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LC Evaluation of Dyad Candida Bacterial Infection Irritant Dermatitis

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LC Evaluation of Dyad Candida Bacterial Infection Irritant Dermatitis All mother / baby dyads triaged by Breastfeeding patient calls with lactation consultant phone triage nipple / breast pain protocol Office visit Manage per postpartum EPDS screen > 10 or All mothers receive EPDS on Yes depression protocol: 10-12 concern for depression? arrival to pediatrics or OB clinic intermediate, 13+ high risk No LC evaluation of dyad Assess infant oral anatomy, latch, milk transfer, bresat, pumping Evaluation and management with NP / CNM / MD Wedge-shaped breast Yes Fever, malaise, systemic symptoms? erythema? Mastitis Nipple fissures, yellow crust, erosions, pustules, rind over nipple that occludes Bacterial infection ductal openings? Tender, burning, red, fissures w/o Nipple appears exudate; itching, oozing with well- traumatized? Yes Irritant dermatitis defined plaques? Nipple “bleb” or blister that is exquisitely sensitive to touch, latch? Milk bleb Palpable lump in breast Develops gradually and is associated that decreases in size Yes with localized pain Blocked duct with milk removal? Prior nipple trauma with persistent pain Shooting pain, blanching / despite intact skin? Past history of deep purple color Yes Raynauds’ or migraines, cold Vasospasm changes after feeding? sensitivity? Infant pulls off breast in Infant coughs with let down? Explosive distress with feeds? Pain Yes stools, excellent weight gain? Oversupply with latch, not pumping? Documented appropriate milk transfer? Visible dilated capillaries in areola / nipple after nursing / with light touch? Exquisite sensitivity of Yes Pain lasting > 2 wks? History of nipple to light touch? Functional pain functional pain syndromes/ dysautonomia? Breast tenderness with Tenderness on breast palpation, pain palpation without Yes with manual expression? Ductal infection erythema? Infant w/ oral thrush / Inframammary rash, itching? No diaper rash / systemic Yes response to topical mupirocin / barrier Candida candidemia? ointment for dermatitis? © University of North Carolina School of Medicine / Last updated August 2012 Breast tenderness w/ reddened, sore area that feels warm. Risk factors for ORSA Flu-like symptoms, generalized body aches, fatigue Phone call? Chills or fever ≥101 F orally[1] Recent hospitalization Residence in a long term care facility Recent antibiotic therapy Injection drug use Mastitis See phone Hemodialysis triage protocol Incarceration Military service Milk sample for aerobic culture for Sharing needles, razors or other sharp objects recurrent mastitis, ORSA risk factors, Sharing sports equipment severe symptoms or at clinician Health care worker discretion. Penicillin Yes allergy? No Supportive Care Yes, Severe? No, rash anaphylaxis “Rest, fluids, empty the breast.” No risk to infant continuing breastfeeding during infection, risk to mom with abrupt weaning. Dicloxacillin Cephelexin Clindamycin Nurse / pump every 2-3 hours. For pain and 500mg PO QID 500mg PO 300-450 mg PO fever, recommend: Acetaminophen 650-1000 x 10 days QID x 10 days QID x 10 days mg q4-6 hours (maximum 4g /day) or Ibuprofen 400-600 mg q6h. Counsel patient that symptoms should improve in 24 to 48 hours. If symptoms progress after 12 hours or persist after 24-48 hours, she should be seen in OB clinic by the appropriate UOG/resident Review mastitis supportive provider, or come to the ER if after hours or care, contact LC on call weekend for evaluation Blocked duct Blocked Yes protocol duct? Mass persists Yes >2 days? No No Improving after 48 Complete antibiotic Yes hours? course No SAME DAY E&M Provider Visit Yes Concern for abscess on physical exam? No Reconsider diagnosis Organism sensitive to Breast ultrasound – see Review culture results prescribed antibiotics Abscess protocol ORSA No cultures done Consider Abscess diagnosed ultrasound Collect milk for culture, consider Review sensitivities and treat accordingly. empiric change of antibiotics to Ultrasound-guided drainage, continue Advise mother that she will need to be clindamycin, or trimethoprim / nursing on affected side[2]. Incision recultured at the time of any future hospital sulfamethoxazole if infant > 4 wks, for and drainage for refractory cases. admission. ORSA coverage. © University of North Carolina School of Medicine / Last updated May 2013 Nipple fissures, yellow crust, erosions, pustules, no systemic symptoms? Bacterial infection Severe pain[3]? Yes No Treat with systemic Mupirocin 2% ointment antibiotics per mastitis TID for < 14 days, review protocol mastitis precautions. Supportive measures: Address latch, continue frequent breastfeeding. Blocked Duct Blocked Yes Protocol duct? No Complete prescribed Improvement in Yes treatment, follow-up as 2-3 days? needed No Obtain cultures of