Hello Janet,

The 8th edition of the Lawrence & Lawrence text, Breastfeeding:  A Guide for the Medical Profession, includes this information on breast abscess in Appendix J, which is also from the current protocol on mastitis from the Academy of Breastfeeding Medicine:

"Abscess: If a well-defined area of the breast remains hard, red, and tender despite appropriate management, then an abscess should be suspected. This occurs in about 3% of women with mastitis. The initial systemic symptoms and fever may have resolved. A diagnostic breast ultrasound will identify a collection of fluid. The collection can often be drained by needle aspiration, which itself can be diagnostic as well as therapeutic.  Serial needle aspirations may be required.  Ultrasound guidance for needle aspiration may be necessary in some cases. Fluid or pus aspirated should be sent for culture. Consideration of resistant organisms should also be given depending on the incidence of resistant organisms in that particular environment.  Surgical drainage may be necessary if the abscess is very large or if there are multiple abscesses. After surgical drainage, breastfeeding on the affected breast should continue, even if a drain is present, with the proviso that the infant’s mouth does not come into direct contact with purulent drainage or infected tissue. A course of antibiotics should follow drainage of the abscess. "

From the 2021 edition of Wambach & Spencer's Breastfeeding and Human Lactation: 

"An abscess, like a boil, is basically a collection of pus that must be drained . . . . For small abscesses (3 cm or smaller) the recommended first line of treatment is fine-needle aspiration, single or repeated, preferably under ultrasound guidance.  Percutaneous aspiration without ultrasound guidance is also a choice for these small abscesses, especially in facilities without ultrasound.  For abscesses larger than 3 cm, a percutaneous suction catheter can be placed for 3 to 7 days and appears to be effective, low in complications, and cosmetically acceptable.  An oral antibiotic effective against penicillin-resistant staphylococci for 10 days is used in combination with the aspiration.  For a larger abscess, the physician makes an incision and drains the area.  A drain is placed in the incision to promote drainage; in addition, manual expression helps to eliminate pus and milk.  The incision heals from the inside out within a week or two.  Oral antibiotics are also used with this treatment.  Dr. Susan Love (2000) recommended that her patients go home and rest; start taking daily showers (after 24 hours) and letting the water run over the breast to wash away bacteria; and then redress the incision."  

Over a decade ago, I observed one large, firm area of the breast that was not red, with a somewhat rectangular shape in the upper quadrants.  The mother denied any tenderness in the area, but the area was distinctly firm to the touch, and she reported that when she pumped that breast, only a brownish fluid came out of the nipple.  The mother reported earlier signs and symptoms that were consistent with mastitis in that part of the breast, but stated that her physician had advised her that she did not have mastitis.  As we know, when mastitis is not treated in a timely manner or is not treated at all, these are risk factors for breast abscess.   The consult occurred on a weekend, when the patient's physician did not have scheduled office hours, and neither she nor I could reach a live person there - - only a telephone recording at the doctor's office number during after-hours with advice to go to the nearest emergency room as needed.  I advised the mother to continue trying to reach her physician, and to go to the emergency room if she was unable to reach her physician that day.  In telephone follow-up with this mother, she confirmed that she was diagnosed with a breast abscess and treated with incision and drainage, followed by packed gauze to the wound for over two weeks.  She also followed up in the lactation office after the drainage tube and packing was removed - - I think she needed in-person communication with her IBCLC to reflect on the stress of not being promptly treated for mastitis (she wasn't treated at all), which led to the even more stressful experience of a large breast abscess.  

Another patient saw her physician not once, not twice, but three times for classic mastitis symptoms without being treated for mastitis (this was in the same city - - could this have been the same physician as in the above case?).  This mother also stated her physician insisted she did not have mastitis at each of those three visits.  I saw her after her first visit to her physician for signs and symptoms consistent with mastitis, and referred her back to her physician to rule out mastitis.  The mother requested another home consult for unresolved mastitis symptoms, and on each of our two home consults, I referred the mother to her physician, in addition to our standard recommendations for mastitis care.  Of course there was the challenge of patient teaching in the context of the cognitive dissonance of a (male) physician saying three times to the patient:  "No mastitis here" versus the IBCLC referring the patient back to the physician, not once but twice, to rule out mastitis.  At the second consult, I was then in a position to discuss, with utmost diplomacy, the option of a second medical opinion for this mother's signs and symptoms that were consistently being untreated by her physician.  She had felt well cared for during her pregnancy by her physician, and it was challenging to discuss her signs and symptoms that were consistent with mastitis, while not acknowledged as such by her trusted physician.

A year or two later, in the same large urban area as the two above-mentioned cases and during a home visit with another client, I noted bilateral redness that was warm and painful to the touch in both lower quadrants of both breasts.  The mother stated she had already called her OB-GYN, who wanted her to be seen by a lactation consultant before calling in a prescription for mastitis, and the mother was instructed by this physician to call her while the lactation consultant was still present - - her doctor wanted to speak with the LC.  I advised the mother that her clinical signs and reported symptoms were consistent with mastitis in both breasts.  The mother then called her OB-GYN who did indeed want to speak with me, and the mother handed me the telephone.  I identified myself and gave a report of my visual and manual assessment of the breasts, as well as the mother's reported symptoms.  The OB-GYN thanked me for the information, saying she wanted to be sure it was mastitis before calling in a prescription for this patient, and asked to speak again with her patient.  I handed the phone back to my patient, who chatted very briefly with her OB-GYN, and then they ended the call.  The mother said to me, "She's going to call in a prescription of antibiotics for me.  She just wanted to be sure what was going on first, and she appreciated your description."  

Some days lactation management is much like climbing difficult terrain in the face of various obstacles.  On other days, one could fly on giddy happiness alone.   I was in near disbelief and so very grateful after that particular consult for the physician's diagnosis of bilateral mastitis that followed her brief phone conversation with her patient's IBCLC.   That mother was so fortunate to be given the most prompt treatment of her symptoms, and all patients deserve such prompt care.  

Let us hope that your patient's physician will reconsider the approach of proclaiming that breastfeeding shall end if the abscess does not resolve within the physician's stated timeline, as if lactation will immediately cease and desist upon the physician's command.  If the physician's response is to do nothing else to help this mother but to advise breastfeeding cessation, such unfortunate medical advice may exacerbate the abscess.  

Sending warmest wishes for this mother's recovery, 

Debbie

Debra Swank, RN BSN IBCLC
Program Director
More Than Reflexes Education
Elkins, West Virginia USA
http://www.MoreThanReflexes.org

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