Lactational Abscesses Take Center Stage

Wednesday, August 7, 2019

Chelsea Hardin, MD, FACS

Breasts — what an amazing evolutionary modification of the lowly sweat gland! And yet, it seems that when our breasts are not actively trying to “take us out” with breast cancers, they are making us miserable with cysts, infections, masses and pain. At least that’s how it seems from my perspective, as a general surgeon with a focus on breast health!

Lately, I have noticed an uptick in breast abscesses, particularly in nursing mothers. Nursing is a tricky thing! I’m not sure we’re any better at it now than our ancestors were 2,000 years ago. Once a breast begins to produce milk in the postpartum period, it is important to keep the breast fully drained every few hours; failure to do so can result in engorgement.

Sometimes a segment of the breast doesn’t drain well because the associated duct is plugged due to anatomic issues (i.e., nipple trauma and swelling), poor infant sucking, or even a protein plug. This “plugged duct” rapidly progresses to a painful, bulging mass in the breast. Now, the clock is ticking, and the mother only has about 12-24 hours before the milk in this portion of the breast becomes colonized (typically with S. aureus). The breast will quickly become tender and red, and the mother will often note fevers, chills and malaise.

Sometimes the abscess is obvious on exam; if not, an urgent ultrasound will help distinguish simple mastitis from an abscess. Start dicloxacillin or cephalexin (Clindamycin if there is a penicillin allergy, or Septra if there is reason to worry about MRSA). Then, give us a call at 503-935-8000 to reach one of The Oregon Clinic’s surgical groups and schedule an appointment.

Once a breast begins to produce milk in the postpartum period, it is important to keep the breast fully drained every few hours; failure to do so can result in engorgement. 

Most lactational abscesses can be managed in the office — for smaller abscesses, serial aspiration in the office is enough to get the infection under control. It is vital for the mother to continue nursing or pumping on the affected side during this time period. There is a definite “ick” factor here but preventing engorgement and milk stagnation is crucial. For larger abscesses, a very small (< 1cm) incision to drain the abscess is usually sufficient.

Most important is to avoid a large debridement that can disrupt lactating tissue and potentially result in a dreaded “milk fistula.” If you haven’t heard of this nasty little entity before, a milk fistula occurs when a disrupted duct drains milk through the incision onto the skin, sometimes in large volumes. It’s messy and disconcerting to the mother, but thankfully this problem is rare and usually self-limited. In the worst-case scenario, the mother has to stop nursing (at least on the affected side).

It’s not a bad idea to offer support from a lactation consultant if the mother is new to nursing — there’s nothing like a major complication to put you off the whole breastfeeding thing for good. Sometimes simple changes in nursing technique can prevent this complication from happening again.

Finally, a good inspection of the nipple is useful, and lanolin ointment can soften crusts/scabs and keep the ducts patent at the tip of the nipple. If the infection lingers, is resistant to antibiotics or recurs repeatedly in the same location, it’s time to consider inflammatory carcinoma.