A flurry of emails about breast abscess has come to me over the past few weeks. Unfortunately too many came after the mother had an incision and drainage procedure on the breast which is not the best treatment. The following is an excerpt from my recently revised book, Dr Jack Newman’s Guide to Breastfeeding. Breast abscess An abscess is a pocket of pus formed in an infected area, because the body could not completely fight off the infection on its own. It is the body’s way of preventing infection from spreading. In other words, formation of an abscess is a protective mechanism. Without any medical intervention, an abscess will usually work its way to a surface and drain, which cures it. An abscess in the brain is serious, even potentially fatal. But while a breast abscess can be painful it is not usually dangerous. How to Diagnose an Abscess Usually the mother will have a history of mastitis and a lump in the breast which is painful if squeezed but not necessarily painful when not touched. Sometimes it feels as though there is fluid in the lump. The skin may look very red, but sometimes there is little redness. And sometimes the lump is not painful even when touched. If I suspect an abscess or if I am unsure what the diagnosis is but believe the lump contains fluid, I will aspirate it with a needle and syringe. It is a bit tricky because you don’t always know where to put the needle; as well, sometimes the pus is very thick and hard to get out. If aspiration yields pus, the mother has an abscess. I continue aspirating as much as possible because, at least temporarily, the mother gets relief from pain. If aspiration yields milk, the mother has a milk cyst (galactocele). I usually stop aspirating the lump at that point as milk cysts will almost always refill quickly. If it’s not interfering with breastfeeding, it’s better to leave it alone. A milk cyst will dry up when the mother is no longer breastfeeding, but this is not a reason to stop breastfeeding. On one occasion, aspiration yielded a clear yellow fluid (serum). The laboratory sent back an urgent report, that there were cancerous cells in the fluid. The mother’s lump, which was called a blocked duct by her doctor for several months, was actually breast cancer. How to Treat an Abscess In 2004 a study Ulitzsch D, Nyman MKG, Carlson RA. Breast abscess in lactating women: US-guided treatment Radiology 2004;232:904-909 showing that the approach described below was superior in breastfeeding women as compared to incision and drainage was published. However, we had started the same approach some time before this article was published with the help of the radiologists at North York General Hospital in Toronto. Essentially: 1. The abscess is located and “mapped” with ultrasound. 2. A catheter is placed, as far as possible from the nipple and areola, into the abscess and left in place. 3. The mother is encouraged to continue breastfeeding on both breasts. 4. We usually continue antibiotics until the catheter is taken out. 5. The catheter is withdrawn when there is no further drainage from the abscess. This can be done by a nurse who visits the mother at home. In the 10 or more years since we have used this approach to treatment, more than 100 mothers with breast abscesses have come to our clinic. All were treated in this way, all continued breastfeeding without interruption on both breasts, and amongst all these mothers only one had a fistula, which healed without special treatment in a few weeks and only one had a recurrence of the abscess which also healed after repeating the treatment. This approach is far superior to incision and drainage. Why? 1. Too many surgeons open the abscess with an incision which is much too close to the nipple and areola. In fact, many prefer using a peri-areolar incision (around the line between the brown part of the breast and the rest of the breast). This is apparently done for “aesthetic” reasons, but as you can see from the photo, it doesn’t always turn out to be an “invisible scar”. A peri-areolar incision increases the risk of a fistula, makes it impossible for the mother to put the baby to that breast (because of pain) and compromises milk production, not only for this baby but also for any future baby. 2. There is an approximate 7% recurrence rate with surgery. The procedure we now recommend has a recurrence rate of much less than 1%. 3. Often mothers are admitted to the hospital and given a general anesthetic for the incision and drainage. Ultrasound localization and placement of a catheter is done on an outpatient basis with local anesthetic. 4. Pain from an incision and drainage is more severe and lasts longer than pain from ultrasound and catheter drainage (most mothers describe pain as minimal). 5. Radiologists tend to be much more breastfeeding-friendly than most surgeons. Of course, some surgeons are breastfeeding friendly and not all radiologists are, but once I pointed out to the radiologists that the mother did not have to interrupt breastfeeding on the side of the abscess, they changed their advice to stop. I have often had very strong resistance from surgeons who feel strongly that the mother should stop breastfeeding on both sides. Here is an email from a mother we saw at the clinic in July 2014. It is posted here with permission from the mother: I know you’re a busy man but I just had to send you a quick email to thank you for the support and guidance you gave me back in July when I was experiencing some major issues with breastfeeding. I had just about every complication that a breastfeeding mother can have resulting in an abscess in my left breast. After the surgeon did an incorrect incision to drain it which left me with more issues, you encouraged me to keep going when I was at a total loss. I did keep going and have now been able to experience the incredible side of breastfeeding. I only had to supplement with formula for 5 days while my supply increased (I did this with the use of a lactation aid which kept baby on the breast and helped to increase my supply, not with a bottle) and otherwise have been nursing exclusively since my now 4.5 month old was born! I am currently only able to nurse from one side due to the damage to the other side but I’m optimistic that I’ll still be able to get her back on the left side as I’ve kept it producing milk and it’s pretty much healed up…just a matter of getting her back used to that breast. But even just being able to use one side I have to say that breastfeeding my beautiful and healthy little girl has been the most incredible experience ever…like nothing else!! So…thanks again for everything! I appreciate your help and expertise more than you’ll ever know!
Posted on: Sun, 02 Nov 2014 09:39:25 +0000
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