I am a Registered Nurse and Board Certified Lactation Consultant in the hospital setting. I do a lot of phone triage with moms that have breastfeeding questions and concerns on an outpatient basis. I wrote this article in the present tense following guidelines for a program offered to nursing staff by the institution I work at. The program awards employees for advancing their profession in the institution. The level of excellence is decided by a diverse committee of nursing professionals.

On Monday morning Annie , age 27, called me in the morning to report classic symptoms of mastitis - body aches and pains, fever, red swollen tender right breast with markedly decreased milk flow. Mastitis is a common condition in lactating women, with an estimated prevalence of 20% in the first six months post partum. The majority of cases occur in the first 6 weeks. Mastitis is a condition that ranges from subclinical mastitis and non-infectious inflammation to infectious processes, including abscess. Subclinical mastitis can occur without any obvious symptoms, except impaired milk supply. This condition is infrequently addressed in the lactation literature. "Health Care Providers must discover ways to assist the mom with the usual symptom of low milk supply and consider this a possibility." I know in my practice, and from other the evidence and guidelines out there that we all automatically give suggestions on how to increase milk production which is to increase the number of feeds or pumping. The more frequently the breasts are stimulated and emptied the more they produce. Using relaxation techniques is also often suggested to combat stress. Getting more rest and a balanced diet are also suggested. Herbal and medicinal galactogogues are also suggested.

When any inflammatory breast changes occur, milk flow is obstructed and effective breast drainage is impaired. The usual clinical definition of infective mastitis is a tender, hot, swollen, wedge-shaped area of the breast associated with a fever of 38.5C or greater, chills, flulike aching, headache and systemic illness. It is usually uni-lateral and is most often located in the upper outer breast quadrant, even though it can occur in any area of the breast. Predisposing factors to mastitis is anything that causes milk stasis. Some of these causes include missed pumping sessions, damage to the nipple, maternal stress and fatigue, malnutrition or anemia, rapid weaning, pressure on the breast, illness in the mom or vigorous exercise especially of the upper arms and chest. Breakdown of the skin from a crack or fissure of the nipple provides an avenue of germ entry into the breast tissue. The bacteria then can adhere to the cells lining the milk duct. This makes milk stasis a real concern since unresolved, it can lead to abscess formation. Breastmilk composition changes during a breast infection. Levels of some antinflammatory components rise to protect the baby from untoward effects of consuming mastitic milk. Elevated levels of sodium and chloride cause the breastmilk to taste salty.

I'll give you a little history of Annie. She gave birth to a beautiful healthy baby girl in April by unexpected C-Section . She lives with her fiancee. Hospital stay was uneventful. There's a family history of breast cancer. Her mother had a "cyst" that was removed at age 24 and reported as benign. At 48 , she had a mastectomy and unexpectedly passed away post-op eratively. This was in 2004. Her father was left with 3 daughters and as Annie says, "he hasn't been the same since." The family members are all afraid of hospitals, etc. Mothers Day is in a few days. There's so much emotion going on here. Anyways, she had gotten sore and cracked nipples early on and decided to 100% pump breasts and feed baby breastmilk by bottle. Right breast produced 3 ounces , and left 1 1/2 ounces each pumping session up with 5 days ago. Pain had gotten progressively worse so she spoke with her obstetrician that Sunday (5 days after onset of symptoms). Most physicians prescribe antibiotics over the phone in accordance with the classic symptoms listed above. The World Health Organization suggests that a culture and sensitivity should be done on the milk if there is no response to antibiotics within 2 days, if the mastitis recurs, if it is hospital-acquired mastitis, or in severe or unusual cases. Testing is expensive and may not be covered by insurance. Lab studies take several days for results. Also results can be skewed because the breast is made up of 6 to 9 seperate ductal systems so unless someone can figure exactly what lobe is infected and how to get expressed milk from just that area, a colony count may not provide accurate information. If infected milk was obtained leukocyte count of >10 to the 6th and bacteria 10 to the 3rd per ml of milk indicates infective mastitis. The Sodium level is greater than 100meq/L, Chloride >80 meq/l and potassium < 8 meq/dl. sIgA and lactoferrin were also found to be increased with increased severity of disease process.To collect a specimen mom should wash her hands and breast and then hand express a few milliliters of milk and then catch a midstream sample into a sterile container. Her doctor sent her to the emergency room. She was non compliant. . She didn't want to have to pay an Emergency Room deductible and she doesn't like hospitals or anything to do with breast "lumps and bumps."

