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Home , Cracked nipple, Mastitis

patient presents with / 

All / baby dyads assessed by consultant; LC Evaluation: , oral if treated by phone, eval within anatomy, transfer, 48 hours pumping regimen

PPD screen

Edinburgh PDS > 12? Manage per protocol yes Maternal evaluation

Nipple fissures, yellow crust, erosions, Impetigo pustules, no systemic symptoms? yes

no

Shiny, bright red or flaky with stabbing or burning pain? Pustules w/ Yeast satellite lesions? Infant w/ oral thrush / yes rash? Pain during feeding despite good milk transfer? Nipple pain only? no

yes Tender, burning, red, fissures w/o exudate; itching, oozing with well-defined Dermatitis no plaques yes no

Past history of Raynauds or migraines, cold sensitivity, blanching of nipple after Raynauds nursing followed by marked erythema, yes sharp, shooting pain?

Fever, malaise, systemic symptoms?  Wedge-shaped breast erythema? yes no

Shooting pain with let down and shortly after feeds? Infant pulls off the breast Oversupply Nipple and breast and coughs or chokes with feeds, pain? explosive stools, excellent weight gain? yes Transfer >60 cc per feed? yes

no

Deep pulling, throbbing pain after feeding, ternderness on breast Ductal infection palpation, pain with manual expression. yes

UNCH Nipple and Algorithm v 1.0 / Last updated 6/10/2009 Nipple fissures, yellow crust, erosions, pustules, no systemic symptoms?

Local impetigo

Severe pain? yes no

Treat with systemic Mupirocin 2% ointment TID per mastitis for < 14 days, review mastitis protocol1 precautions. 

Supportive measures: Position infant with chin or Continued frequent Blocked nose pointing toward breastfeeding.  duct? blockage. Soak nipple after feeding; use hand massage and pump to empty breast after feeds.

Not improved in 2-3 days?

Obtain cultures of fissures and send for aerobic culture and yeast screen Review sensitivities and treat accordingly. Advise patient that she may need to be recultured Review culture result, at time of any future hospital consider alternate ORSA? admission.  antibiotics.

Sensitive organism or Yeast? negative culture?

Consider alternate diagnoses: Yeast vs. irritant Treat per yeast protocol dermatitis Reevaluate latch, pump use

UNCH Nipple and Breast Pain Algorithm v 1.0 / Last updated 6/10/2009 Return to main page Shiny, bright red or flaky skin with stabbing or burning pain1? Pustules w/ satellite lesions? Infant w/ oral thrush / diaper rash? Pain during feeding despite good milk transfer?

Yeast

Obtain cultures and send for Pediatric provider: Evaluate infant for aerobic culture and yeast screen Evaluate signs of oral thrush: White plaques on Infant buccal mucosa and/or palate. 

Thrush? Treat with topical Ketoconazole applied to breast after each feed x 14 days. Topical nystatin 100,000 u/mL susp, 0.5 Review contact dermatitis precautions. mL swabbed over mucosal surfaces after each feeding x 14 days2

If pain with application of Ketoconazole, Not improved switch to Clotrimazole or nystatin. in 5-7 days?

Not improved Treat with oral diflucan 6mg/kg loading, in 4-5 days? 3mg/kg qd x 7 days3 Review final culture results Yeast?

Culture positive for ? Fluconazole 200 mg x 1, then 100 mg qd x 13 days. Ensure patients Treat per sensitivities for complete medication list is in WEBCis bacterial ductal infection for drug interaction assessment. 

Negative Not improved culture? in 5-7 days?

Reculture milk and nipples for yeast and bacteria. Reevaluate latch, pump Reevaluate latch, use. Consider alternative diagnoses. pumping, consider alternate diagnoses Evidence of persistent yeast?

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

UNCH Nipple and Breast Pain Algorithm v 1.0 / Last updated 6/10/2009 Return to main page Tender, burning, red, fissures w/o exudate; itching, oozing with well- defined plaques1.

Dermatitis

Obtain nipples cultures and send for aerobic culture and yeast screen

Tender, burning, red, fissures Itching, oozing with well- w/o exudate, ill-defined defined plaques, excoriations. borders

Irritant dermatitis Contact dermatitis

Aquaphor or Zinc Oxide after 1. Remove cause – topical creams, wipes, each feed, cover with gauze moisturizes; assess for pattern matching pump or nipple shells. Wear cotton flange. Switch to hypo-allergenic detergent. If bras. If ointment is still visible infant eating solids, rinse nipple after feeds – food before the next feeding or in mouth may be allergen. pumping, wash off the nipples 2. Apply high potency steroid – Lidex 0.05% with water and Cetaphil ointment – BID x 14 days. cleanser.  3. Use Aquaphor between steroid doses until tissue heals. If ointment is still visible before the next For severe symptoms, apply feeding or pumping, wash off the nipples with high potency steroid – Lidex water and Cetaphil cleanser.  0.05% BID x 2-3 days  4. For severe itching,consider Zyrtec – balancing theoretical risk of decreased milk supply. See patient handout.

