar with incising and draining abscesses. Breast abscesses need just a little more care afterwards. If the surgeon tells you that there's a risk of milk fistula and you'll have to stop breast feeding beware! You want the surgeon to make a milk fistula. A milk fistula is where milk keeps leaking out of a hole in the breast. If the milk doesn't leak out it will just pool inside making a big milk bubble. You can keep breastfeeding. You might even consider going to another surgeon - preferrably one who specialises in breasts.

The operation goes something like this:

  1. A general anaesthetic should be administered with special care that no drugs will be used that may cross the breast milk and affect the baby.
  2. An incision should be made avoiding the areola, preferably set back a little to allow breastfeeding while the wound heals.
  3. The wound should be thoroughly swabbed and flushed out to get rid of all the infection.
  4. A small tubular drain, like a yates drain or a penrose drain, should be put in during the operation.
  5. The tubular drain should be replaced by a nurse with saline gauze wick after the general anaesthetic has worn off.
Not all surgeons know about this, so its a good idea to talk it through first.

The key thing is to let the wound drain for a few weeks after the operation. The wound needs to be packed with gauze, not seaweed sticks. The difference with breast abscesses is that there's milk leaking into the cavity all the time. Eventually these ducts will stop producing milk but until then you need to keep the milk flowing out of the breast. If the wound isn't packed the skin will heal and the cavity will keep filling up with milk, making it swollen like it was before the operation.

Aside: A cavity filled with milk is known as a galactocoele. It isn't dangerous so much as inconvenient. If it gets big enough it will make breastfeeding difficult. Aspiration can ease the discomfort. But back to the topic.

While the wound is healing you can expect milk to flow out of the wound at each feed. The milk keeps the wound wonderfully clean and promotes healing too. You can keep a pad over the wound to soak up the milk, but remember to keep changing it after every feed to prevent infection, just like you would with a regular nursing pad. Each day the packing will need to be changed, each time a little less will be put in. Hopefully you'll have a nurse to visit you every day to change the dressing, otherwise it means a trip to the doctor every day. I did get my husband to have a go towards the end when the gauze ribbon would fall out because it was so short, and he did a good job.

Hopefully within a fortnight or so the wound will stop leaking milk and will have become so small that the packing keeps falling out. Congratulations! You've weathered the storm and now you're slightly scarred but still breastfeeding.

The Next Baby

One question that no one could give me a sure answer for was, what will feeding the next baby be like. Now, two years on, I have a five month old, fully breast-fed, big baby boy so I can tell you. I had grazed nipples again - this time nipple shields were great. I did have mastitis, but it was on the other side, and a course of antibiotics cleared it up. I was also taking lecithin, and it was only when I stopped for a while that I got the mastitis. I've stopped taking it again and I haven't had any trouble. I have been able to feed Christopher normally on both sides, which makes life much easier. The scarring has softened, but still noticeable. The milk ducts where the abscess was haven't regenerated, so I seem to have less milk on that side.

Breast Pumps

There are several different kinds of breast pumps available. The Australian Breastfeeding Association hires out Medela and Ameda pumps. I have the basic Medela hand pump which is the same sort they use in hospitals, at least in my area. This hand pump can be attached to an electric motor which is available for hire from some chemists or through groups like the Australian Breastfeeding Association.

The first breast pump I bought was awful. It helped crack my nipples and prevent them from healing. In hospital I found someone had had a similar experience with a similar pump. So I don't recommend the little battery operated units. They work by creating a vacuum with a little fan, which is kind of like sticking the hose of a vacuum cleaner to your breast. It was also more expensive than the Medela hand pump.

One good thing about the Medela hand pump that I haven't seen written down anywhere is that you don't have to pump it all by yourself. The piston can be attached to the breast cup by a tube which means some generous soul can sit next to you and pump for you. This worked well when I was trying to combine expressing milk with a hot relaxing shower. It would be ideal for sitting in a hot bath.

References