Harvard-MIT Division of Health Sciences and Technology HST.071: Human Reproductive Biology LACTATION

Transcription

1 LACTATION

2 LACTATION DISORDERS Early discharge from the hospital following delivery is currently the norm. In most instances, mothers are sent home before lactation is well established. The opportunity to teach about and observe problems that appear in the immediate postpartum period is thus foreshortened. Patients must be encouraged to communicate to their physicians symptoms of breast disease as they appear. These include sore nipples, painful breasts, localized inflammation and/or swelling, and fever or chills. BREAST ENGORGEMENT Breast engorgement is a common occurrence during the early puerperium. It usually begins during the second or third postpartum day. The breasts become full, hard, warm, and tender to palpation. The woman complains of throbbing and aching pain which is only relieved when she is lying on her back. Initially, breast engorgement is produced by the increased vascularity and lymphatic distention that precedes lactation. Manual expression or mechanical pumping is not productive and may be traumatic. At this early stage, the mother should be advised to wear a well-fitting brassiere 24 hours a day. If left alone, the engorgement will subside as the milk begins to flow. The breast becomes progressively softer thereafter. Accumulation of milk within the lacteals and lactiferous ducts, as a result of poor emptying, may lead to severe engorgement. The breasts become much fuller and very tender. The areola becomes engorged, obliterating the nipple. The axillary region is extremely painful due to tension on Cooper's ligament. Therapy is essentially symptomatic. The mother should be encouraged to continue breast

3 feeding to relieve the distention due to the accumulation of milk. Manual expression or mechanical pumping is helpful. This permits manual compression of the areola so that the nipples regain their original shape. Breast massage in a radial fashion (from the periphery to the areola) will soften the peripheral lobules. Emptying the gland is the appropriate treatment. Mild analgesics (e.g., codeine) provide temporary relief. Cold packs are said to help some patients during the early stages of engorgement by reducing vascularity. Warm packs or a warm shower may be helpful at a later stage. A tight brassiere provides relief by supporting the engorged breasts. The woman may require hypnotic medication to obtain some rest. Breast engorgement can also be seen when breast feeding is abruptly halted. Its presentation is similar to that which occurs in the immediate postpartum period. Treatment is symptomatic. Support of the breasts by a tight binder and cold packs have proven effective. SORE NIPPLES Some nipple tenderness is common during the first days of nursing. Its persistence or progression requires measures to avoid cracking the nipple. Painful nipples are frequently given as the reason for mothers to abandon breast-feeding during the first few postpartum days. Breast-feeding can be successfully continued in most instances. Steps to be taken to improve and prevent recurrence of nipple soreness include the following. (a) Prolonged nursing should be avoided. Manual initiation of milk flow hastens the letdown reflex and shortens feeding time. Initiation of feeding on the healthy breast also facilitates the letdown reflex reducing the force exerted on the nipple by the infant to extract milk. (b) Nipples should be exposed to air for minutes after each feeding. Anhydrous lanolin cream or vitamin A and D ointment applied

4 to the irritated area between feedings promote healing. (c) Nipples should be rinsed with plain water. Washing the breasts with soap and water before feedings dries the skin and may cause sore nipples. Nursing brassieres ought to be rinsed thoroughly to eliminate any residue of detergent which will irritate the nipple between feedings. (d) A soft, clean cloth can be used to cover the nipples between feedings. (e) Breast engorgement must be avoided because it flattens the nipple. This makes sucking more difficult and the infant tends to irritate the nipple further. CRACKED NIPPLES A nursing woman complaining of sore nipples must be evaluated for the presence of nipple fissures. They can be exquisitely painful. Nipple cracks can be circular on the nipple-areolar junction or vertical on its long axis. Treatment consists of (a) discontinuing feedings from the affected breast for hours. (b) To prevent engorgement, the breast should be manually expressed or pumped. (c) A small amount of breast milk is gently applied over the injured nipple and allowed to air dry. (d) Analgesics, when required, must be short acting (e.g., codeine) and given immediately after nursing. (e) Lanolin cream and/or vitamin A and D ointment are useful. Small amounts ought to be used to avoid the need for removal of the remnant before the next feeding. (f) If nursing with the affected breast is continued, the use of a nipple shield is required to prevent further irritation to the cracked nipple. GALACTOCELE Galactoceles, also known as milk-retention cysts, are usually the result of the occlusion of the lactiferous duct. It may affect one or more lobules. The patient presents with a painful breast in which a lump or cyst can be easily identified. The cyst and surrounding tissue are sensitive to touch but show no sign of inflammation. Pain is usually due to pressure on the contiguous

