History, physical and laboratory findings, and clinical outcomes of lactating women treated with antibiotics for chronic breast and/or nipple pain

It's Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain

Introduction: Health care providers treating lactating women for nipple and breast pain often attribute symptoms to Candida albicans infection. However, multiple other conditions may present with pain, erythema, and pruritis. We explored the experience of a breastfeeding medicine practice that received referrals for patients failing antifungal therapy and who desired further evaluation for alternative diagnoses. Materials and Methods: We conducted a retrospective chart review of breastfeeding women referred for evaluation of "yeast" to a breast surgery/breastfeeding medicine practice from July 2016 to August 2019. Results: Twenty-five women met inclusion criteria. Median age was 33 (range 24-43) and median months postpartum was 4 (range 0.5-18). All 25 women reported minimal to no improvement on oral and/or topical antifungal therapy. In addition to history and examination, milk culture was obtained in four women, punch biopsy in one, and core needle biopsy in one. No woman was confirmed to have a diagnosis of Candida. Diagnoses were changed to the following: subacute mastitis/mammary dysbiosis (n = 8), nipple bleb (n = 6), dermatitis (n = 6), vasospasm (n = 2), milk crust (n = 1), hyperlactation (n = 1), and postpartum depression (n = 1). Treatment included discontinuation of antifungal medication, as well as the following per individual diagnoses: antibiotics and probiotics; 0.1% triamcinolone cream; heat therapy; discontinuation of exclusive pumping; and antidepressant medication and counseling referral. All women experienced resolution of symptoms following revision of diagnosis and change in management (range 2-42 days). Conclusion: While persistent nipple and breast pain in breastfeeding is often attributed to Candida, this cohort demonstrates that providers should consider multiple other conditions in their differential diagnosis. Accurate, timely diagnosis is crucial, as pain is a risk factor for premature cessation of breastfeeding. Symptomatic resolution occurs on appropriate therapy.

Mammary Dysbiosis and Nipple Blebs Treated With Intravenous Daptomycin and Dalbavancin

INTRODUCTION

Mammary dysbiosis, also known as subacute mastitis, may be associated with nipple blebs. These overlapping diagnoses represent a challenging clinical scenario during lactation. Little research has been published on etiology, management strategies, and outcomes of these concurrent diagnoses.

MAIN ISSUE

We document the treatment and outcome of a patient who presented with left-breast dysbiosis and nipple blebs and whose milk culture grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus. She was treated safely and effectively with intravenous daptomycin and dalbavancin. This has not been described previously in the lactation literature.

MANAGEMENT

The 35-year-old lactating gravida 3, para 3 patient presented at 6 months postpartum to a breast surgery clinic with a 1-week history of worsening deep left-breast pain, blebs, and recurrent plugging. She was afebrile and she had no erythema or induration on her breast exam. A culture of her milk grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus, and she was referred to infectious disease for assistance with intravenous antibiotic therapy. She continued to feed expressed milk throughout treatment and demonstrated complete resolution of symptoms 8 weeks later.

CONCLUSIONS

We report that in patients with a multi-drug-resistant, methicillin-resistant Staphylococcus aureus-positive human milk culture and a clinical presentation of mammary dysbiosis and nipple blebs, intravenous daptomycin and dalbavancin may be an effective treatment.

Moving toward a better understanding of the experience and measurement of breastfeeding-related pain

Purpose: Despite how commonly breastfeeding-related pain is experienced in the postpartum period, and its frequent implication in breastfeeding cessation, this unique type of pain is not well evaluated nor assessed. The purpose of this study was to gain a comprehensive description and understanding of breastfeeding-related pain among postpartum breastfeeding women. Methods: This study employed a mixed methods approach using a descriptive-interpretive qualitative approach, in addition to administering the Short-Form McGill Pain Questionnaire, second version, to comprehensively gain both quantitative and qualitative descriptors of breastfeeding-related pain. Fourteen partnered and educated women living in Southern Ontario with experience of breastfeeding-related pain took part in this study. Results: The results from this study suggest that breastfeeding-related pain is often experienced as severe and distressing, and comprises various elements of pain including continuous, intermittent, neuropathic, and affective components. Conclusion: Breastfeeding-related pain is multidimensional and can be severe and distressing for women. Current measurement tools may not adequately reflect the multidimensional components of this unique type of pain, which may limit the effectiveness of health care providers to help with its identification and management.