Not improved in 5-7 days? Reevaluate latch, pump use. Consider dermatology Review final culture result Negative referral. culture?

Staph or other Yeast? pathogen?

Treat per impetigo protocol Treat per yeast protocol

UNCH Nipple and Breast Pain Algorithm v 1.0 / Last updated 6/10/2009 Return to main page , malaise, systemic symptoms? Wedge-shaped breast erythema?

Mastitis1 

Office visit Unable to be seen that day

Consider milk cultures for aerobic culture Call in treatment, arrange follow-up with and yeast screen. LC within 48h.

Penicillin allergy? yes no

Cephalexin 500 mg BID or  Clindamycin 300mg QID x 500 mg QID x 10-14 days 10-14 days 

Supportive measures: Rest, adequate fluids, and continued frequent breastfeeding, starting on the affected breast if tolerated

Not improved in 48h? Review sensitivities and treat Review final culture result or accordingly. Advise patient that she culture if not done at will need to be recultured at time of presentation. ORSA? any future hospital admission.  Sensitive organism?

Ultrasound to rule out Breast clinic consultation for if no response to ultrasound-guided drainage2. 48h of appropriate abx or if Continue nursing on affected side.  Abscess? clinical suspicion for abscess. Schedule: 6-1081 Incision and drainage  for refractory cases. Unremarkable ultrasound

Breast clinic evaluation if persistent symptoms despite antibiotics

UNCH Nipple and Breast Pain Algorithm v 1.0 / Last updated 6/10/2009 Return to main page Past history of Raynauds or migraines, cold sensitivity, blanching of nipple after nursing followed by marked erythema, sharp, shooting pain?

Raynauds1

Obtain milk and nipple cultures and send Treat per ductal infection protocol. for aerobic culture and yeast screen + culture?

Supportive measures: Reduce vasconstrictive meds (sudafed, caffeine), dress warmly, heating pad or Check baseline pressure. warm rice sock to breast after feeding.  Partial Consider nifedipine 30 XL QD F/u 7-10 d response?

Diagnosis of Raynauds Negative culture, based on response to rx not improved?

Reevaluate latch, pump use, consider Notify primary care physician / consider alternate diagnoses. workup for Raynauds- associated autoimmune disease 

Consider trial of acupuncture for refractory nipple / breast pain. 

UNCH Nipple and Breast Pain Algorithm v 1.0 / Last updated 6/10/2009 Return to main page Shooting pain with let down and shortly after feeds? Infant pulls off the breast and coughs or chokes with feeds, explosive stools, excellent weight gain? Transfer >60 cc per feed?

Oversupply1

Obtain milk and nipple cultures and send Treat per ductal infection protocol. for aerobic culture and yeast screen + culture?

Supportive measures: Reduce pumping, consider alternating sides for feeds, warmth to breast after feeds, LC protocol for decreasing . F/u 7-10 d Partial response, oversupply – see patient infant > 3wks old? handout.

Negative culture and not improved?

Reevaluate latch, pump use, consider alternate diagnoses.

UNCH Nipple and Breast Pain Algorithm v 1.0 / Last updated 6/10/2009 Return to main page Deep pulling, throbbing pain after feeding, tenderness on breast palpation, pain with manual expression.

Ductal Infection

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

Negative culture? Review culture result

Yeast Bacteria

Treat with oral diflucan per Treat per sensitivities with Consider acupuncture for yeast protocol. narrowest spectrum management of refractory x 14 days. breast pain

Evaluate for clinical response

No response? Partial improvement? No Consider empiric treatment Reevaluate latch, pump use, improvement? consider oversupply, for chronic bacterial alternate diagnoses. infection: cephalexin 500 mg QID, dicloxacillin 500 mg QID, erythromycin 333 mg TID, amoxicillin / clavulonate 875 mg BID x 14 days

In case series, some women reported resolution after > 6 wks of antibiotics.1

UNCH Nipple and Breast Pain Algorithm v 1.0 / Last updated 6/10/2009 Return to main page References

