CLINICAL PRACTICE: Clinical update in lactating women – or something else?

Lisa Helen Amir, MBBS, MMed, IBCLC, is a PhD candidate, Centre for the Study of ’ and Children’s Health, La Trobe University, and sessional general practitioner, Women’s Clinic on Richmond Hill, Victoria.

BACKGROUND Mastitis is a common problem for lactating women. However, medical practitioners may not recognise that there are also other causes of during lactation. OBJECTIVE This article presents a case study that demonstrates several common causes of breast and pain in a lactating woman. DISCUSSION Once medical practitioners are aware of the presenting features of mastitis, and vasospasm, they will be able to conduct a careful history and examination and make the correct diagnosis.

Maria struggles into your consulting room with her first baby, one week old Ben. Maria complains that she feels very unwell and the outer aspect of her left breast is red, hot and painful (Figure 1). Maria and Ben are still learning how to breastfeed, and Maria’s hurt when she feeds.

What is the most likely any difficulty. (See diagnosis? Resources at end of article for further Infective mastitis. information). If observing a breastfeed is not possi- What will you look for on ble, suggest that a local expert observe a examination? feed; this may be the Maternal and Child The source of infection in a postpartum Health nurse, an Australian woman may be her , uterus or Breastfeeding Association (ABA) breast- urinary tract.1 Her breasts should be feeding counsellor or International Board examined for any red, hard, tender or hot Certified Lactation Consultant. Many Figure 1. Breast mastitis areas. Her nipples should be checked for maternity hospitals now provide breast- evidence of damage. If she has had a cae- feeding clinics where women and their sarean section, her wound should be babies can spend several hours with an checked. A midstream urine test may be experienced lactation consultant. necessary. Causes of nipple and breast pain are outlined in Table 1. What will be your The baby’s mouth should be examined management plan? to check the integrity of the palate and It is important to maintain drainage of the assess for the presence of a significant breasts, either by breastfeeding and/or tongue-tie (Figure 2).2 Observation of a expressing the breasts at least four hourly breastfeed will help in the assessment of by hand or . It may help to Figure 2. Tongue-tie

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Table 1. Causes of nipple and breast pain23 position the baby to maximise breast drainage by pointing the baby’s chin causes • incorrect attachment toward the blockage. • incorrect sucking Women with mastitis should be • misalignment of ’s nipple and baby’s mouth offered regular analgesia. A nonsteriodal • tongue tie anti-inflammatory, such as , will • cleft palate help relieve as well as pain and . Very little ibuprofen enters the Trauma • pinched nipple breast and it is considered safe in • blow to the breast lactation.3 Alternatively, • incorrect use of a breast pump may be offered. • ill fitting brassiere In the early masti- Dermatological conditions • dermatitis tis associated with damaged nipples is – atopic almost always caused by – contact (irritant or allergic) aureus. The Australian • psoriasis Guidelines recommend or Infection • bacterial nipple or breast infection flucloxacillin as the preferred 4 • for mastitis. Cephalexin may be used in • fungal women who are allergic to penicillin, or • viral, eg. herpes clindamycin if she is highly allergic to penicillin.4 Dicloxacillin may cause Lactational conditions • engorgement phlebitis when given intravenously, so flu- • blocked duct cloxacillin should be used if the antibiotic • forceful milk ejection is required parenterally. • rapid refilling of the ducts Women with mastitis need to rest, so • Maria should be encouraged to ask any Other breast conditions • fibrocystic disease relatives or friends for practical help at • adhesions or surgical scars home. Suggest to Maria that she return to Hormonal conditions • premenstrual breast changes see you if she has not improved within • 48 hours. Neurovascular conditions • vasospasm of the nipple Ten days later Maria returns to see • Raynaud’s phenomenon you because her nipples and breasts • nerve response to damaged nipples are still painful. On further Musculoskeletal conditions • tender costochondral junctions questioning, she describes her nipples (Tietze’s syndrome) as feeling sunburnt and she experiences shooting, stabbing • back in the breast, especially after feeds. • sleeping in an uncomfortable position • strenuous upper body exercise • uncomfortable position for breastfeeding Disease • • lung disease • gall stones

