Maintaining Breastfeeding During the Treatment of Breast Abscesses Is Not Contraindicated

Abstract

Background:

World Health Organization guidelines recommend maintaining breastfeeding if a woman develops breast abscess, because of benefits to her recovery and the infant's health. However, clinical staff recommend weaning to promote faster recovery from the abscess. The purpose of this study was to determine whether maintaining breastfeeding after development of a breast abscess has any influence on the resolution of the breast abscess.

Methods:

The records of 212 patients who were breastfeeding and developed breast abscess treated at Guangzhou Women and Children's Medical Center from January 2018 to December 2019 were retrospectively reviewed. Patients were divided into two groups: those who maintained breastfeeding (study group) and those who stopped breastfeeding (control group).

Results:

There were 139 patients in study group and 73 patients in the control group. Baseline characteristics were similar between the two groups. The time to cure in the study group and in the control group was 7.20 ± 2.21 days and 7.01 ± 2.39 days, respectively (t = 0.579, p = 0.563). Common complications were milk fistula and galactocele, and the frequency of both was similar between the two groups (milk fistula: 7.9% versus 8.2%, respectively; χ² = 0.006, p = 0.938; galactocele: 8.6% versus 9.6%, respectively; χ² = 0.054, p = 0.817). There was no significant difference in the recurrence rates between the two groups (5.0% versus 2.7%; χ² = 0.184, p = 0.668).

Conclusion:

Maintaining breastfeeding during treatment of breast abscess does not affect the outcome of treatment provided, on condition that the abscess is treated appropriately.

Background

Breast abscess is one of the major complications of lactation mastitis, and is mostly caused by improper or untimely treatment of mastitis.¹ Breast abscess occurs in 1% to 6% of postpartum women who are breastfeeding.² Breast abscess and treatment are very painful, which is a common reason many women stop breastfeeding.³ The primary treatment of breast abscess is adequate drainage and the use of antibiotics based on culture results.⁴ Many lactation guidelines recommended breastfeeding be continued during treatment of breast abscess.^1,2,5

However, a considerable number of medical staff believe that weaning is necessary to promote adequate treatment of breast abscess.⁶ It is generally believed that breastfeeding is irreplaceable, and provides many benefits for mothers and infants.^7–11 In contrast, clinicians are more concerned about treatment of the abscess and believe, based on the past experience, that weaning from breastfeeding is beneficial to treatment of the abscess.^6,12

Previous studies of breastfeeding after the development of breast abscess have mainly been focused on safety with respect to the infants, that is, whether the milk from the affected breast will be harmful to the infant.^2,13–16 Study has indicated that it is safe to continue breastfeeding with healthy contralateral breast, while breastfeeding with the affected breast should be stopped.² However, recent studies have shown that the levels of white blood cells (WBCs) and immune factors are elevated in the milk of the affected breast, and no adverse effects occur when breastfeeding with the affected breast.^14,16 Furthermore, rational use of antibiotics or related drugs should not cause any harm to the infant when breastfeeding is continued.¹⁵

Some studies have suggested that weaning or inhibiting lactation can increase breast swelling and adversely affect treatment of abscess.^17,18 However, few studies have focused on whether maintenance of lactation will affect the treatment of breast abscess.¹⁹ If the pain caused by continued breastfeeding in the presence of abscess increases and the treatment time is prolonged, both the mother and the infant may be affected physically and mentally. As such, continuing breastfeeding in the presence of abscess may not be an optimal choice. Hence, investigation of whether maintenance of lactation influences breast abscess treatment outcome is worthy of study.

At our hospital, it is recommended that women continue breastfeeding during treatment of breast abscess provided the abscess is being treated adequately with sufficient drainage of pus.⁴ However, some patients prefer to stop breastfeeding when breast abscess develops. Thus, the purpose of this study was to determine whether there is any difference in the outcome of breast abscess treatment between women who maintain breastfeeding and those who stop breastfeeding.