Impetigo Raynauds 1. Livingstone V, Stringer LJ. The 1. Anderson JE, Held N, Wright K. treatment of Staphyloccocus aureus Raynaud's phenomenon of the nipple: infected sore nipples: a randomized a treatable cause of painful comparative study. Journal of Human breastfeeding. Lactation 1999;15(3):241-6. 2004;113(4):e360-4. 2. Delgado S, Collado MC, Fernandez L, Yeast Rodriguez JM. Bacterial Analysis of 1. 1. Francis-Morrill J, Heinig MJ, : A Tool to Differentiate Pappagianis D, Dewey KG. Diagnostic Raynaud's Phenomenon from value of of Infectious Mastitis During Lactation. mammary candidosis among lactating Curr Microbiol 2009. women. J Hum Lact 2004;20(3):288-95; quiz 96-9. Oversupply 2. Su CW, Gaskie S, Jamieson B, 1. Woolridge MW, Fisher C. Colic, Triezenberg D. Clinical inquiries. What "overfeeding", and symptoms of is the best treatment for oral thrush in malabsorption in the breast-fed healthy ? J Fam Pract baby: a possible artifact of feed 2008;57(7):484-5. management? Lancet 1988;2(8607): 3. Goins RA, Ascher D, Waecker N, 382-4. Arnold J, Moorefield E. Comparison of fluconazole and nystatin oral Ductal Infection suspensions for treatment of oral 1. Eglash A, Plane MB, Mundt M. History, in infants. Pediatr Infect Dis Physical and Laboratory Findings, and J 2002;21(12):1165-7. Clinical Outcomes of Lactating Women Treated With Antibiotics for Chronic Dermatitis Breast and/or Nipple Pain. J Hum Lact 1. Barankin B, Gross MS. Nipple and 2006;22(4):429-33. areolar eczema in the breastfeeding woman. J Cutan Med Surg 2004;8(2): 126-30.

Mastitis 1. Academy of Breastfeeding Medicine. ABM Protocol #4: Mastitis. Breastfeeding Medicine 2008;3(3): 177-80. 2. Christensen AF, Al-Suliman N, Nielsen KR, Vejborg I, Severinsen N, Christensen H, et al. Ultrasound-guided drainage of breast : results in 151 patients. Br J Radiol 2005;78(927): 186-88.

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  )#%$#$+ University of North Carolina Hospitals Patient information Chapel Hill, NC 27514

Lactation Microbiology test request form Coll. Date Coll. Time Coll. By

Atten MD Pager # MD Code Alison Stuebe 216-1005 30246 Ord MD Pager # MD Code

Chief complaint (Dx code) [ ] Sore Nipples (676.34) Specimen Type: Cultures LEFT nipple swab ARWND Culture, Aerobic – surface swab and gram stain RIGHT nipple swab YSTS Culture, Yeast Combine left and right swabs for culture

[ ] Acute mastitis (675.14) Specimen Type: Cultures LEFT breast, expressed milk ARWND Culture, Aerobic – drainage and gram stain RIGHT breast, expressed milk YSTS Culture, Yeast Combine left and right milk samples for culture

[ ] Open wound / (676.14) Specimen Type: Cultures [ ] LEFT nipple wound swab ARWND Culture, Aerobic – surface swab and gram stain [ ] RIGHT nipple wound swab YSTS Culture, Yeast [ ] Culture left and right swabs separately

[ ] Chronic breast pain (782.0) Specimen Type: Cultures LEFT breast, expressed milk ARWND Culture, Aerobic – drainage and gram stain RIGHT breast, expressed milk YSTS Culture, Yeast Combine left and right milk samples for culture

Specimen Type: Cultures LEFT nipple swab ARWND Culture, Aerobic – surface swab and gram stain RIGHT nipple swab YSTS Culture, Yeast Combine left and right swabs for culture

Other [ ] abscess, breast 675.14 [ ] Other specified nipple/breast infection 675.84 [ ] Candidiasis, nipple or breast 112.89 [ ]______Specimen Type: Cultures [ ] LEFT breast, expressed milk [ ] ARWND Culture, Aerobic – drainage and gram stain [ ] RIGHT breast, expressed milk [ ] YSTS Culture, Yeast [ ] Combine left and right milk samples for culture [ ] Culture left and right samples separately Specimen Type: Cultures [ ] LEFT nipple swab [ ] ARWND Culture, Aerobic – surface swab and gram stain [ ] RIGHT nipple swab [ ] YSTS Culture, Yeast [ ] Combine left and right swabs for culture [ ] Culture left and right swabs separately               #      "    !    $  '&%"          Instructions for lactation microbiology form  Sore Nipples (676.34)                                 !

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