5 glandular tissue. The content of the cyst is at first pure milk. The mass is ordinarily fluctuant to palpation. Compression of the cyst may result in milk secretion. Spontaneous resolution is not unusual. If the cystic enlargement does not subside within hours, aspiration is indicated. The woman should refrain from massaging the breast. Because the lactating woman is not immune from breast cancer, ultrasonographic evaluation should be done. It will generally confirm the cystic nature of the mass. Aspiration of the fluid- filled cyst can be performed under local anesthesia. Breast-feeding does not have to be discontinued. Infection rarely ensues. PUERPERAL MASTITIS Infection of the lactating breast is at present a sporadic event. It commonly presents itself between the second and third postpartum weeks. A moderate degree of breast engorgement routinely precedes the appearance of puerperal mastitis. The mother will relate progressive breast discomfort between feedings. Increased unilateral mammary pain differentiates a bacterial inflammatory process from functional breast engorgement. The lactating woman will complain of pain localized over a segment of the affected breast. Intralobular involvement produces a wedge-shaped area of cellulitis. This portion of gland feels hard to palpation. Breast discomfort may become exaggerated during nursing. Low-grade fever of hours' duration may be reported preceding the appearance of chills and temperature spikes to 40 0 C (104 0 F). The breast becomes progressively hard and reddened. Generalized malaise is not uncommon. Staphylococcus aureus is the organism most commonly found in patients with puerperal

6 mastitis. Her newborn infant who has been colonized within the nursery by a nosocomial coagulase-positive penicillin-resistant staphylococcus usually infects the mother. The infant may be totally asymptomatic. It is unclear if the presence of nipple cracks is essential for bacterial invasion to occur. The offending organism may gain access to the gland through its lactiferous ducts. Complete resolution within hours accompanies prompt diagnosis and treatment. Culture of the expressed milk is indicated before therapy is initiated. The choice of antibiotics will be influenced by the prevalent type of staphylococcal organism in the hospital in which the woman delivered (the nursery in particular). Initial therapy consists of the following measures. (a) Give oral antibiotics, e.g., a penicillinase- resistant penicillin such as dicloxacillin mg. every 6 hours for 10 days. Cephalosporins and erythromycin have also proven effective. (b) Nursing from the affected breast must be discontinued. (c) A tightly fitted brassiere provides adequate support. (d) Cold packs and mild analgesics are useful measures for symptomatic relief. Nursing from the inflamed breast may be resumed after the mother has remained afebrile for 24 hours. BREAST ABSCESS Suppuration with abscess formation may complicate puerperal mastitis. Persistence of fever and chills beyond 48 hours after therapy has been initiated alerts the physician of this possibility. Delayed initiation of therapy for puerperal mastitis is usually contributory. A segment of breast appears inflamed, hardened, and tender to palpation. Fluctuation can sometimes be observed. Persistent mastitis despite appropriate therapy may indicate a deeply located abscess even in the absence of the aforementioned clinical signs.

7 Treatment of a breast abscess is surgical by drainage. Antibiotic therapy alone is not sufficient. Evacuation of the purulent material can be accomplished by repeated aspiration with a largebore needle. When more than one lobe is involved, multiple abscess cavities are to be expected. Incision and drainage of all loculations is the appropriate therapy. This is best performed under general anesthesia. Antibiotic therapy must be continued until healing is completed. It is prudent to discontinue nursing.