Breast Surgery and its effect on breastfeeding (part 2)
There are surgeries that are done on the breasts before a woman has children and can impact her ability to produce milk.
Blebs/blocked ducts/mastitis and on occasion, abscess, usually occur when the mother has an abundant milk supply but the baby does not have a good latch. A galactocoele seems to arise in a blocked duct if the blocked duct does not resolve quickly.
And why does the baby not latch on well?
- Use of artificial nipples such as bottles, and nipple shields, and more than very occasional use of pacifiers
- The baby has a tongue tie. Some tongue ties are obvious, but many tongue ties are more subtle and require an evaluation that goes farther farther than just looking but includes feeling under the baby’s tongue, evaluating the upward mobility of the tongue, as well and knowing what is normal and not normal. Unfortunately, few health professionals, including many lactation consultants, know how to evaluate whether or not the baby has a tongue tie.
- The mother has had a decrease in her milk supply. On the other hand, blebs/blocked ducts/mastitis may occur because milk supply has decreased. Recurrent blocked ducts and sometimes even a single blocked duct or mastitis may result in milk supply decreasing. Late onset decreased milk supply is common and results the baby slipping down on the nipple and pulling at the breast. The baby may pull off the breast when milk flow slows resulting in a breast that does not drain well. In fact, the mother may feel her milk supply is still good, even “overabundant” because the breasts are frequently “full”, even immediately after a feeding. For more information on late onset decreased milk supply and what can be done. A common cause of late onset decreased milk supply is feeding the baby on one breast at every feeding and worse, “block feeding”. Click these links Really good drinking with English text, Twelve day old nibbling, English Text, “Borderline” drinking for video clips showing babies drinking well at the breast, or not. Watch the videos, read the texts and then watch the videos again. Following the Protocol to manage BM intake may change things so the baby does gain well.
Galactocoele or milk cyst
Having made the diagnosis, I believe the best thing to do with a galactocoele is to leave it alone. I will aspirate a galactocoele once to prove the diagnosis as neither history nor physical examination distinguishes it from other lumps in the breast. If the aspiration yields milk, the lump is a galactocoele. If it yields pus, it is an abscess.
True, when palpating the lump, one usually gets the impression that there is fluid in the lump, but not always, especially if the galactocoele or abscess are quite deep in the breast. Also, the feeling of fluid in the lump does not distinguish a galactocoele from an abscess. An abscess tends to be tender if squeezed, but not particularly painful unless rapidly enlarging. A galactocoele is usually not tender and not painful unless rapidly enlarging.
Once the diagnosis is proved, I am repeating myself in order to emphasize, a galactocoele should be left alone. Repeated aspirations of a galactocoele do nothing as the galactocoele will quickly refill after aspiration. Though the risk of infection is low if properly done, each aspiration does carry a small risk of infection. A galactocoele can be quite large but usually stops growing once the pressure inside the galactocoele equals the pressure outside the galactocoele.
Doing surgery on a galactocoele while the mother is still producing milk, as recommended by some surgeons, is a recipe for disaster especially since it is rarely necessary and should be avoided if at all possible. A galactocoele will almost always disappear over time once the mother stops breastfeeding, but she should not stop breastfeeding simply because the galactocoele is there. It causes no harm in the long run to leave it alone.
This photo shows what can go wrong when a galactocoele is operated upon. True, the result is rarely this bad, but this sort of result is not okay even if it does occur only rarely.
Less dramatic but also a problem is that the mother will have continued leaking of milk from the incision after the surgery. In effect, the galactocoele has been “exteriorized”. Instead of the milk staying inside the breast, the milk now leaks out (sometimes pours) into the mother’s clothing. And the leaking is more likely if, as usual, the mother is told by the surgeon to stop breastfeeding on that side (or stop completely). Where will the milk go out, if it doesn’t go out the usual way? Out the area of least resistance to flow of fluid, the incision. So, it is best that the mother continue breastfeeding and the milk “exits” the usual way.
If the mother in the photo above had not had surgery, she would have remained with a lump in the breast, unlikely to be more than mildly painful, she would have continued breastfeeding, and the galactocoele would have dried up once she stopped breastfeeding. As it is, she was hospitalized for the procedure and stayed in hospital for well over a week. And even then, her problems were not over.
A typical history of breast abscess follows a typical time line. A mother develops the signs and symptoms of mastitis, sees her physician and is treated with an antibiotic, all too often an inappropriate one. Even though it has been known for decades that the most common infecting organism in mastitis by far is Staphylococcus aureus, too often mothers are treated with antibiotics such as amoxicillin or erythromycin. Amoxicillin will not kill Staphylococcus aureus and only a small minority of Staphylococcus aureus is sensitive to erythromycin. Furthermore, the nausea, vomiting and abdominal pain that occurs not infrequently with erythromycin make it a poor choice for treating mastitis.