She has been using a hand pump. These pumps are very difficult to regulate suction strength and speed which can traumatize tissue even further. In a recent article in a journal, was reported that the most common problems reported to the Food and Drug Administration for manual breast pumps were tissue damage and infection. I offered a consult to try a hospital grade breast pump for milk expression and to get a visual of what was going on. She refused at this time. We implemented hand outs on treating plugged ducts and breast engorgement. The most important step in suspected mastitis management if frequent and effective milk removal. Besides giving verbal instructions I e-mail the plan of care to the mom also since adults learn better by repetition and visualization.

It's the next day. She spoke to her doctors office the previous day and was started on an antibiotic. However, delay of antibiotic treatment beyond 24 hours, increases the incidence of severity and possible abscess formation. It has been 5 days since onset of symptoms. The breast is still very tender and she states that she is not able to express any milk due to pain. I encouraged her to come in again for a consult but she declined. She's still following the care plans and doesn't want to bother her doctors.

Now it's 4 days since she first reported symptoms to a health care provider. We spoke again. She was relieved because some milk had started to flow from affected breast. She can express 1/4 of an ounce or so every 3 hours during the day and 1oz. in the morning. She was able to sleep for the first night in a week because pain was less. Breast is still very tender. It's now 48 hours since oral antibiotic treatment began. Symptoms at this point in time should be appreciably better with proper treatment. We talked again later in the day because a "hard spot in the breast down near the rib cage has now seemed to of moved up under the areola where the breastshield touches the breast. She can't touch the whole underside of the breast, brush breast up against anything etc. without excruciating pain. I have never met Annie so I really don't know her pain tolerance at all. At this point, I just can't get a good feeling about what is going on . You can only assess so much over the phone. We talked a little more just for me to find out that she was put on amoxicillin. Recent research shows that the most common germ in infective mastitis is penicillin-resistant staph aureus. The preferred antibiotics should be penicillinase resistant penicillins such as Dicloxacillin or Flucloxacillin. Keflex can also usually be used safely in women with suspected Penicillin allergy, but Clindamycin is suggested for cases of severe penicillin hypersensitivity. My suggestion again was for her to be seen by her doctor for prescription change. She didn't want to bother her doctor so she might wait and see how she feels in the morning. I come in the next morning and she's in my office holding her breast. It's extremely painful. I ask permission to assess the breast. It's very swollen, red, and extremely tender from 3 to 9 o'clock. She talked to her doctor last night and they sent her here to use a hospital grade breast pump. I set her up with this and then went to find her doctor to see if she had time to examine her. I'm really concerned that she has a breast abscess from milk stasis. I spoke to her doctor who was in the Operating Room and got an order for a stat sonogram and antibiotic change to Keflex. She pumped 2cc of chocolate blood tinged fluid . This process was so painful she was crying uncontrollably. She did have an abscess that was aspirated by the radiologist for 70cc chocolate colored, non viscous cloudy fluid. The sonogram also showed edema and inflammatory changes in the subcutaneous tissues. She was then admitted to pediatrics for IV antibiotic treatment with Unasyn pending culture sensitivity.

I come in the next morning and go see how things are going and this breast looks more inflamed and irritated since yesterday. It's extremely painful for Annie. Everything starts going in fast motion. A surgical consult with Dr. R. is ordered. The surgeon sees her and within 1/2 hour she's off to the Operating Room.. I ask if I can go into the Operating Room with her. I'm just so curious to see what is going on. She is fine with me coming along. Annie wanted me to stay with her until they put her to sleep anyways and then be at her bedside when she woke up. She was so afraid that she had breast cancer. No one from her family was here with her. I never this surgeon before. What a great lady. She hugs her young patient and gives her kiss and tells her she'll take good care of her. I was so impressed with her bedside manner. The breast was incised and 150ml of foul smelling fluid came pouring out of incision. There was inflamed and necrotic tissue removed from the breast. This tissue is gray in color and Dr. R. keeps cutting away trying to find healthy tissue. Basically, all of the breast tissue is removed from below the areola. She will need reconstructive surgery. Dr. R. found this case to be very bad, she doesn't usually see this extreme in lactating women.

I asked Dr. R. what she thought the outcome would have been if Annie would of went to the Emergency Room when instructed by her doctor. She feels this situation would have been avoided. I then asked her what she thought the outcome may have been if she was on a penicillanase resistant staph aureus antibiotic. Of course the culture showed resistance to penicillin that she was on for 72 hours. She thinks she still would of abscessed and needed surgery but that damage would not of been so extensive.

Annie has a long road to recovery. The wound was left open with a wound vac applied. The wound is 5cm x 7cms and it's anticipated it will take months to heal.

Now my goal is to make sure prescribing doctors have knowledge of proper first line of treatment against mastitis. American Academy of Breastfeeding Protocol for Mastitis is made available to office staff. I also want breastmilk producing moms to heed their physicians advice.