Molly

Thanks for alerting us to the Cochrane Review on Antibiotics for 
mastitis in lactating women.  I just looked up the link you sent and 
found this plain language summary, which seems somewhat clearer than 
the abstract:

Plain language summary: Antibiotics for mastitis in breastfeeding women
Inflammation of breast or mastitis could be infective or 
non-infective. Infective mastitis is one of the most common 
infections experienced by breastfeeding women. The condition 
(infective or not) varies in severity, ranging from mild symptoms 
with some local inflammation, redness, warmth and tenderness in the 
affected breast through to more serious symptoms including fever, 
abscess and septicemia, which may require hospitalization. Recovery 
can take time, and there may be substantial discomfort for the 
affected mother and her baby. Mastitis usually occurs during the 
first three months after birth and result in the mother being 
confined to bed for one day, followed by restricted activity. The 
condition is associated with decreased milk secretion, decreased 
productivity, and in difficulties caring for the baby. This burden to 
mothers, along with the cost of care, the potential negative impact 
on continuation of breastfeeding, and the danger of serious 
complications such as septicemia, makes mastitis a serious condition 
which warrants early diagnosis and effective therapy. The review 
included two studies and approximately 125 women. One study compared 
two different antibiotics, and there were no differences between the 
two antibiotics for symptom relief. A second study comparing no 
treatment, breast emptying, and antibiotic therapy, with breast 
emptying suggested more rapid symptom relief with antibiotics. There 
is very little evidence on the effectiveness of antibiotic therapy, 
and more research is needed.

[Me again]  This review included only two studies of only 
approximately 125 women.  That's not nearly enough, IMHO, to say that 
there is little evidence on the effectiveness of antibiotic therapy 
..... and yet this inconclusive expert opinion will be enshrined 
forever in a Cochrane Review to guide future practice.

I know that we set great store by Cochrane Reviews.  But speaking 
entirely personally, I'm coming to the conclusion that some of them 
are not terribly helpful.  I think it's the rather "selective" way 
that their so-called selection criteria are determined.  When you 
think about it, anyone could skew the results of almost any review 
article by deciding in advance what to include and what to 
exclude.  The insistence on relying solely on randomised controlled 
trials misses the extremely useful observational trials that have 
been done, leaving out some really crucial research.  I'm also 
becoming concerned about planned randomised controlled trials - when 
certain drug therapies are already known to combat certain infections 
- and the implications of withholding therapy from mothers and babies 
in the placebo arms.  Why do this?  Just so that randomisation can be 
achieved to subsequently "prove" that something already tried and 
tested to work really does so??

This little review will not alter my experience and observation of 
working with mothers who get mastitis which has shown me that if you 
catch engorgement and plugged ducts early enough (within 24 hours of 
the first Sx) and resolve them very promptly with frequent and 
thorough breast drainage, then mastitis should be almost entirely 
preventable without the use of antibiotics.  But if these conditions 
are left - and the longer they're left the higher the risk - then 
treatment with an appropriate antibiotic (and you can culture the 
milk to find out what that is) _and_ continued thorough breast 
drainage can almost always prevent mastitis progressing to 
abscess.  On the other hand, when mothers don't know what to do and 
when doctors delay prescribing, then the risks of lactation failure 
and abscess, with much pain/suffering and disastrous consequences to 
everyone - are high.  Consequently, my mastitis care plan would 
include daily face to face follow-ups until it can be _seen_ that any 
fever, pain/tenderness, inflammation and induration are resolving, 
and prompt medical referral for advice about antibiotic therapy, or 
repeat therapy, until I know it's quite over - irrespective of some 
little Cochrane Review of 125 subjects!

Pamela Morrison IBCLC
Rustington, England

-------------------------------------
Date:    Mon, 15 Feb 2010 09:22:23 -0800
From:    Molly Brannigan <[log in to unmask]>
Subject: Mastitis - Evidence for Antibiotics?

Hello All-

Speaking of evidence-based practice, has anyone read this Cochrane review
which suggests that their is insufficient evidence for the efficacy of
antibiotics for mastitis!?

Cochrane Database Syst
Rev.<javascript:AL_get(this,%20'jour',%20'Cochrane%20Database%20Syst%20Rev.');>
2009
Jan 21;(1):CD005458.
Antibiotics for mastitis in breastfeeding women.

Jahanfar 
S<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Jahanfar%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract>

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