Even worse, many mothers are told they must stop breastfeeding when they have mastitis or when taking antibiotics. This makes no sense at all, and it should be pointed out that a time-honoured principle of medicine and surgical treatment is to drain an area of infection and swelling. And the best way to do that is to have the baby continue to breastfeed on the affected side.
Furthermore, the concern about the baby getting the infection is not valid. First of all, the mother had the bacteria on her body well before developing the mastitis and so the baby has been exposed to the bacteria well before the mother was aware of being unwell. In fact, breastfeeding mothers and babies share all their germs, and this is a good thing. Furthermore, breastfeeding protects babies against infection; this has been known for years, but it seems modern doctors have forgotten, even though the evidence continues to accumulate of how protective breastfeeding is.
As for the mother taking antibiotics, this is not reason to interrupt breastfeeding. The antibiotics used for the treatment of mastitis are also drugs we use frequently for babies should they require them (and too often when they don’t require them, but that’s another story). Amounts of any drug that enters the milk is minuscule and antibiotics are not exceptions.
What to do
The first thing to emphasize is that a breast abscess, though distressing to the mother and the physician, is not a dire emergency. Mothers and babies are frequently sent rushing to the emergency department for immediate treatment when a more restrained, thoughtful approach would be much better.
The diagnosis of breast abscess can be made by aspirating the mass (photo below). This not only makes the diagnosis (aspiration will reveal that the content of the mass is pus, as in this photo) but also gives some relief to the mother if she is in pain. Furthermore, a sample for the laboratory for culture and sensitivity of the organism causing the abscess is available (almost always, in our experience, Staphylococcus aureus and not rarely these days MRSA – methicillin resistant Staphylococcus aureus).
Aspirations can be repeated every few days if necessary, but this routine of returning to the doctor’s office over and over is not easy for a new mother and her baby and even less so if she has other young children at home. Furthermore, repeated aspirations do not always work to treat the abscess definitively.
However, incision and drainage, as done by most surgeons also is not a good idea. Surgeons, as a group, do not consider breastfeeding important, it seems. Stopping breastfeeding on the affected breast, which, at least from our experience, most surgeons recommend, risks milk continuing to leak out the incision once the infection is cured, as with a galactocoele. Where will the milk come out if not from the nipple? Yes, the area of least resistance, the incision. And not emptying the breast by breastfeeding causes the mother additional pain from engorgement.
Some surgeons go even further and strongly recommend the mother stop breastfeeding completely, even on the unaffected side. Now why would they do this?
The reason, I think, is that they want the breast with the abscess to dry up (well, why does the breast with the abscess need to dry up is another question). And surgeons, as a group, do not seem to understand that a mother can dry up on just one breast if it is necessary, which it usually is not. They believe, it seems, that breastfeeding on the unaffected breast will keep the milk going on the affected side, the one with the abscess. Do they really understand so little about breastfeeding and how the breastfeeding works? What would we think about a gastrointestinal surgeon who didn’t understand how the gut works?
The way to treat an abscess?
If I diagnose a breast abscess, I will send the mother and baby to an intervention radiologist who uses another approach than incision and drainage favoured by surgeons. This approach allows the baby to continue breastfeeding on both breasts while resulting in far fewer complications for the mother. The approach is outlined in this article.
Here’s how it works: The radiologist maps out the abscess with ultrasound and inserts a catheter into the abscess to drain it. The catheter is kept in place until there is no further drainage and then removed. The mother continues breastfeeding on the affected side as she would have normally if she hadn’t developed the abscess.
In general, we continue antibiotics based on the sensitivity of the bacterium until the mother is cured.
Our experience with this procedure?
In the 12 or more years that we have been referring our patients with breast abscess to the intervention radiologists at the nearby hospital, we have seen a few more than 100 mothers with abscess. Happily, the numbers have decreased over the years. I hope this is because fewer mothers are developing an abscess due to their getting better help with positioning and latching babies on, as well as other rational information on breastfeeding, but I wonder. Perhaps more mothers are being referred to intervention radiologists rather than to surgeons.
So what results have we had? Only one mother that I can remember stopped breastfeeding despite our encouragement to keep breastfeeding. One mother had a recurrence of an abscess which was treated in the same way and she then she was cured. One mother, we feared, was developing a fistula (a leakage of milk from the site of the catheter insertion that does not stop), but in fact, after 3 weeks the leakage stopped.
Does incision and drainage, the surgeon’s approach, prevent recurrence? No, according to the literature about 7% of abscesses recur after incision and drainage. As you can see, our results show a rate of recurrence of less than 1%.
Continue reading about what to do in case you find a lump in your breast at a time when you are breastfeeding your baby.
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Copyright: Jack Newman, MD, FRCPC, 2017, 2018