fissures and send for aerobic culture Review culture Sensitive organism result, consider ORSA or skin flora? alternate antibiotics. Skin yes healed? Positive yeast screen No Review sensitivities and treat accordingly. Reeval latch, suck, pump Eval for Treat per yeast Advise patient that she may need to be use. Consider vasospasm, protocol recultured at time of any future hospital dermatology referral functional pain admission. © University of North Carolina School of Medicine / Last updated August 2012 Tender, burning, red, fissures w/o exudate; itching, oozing with well-defined plaques[4]. Dermatitis Physical exam Tender, burning, red, fissures w/o Itching, oozing with well-defined plaques, exudate, ill-defined borders excoriations. Irritant Dermatitis Contact dermatitis Barrier (Petrolatum, Aquaphor or Zinc Oxide) after Remove cause – topical creams, wipes, moisturizes; each feed, may cover with gauze or nipple shells. assess for pattern matching pump flange. Switch to Wear cotton bras. If ointment is still visible before hypo-allergenic detergent. If infant eating solids, rinse the next feeding or pumping, wash off the nipples nipple after feeds – food in mouth may be allergen. with water and gentle cleanser (Cetaphil, equivalent generic). **Hydrogels should not be Apply high potency steroid – Lidex 0.05% ointment – used with any topical ointment or cream. BID x 14 days. For severe symptoms, apply high potency steroid Use Aquaphor between steroid doses until tissue – Lidex 0.05% BID x 2-3 days heals. If ointment is still visible before the next feeding or pumping, wash off the nipples with water and Cetaphil cleanser. For severe itching,consider Cetrirzine (Zyrtec), balancing theoretical risk of decreased milk supply. Not improved in 5-7 days? Nipples cultures for aerobic culture ± yeast screen Review final culture result Negative culture, persistent Staph or other Positive yeast screen bacterial pathogen pain Treat per bacterial infection Treat per yeast protocol Skin healed? yes protocol No Reevaluate suck, latch, Eval for vasospasm, pump use. Consider functional pain dermatology referral © University of North Carolina School of Medicine / Last updated August 2012 Palpable lump or knot which develops gradually and is associated with localized pain, may decrease in size with milk removal. Blocked Duct Erythema, Mastitis fever, systemic Yes protcol symptoms? No Pump type, flange fit New flange, different prevents complete yes pump as indicated. emptying? No Infant jaw alignment, suck Stretching exercises exam, cranial symetry, yes for torticollis, consider spinal alignment affecting OT/PT/Speech referral drainage? No Position infant with chin or nose pointing toward blockage. Over 24 hours, soak affected breast before and/ or after most feedings in warm (not hot!) water. Use hand massage and pump to empty breast after feeds. Wear loose-fitting bra, get plenty of rest. Breast ultrasound / clinic Mass persists referral – page Susan Yes 10-14 days? McKenny, Breast Clinic NP, or radiology, 966-1081 ext 1 Persistent plugging, no dominant mass Recurrent/persistent blocked ducts: Consider Lecithin 1200 mg TID-QID Normal ultrasound, persistent plugging Consider cultures / systemic antibiotics. © University of North Carolina School of Medicine / Last updated August 2012 Nipple “bleb” or blister that is exquisitely sensitive to touch, latch? Milk bleb Blocked Duct Blocked Yes Protocol duct? No Soak nipple before and/or after most feedings in warm (not hot!) water. Mupirocin per bacterial infection protocol 5-7 days Unroof bleb with sterile needle after No Yes prepping nipple with alcohol wipe. improvement? Tx w/ mupirocin x 7 days. Recurrent/persistent blocked ducts: Consider Lecithin 1200 mg TID-QID Consider cultures / systemic antibiotics. © University of North Carolina School of Medicine / Last updated August 2012 Shooting pain, blanching / deep purple color changes after feeding? Prior nipple trauma with persistent pain despite intact skin? [5] Past history of Raynauds’ or migraines, cold sensitivity? Vasospasm Supportive measures: After each feed / milk expression, cover breasts and apply heating pad on low or warm rice sock for 5 minutes. Eliminate vasoconstrictive meds (sudafed, caffeine), increase ambient temperature, dress warmly. F/u 7-10 days Consider nifedipine 30 XL per day after documenting Continue supportive Response to Yes Partial baseline blood pressure, measures PRN supportive measures review orthostatic precautions. No Reevaluate suck, latch, pump Response to use, consider alternate No treatment? diagnoses yes If history of Raynaud’s Persistent pain symptoms in hands/ feet, notifiy primary provider / consider workup for Raynaud’s associated Functional Pain autoimmune disease © University of North Carolina School of Medicine / Last updated August 2012 Full drainage / scheduled block feeds Infant
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