Patients and Methods

General information

The records of patients who were breastfeeding and developed a breast abscess treated at Guangzhou Women and Children's Medical Center from January 2018 to December 2019 were retrospectively reviewed. Patients who presented to the department of breast surgery at our hospital with breast abscess were admitted for a number of reasons including large abscess cavity that was unsuitable for needle aspiration and drainage, living a long distance from the hospital, ineffective treatment at another hospital, and if the patient requested admission for treatment.

Inclusion criteria for this study were (1) breast abscess that was clinically diagnosed during breastfeeding, (2) hospitalization and discharge after achieving a cure based on the standard definition, (3) unilateral breast abscess, (4) treatment by puncture and drainage, (5) no change in decision to maintain lactation during hospitalization, and (6) had at least one follow-up visit after successful treatment and discharge. Exclusion criteria were (1) did not undergo surgical puncture and drainage (e.g., the abscess ruptured or resolved without drainage), (2) treated with methods other than puncture and drainage, such as incision and drainage or fine needle aspiration, (3) treatment method was changed from puncture and drainage if there was no improvement within 3 days, and (4) did not follow the treatment plan during hospitalization.

A total of 212 patients met the study inclusion criteria, and they were divided into two groups: study group that included patients who continued breastfeeding during treatment (n = 139), and control group that included patients who stopped breastfeeding during treatment (n = 73). All patients were diagnosed with breast abscess by color Doppler ultrasound examination before treatment, and were treated with puncture and catheter drainage of the breast abscess. All patients provided written consent for all procedures performed, and were informed that their clinical data might be used for research purposes. The study was approved by the ethics committee of Guangzhou Women and Children's Medical Center (approval number: 2021266A01). Because of the retrospective nature of the study, the requirement of informed patient consent for the study was waived.

Treatment

All patients were treated with puncture and catheter drainage of the abscess, and pus was collected for bacterial culture. In brief, local anesthesia was applied, a trocar was used to puncture the abscess cavity under ultrasound guidance. Fluid in the abscess was removed by suction, and the abscess cavity was irrigated with normal saline until the fluid that was washed out was clean. A drainage catheter was placed into the abscess cavity through the trocar, and was connected to a negative pressure drainage bottle.^20,21

The drain was checked and maintained every 1–2 days, and was left in place until the standard definition of a clinical cure was met, after which the catheter was removed. Some patients received treatment with antibiotics: a first-generation cephalosporin was used at the beginning of treatment, clindamycin was administered to patients with an allergy to penicillin, and subsequently antibiotic treatment was adjusted based on antimicrobial culture and sensitivity results.

Patients were admitted to the ward of the breast surgery department of our hospital, and regrettably there was no parent–child ward and thus the mother and infant were separated during hospitalization. All patients were advised to continue breastfeeding and informed of the benefits of breastfeeding; however, weaning was permitted if that was the choice of the patient. Patients who maintained lactation were instructed to regularly empty the breast through hand expressing or use of a breast pump to ensure the maintenance of milk production during hospitalization. For natural weaning during hospitalization, patients gradually reduced both the frequency of milk expression and the amount of milk expressed. In some cases, the patient had already weaned before admission.

The criteria for a clinical cure of the breast abscess were (1) normal body temperature; (2) resolution of redness and swelling over the abscess site; (3) size of residual cavity was <2 cm, and no significant echo was detected by color Doppler ultrasound examination of the breast; (4) daily drainage volume was <5 mL and nonpurulent, or if the volume was >5 mL and the drainage fluid was milk-like colored without any obvious sediment or evidence of necrosis for 3 consecutive days; and (5) normal WBC count and C-reactive protein level. A cure required that criteria 1 to 4 were met, whereas criterion 5 was not necessary.²¹ The definition of “cure time” was the number of days between puncture and catheter placement and when the criteria for cure were met and the catheter was removed.

