KEEPING ABREAST Therapeutic choices for the treatment of lactational mastitis.Valerie Rzepka, NP-PHC Student
Nellie TurnerHistory of Presenting Illness: 31 years old• Mid-October, presented at ER (pseudonym) with: • right breast engorgement • erythema • Firmness • edema • generalized malaise • fever • chills• Treated for lactational mastitis with Cephalexin 500mg po, qid x 10 days• Returned after completion of antibiotics for continued unresolved symptoms.• Cephalexin extended for 5 days.• Returned 1 week later with continued, unresolved symptoms
Nellie TurnerPast Medical History 31 years old (pseudonym)• Nellie reports her health to be quite good: • Planned pregnancy, previously used NuvaRing for contraception. • Mild anemia during pregnancy • Mild eczema in the winter months, • Occasional migraines • Chronic neck and back pain secondary to MVC in 1996 • Deviated nasal septum – ENT Surgery deferred due to pregnancy. • No chronic medical conditions, • No known allergies, • She denies weight loss and change in diet. • Reports significant change in her energy, activity level and sleep pattern since the onset of the infection.
Nellie TurnerPast Medical History 31 years old (pseudonym)• Gravida 1, Para 1. Followed by Nottawasaga Midwives for this unremarkable first pregnancy.• Spontaneous Vaginal Delivery of a healthy baby boy at 38 weeks gestation on July 10, 2012.• Baby is solely breastfed every three to four hours or on demand.• Aside from cracked nipples, treated with a lanolin-based over-the-counter ointment, has had no issues with lactation, latch or suck.
Nellie Turner 31 years old Baby Jonah (pseudonym) (pseudonym) • Baby born via SVD, weight: 3620g. (7.9lbs) • Satisfactorily growing and gaining weight according to the growth chart. • Currently 4 months old, active, alert, and is meeting all of his developmental milestones. • Feeds every 3 to 4 hours, and has 6 to 7 heavy wet diapers per day, along with 2 to 3 yellow seedy stools.• Since initiation of antibiotics in October, Nellie reports Jonah has been having loose green stools, but no other ill effects.
• Inflammatory condition of the breast3,5• May or may not be accompanied by infection.1,3.• Usually associated with lactation, so it is also called “lactational mastitis”1• Occurs in 9-12% of all breastfeeding women2,3,4,5• Most common in the 2nd or 3rd week of breastfeeding, but can occur at any time. 2,5• Usually associated with Staphylococcus aureus (S. aureus), introduced through a break in the skin (cracked nipple), which characteristically can also cause abscess development.4• Nellie reports having cracked nipples in the week prior to the infection.
• Risk Factors associated with Mastitis:5 • Cleft lip or palate • Cracked nipples • Infant attachment difficulties • Local milk stasis • Missed feedings • Nipple piercing • Plastic-backed breast pads • Poor maternal nutrition • Previous mastitis • Primiparity • Restriction from a tight bra • Short frenulum in infant • Sore nipples • Use of a manual breast pump • Yeast infection
1. To provide prompt and effective treatment so to prevent complications such as an abscess.2. To provide effective pain relief.3. To encourage continued breastfeeding.
Non-Pharmacological• Improved breastfeeding technique/ alternative positions. 5• Continuation of breastfeeding, especially on affected breast, as often as possible. • Milk from a breast with mastitis contains increased levels of some anti-inflammatory components that may be protective for the infant. • Some infants may dislike the taste of milk from the infected breast, possibly because of the increased sodium content.5 • Holding the infant with the chin towards the affected part of the breast, helps to facilitate milk removal from that section• Apply heat: warm compresses, warm bath or shower;• Gentle massage of any lumpy areas while the infant is feeding to help the milk to flow• Avoid anything that could obstruct the flow of milk, such as tight clothes or bra• Mom should drink plenty of fluids and get lots of rest 5• Application of Cabbage Leaves 17 or Sliced Potatoes 16 to the breast have no scientifically proven efficacy, but anecdotal reports are supportive.
Non-Pharmacological –Lactation Consultation and Counselling• Mastitis is painful and frustrating, makes many women feel very ill, and can leave infants unsatisfied after feeding.• In addition to effective treatment and control of pain, a woman needs emotional support.• May have received conflicting advice from professionals, family members or friends. May have been advised to stop breastfeeding, or given no guidance either way. May be confused and anxious, and unwilling to continue breastfeeding.• Needs reassurance about value of breastfeeding; it is safe to continue; milk from the affected breast will not harm infant, and that breast will recover both its shape and function subsequently.• Needs encouragement• Needs clear guidance about all measures needed for treatment, and how to continue breastfeeding or expressing milk from the affected breast.• Will need follow up to give continuing support and guidance until she has recovered fully.
