Well, after quite a few years, the last 7 as a hospital-based LC, I have
seen my first breast abcess, and it was a *big* one.  Unlike a recent
poster, I dealt with cooperative MD's who were open to collaboration, and
the mother is still breastfeeding on the unaffected breast.  I do wonder in
hindsight, of course, whether we should have seen this coming, since this
was a 5-week postpartum mother we had been dealing with all along.
Comments are very welcome so we can learn from this.

This was a G3P1 mother who reported having "not enough milk" with her first
child, and she thought perhaps she had not breastfed often enough.  Baby
was born on 3/15 and was seen by my colleagues several times to deal with
cracked nipples, worse on the right side, and a decreased milk supply.  She
is a little slow mentally and it has always been hard to pull from her
exactly what is going on.  On 4/1 with phone follow-up she reported not
feeling well, having a cold, and the doctor put her on amoxicillin.  On 4/7
my colleague noted a golf-ball sized lump under her right nipple that was
painless and baby got less milk from that side during feeding weights.  The
lump was noted to be the same on 4/16, also on 4/16 mom started 3
fenugreek/day and increased to 6/day on 4/19.  On 4/21 the lump was larger
and now painful during nursing.  Never any reports of fever or feeling
worse than the "cold" symptoms she reported on 4/1.  The LC emailed the
doc, was thinking maybe galactocele (we've never seen one of those
either!), mom was seen on 4/22 and started on dicloxacillin.  On 4/23 baby
got the most ever during a feeding we weighed (54cc) but the breast was
throbbing.  Late on 4/24 she was sick enough to be hospitalized--rt. breast
was sore, swollen, red, and she was started on IV antibiotics.

I saw the mother in person for the first time on 4/25.  She was also seen
by a surgeon later that day so I tagged along.  The surgeon did not feel
anything indicative of an abcess at that time since the whole breast was
swollen and firm.  We had a nice chat at that time--the surgeon (a woman)
was open to whatever pumping, icing, etc. I suggested but didn't quite
understand why the mother didn't just wean to formula.  She thought BF was
fine if you had the time, but "surely you don't know any MD's who BF!"  I
named off quite a few, and got her a copy of the Dec. AAP statement to read
to gently try a bit of educating.

Mom continued on the IV antibiotics with little change so 4/27 was
scheduled for surgery.  Learning from Lactnet, I called the surgeon, spoke
to her assistant, and asked (*really* politely) if she'd please make the
incision radially instead of circumferentially.  She called me back herself
to ask why (I explained about cutting less ducts), and we discussed where
the best place to make the incision would be.  Later that day she called to
ask me to come down to surgery, had me gown and glove so I could look and
feel inside the mom's breast at what she'd found. (!) First of all I was
impressed and grateful for the learning experience.  But oh my
goodness--there was intact breast tissue of about 1/2 inch underneath the
outside skin and nipple of the breast, and breast tissue along the chest
wall, but in the middle there was just a cavern.  I could put my fingers
all the way through her breast underneath the nipple and across to the
other side.  No wonder she had not been pumping much on that side--the
ductal connections were gone!

After surgery we decided to just see what happened--there was no fullness
at all for about 24 hrs., she pumped then and got 10cc so started pumping
at that point, got nothing a few times and just another few cc's, so we
decided to stop trying.  Having seen the internal destruction, there didn't
seem to be a lot of point.  It was interesting to me that neither her MD or
the surgeon seemed to know that individual breasts and even individual
lobes of the breast can cease production and the rest continue, so I got a
chance to educate there, also.  She went home 4/30 with about a 1" open
incision with drain in place, nursing on the other side.  Since her supply
was always marginal I don't know what will happen, but once she's healed
and off the antibiotics we'll probably restart the fenugreek and discuss
Reglan.

In hindsight, I'm thinking maybe the "cold" she had on 4/1 was really a
breast infection, (obvious portal of entry from the badly cracked nipple
earlier) and the painless lump shortly after was the abcess starting?
Should we have seen this coming?  She cultured out penicillin-resistant
staph, so the infection would have been resistant to the amoxicillin,
right?  Was it just a coincidence that she got so sick after the
dicloxicillin was started?  Did the fenugreek have any effect?  Thanks for
any thoughts if anybody read this whole thing!

Becky Krumwiede, RN, IBCLC, Appleton, Wisconsin
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