Outcome measures and standards

Data extracted from the medical records included patient age, time of abscess onset, maximum diameter of the abscess cavity, the use antibiotics or not, time to cure, complications related to the abscess within 1 month after discharge, and recurrence of the breast abscess. Continuous data are expressed as mean ± standard deviation and compared with the t test, and categorical data are expressed as count and percentage, and examined with the χ² test. In all analyses, a value of p < 0.05 was considered to indicate a statistically significant difference.

Results

Baseline data

The mean age of the 212 patients was 30.18 ± 4.34 years, and the mean maximum diameter of the abscess cavities was 5.50 ± 2.22 cm. Overall, 53.3% of the patients were treated with antibiotics. In the whole group, 80.2% of the abscesses were diagnosed within the first 3 months after delivery. There were no statistical differences between the two groups with respect to age, time of onset, size of the abscess, and the percentage of patients who were treated with antibiotics. Baseline data of the two groups are summarized in Table 1.

Table 1.

Clinical Characteristics of the Study Group and the Control Group

Group	No.	Age (years)	Onset time					Maximum diameter of the abscess cavity (cm)	Antibiotics therapy
Group	No.	Age (years)	Within the first week, n (%)	During the first week to the first month, n (%)	During the first to third month, n (%)	During the third month to the first year, n (%)	Beyond the first year, n (%)	Maximum diameter of the abscess cavity (cm)	No, n (%)	Yes, n (%)
Study group	139	30.18 ± 4.03	7 (5.0)	50 (36.0)	60 (43.2)	21 (15.1)	1 (0.7)	5.31 ± 2.22	71 (51.1)	68 (48.9)
Control group	73	30.18 ± 4.91	1 (1.4)	22 (30.1)	30 (41.1)	17 (23.3)	3 (4.1)	5.85 ± 2.19	28 (38.4)	45 (61.6)
Test value		t = 0.003	Pearson $χ^{2}$ = 6.935					t = 1.697	$χ^{2}$ = 3.113
p Value		0.998	0.139					0.091	0.078

The time to cure

On admission to the hospital, patients received routine bloods tests and coagulation studies, and an ultrasound of the breast abscess. The treatment plan of puncture and catheter drainage was based on all findings at the time of admission. The mean time to cure was 7.09 ± 2.70 days, and the longest hospital stay was 15 days and the shortest stay was 2 days. The time to cure of the study group was similar to that of the control group (7.20 ± 2.21 days versus 7.01 ± 2.39 days, respectively; t = 0.579, p = 0.563).

Follow-up

Patients were required to follow-up on the 3rd day and 7th day after discharge, and 1 month after discharge. Telephone follow-up after discharge for 1 month was required for those who did not do the follow-up visits. All complications related to abscess treatment that occurred within 1 month were reviewed. Common complications included milk fistula and galactocele. Recurrence was defined as new inflammation at the original abscess site within 1 month that required retreatment.

Milk fistula was defined as milk leakage from the drainage tube orifice for longer than 3 days after the catheter was removed. A total of 17 cases of milk fistula occurred after treatment (incidence 8.0%): 11 cases were in the study group (7.9%) and 6 in the control group (8.2%). The difference was not statistically significant (χ² = 0.006, p = 0.938). The mean time for resolution of milk fistula in the study group was 9.73 ± 7.56 days and that in the control group was 5.20 ± 0.84 days (t = 1.310, p = 0.211).

Galactocele was defined as the relapse of the mass at the original abscess site, without any associated redness and swelling of the skin, and no progressive enlargement. A total of 19 cases of galactocele occurred (incidence 9.0%): 12 cases were in the study group (8.6%) and 7 in the control group (9.6%). The difference was not significant (χ² = 0.054, p = 0.817). There was a recurrence of the abscess in 9 of the 212 patients (4.2%). The recurrence rate in the study group was 5.0%, and that in the control group was 2.7%. The difference was not statistically significant (χ² = 0.184, p = 0.668).