ABM Clinical Protocol #30: Breast Masses, Breast Complaints, and Diagnostic Breast Imaging in the Lactating Woman

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Mammary candidiasis: A medical condition without scientific evidence?

Many physicians, midwives and lactation consultants still believe that yeasts (particularly Candida spp.) play an important role as an agent of nipple and breast pain despite the absolute absence of scientific proofs to establish such association. In this context, the objective of this study was to investigate the microorganisms involved in sore nipples and/or painful "shooting" breastfeeding by using a variety of microscopy techniques, as well as culture-dependent and-independent identification methods. Initially, 60 women (30 diagnosed as suffering "mammary candidiasis" and 30 with no painful breastfeeding) were recruited to elucidate the role of their pumps on the milk microbial profiles. After realizing the bias introduced by using such devices, manual expression was selected as the collection method for the microbiological analysis of milk samples provided by 529 women with symptoms compatible with "mammary candidiasis". Nipple swabs and nipple biopsy samples were also collected from the participating women. Results showed that the role played by yeasts in breast and nipple pain is, if any, marginal. In contrast, our results strongly support that coagulase-negative staphylococci and streptococci (mainly from the mitis and salivarius groups) are the agents responsible for such cases. As a consequence, and following the recommendations of the US Library of Medicine for the nomenclature of infectious diseases, the term "mammary candidiasis" or "nipple thrush" should be avoided when referring to such condition and replaced by "subacute mastitis".

Identification of Emerging Human Mastitis Pathogens by MALDI-TOF and Assessment of Their Antibiotic Resistance Patterns

Lactational mastitis constitutes one of the main causes of undesired weaning, depriving the mother–infant pair from the benefits of breastfeeding; therefore, this condition should be considered a relevant public health issue. The role of specific microorganisms remains unclear since human milk cultures and antibiotic susceptibility testing (AST) are not routinely performed, despite the fact that this would be key to ensure an early and effective diagnosis and treatment. The objective of this study was to describe the culturable microbial diversity in 647 milk samples from breastfeeding women with clinical symptoms of mastitis by Matrix-Assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF) VITEK MS technology and to analyze the antimicrobial susceptibility profiles of a collection of isolates from these samples by the VITEK 2 AST system. Staphylococcus epidermidis was the most common species isolated from mastitis samples (87.6%), while Staphylococcus aureus was detected in 22.1%. Streptococci constituted the second (68.6%) most prevalent bacterial group, with Streptococcus mitis/oralis, Streptococcus salivarius, and Streptococcus parasanguinis detected with frequencies of 40.8, 36.8, and 14.4%, respectively. The antibiotic susceptibility profiles of 642 staphylococcal isolates indicated a remarkable resistance to benzylpenicillin (88.3%) and erythromycin (67.3%) with differences between species. A high percentage of Staphylococcus isolates were resistant to at least one antibiotic (Staphylococcus hominis, 100%; S. epidermidis, 98.2%; S. aureus, 92.9%; Staphylococcus lugdunensis, 90.5%) and the percentage of multidrug-resistance (MDR) isolates was noticeable (S. hominis, 81%; S. epidermidis, 64.4%; S. aureus, 11.5%; S. lugdunensis, 10.5%). In relation to streptococcal isolates (n = 524), AST revealed high or moderate percentages of resistance to erythromycin (68.7%), benzylpenicillin (63.7%), ampicillin (51.5%), and tetracycline (30.8%). Antibiotic resistance to at least one antibiotic was detected in 97.6% of S. parasanguinis, 92.6% of S. salivarius, 83.3% of S. mitis/oralis, and 72.4% of Streptococcus vestibularis isolates. A significant number of MDR streptococcal isolates was also found (S. parasanguinis, 51.2%; S. salivarius, 39.3%; S. mitis/oralis, 34.6%; and S. vestibularis, 19%). The results highlight the important role of coagulase-negative staphylococci and streptococci as human mastitis-causing agents. Moreover, the high rates of antimicrobial resistance among these microorganisms must be contemplated as an issue of clinical relevance in relation to treatment options.