Figure 3. Candida infection

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familiar with vaginal thrush following a of fluconazole are used for breast candidi- course of antibiotics, but may not have asis.5,12,14 Fluconazole is considered safe for heard about nipple or breast thrush. It is breastfeeding mothers.3 My routine is to useful to explain that the treatment may prescribe nystatin for at least a week fol- take a week or more to be effective, and lowing the fluconazole. Treatment for that the baby should be treated even if nipple and breast is based on asymptomatic to prevent mother and clinical experience, as trials are lacking.14 baby passing candida back and forth between each other.9 The preferred treatment for the baby Maria brings Ben to see you when he is five weeks old because she has is oral miconazole gel, one quarter of a noticed spots on his face and wonders Figure 4. Breast abscess teaspoon after feeds, four times per day. if this is thrush. She followed the can apply this directly onto the What is the most likely thrush treatment for more than two weeks and she is no longer diagnosis? tongue and inside the cheeks with a clean finger. If the oral gel upsets the baby, nys- experiencing breast pain after feeds. Candida infection of the nipples and tatin oral drops, 1 mL four times per day However, her nipples are still painful. 5 On questioning, it appears that the breasts (Figure 3). after feeds can be used. If clinically indi- pain usually occurs after feeds or cated, the baby’s bottom can be treated when she is cold and her nipples What will you look for on with an antifungal ointment, eg. micona- blanch. In cold weather, she examination? zole with zinc oxide ointment. experiences painful fingers which she When breast pain persists after an Oral miconazole gel can also be attributes to poor circulation. episode of mastitis, it is important to applied topically to the nipples after feeds. examine the breasts in order to exclude Mothers should be advised to use a small Most likely diagnosis? an abscess (Figure 4). Sometimes an amount of gel and rub it in well. The gel ultrasound is helpful in excluding a deep can irritate a small proportion of women, Ben’s face abscess or other breast pathology. An so suggest a change to nystatin ointment if Acne neonatorum.15 These self limiting abscess can usually be managed by this occurs. If nipple thrush is persistent, papular lesions tend to develop on the repeated needle aspiration.6 Women with gentian violet 0.5% aqueous may be tried. face.15 Candida tends to occur in moist, breast lumps that don’t resolve should be It only needs to be applied twice a day, occluded areas, not on the face. referred for a surgical opinion, as breast usually for seven days. Gentian violet is may present during lactation.7 no longer used in babies’ mouths because Maria’s nipples Inflammatory presents as overuse may cause ulceration.10 It is a dye Vasospasm is likely (Figure 5).16 an enlarged, red breast; a lump may not which is hard to remove from the and Differential diagnoses for persistent be present.7 and concerns about carcinogenic- nipple pain would be incorrect attach- If nipple damage is still present, check ity have reduced its use11 with many ment, persistent candida infection or for any yellow exudate, which may indi- pharmacies no longer stocking it. nipple eczema/dermatitis. Dermatitis of cate a bacterial infection.8 Candida Although not first line treatment, careful the nipple/ appears as a red itchy infection of the nipple usually appears as use of gentian violet is considered safe.12 rash with a well demarcated edge and redness only, with white growth on the In addition to topical nipple treat- responds to a potent cortisone ointment nipple being unusual.5 ment, oral antifungals are usually given to Examine the baby under a good light, the mother. Traditional treatment for looking for oral thrush. Oral candida may symptoms of nipple/breast candidiasis is appear only as a white filmy appearance oral nystatin capsules two capsules three on the buccal mucosa. White spots on the times per day taken after meals.13 Women gums are usually Epstein’s pearls, rather will usually need to continue nystatin for than thrush. at least two weeks. If breast pain is severe or does not respond to nystatin, flucona- What will be your zole 150 mg capsule can be given once per management plan? day for up to 10 days (depending on level First, explain the pathophysiology of of pain and ability to afford these expen- candida . Many women will be sive capsules). In the USA, 14 day courses Figure 5. Nipple vasospasm