Discussion

Breast milk is natural, and provides the best nourishment for infants.^22,23 In addition to providing nutrients for the baby's growth and development, it contains a large number of immune components, which cannot be simulated in formula milk.^24,25 Studies have shown that breastfed babies have a higher intelligence quotient than those fed with formula milk.⁸ Breastfeeding also benefits the mother. In addition to promoting emotional bonding between the mother and her baby, it helps the mother to lose weight after giving birth.²⁶

In the long term, breastfeeding can also reduce the risk of breast cancer and ovarian tumors.^11,27 Therefore, breastfeeding mothers should not give up breastfeeding prematurely, except as a last resort. However, there can be complications associated with breastfeeding, including early postpartum breast swelling, nipple pain, milk stasis, acute mastitis, breast eczema, and Raynaud's phenomenon.^28,29 Even an experienced mother can experience some of the aforementioned complications, and thus successful breastfeeding is not as simple as thought.²⁹

Breast abscess is the most serious complication related to breastfeeding, and typically cannot be resolved with conservative treatment.³⁰ This is because the accumulation of pus in the abscess must be drained surgically. Surgery is typically incision and drainage, and can result in a large incision or an open wound.³¹ Maintaining lactation can fill the cavity with milk, and may not be conducive to the healing of the residual cavity. Furthermore, milk is a good bacterial culture medium thus potentially negatively impacting on the healing process. These concerns most likely served as the basis of the previous recommendations to stop breastfeeding when treating breast abscesses^19,31–33

In recent years, the concept of minimally invasive treatment of breast abscess has become more accepted by doctors and nurses. Common minimally invasive drainage methods include needle aspiration, and catheter drainage, and standard incision and drainage has gradually been abandoned.^13,34–36 Minimally invasive treatment of breast abscesses is associated with a reduced healing time and a better final cosmetic appearance, and importantly only minimally interferes with breastfeeding.

Owing to the promotion of minimally invasive methods, it is possible to treat breast abscesses while maintaining lactation, but it is not clear whether continuing to breastfeed will affect the treatment outcome of the abscess. For ethical reasons, it is impossible to perform a prospective randomized controlled study to address this issue, and it can only be explored through retrospective analysis of data. Notably, few studies have attempted to examine this issue.¹³ General guidelines indicate that breastfeeding can be continued when a breast abscess develops, but they do not address if maintenance of lactation will affect the outcome of breast abscess treatment.

In this study, we retrospectively analyzed the data of women who were breastfeeding and developed breast abscess and were treated at our hospital. Our analysis showed that the time to resolution of the breast abscess was similar between women who maintained breastfeeding and those who stopped breastfeeding. This indicates that maintaining lactation will not affect the treatment outcome of breast abscess provided it is treated with minimally invasive drainage.

Furthermore, we found that maintaining lactation did not increase the risk of abscess recurrence, nor did it increase the risk of the complications: milk fistula and galactocele. Patients with mammary fistula at the time of discharge were instructed in wound care and to continue care until the fistula had resolved, and there was no significant difference in the recurrence rate between the two groups.

Limitations

Limitations of this study include its retrospective nature and the relatively small number of patients. However, as already mentioned a prospective randomized study to examine this issue cannot be performed due to ethical reasons.

Conclusions

In conclusion, the results of this study indicate that maintaining breastfeeding during minimally invasive puncture and drainage of breast abscess does not affect the outcome of treatment, and does not increase the risk of complications. The time for complete resolution of the breast abscess is similar between patients who maintain breastfeeding and those who stop breastfeeding. To our knowledge, this study is the first clinical study of maintaining lactation while undergoing treatment of breast abscess treatment, and we hope the results will guide other researchers who are studying the same issue.

Footnotes

Acknowledgments

We give our special thanks to our patients who participated in the project.

Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

This study was supported by the fund from Guangzhou Women and Children's Medical Center (Grant No. GWCMC2020-6-009).

References

Amir LH; Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #4: Mastitis, revised March 2014. Breastfeed Med, 2014; 9(5):239–243; doi: 10.1089/bfm.2014.9984.

World Health Organization. Mastitis: Causes and Management, 1st ed. World Health Organization: Geneva, Switzerland; 2000; pp. 7–9.

