What are the management options for a lactating breast with pain or complications?

Management of Lactating Breast Pain and Complications

For lactating women experiencing breast pain or complications, prompt evaluation and appropriate management are essential to maintain breastfeeding and prevent serious complications such as abscess formation. 1

Initial Assessment and Common Complications

Nipple Pain and Damage

• Nipple pain is a common complication that can lead to early termination of breastfeeding if not properly addressed 2
• Causes include mechanical irritation from poor latch, infant mouth anomalies, bacterial or yeast infections 1
• Management options:
  • Application of expressed breast milk or lanolin may help heal nipple injuries 3
  • Nipple shields may be considered, though evidence for effectiveness is limited 3
  • Correction of breastfeeding technique with assistance from a lactation consultant is crucial 1

Breast Engorgement

• Breast engorgement is a physiological event during lactation that can become problematic 2
• Management:
  • Frequent, complete emptying of the breast through effective breastfeeding technique 1
  • Manual breast expression or using a breast pump may help prevent engorgement 3
  • Continued breastfeeding is recommended to relieve engorgement 4

Inflammatory Conditions

Mastitis

• Occurs in approximately 10% of breastfeeding mothers in the US 1
• Presents with focal breast tenderness, fever, and malaise 1
• Management:
  • Optimize breastfeeding technique with assistance from a lactation consultant 1
  • Continue breastfeeding from the affected breast to ensure drainage 4, 3
  • Obtain bacteriological sample of milk when mastitis is suspected 3
  • When antibiotics are needed, those effective against Staphylococcus aureus (e.g., dicloxacillin, cephalexin) are preferred 1
  • Be aware of increasing prevalence of methicillin-resistant S. aureus (MRSA) 1

Breast Abscess

• Most common complication of mastitis that can be prevented by early treatment 1
• Management:
  • Surgical incision and drainage or needle aspiration is necessary 3
  • Iterative puncture is an alternative to surgical drainage in moderate cases 3
  • Breastfeeding can usually continue during treatment of a breast abscess 1

Medication Considerations for Lactating Women

Safe Analgesic Options

• Paracetamol (acetaminophen) is safe - infant exposure via breast milk is significantly less than pediatric therapeutic doses 4
• NSAIDs considered safe during breastfeeding include:
  • Ibuprofen - extensively used during lactation with good safety profile 4
  • Diclofenac - small amounts detected in breast milk, considered safe 4
  • Naproxen - despite longer half-life, widely used and considered compatible with breastfeeding 4

Medications to Use with Caution or Avoid

• Codeine should not be used by breastfeeding women due to risk of excessive sedation in infants related to metabolic differences 4
• Opioids should be used with caution, especially with multiple doses and in babies under 6 weeks old 4
• If opioid analgesia is required, morphine is recommended at the lowest effective dose for the shortest time possible 4
• Aspirin should not be used in analgesic doses during breastfeeding 4

Special Considerations

Imaging for Breast Masses

• Ultrasound is the first-line imaging examination for lactating women with breast masses due to its high sensitivity 4
• Mammography may be performed if needed, with breastfeeding or pumping encouraged prior to examination to minimize breast density 4
• Most palpable masses in lactating women (>80%) are benign, but prompt evaluation is essential as pregnancy-associated breast cancer can occur 4

Surgical Procedures During Lactation

• Women should be encouraged to breastfeed as normal following surgery 4
• There is no need to express and discard breast milk after anesthesia 4
• Opioid-sparing techniques are preferable for breastfeeding women 4
• Local and regional anesthesia have benefits with minimal interference with breastfeeding 4
• Day surgery is preferable when possible to avoid disrupting normal routines 4

Prevention Strategies

• Frequent, complete emptying of the breast reduces risk of mastitis 1
• Optimizing breastfeeding technique is essential for prevention of complications 1
• Breastfeeding support should be accessible for lactating women, especially those undergoing medical procedures 4