Val - what a shame that the mastitis progressed to abscess.  You gave a very
full account of what happened, and ask why, when mom did everything she
could think of, did she still develop an abscess?  You also mention other
implicating factors (1) ultrasound treatment (2) this breast produced less
milk  (3) second baby with first dying at birth, so possible history of
engorgement (?scar tissue within the breast) (4) fibrocystic disease and (5)
family history of breast cancer.

From the way you described this case, which was very clear, I think the key
sentence was, "By 5 days the red area was worse and Mum went to her gp, who
was not concerned".  My gut feeling about this would be that the other
factors are red herrings (distractors).

Firstly, I don't think there is any research (is there? - could be wrong) to
show that ultrasound has any benefit in treating mastitis.  I worked with a
mom a couple of years ago who also had this treatment, and my main
impression afterwards was that the ultrasound just delayed diagnosis of an
abscess by reassuring the mom that she was "doing something", and did
nothing for the mastitis/abscess itself.

Secondly, having worked with maybe 10 - 12 cases of mastitis that progressed
to abscess (I hate them!) I've developed a "hunch" that mastitis becomes a
potential abscess *very early on* - i e within about 3 - 4 days of the first
Sx of mastitis.  In every single case for one reason or another (always
clear with hindsight) treatment was delayed past that vital 3 - 4 day
period.  So here's my care plan to prevent abscess (or post-mortem if you
like, about why an abscess occurred).

1.  Any Sx of pain and lumpy areas in the breast (plugged duct)? - drain
affected breast (breastfeed baby with breast compression, and/or manual
expression, pump, whatever) every 2 hours if awake, set the alarm and drain
every 3 hours at night.  Use cabbage in between and hopefully get more rest.

2.  If plugged duct has become mastitis (as above but with any kind of
accompanying inflammation, with or without fever) treat as above for 24
hours, then seek medical advice about an antibiotic.  The GPs here will
prescribe for any inflamed breast that walks through their door, and I
*agree* with this (I know it's controversial, but an abscess is just too
awful).  My criteria is 24 hours - if Sx are not resolving *well* within 24
hours then I think it's time to bring out the big guns (Abx).

3.  If mastitis has become abscess (as above, pain/lumpy area/inflammation)
and symptoms are not going away but becoming worse (I repeat, with or
without fever) then treat as above, but send mom back to the GP for a
diagnostic scan of the breast to check for abscess formation and ongoing
referral to a surgeon for incision and drainage.  It seems though that it
takes time for the abscess to become obvious enough for anyone to *do*
anything about it, and in my experience, the mom often goes on doing all she
can to clear it for 2 - 3 weeks before finally the decision is made to refer
to the surgeon, who then jumps around and acts as if it's a medical
emergency - which of course, it is!

It's such a shame - it's during those first 3 - 4 days of that
pain/tenderness and induration that we need to be jumping around and making
sure that the mom treats the Sx aggressively (drainage, drainage, drainage
...) so that it doesn't progress - to mastitis - or to abscess.

Regarding Val's query about mom continuing to express the affected breast,
but not breastfeeding from it, this sounds like the most logical way to go.
Usually the surgeon recommends continuing to drain the breast, and resuming
breastfeeding about a week after the expressed milk seems clear of
blood/pus. The baby needs to be positioned so that his mouth does not come
into contact with the incision.  Some of the mothers I have worked with have
elected to continue breastfeeding on the unaffected side and to
*graaaaaduallyyyy* suppress lactation on the abscessed breast by expressing
slightly less often and then less often again over a period of 2 - 3 weeks,
but this needs to be done with great care to avoid another flare-up of the
infection and a second abscess.

Best wishes to this mom, she's been through a lot.  It sounds as if she has,
indeed, done all she can, and it's not her fault if the "system" let her down.

Pamela Morrison IBCLC, Zimbabwe
malto:[log in to unmask]

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