Ahluwalia

, Morrow

, Hsia

. Why do women stop breastfeeding? Findings from the pregnancy risk assessment and monitoring system. Pediatrics, 2005; 116(6):1408–1412.

Luo

, Long

, Cai

, et al. Abscess drainage with or without antibiotics in lactational breast abscess: Study protocol for a randomized controlled trial. Infect Drug Resist, 2020; 21(13):183–190; doi: 10.2147/IDR.S221037.

Jacobs

, Abou-Dakn

, Becker

, et al. S3-guidelines for the treatment of inflammatory breast disease during the lactation period: AWMF Guidelines, Registry No. 015/071 (short version) AWMF Leitlinien-Register Nr. 015/071 (Kurzfassung). Geburtshilfe Frauenheilkd, 2013; 73(12):1202–1208; doi: 10.1055/s-0033-1360115.

Gattuso

, Franks

. Lactation-related infections. Community Pract, 2015; 88(6):24–25.

Victora

, Bahl

, Barros

, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet, 2016; 387(10017):475–490; doi: 10.1016/S0140-6736(15)01024-7.

Bernard

, De Agostini

, Forhan

, et al. Breastfeeding duration and cognitive development at 2 and 3 years of age in the EDEN mother-child cohort. J Pediatr, 2013; 163(1):36–42; doi: 10.1016/j.jpeds.2012.11.090.

Feehley

, Plunkett

, Bao

, et al. Healthy infants harbor intestinal bacteria that protect against food allergy. Nat Med, 2019; 25(3):448–453; doi: 10.1038/s41591-018-0324-z.

10.

Azad

, Vehling

, Chan

, et al. Infant feeding and weight gain: Separating breast milk from breastfeeding and formula from food. Pediatrics, 2018; 142(4):e20181092; doi: 10.1542/peds.2018-1092.

11.

Islami

, Liu

, Jemal

, et al. Breastfeeding and breast cancer risk by receptor status—A systematic review and meta-analysis. Ann Oncol, 2015; 26(12):2398–2407; doi: 10.1093/annonc/mdv379.

12.

Banapurmath

, Banapurmath

, Mallikarjuna

, et al. Successful management of breast abscess with ongoing breastfeeding. Indian Pediatr, 1995; 32(4):488–491.

13.

Irusen

, Rohwer

, Steyn

, et al. Treatments for breast abscesses in breastfeeding women. Cochrane Database Syst Rev, 2015; 17(8):CD010490; doi: 10.1002/14651858.CD010490.pub2.

14.

Hassiotou

, Hepworth

, Metzger

, et al. Maternal and infant infections stimulate a rapid leukocyte response in breastmilk. Clin Transl Immunol, 2013; 2(4):e3; doi: 10.1038/cti.2013.1.

15.

Giess

, Golshan

, Flaherty

, et al. Clinical experience with aspiration of breast abscesses based on size and etiology at an academic medical center. J Clin Ultrasound, 2014; 42(9):513–521; doi: 10.1002/jcu.22191.

16.

Matheson

, Aursnes

, Horgen

, et al. Bacteriological findings and clinical symptoms in relation to clinical outcome in puerperal mastitis. Acta Obstet Gynecol Scand, 1988; 67(8):723–726; doi: 10.3109/00016349809004296.

17.

Thomsen

, Espersen

, Maigaard

Course and treatment of milk stasis, noninfectious inflammation of the breast, and infectious mastitis in nursing women. Am J Obstet Gynecol, 1984; 149(5):492–495; doi: 10.1016/0002-9378(84)90022-x.

18.

Benson

EA.

Management of breast abscesses. World J Surg, 1989; 13(6):753–756; doi: 10.1007/BF01658428.

19.

Scholefield

, Duncan

, Rogers

Review of a hospital experience of breast abscesses. Br J Surg, 1987; 74(6):469–470; doi: 10.1002/bjs.1800740613.

20.