Nipple Pain Incidence, the Predisposing Factors, the Recovery Period After Care Management, and the Exclusive Breastfeeding Outcome

BACKGROUND

Nipple pain is the most common complaint of breastfeeding mothers during the immediate postpartum period. Persistent nipple pain is associated with low breastfeeding rate at 6 months postpartum.

OBJECTIVE

To further explore the incidence of nipple pain, associated predisposing factors, time for recovery after management, and the impact on exclusive breastfeeding rates.

MATERIALS AND METHODS

Included in this study were 1,649 singleton, pregnant women who delivered and had their 1-week follow-up at the breastfeeding clinic during the period of January 2013 to December 2015. The mothers who experienced nipple pain were analyzed for the incidence, the predisposing factors, and the recovery period after care management. The breastfeeding outcome comparison of both, mothers with and without pain, was measured by the exclusive breastfeeding rate at the sixth week postpartum.

RESULTS

The incidence of nipple pain was at 9.6% by day 7. A predisposing factor of nipple pain was primiparity (relative risk = 1.8, 95% confidence interval 1.3-2.5). The reasons for nipple pain were inappropriate positioning and latching (72.3%), tongue-tie (23.2%), and oversupply (4.4%). The recovery period after care management was 1-2 weeks. There were no statistically significant differences between the 6-week exclusive breastfeeding rates of the mothers with nipple pain with treatment and the mothers without nipple pain.

CONCLUSION

Persistent nipple pain was a common problem. The active management, including early detection and treatment, would help the mothers recover within a 2-week period and there was no significant difference of exclusive breastfeeding rates between the mothers who had early care management and the mothers without nipple pain.

ABM Clinical Protocol #26: Persistent Pain with Breastfeeding

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Chronic Mastitis, Mastalgia, and Breast Pain

Whereas the management of acute mastitis seems clear, there is little scientific evidence to support management of chronic mastitis/breast pain. This article reviews bacteriological findings, their possible meanings, and their use in clinical settings. Clinical experience, newer and more accurate microbiological techniques, and the growing knowledge about our metagenome have many insights to offer.

Dermatoses of the breast in lactation

Dermatoses of the breast during lactation can be difficult to diagnose because of their overlapping clinical appearances. It is important to properly diagnose and treat nipple dermatitis since it can be a significant source of pain when nursing. Poorly controlled nipple pain in nursing mothers is one of the primary reasons for breastfeeding to be discontinued earlier than is recommended. Therefore, it is relevant for practicing dermatologists to be aware of certain facts in a patient's history, specific physical exam findings, and the most appropriate laboratory tests used to diagnose these conditions. In addition, the therapeutic approach should be effective and safe for the mother and infant. This review article provides dermatologists with a detailed discussion on the clinical features and management of various breast dermatoses seen in lactation, including atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, psoriasis, bacterial infections, yeast infections and herpes simplex virus infections.

Role of oral antibiotics in treatment of breastfeeding women with chronic breast pain who fail conservative therapy

BACKGROUND

Although breast pain remains a common cause of weaning, controversy exists regarding the etiology of chronic pain. Prospective studies are needed to define optimal treatment regimens. We evaluated patient history, exam, and bacterial cultures in breastfeeding women with chronic breast pain. We compared pain resolution and breastfeeding complications in patients responding to conservative therapy (CTX) (n=38) versus those in patients failing CTX and receiving oral antibiotic treatment (OTX) (n=48).

SUBJECTS AND METHODS

We prospectively enrolled 86 breastfeeding women with breast pain lasting greater than 1 week and followed up patients through 12 weeks.

RESULTS

Higher initial breast (p=0.012) and nipple pain severity (p=0.004), less response to latch correction (p=0.015) at baseline visit, and breastmilk Staphylococcus aureus growth (p=0.001) were associated with failing CTX. Pain type was not associated with failure of CTX. When culture results were available at 5 days, breast pain remained higher (p<0.001) in patients failing CTX and starting antibiotics. OTX patients then had more rapid breast pain reduction between 5 and 14 days (score of 3.1 vs. 1.3; p<0.001). By 4 weeks there was no difference (1.8/10 vs. 1.4/10; p=0.088) in breast pain level between groups. Median length of OTX was 14 days. At 12 weeks, weaning frequency (17% vs. 8%; p=0.331) was not statistically different.

