LC Evaluation of Dyad Candida Bacterial Infection Irritant Dermatitis

Home , Breast pain

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.

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?

Complete prescribed Improvement in Yes treatment, follow-up as 2-3 days? needed

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.

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

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?

Pump type, flange fit New flange, different prevents complete yes pump as indicated. emptying?

Infant jaw alignment, suck Stretching exercises exam, cranial symetry, yes for torticollis, consider spinal alignment affecting OT/PT/Speech referral drainage?

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.

Milk bleb

Blocked Duct Blocked Yes Protocol duct?

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 pulls off breast in distress with feeds? Using a double electric pump, empty both Pain with latch, not pumping? breasts completely. Feed baby on both sides after drainage. This provides infant Infant coughs with let down? Fussy, colicky slow-flow, fat-rich hind milk. baby with reflux, short, frequent feeds, green or mucousy stools, excellent weight Following full drainage, block feed by gain? Documented appropriate milk offering infant one breast for all feedings for transfer? Onset 3-6 wks pp? [6-7]] 3 hours, and then switch to the other breast. Gradually increase the length of the blocks as needed to down-regulate milk production.

Ref: [7] van Veldhuizen-Staas C,. Int Oversupply Breastfeed J 2007 http://bit.ly/NIOO5w

Overactive milk letdown? Yes

Let down into burp cloth before latching baby

Overproduction? Yes

Supportive measures: Reduce pumping, consider alternating sides for feeds, warmth to breast after feeds per vasospasm protocol, ibuprofen 400-600mg q4-6 hours. Follow-up 7-10 days.

Continue to alternate Response to Consider full drainage and/or breast with feeds, reduce Infant > 3 yes supportive Partial Yes scheduled block feeds to heat / NSAIDs as weeks old? measures? decrease supply. tolerated.

If breast tender with palpation, obtain milk and nipple cultures and send for aerobic culture

Positive culture for Treat per sensitivities using Yes single organism? ductal infection protocol

Reevaluate suck, latch, pump use, consider alternate diagnoses

© University of North Carolina School of Medicine / Last updated August 2012 Absence of visible trauma to nipple? Functional dysautonomia / Centrally Exquisite sensitivity of nipple to light touch? mediated pain syndromes [9,10] Onset of severe pain from first latch? Non-painful Persistent pain for >2 weeks? · Syncope Visible dilated capillaries in areola / nipple · Postural Tachycardia Syndrome after nursing / with light touch? History of (POTS) functional pain syndromes/dysautonomia? · Chronic Fatigue Syndrome · Cyclic Vomiting Syndrome Painful · Functional Dyspepsia Functional Pain · Functional Abdominal Pain · Abdominal Migraine · Migraine Headache Ibuprofen 600-800 mg QID for · Irritable Bowel Syndrome (IBS) inflammation. · Interstitial Cystitis · Complex Regional Pain Syndrome Counsel re mindfulness, deep (CRPS) breathing, “Suffering = pain x · Raynaud’s Syndrome resistance” · Fibromyalgia · Myofascial Pelvic Pain Consider massage for trigger- point release.

History of allergies / Yes Non-sedating anti-histamine dermatographia?

Improvement? Yes Taper ibuprofen as tolerated.

Propranolol 20 mg TID for centrally mediated pain syndrome[8], maximum dose 240mg/QD

Tricyclic antidepressant – Nortriptyline 25-50 PO QHS, titrate up q2-3 days, maximum dose 150mg/day. Taper gradually to discontinue

SNRI – Duloxetine (Cymbalta) – start 30 mg PO QD x 1 week, increase to 60 mg QD

Persistent symptoms?

Referral to chronic pain specialist or acupuncture provider.

UNC resources: Referral to Denniz Zolnoun for pain mapping eval or Ken Morehead for trial of acupuncture for refractory nipple / breast pain.

Ductal infection

Obtain milk and nipple cultures for aerobic culture ± yeast screen

Supportive measures: Warmth to breast after feeds per vasospasm protocol, ibuprofen 400-600mg q4-6 hours. Follow-up 5-7 days.

Response to Consider treatment with Gradually taper heat / yes supportive Partial Nifedipine per vaspasm NSAIDs as tolerated. measures? protool

No Positive culture? Yeast

Bacteria

Treat per sensitivities with Treat with oral diflucan per narrowest spectrum yeast protocol antibiotic x 14 days

Reevaluate suck, latch, pump use, consider No Clinical response? alternate diagnoses

Partial

Healthy infant >4 Consider trimethoprim / wks, no h/o Sulfa Yes sulfamethoxazole DS allergy or G6PD 1 tab BID x 14 days deficiency? No Consider empiric treatment for chronic bacterial lactiferous duct infection:

cephelexin 500 mg QID, dicloxacillin 500 mg QID, erythromycin 500 mg QID, amoxicillin/clavulonate 875 mg BID x 14 days

In case series, some women reported resolution after >6 weeks of antibiotics[11]

© University of North Carolina School of Medicine / Last updated August 2012 Infant w/ oral thrush / diaper rash / systemic candidemia? Rash under breast with pruritis, erythema? Shiny, red nipples with flaking skin? [12] No response to topical mupirocin / barrier ointment for dermatitis?

Candida

Suspect Defer cultures until 48 Topical or systemic antifungal Yes resistant No hours after last dose of used in past 24-48 hours? candida? antifungal.