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(eg. mometasone furate ointment once breastfeeding early experience this as a Acknowledgments per day) within several days.17 personal failure.20 Lisa Amir has a NHMRC Management Research scholarship. Several months later, Maria rings to Explain to Maria that nipple vasospasm say that one breast is sore and she can occur as a reaction to nipple damage has a headache. Ben slept through the Conflict of interest: none declared. or pain. Exposure to the cold can exacer- night and she woke up with engorged bate the pain. The principal management breasts. Resources strategy is to keep the nipples warm: Australian Breastfeeding Association don’t exposure them to air, wear extra website: http://www.breastfeeding.asn. layers of clothes. Breast warmers Most likely diagnosis? au/bfinfo/care.html (Flectalon, from Sweden) are breast pads Noninfective mastitis. Material from Canadian paediatrician, made from insulating material and may Dr Jack Newman: http://users.erols.com/ be helpful; they are available from ABA Management cindyrn/31.htm. or pharmacies. Magnesium has been Maria should aim to improve drainage of found useful for relieving vasospasm of her painful breast by increasing the fre- SUMMARY OF coronary and cerebral arteries and quency of feeds or expressing in addition IMPORTANT POINTS improving peripheral circulation in to feeding until this episode resolves. vasospastic patients.18 Although studies Most women find heat and massage of the are needed to assess the effectiveness of area helps to relieve the blockage. • Mastitis is an inflammation of the breast. Antibiotics are necessary magnesium in the treatment of nipple Analgesia, such as ibuprofen, should be in severe cases or when the nipple vasospasm, clinical experience has found taken regularly. is damaged or if symptoms persist magnesium and calcium supplements Antibiotics are not required at longer than 24 hours. effective. If these measures don’t help, present, unless symptoms last more than The recommended antibiotic is nifedepine slow release 30 mg tablet once 24 hours.22 A prescription can be given dicloxacillin or flucloxacillin, per day may be prescribed.5,16 with instructions to begin if the problem 500 mg four times per day. is not improving in 24 hours. The addition • Burning nipple pain and shooting breast pain may be caused by of nystatin capsules, two capsules four candida infection. Antifungal When Maria brings Ben for his times per day with the antibiotic, may treatment is needed for mother and immunisations at eight weeks, you help avoid a recurrence of breast thrush. baby. tentatively ask how breastfeeding is going. Finally, feeding is now pain free, Women are at risk of mastitis when- • Vasospasm of the nipple causes Maria responds with a smile. ever there is a reduction in breast pain associated with nipple Congratulations to mother and doctor drainage, eg. baby is unwell and not blanching. Nipples should be kept warm to reduce vasospasm, oral for clearing some of the common feeding properly or external pressure on hurdles in initiating breastfeeding. nifedipine may be needed to break the breasts, eg. tight clothing, car seatbelt. the cycle of vasospasm. Antibiotics are not necessary in inflamma- tory mastitis.22 Anticipatory guidance can A high proportion of women in Australia help women overcome these episodes. initiate breastfeeding with 82% of women References breastfeeding at hospital discharge.19 Conclusion 1. Yokoe D S, Christiansen C L, Johson R, et al. Epidemiology of and surveillance for Although women have a range of expec- Many women who give up breastfeeding in . Emerg Infect Dis tations regarding how long they will the early postpartum period are disap- 2001; 7(5):837–841. breastfeed, they generally plan to breast- pointed they were unable to breastfeed for 2. Marmet C, Shell E, Marmet R. Neonatal 20 frenotomy may be necessary to correct feed for months, rather than weeks. Yet longer. General practitioners can support breastfeeding problems. J Hum Lact 1990; many women give up breastfeeding in the women to breastfeed by treating their prob- 6(3):117–121. early weeks for a range of reasons. The lems and referring them to the Australian 3. Hale T. and mother’s milk. 5th most common reason given for early ces- Breastfeeding Association (formerly edn. Texas: Pharmasoft Medical Publishing, 1996. sation of breastfeeding is ‘not enough Nursing Mothers’ Association of Australia) 4. Therapeutic Guidelines: Antibiotic. North milk’,21 but nipple and breast problems for mother-to-mother support. Many mater- Melbourne, Australia: Therapeutic may also force some women to wean pre- nity hospitals offer breastfeeding clinics Guidelines Limited, 2000. 5. Gross S M. Pain in the breastfeeding maturely. Some women who give up staffed by qualified lactation consultants.

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