CONCLUSIONS

Initial pain severity and limited improvement to latch correction predicts failure of CTX. S. aureus growth is more common in women failing CTX. For those women not responding to CTX, OTX matched to breastmilk culture may significantly decrease their pain and is not associated with increased complications.

A case control study of bacterial species and colony count in milk of breastfeeding women with chronic pain

BACKGROUND

An infectious etiology for chronic breast pain in breastfeeding women continues to be debated. Although recent data suggest that Staphylococcus aureus and coagulase-negative Staphylococcus (CNS) may cause chronic breast pain, no studies have used quantitative cultures to address this question. In this study we compared bacterial species and colony counts between breastfeeding women with (cases) and without (controls) chronic pain.

SUBJECTS AND METHODS

We enrolled 114 breastfeeding women in a prospective cohort study. Cases (n=61), breastfeeding women with breast pain for >1 week and no signs of acute infection, were matched with controls (n=53) by weeks postpartum and parity.

RESULTS

More cases had a history of mastitis (14% vs. 2%, p=0.036), cracked nipples (64% vs. 17%, p=0.001), and other breastfeeding difficulties. Enterobacter species growth was less likely in cases (0% vs. 7.5%, p=0.029). Cases had a significantly higher growth of S. aureus (19.7% vs. 1.9%, p=0.003). CNS frequency was similar between groups (75% vs. 79%, p=0.626), but median colony count growth was significantly lower in cases (900 colony-forming units/mL vs. 5,000 colony-forming units/ml, p=0.003). Growth of CNS and S. aureus was negatively correlated (r=-0.265, p=0.004).

CONCLUSIONS

Higher S. aureus growth in cases supports a pathogenic role for S. aureus and reinforces the need for future antibiotic treatment studies in breastfeeding women with chronic pain. In contrast, similar CNS frequency between groups, lower CNS colony counts in cases, and a negative correlation between S. aureus and CNS growth suggest that neither CNS, nor its overgrowth, causes chronic breast pain.

Breast disease in the pregnant and lactating patient: radiological-pathological correlation

OBJECTIVE

Substantial physiological changes occur during pregnancy and lactation, making breast evaluation challenging in these patients. This article reviews the imaging challenges of the breast during pregnancy and lactation. The normal imaging appearance, imaging protocols and the imaging features of each commonly encountered benign and malignant entity with pathological correlation and supporting examples is described. An awareness of the imaging features of the breast during these physiological states and of various benign and malignant diseases that occur permits optimal management.

CONCLUSIONS

Evaluation of the pregnant and lactating patients who present with a breast problem is challenging. Although ultrasound may characterise the finding in many cases, mammography and even MRI may have a role in the management of these patients.

TEACHING POINTS

• To review physiological changes of the breast during pregnancy and lactation • To review imaging protocols of the breast during pregnancy and lactation • Discuss imaging findings with pathological correlation of benign and malignant diseases in pregnancy and lactation • Discuss pathological correlation of imaging findings in pregnancy and lactation.

Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia

OBJECTIVE

To investigate Candida species and Staphylococcus aureus and the development of 'nipple and breast thrush' among breastfeeding women.

DESIGN

Prospective longitudinal cohort study.

SETTING

Two hospitals in Melbourne, Australia (one public, one private) with follow-up in the community.

PARTICIPANTS

360 nulliparous women recruited at ≥36 weeks' gestation from November 2009 to June 2011. Participants were followed up six times: in hospital, at home weekly until 4 weeks postpartum and by telephone at 8 weeks.

MAIN OUTCOME MEASURES

Case definition 'nipple and breast thrush': burning nipple pain and breast pain (not related to mastitis); detection of Candida spp (using culture and PCR) in the mother's vagina, nipple or breast milk or in the baby's mouth; detection of S aureus in the mother's nipple or breast milk.