Obtain nipple and milk cultures and send for Yes aerobic culture and yeast screen

Infant with signs of oral thrush: White plaques on No infant rx unless positive Assess infant No buccal mucosa and/or maternal culture palate. Topical antifungal vs. mupirocin treatment while awating cultures Yes Topical nystatin 100,000 u/mL susp, Treat with topical mupirocin[13], 0.5 mL swabbed over mucosal clotrimazole or ketoconazole surfaces after each feeding x 14 applied to breast after each feed x days[14]; Consider compounded 14 days. Review contact dermatitis clotrimazole ointment. precautions No improved If pain with application of after 5-7 days/ Ketoconazole, switch to Clotrimazole or nystatin. Treat with oral diflucan 6mg/kg loading, 3mg/kg qd x 7 days[15]

Review final yeast screen and culture results Positive Negative culture yeast screen, or skin flora? Bacterial infection? persistent symptoms

Fluconazole 200 mg x 1, then 100 mg qd x 13 Reevaluate suck, latch, Treat per sensitivities days. Check LFTs if history of HELLP/ pumping, consider for bacterial ductal Preeclampsia/liver disease. Ensure patient’s alternate diagnoses infection complete medication list is in WebCis for drug interaction assessment.

Not improved after 7-10 days?

Reculture milk and nipples for yeast and bacteria. Reevaluate latch, pump use. Consider alternative diagnoses

Laboratory evidence of persistent yeast?

Check CBC, LFTs. Fluconazole 400 mg x 1, then 200 mg qd x 13 days. Neutropenic precautions.

Infant with inadequate output in last 24 hours? Yes Same-day evaluation in pediatric clinic or ED if after hours

Infant with weight loss / inadequate gain? Yes Schedule evaluation in pediatric clinic within 24 hours

Breast tenderness w/ reddened, sore area that feels warm, Flu-like symptoms, generalized body aches, Yes Manage per mastitis phone triage protocol fatigue, Chills or fever ≥101 F orally

· Infant > 2 weeks old? · Nipples with bleeding, cracks, scabs or yellow crust? · Pain >8/10? Yes Schedule evaluation in pediatric clinic within 24-48 hours · Pain worsening or lasting more than 3-5 days? to any · Pain worsens after initial latch? · Pain causing mom to turn away from shower, avoid towel-drying nipples?

Dyad candidate for trial of supportive care measures

Position infant with chin or nose pointing toward Palpable lump or knot which develops gradually and is blockage. Over 24 hours, soak nipple before and/or after associated with localized pain, may decrease in size with Yes milk removal. White plug at the ductal opening. most feedings in warm (not hot!) water; use hand massage and pump to empty breast after feeds.

Infant with pediatric-provider-diagnosed oral candida Yes Lotrimin AF to nipples after every feeding or candidal diaper rash?

Using Lanolin or other OTC nipple cream or ointment Yes Discontinue OTC creams / ointments without any relief?

Upright football hold. Apply heating pad x 5 minutes, followed by Aquaphor / vaseline to nipples, after each feed.

Call Warmline to schedule evaluation in Pain not markedly improved in 48-72 hours? pediatric clinic within 24-48 hours References 1. Academy of Breastfeeding Medicine, Clinical Protocol #4: Mastitis. Breastfeeding Medicine, 2008. 3(3): p. 177-180. 2. Christensen, A.F., et al., Ultrasound-guided drainage of breast abscesses: results in 151 patients. Br J Radiol, 2005. 78(927): p. 186-188. 3. Livingstone, V. and L.J. Stringer, The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study. Journal of Human Lactation, 1999. 15(3): p. 241-6. 4. Barankin, B. and M.S. Gross, Nipple and areolar eczema in the breastfeeding woman. J Cutan Med Surg, 2004. 8(2): p. 126-30. 5. Anderson, J.E., N. Held, and K. Wright, Raynaud's phenomenon of the nipple: a treatable cause of painful breastfeeding. Pediatrics, 2004. 113(4): p. e360-4. 6. Woolridge, M.W. and C. Fisher, Colic, "overfeeding", and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management? Lancet, 1988. 2(8607): p. 382-4. 7. van Veldhuizen-Staas, C.G., Overabundant milk supply: an alternative way to intervene by full drainage and block feeding. Int Breastfeed J, 2007. 2: p. 11. 8. Nackley, A.G., et al., Catechol-O-methyltransferase inhibition increases pain sensitivity through activation of both beta2- and beta3-adrenergic receptors. Pain, 2007. 128(3): p. 199-208. 9. Ossipov, M.H., G.O. Dussor, and F. Porreca, Central modulation of pain. J Clin Invest, 2010. 120(11): p. 3779-87. 10. Chelimsky, G., et al., A comparison of dysautonomias comorbid with cyclic vomiting syndrome and with migraine. Gastroenterology research and practice, 2009. 2009: p. 701019. 11. Eglash, A., M.B. Plane, and M. Mundt, History, Physical and Laboratory Findings, and Clinical Outcomes of Lactating Women Treated With Antibiotics for Chronic Breast and/or Nipple Pain. J Hum Lact, 2006. 22(4): p. 429-433. 12. Francis-Morrill, J., et al., Diagnostic value of signs and symptoms of mammary candidosis among lactating women. J Hum Lact, 2004. 20(3): p. 288-95; quiz 296-9. 13. de Wet, P.M., et al., Perianal candidosis--a comparative study with mupirocin and nystatin. Int J Dermatol, 1999. 38(8): p. 618-22. 14. Su, C.W., et al., Clinical inquiries. What is the best treatment for oral thrush in healthy infants? J Fam Pract, 2008. 57(7): p. 484-5. 15. Goins, R.A., et al., Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants. Pediatr Infect Dis J, 2002. 21(12): p. 1165-7.