In response to Rebecca's post about unresolving infection, I feel for this
mother.  Breast abscess is evidence of a complete breakdown of preventive
care IMHO and about the worst thing that can happen to a new mother.  I've
worked with more abscesses than I care to think about.  They often take far
too long to diagnose, and after surgery the affected breast takes far too
long to heal.   The case that you describe Rebecca sounds firstly as if it
was a mis-diagnosis of Thrush, so that treatment of the original infection
was delayed.  The fact that milk cultures grew nothing was probably because
the abscess had walled itself off, and no infection was leaking into the
milk.  If the mother is again experiencing symptoms of infection and she
has not been draining the affected breast because she hopes that it will
dry up - and for "emotional reasons" - wants to be done with it, I think
you need to explain to her that she cannot do this yet, until the whole
infection is resolved.

If this was my client I would refer her back to her surgeon with a request
for another culture to identify exactly what organism is causing the
recurrence of pain, inflammation and swelling, and treatment with the
appropriate antibiotic.  If a further abscess has occurred (visible perhaps
with an ultrasound scan?) then that, too, will obviously need to be
surgically drained.  I would also impress on the mother that she needs to
keep this breast *extremely* well drained by whatever means possible until
*all* symptoms have resolved, perhaps every 2 - 3 hours around the
clock.   I would express much sympathy and regret that this is necessary,
and say I understand that she just wants it to go away, but this is not
possible.  Milk will leak from the incision, yes.  It will be messy and
painful, yes.  But eventually it will heal, and healing is being *delayed*
by her denial and inaction.  If she wants to shut down that breast she can
- but later, not now, not until the infection is over, and then only very
very gradually.

I'd forget the possibility of Thrush and antifungals.  I'd even forget the
dietary supplements.  I'd think infection, infection,
infection.  Antibiotics and drainage - yes, if necessary for a month or so
- for as long as it takes to *completely* resolve.  There are no choices in
this kind of situation.

Pamela Morrison IBCLC

Date:    Fri, 3 Sep 2004 14:03:49 -0500
From:    Rebecca DeYoung Daniels <[log in to unmask]>
Subject: Unresolving Infection

Last month I presented a situation where my client had appeared at 6 weeks
w/ multiple problems, many due to bad advice by her now former physician.
In brief, she transferred to a very good and breastfeeding-friendly
physician where she was given a Diflucan 'script for a month.  We got milk
supply back up, but her right breast was still quite indurated after a 2nd
round of antibiotics for mastitis.  Milk cultures were obtained and nothing
unusual grew.  Short version of a very long story is that she has now been
hospitalized twice in the last 3 weeks...once for IV antibiotics and the
second time because her doc was concerned we were dealing w/ inflammatory
breast cancer given the continued induration.  Biopsy came back benign, she
had a very deep abscess drained 10 days ago and has been on IV, then oral,
antibiotics since then.  The drain tube is still in place.  She is again
experiencing excurciating throbbing, increased redness and continued
induration of this breast.  She remains on Diflucan, but does have some
slight symptoms of vaginal yeast.  Meanwhile, she was in the process of
reducing her expressing on the right side for emotional reasons after the
drain tube was placed.  She just wanted to be "done" with that breast and
the left side responded to increased nursing and is making enough for her
little girl.  She does have some leaking of milk in the incision and a few
drops leak on the right breast, but she cannot express anything.

Here are my questions (other than I am frustrated for her...she has done
*everything* to keep breastfeeding going)...
1.  One surgeon has told her to wean completely or she will continue making
milk on her right side and that the continued milk production is the cause
of the problems.  She wants to continue nursing on the left side, but she
also just wants the right breast to be better.  I've given her the textbook
information and my experience w/ drying up one side.  Any other helpful
information?  *I want to know WHY this is happening...not just solutions
that we think might help "it" go away.  What is IT?*
2.  Following #1, I think it's odd that this is a recurring event.  She
can't be on antibx forever and I have a call in to her doc re.
antibx-resistant strains and whether they checked that angle.  Could it also
be the ugly yeast rearing its head somehow or is that far-fetched?
Cellulitis is definitely part of the picture and I know that takes time to
resolve, but this redness and throbbing that was gone and is now back???
3.  I would really like her to see a breast doc; KU Med is the main one in
our metro area.  There is at least one (I'm told) who is
breastfeeding-friendly, but I would like to equip her w/ good questions
before she walks into a potluck clinic setting.  Is this a silly idea?  Her
current general surgeon is competent, but not extremely
breastfeeding-knowledgeable...for example, the incision for the abscess
drainage and tube placement probably severed more ducts than necessary,
IMHO.
4.  BTW, she's also been taking probiotics, grapefruit seed extract (used it
both topically and orally) and her mother is a professor of clinical
nutrition who has loaded her w/ all the right foods.  Anything else to think
about it in this arena?
5.  This scenario has been persisting for several months.  Any advice for me
since I am exhausted, both resource-wise and emotionally???  Her new family
doc is wide open to your advice, too.  He's been a local LLL medical
associate and wants this to work.

Thanks so much!  No suggestion is too trivial; she welcomes the assistance
and asked me to post.

Frustrated in KS,
Rebecca DeYoung Daniels, MBA, RD, LD, IBCLC, RLC & MOM to 5
<

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