RESULTS

Women with the case definition of nipple/breast thrush were more likely to have Candida spp in nipple/breast milk/baby oral samples (54%) compared to other women (36%, p=0.014). S aureus was common in nipple/breast milk/baby samples of women with these symptoms as well as women without these symptoms (82% vs 79%) (p=0.597). Time-to-event analysis examined predictors of nipple/breast thrush up to and including the time of data collection. Candida in nipple/breast milk/baby predicted incidence of the case definition (rate ratio (RR) 1.87 (95% CI 1.10 to 3.16, p=0.018). We do not have evidence that S aureus colonisation was a predictor of these symptoms (RR 1.53, 95% CI 0.88 to 2.64, p=0.13). Nipple damage was also a predictor of these symptoms, RR 2.30 (95% CI 1.19 to 4.43, p=0.012). In the multivariate model, with all three predictors, the RRs were very similar to the univariate RRs. This indicates that Candida and nipple damage are independent predictors of our case definition.

Caring for new mothers: diagnosis, management and treatment of nipple dermatitis in breastfeeding mothers

Breastfeeding is thought to be the most optimal form of infant nutrition. Nursing mothers are generally advised to continue breastfeeding until the infant is two years of age or beyond. Unfortunately, however, a majority of nursing mothers will discontinue breastfeeding much earlier than recommended. The most common reason for early discontinuation of breastfeeding is nipple pain. It is, therefore, essential that dermatologists know how to appropriately diagnose and effectively treat nipple pain associated with nipple dermatitis among nursing mothers. This review article provides a detailed discussion on the clinical features and management of various causes of nipple dermatitis during lactation, including problems with infant latch-on, congenital oral anomalies, plugged lactiferous ducts, atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, yeast infections, bacterial infections, herpes simplex virus, and Raynaud's phenomenon of the nipple.

Antibiotics for mastitis in breastfeeding women

BACKGROUND

Mastitis can be caused by ineffective positioning of the baby at the breast or restricted feeding. Infective mastitis is commonly caused by Staphylococcus aureus. The prevalence of mastitis in breastfeeding women may reach 33%. Effective milk removal, pain medication and antibiotic therapy have been the mainstays of treatment.

OBJECTIVES

This review aims to examine the effectiveness of antibiotic therapies in relieving symptoms for breastfeeding women with mastitis with or without laboratory investigation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2012), contacted investigators and other content experts known to us for unpublished trials and scanned the reference lists of retrieved articles.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-RCTs comparing the effectiveness of various types of antibiotic therapies or antibiotic therapy versus alternative therapies for the treatment of mastitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When in dispute, we consulted a third author.

MAIN RESULTS

Two trials met the inclusion criteria. One small trial (n = 25) compared amoxicillin with cephradine and found no significant difference between the two antibiotics in terms of symptom relief and abscess formation. Another, older study compared breast emptying alone as 'supportive therapy' versus antibiotic therapy plus supportive therapy, and no therapy. The findings of the latter study suggested faster clearance of symptoms for women using antibiotics, although the study design was problematic.

AUTHORS' CONCLUSIONS

There is insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for the treatment of lactational mastitis. There is an urgent need to conduct high-quality, double-blinded RCTs to determine whether antibiotics should be used in this common postpartum condition.

Results of microbial testing exploring the etiology of deep breast pain during lactation: a systematic review and meta-analysis of nonrandomized trials

INTRODUCTION

Controversy over the etiology of deep or burning breast pain during lactation continues to persist, despite a long history of published studies and case reports. This article reviews the literature exploring the etiology of deep breast pain, summarizes the results, and identifies possible explanations for the controversies surrounding this disorder.

METHODS

A clinical query and a librarian-assisted search of MEDLINE were used to find articles published between 1896 and 2010. Inclusion criteria consisted of comparing microbial testing results from symptomatic and asymptomatic lactating women. Cases were restricted to those experiencing deep or burning breast pain when possible.

RESULTS

Prospective studies consisting of 1 unmatched case-control and 6 cohorts were found. Trials typically detected higher microbial levels in the milk or nipple(s) or both of symptomatic women, irrespective of the detection method or type and range of microbes (bacterial, yeast, or fungal) studied. Case milk samples were positively associated with finding Staphylococcus aureus (relative risk ratio [RR] 7.29; 95% confidence interval [CI], 3.25-16.36) or Candida (RR 8.45; 95% CI, 3.96-18.06). Moreover, recent reports about small-colony variants and biofilm-producing organisms may explain the atypical symptoms unique to this disorder.

