Becky wrote asking for clarification on my thoughts that antibiotics might
be needed if breasts were becoming engorged in a mom who had had a previous
breast reduction, saying "We see *many* bottle-feeding moms in the states
that aren't treated with anything, and they don't need antibiotics.  An OTC
anti-inflammatory would probably work just as well."

Firstly, although BF is *heavily* promoted here, it doesn't *always* take!
And there are a few moms who make the change-over to bottle-feeding the
minute they leave the hospital (48 - 72 hours postpartum) and then become
engorged and run the risk of subsequent mastitis too.  And no, antibiotics
would not be appropriate merely as a prophylactic, nor for ordinary
engorgement (drainage, drainage, drainage!)

However, from an anatomical point of view a mom who decides to abandon
breastfeeding in the first week is *different* from a mom who has had a
breast reduction (or other breast surgery) in that she will usually leak
spontaneously and - potentially - the ducts have the capability of draining
if only she will make the attempt.  But if the ducts have been severed and
have not re-canalized this is just not possible.  Furthermore, the surgery
may have reduced sensation to the nipples so that the milk-ejection reflex
cannot be stimulated.  IMHO lactation following a breast reduction (or a
previous abscess, lump, whatever) is a particularly risky case because it
takes several days before it becomes clear that the breasts *are* draining.
If they are - well and good. If they are not and/or some lobes become
indurated and will not respond to attempts to massage and drain, then I
watch for fever and inflammation.  If either of these occur then I refer
*very* promptly to the mom's doctor, knowing that an antibiotic will be
prescribed.  A large part of the difficulty lies in knowing whether it is
infective or non-infective mastitis, I agree.  How do you decide in those
first l - 2 crucial days?  I don't think we can yet, but delay in treatment
is the most likely cause of progression to abscess.  I guess the deciding
factors for me are induration with either severe pain and fever, or
inflammation.  You *know* the ducts are not draining, you can only *guess*
at whether the inflammation (mastitis) will progress to abscess or resolve
spontaneously.  The consequences (abscess) are too awful to dither.

Regarding mothers who elect *not* to breastfeed: someone else wrote recently
asking how suppression of lactation would be managed. If I see this in time
I recommend *good* drainage as the milk comes in - express/pump as often as
necessary to keep the breasts comfortable, especially days 4 - day 9
postpartum when the potential for severe engorgement exists, using cabbage,
changed every 2 hours while mother is awake, and then *very* gradually
express/pump slightly less and slightly less so that the breasts stay a
*little* too full, just enough to get the message through to the
milk-producing cells to make less, but not so that the breasts become so
engorged (or lumpy) that they cannot drain at all.  It seems to take about
two weeks altogether for lactation to be suppressed by this method, but in
this way mom avoids damage to the breast tissue and pain/mastitis/abscess.
Furthermore, if mom chooses to re-lactate later, it is easier if the
milk-producing cells remain intact.

I hope this clarifies.  I posted yesterday in answer to Helen's thoughts too
about an anti-inflammatory.  Yes, anti-inflammatories are good, but I think,
in particularly risky cases (previous breast surgery is a red flag to me!) I
would not like to rely on these alone.

Pamela Morrison IBCLC, Zimbabwe