Gao

, Ma

, He

, et al. Negative-pressure suction cannula for treatment of lactational residual milk cavity: A case series study. Breastfeed Med, 2020; 15(6):412–416; doi: 10.1089/bfm.2019.0226.

21.

Long

, Yao

, Luo

, et al. Antibiotic treatment for lactational breast abscess: A retrospective study. Chinese J Breast Dis (Electronic Version), 2021; 15(4):214–217; doi: 10.3877/cma.j.issn.1674-0807.2021.04.004.

22.

Kellams

, Harrel

, Omage

, et al. ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. Breastfeed Med, 2017; 5(12):188–198; doi: 10.1089/bfm.2017.29038.ajk.

23.

Montgomery Rice

Giving “all” babies a great start, nutrition matters. Breastfeed Med, 2018; 13(8):520–523; doi: 10.1089/bfm.2018.0130.

24.

Lönnerdal

Nutritional and physiologic significance of human milk proteins. Am J Clin Nutr, 2003; 77(6):1537S–1543S; doi: 10.1093/ajcn/77.6.1537S.

25.

Donovan

SM.

Human milk proteins: Composition and physiological significance. Nestle Nutr Inst Workshop Ser, 2019; 90:93–101; doi: 10.1159/000490298.

26.

Sharma

, Dee

, Harden

. Adherence to breastfeeding guidelines and maternal weight 6 years after delivery. Pediatrics, 2014; 134(Suppl. 1):S42–S49; doi: 10.1542/peds.2014-0646H.

27.

, Du

, Zhang

, et al. Breastfeeding and ovarian cancer risk: A systematic review and meta-analysis of 40 epidemiological studies. Asian Pac J Cancer Prev, 2014; 15(12):4829–4837; doi: 10.7314/apjcp.2014.15.12.4829.

28.

Berens

, Eglash

, Malloy

, et al. ABM Clinical Protocol #26: Persistent Pain with Breastfeeding. Breastfeed Med, 2016; 11(2):46–53; doi: 10.1089/bfm.2016.29002.pjb.

29.

Xiao

, Loke

, Zhu

, et al. The sweet and the bitter: Mothers' experiences of breastfeeding in the early postpartum period: A qualitative exploratory study in China. Int Breastfeed J, 2020; 15(1):12; doi: 10.1186/s13006-020-00256-1.

30.

Amir

, Forster

, McLachlan

, et al. Incidence of breast abscess in lactating women: Report from an Australian cohort. BJOG, 2004; 111(12):1378–1381; doi: 10.1111/j.1471-0528.2004.00272.x.

31.

Wei

, Zhang

, Fu

Negative suction drain through a mini periareolar incision for the treatment of lactational breast abscess shortens hospital stay and increases breastfeeding rates. Breastfeed Med, 2016; 11:259–260; doi: 10.1089/bfm.2016.0008.

32.

Saleem

, Farooq

, Khan

, et al. Puerperal breast abscesses; Percutaneous ultrasound guided drainage compared with conventional incision and drainage. Prof Med J, 2008; 15(4):431–436; doi: 10.29309/TPMJ/2008.15.04.2921.

33.

Leach

, Eykyn

, Phillips

, et al. Anaerobic subareolar breast abscess. Lancet, 1979; 1(8106):35–37; doi: 10.1016/s0140-6736(79)90469-0.

34.

Falco

, Foroni

, Castagnetti

, et al. Ultrasound-guided percutaneous catheter drainage of large breast abscesses in lactating women: How to preserve breastfeeding safely. Breastfeed Med, 2016; 11:555–556; doi: 10.1089/bfm.2016.0121.

35.

Debord

, Poirier

, Delgado

, et al. [Lactational breast abscesses: Do we still need surgery?]. J Gynecol Obstet Biol Reprod (Paris), 2016; 45(3):307–314; doi: 10.1016/j.jgyn.2015.04.004.

36.

, Zhang

, Feng

, et al. Clinical research on minimally invasive rotary resection in the treatment of lactational breast abscess. Gland Surg, 2021; 10(12):3294–3304; doi: 10.21037/gs-21-729.