DISCUSSION

In lactating women reporting deep breast pain, evidence consistent with infection is persistently found, and explanations exist for the disorder's atypical characteristics. Although lactating women with deep breast pain are more likely to test positive for Candida, the risk of testing positive for S aureus is also present. Thus, these women should have cultures done. Management options include treating immediately while awaiting results or waiting until results are available to guide treatment. With either approach, providers must consider the risk of falsely negative tests.

The role of micro-organisms (Staphylococcus aureus and Candida albicans) in the pathogenesis of breast pain and infection in lactating women: study protocol

BACKGROUND

The CASTLE (Candida and Staphylococcus Transmission: Longitudinal Evaluation) study will investigate the micro-organisms involved in the development of mastitis and "breast thrush" among breastfeeding women. To date, the organism(s) associated with the development of breast thrush have not been identified. The CASTLE study will also investigate the impact of physical health problems and breastfeeding problems on maternal psychological health in the early postpartum period.

METHODS/DESIGN

The CASTLE study is a longitudinal descriptive study designed to investigate the role of Staphylococcus spp (species) and Candida spp in breast pain and infection among lactating women, and to describe the transmission dynamics of S. aureus and Candida spp between mother and infant. The relationship between breastfeeding and postpartum health problems as well as maternal psychological well-being is also being investigated. A prospective cohort of four hundred nulliparous women who are at least thirty six weeks gestation pregnant are being recruited from two hospitals in Melbourne, Australia (November 2009 to June 2011). At recruitment, nasal, nipple (both breasts) and vaginal swabs are taken and participants complete a questionnaire asking about previous known staphylococcal and candidal infections. Following the birth, participants are followed-up six times: in hospital and then at home weekly until four weeks postpartum. Participants complete a questionnaire at each time points to collect information about breastfeeding problems and postpartum health problems. Nasal and nipple swabs and breast milk samples are collected from the mother. Oral and nasal swabs are collected from the baby. A telephone interview is conducted at eight weeks postpartum to collect information about postpartum health problems and breastfeeding problems, such as mastitis and nipple and breast pain.

DISCUSSION

This study is the first longitudinal study of the role of both staphylococcal and candidal colonisation in breast infections and will help to resolve the current controversy about which is the primary organism in the condition known as breast thrush. This study will also document transmission dynamics of S. aureus and Candida spp between mother and infant. In addition, CASTLE will investigate the impact of common maternal physical health symptoms and the effect of breastfeeding problems on maternal psychological well-being.

Cold storage of human milk: effect on its bacterial composition

OBJECTIVES

In the last few years, it has been proved that human milk contains bacteria that constitute an important factor in the initiation and development of the neonatal gut microbiota. In this context, the objective of this study was to evaluate the effect of cold storage on the natural bacterial composition of breast milk.

MATERIALS AND METHODS

Breast milk samples provided by 34 healthy women and collected either by manual expression (n = 27) or breast pump (n = 7), were plated onto several culture media immediately after arrival at the laboratory (day 0) and after storage at -20 degrees C for 6 weeks. A high number of isolates from 8 of the women were identified at the species level.

RESULTS

No statistically significant differences were observed between the counts obtained at both sampling times in those media in which growth was detected. In all of the culture media, bacterial counts in pump-collected samples were higher than in those obtained by manual expression. Staphylococci and streptococci were the predominant bacteria in both fresh and frozen samples, Staphylococcus epidermidis being the most abundant species at both sampling times. Lactic acid bacteria and bifidobacteria were also present in fresh and frozen breast milk samples, but among them, only 1 species (Lactobacillus gasseri) could be isolated at both sampling times.

CONCLUSIONS

The results of this study suggest that cold storage of milk at -20 degrees C for 6 weeks does not significantly affect either the quantitative or the qualitative bacterial composition of breast milk.