Mastitis Adapted from: Mastitis Lactational Algorithm http://www.thewomens.org.au/MastitisLactationalAlgorithmHeat, rest and drain the 24 hrsbreast• Keep feeding frequently• Heat before feeds• Massage during feeds• Analgesia (Tylenol or Advil) No Pharmacological Generalized Alternatives symptoms present? • Fever • Aches • Lethargy Yes
Pharmacological Commence Alternatives Antibiotics If no overall improvement Redness/ in 48 hours, hard after 5 return to If improving: days: clinic. Complete Continue course of antibiotics antibiotics. x 10 days Milk for Ultra C&S sound to r/o abscess Refer/ AdmissionAdapted from: Mastitis Lactational Algorithm for IV Abxhttp://www.thewomens.org.au/MastitisLactationalAlgorithm
Pharmacological• Antibiotic treatment is indicated if either: • cell and bacterial colony counts and culture are available and indicate infection, or • a nipple fissure is visible, or • symptoms do not improve after 12-24 hours of improved milk removal, or • symptoms are severe from the beginning.
Pharmacological : 5, 7,9, 10, 11, 12, 13, 14, 15 • Amoxicillin/clavulanate, (AmoxiClav) 875 mg twice daily • Cephalexin, (Keflex), 500 mg four times daily • Ciprofloxacin, (Cipro), 500 mg twice daily • Clindamycin, (Biaxin), 300 mg four times daily • Cloxacillin, 500 mg four times daily • Trimethoprim/sulfamethoxazole (Bactrim, Septra), 160 mg/800 mg twice dailyUsual courses of oral antibiotics are 10 to 14 days.If patient wishes to continue breastfeeding, safety of the infantmust be considered.
Nellie Turner 31 years old (pseudonym)Prescription Drug Name etc. Dose, Route, Freq, Duration Rating (1-5) NP Pick C A S E SAmoxicillin/clavulanate, 875 mg, bid x 10 days 4 1 4 1 ✓(Clavulin)Cephalexin, 500 mg, qid x 10 days 4 5 3 1 5 ✓ ✓(Keflex)Ciprofloxacin, 500 mg bid x 10 days 4 1 5 1 ✓(Cipro)Cloxacillin 500 mg qid x 10 days 4 5 3 2 5 ✓Trimethoprim/ sulfamethoxazole 160 mg/800 mg bid x 10 1 1 1 3 1 ✓ ✓(Bactrim, Septra) daysRef: 5, 7,9, 10, 11, 12, 13, 14, 15
Nellie Turner 31 years oldConsultation – Collaborating physician 10: (pseudonym)• Nellie returned after her 10-day course of Cephalexin 500mg qid with unresolved symptoms• Cephalexin was extended for 5 days, and Nellie was ordered a breast ultrasound• She returned again once antibiotics were complete, with continued unresolved symptoms. Ultrasound was clear.• Collaborating physician was consulted, and recommended a course of Trimethoprim/ Sulfamethoxazole 160/800mg bid x 10 days.
Referral10 - General Surgery: • if ultrasound shows breast abscess; • for needle aspirate, or incision and drainage of abscess.
Nellie Turner 31 years old (pseudonym) The Therapeutic I Community Health Centre 123 University Avenue, Anytown, ON. N0N 0N0 Phone 416-321-0987_________________________________________________Name: Nellie Turner (DOB: January 1, 1981, NKDA)Address: 1000 Fantasy Lane, Anytown, ON. L0R1B0Date: November 22, 2012 Trimethoprim/ sulfamethoxazole 160 mg/800 mg bid x 10 days. Take one tablet by mouth, twice daily until finished.M: 20 tabsR: 0 repeats Nancy Nurse RN (EC), 54321 (signed) Nancy Nurse, RN (EC), 54321 (printed)
Nellie TurnerMonitoring and Follow up 31 years old (pseudonym)• Important to monitor baby Jonah to signs of dehydration, or secondary infection (e.g. thrush)• Client returned after the 10-day course of, reporting that symptoms have nearly entirely resolved, her energy level had returned, and the erythema and had engorgement had disappeared.• The painful, firm thickening has nearly completely resolved.Acceptability• Client was satisfied with resolution, happy to return to normal functioning, and glad that Baby Jonah continued to do well.
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