Ultrasound imaging of the lactating breast: methodology and application

Ultrasound imaging has been used extensively to detect abnormalities of the non-lactating breast. In contrast, the use of ultrasound for the investigation of pathology of the lactating breast is limited. Recent studies have re-examined the anatomy of the lactating breast highlighting features unique to this phase of breast development. These features should be taken into consideration along with knowledge of common lactation pathologies in order to make an accurate diagnosis when examining the lactating breast. Scanning techniques and ultrasound appearances of the normal lactating breast will be contrasted to those of the non-lactating breast. In addition ultrasound characteristics of common pathologies encountered during lactation will be described.

Antibiotics for mastitis in breastfeeding women

BACKGROUND

Mastitis can be caused by ineffective positioning of the baby at the breast or restricted feeding. Infective mastitis is commonly caused by Staphylococcus Aureus. Incidence of mastitis in breastfeeding women may reach 33%. Effective milk removal, pain medication and antibiotic therapy have been the mainstays of treatment.

OBJECTIVES

This review aims to examine the effectiveness of antibiotic therapies in relieving symptoms for breastfeeding women with mastitis with or without laboratory investigation.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2007), the Cochrane Central Register of Clinical Trials (The Cochrane Library 2007, Issue 4), MEDLINE (1996 to 2007) and EMBASE (January 1985 to 2007). We contacted investigators and other content experts known to us for unpublished trials and scanned the reference lists of retrieved articles

SELECTION CRITERIA

Randomized and quasi-randomized clinical trials comparing the effectiveness of various types of antibiotic therapies or antibiotic therapy versus alternative therapies for the treatment of mastitis were selected.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. When in dispute, we consulted a third author.

MAIN RESULTS

Two trials met the inclusion criteria. One small trial (n = 25) compared amoxicillin with cephradine and found no significant difference between the two antibiotics in terms of symptom relief and abscess formation. Another, older study compared breast emptying alone as "supportive therapy" versus antibiotic therapy plus supportive therapy, and no therapy. The findings of the latter study suggested faster clearance of symptoms for women using antibiotics, although the study design was problematic.

AUTHORS' CONCLUSIONS

There is insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for the treatment of lactational mastitis. There is an urgent need to conduct high-quality, double-blinded randomized clinical trials to determine whether antibiotics should be used in this common postpartum condition.

Conquering common breast-feeding problems

Meeting mothers' personal breast-feeding goals depends on a number of factors, including the timely resolution of any problems she encounters. Nurses are often the first providers who interact with the mother during the perinatal period and are positioned to guide mothers through the prevention and solving of breast-feeding problems. Although many problems may be "common," failure to remedy conditions that cause pain, frustration, and anxiety can lead to premature weaning and avoidance of breast-feeding subsequent children. This article describes strategies and interventions to alleviate common problems that breast-feeding mothers frequently encounter.

Infants of mothers with persistent nipple pain exert strong sucking vacuums

AIM

The objective of this study was to determine whether infants of mothers experiencing persistent nipple pain exerted very strong intraoral vacuums during a breastfeed.

METHODS

Thirty mothers experiencing persistent pain during breastfeeding (Pain group; infants aged 49.4 +/- 35.5 days) were compared to 30 successfully breastfeeding mothers (Control group; infants aged 55.0 +/- 22.7 days). Infant intraoral vacuums were measured via a small milk-filled tube taped alongside the nipple and connected to a pressure transducer. Milk intake was measured using the test weigh method.

RESULTS

Infants in the Pain group applied significantly stronger baseline (-90.8 +/- 54.5 vs. -56.4 +/- 31.4 mmHg, p = 0.004), peak (-214.3 +/- 60.5 vs. 163.2 +/- 62.4 mmHg, p = 0.002) and pause vacuums (-104.8 +/- 67.9 vs. -45.8 +/- 30.3 mmHg, p < 0.001). Despite similar active sucking times (377.5 +/- 175.2 vs. 349.4 +/- 184.0 sec, p = 0.554) the mean milk intake was significantly lower for infants of mothers with nipple pain (41.6 +/- 31.3 vs. 70.7 +/- 30.7 g, p = 0.001).

CONCLUSION

Infants of breastfeeding mothers experiencing persistent nipple pain applied significantly higher vacuum to the breast during breastfeeding despite assistance with positioning and attachment from a lactation consultant. Further investigation into the cause of the abnormally high vacuums is essential to develop successful interventions for these mother-infant dyads.