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Am J. Obstet.Gynecol 1984; 149(5) 492-5N  *   Z}    R    =Leukocyte and bacteria counts in women with clinical mastitis > Q Leukocytes Leukocytes <106/ml milk > 106/ml milk Bacteria milk stasis Non infectious mastitis < 103/ml milk Bacteria Infectious mastitis > 103/ml milk Thomsen et al Course and treatment of milk stasis, non infectious inflammation of the breast, and infectious mastitis in nursing women Am J. Obstet.Gyn 1984: 149(5) 492-5R     $     &4     6Thomsen et al s conclusions  'Milk stasis improved with continued breastfeeding alone Non-infectious mastitis required additional expression of milk after a feed Infectious mastitis was treated effectively only with both removal of milk and systemic antibiotics Without effective removal of milk, non-infectious mastitis was likely to progress to infectious mastitis and infectious mastitis to the formation of an abscess They related cell and bacterial counts to clinical findings and showed it was impossible to be certain from clinical signs whether infection was present or not (' ( Prospective study  946 women followed to three months Strongest risk factors: Previous history mastitis Cracks and nipple sores in same week Using an anti-fungal nipple cream Pattern of frequent short feeding Using a manual pump (for women with no history) Characteristics of the different possible bacterial agents involved not well understood. Foxman, B et al (2002) American Journal of Epidemiology #ZZZYZ8ZZ#)08    &G  3 Osterman and Rahm4    41 episodes of mastitis studied  bacterial cultures taken Group A = 25 cases (61%)  cultured normal skin bacteria Group B = 16 cases (34%)  cultured potentially pathogenic bacteria Lactational mastitis; bacterial cultivation of breastmilk, symptoms, treatment and outcome. 2000 Journal of Human Lactation 16(4):297-302@;Z~ZZ&     Continued  Group A 93% episode finished within a week Rest and frequent breast emptying curative 12% sore nipples Group B 81% longer than a week Outcomes included weaning, abscess, septic fever 75% sore nipples Leukocytes higher than in group Ab_{^{  S0Treatment of mastitis  Supportive counselling effective milk removal - an essential part of treatment antibiotics where appropriate symptomatic treatment 83$ $G$  Supportive counselling  To empower mother to get through mastitis and prevent reoccurrence Reassure about value of breastmilk and that it is safe to continue - milk from affected breast will not harm baby- though it may taste salty Encourage her that it is worth the effort to overcome current difficulties Counter any conflicting information Help her find the underlying cause and understand self-treatment and preventionCLB @J  Effective milk removal  1The most essential part of treatment help her to improve the efficiency of milk removal by improving positioning and latch position baby with chin close to the sore part encourage frequent feeding massage affected part towards nipple during the feed mother may also need to express her milk after feeds j%l$  2 Symptomatic treatment  Pain can be treated with analgesics Rest is essential - in bed if possible, Being in bed with child may also increase frequency of breastfeeding and therefore help milk removal Warm packs on the breast help relieve pain and help milk to flow. Ensure mother drinks sufficient fluidsLejMe+&  Drug treatment for mastitis  Ibuprofen - 400mg three times a day after food ( if no contra-indication for mother) Paracetamol - Two x 500mg four times a day ( no anti-inflamammatory action) Aspirin - should not be used in lactation as analgesic/anti-inflammatory at 2.4g/day dose Antibiotics - ( most safe in lactation, loose nappies, colic etc possible but not clinically important. May cause static weight gain. BEWARE THRUSH!) $ $$ !E &   K-Inappropriate treatment  &IT IS VITAL THAT BREASTFEEDING IS NOT INTERRUPTED as this prevents drainage of the breast and may worsen symptoms Use of drugs to suppress lactation ( bromocriptine and cabergoline) is innapropriate, particularly during an episode of mastitis, due to side effects associated with their use d1?Z         ]  Antibiotics  Flucloxacillin 250mg four times a day Amoxycillin 250-500mg three times a day If allergic to penicillin; Erythromycin 250-500mg four times a day Cephalexin 250-500mg four times a day Mastitis, causes and management WHO 2000tNN N(N    b   F ($ Key Points   Mastitis is not always due to an an infection Infectious mastitis requires medical treatment. Obstructive mastitis can be self- treated The quality of attachment of the baby to the breast is important in both prevention and treatment of mastitis. Thrush and mastitis may be connected Supportive counselling can help mothers understand the causes of mastitis and prevent re-occurrence2d  )%]Enabling Women to Breastfeed; Renfrew, Woolridge and Ross McGill ( areas for future research)"^] &'   . 4There is a need to determine incidence and prevalence of mastitis Need to develop simple differential diagnosis - infectious and non-infectious mastitis Other causes of mastitis - illness, stress, blocked ducts? Ways to prevent nipple trauma? Trial to compare antibiotic therapy vs antibiotic and expressing.X5`&   /)      I,L.Summary of best practice  PSupportive counselling Effective milk removal is an essential part of treatment Ibuprofen for pain relief and anti-inflammatory action if not contra indicted, paracetamol as analgesic if ibuprofen contra-indicated Antibiotics if appropriate symptoms have deteriorated or failed to improve with frequent and effective breast drainage J]] Q M/Effective milk removal  Involves optimising positioning and attachment helping the mother to achieve correct latch herself frequent feeding from the affected side additional expression from the affected side, if necessary helping the mother to recognise early symptoms for prevention of future problems*    0*      p1 Copyright  RThe copyright for these slides lies with Wendy Jones and the Breastfeeding Network. The slides may be used as an educational tool for non-profit making purposes only Reproduction of these slides, other than in their entirity, without written permission from the Breastfeeding Network is strictly forbidden; www.breastfeedingnetwork.org.ukJSq@  S     ` ̙33` ` ff3333f` 333MMM` f` f` 3` ̙33>?" dd@,|?" dd@ f3  " @ ` n?" dd@   @@``PR    @ ` ` p>> (    6ܤ P  T Click to edit Master title style! !  0t   RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  0  ``  X*  0䲟 `   Z*  0 `   Z*B  s *޽h ? ̙33 $Blank Presentation 0 @(    0$" P    T*    0&     V*  d  c $ ?    04*  @  RClick to edit Master text styles Second level Third level Fourth level Fifth level!    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H  0޽h ? ̙33 \ HWendy Jones PhD MRPharmS August 2006 ( 9$? l  C  P   l  C $  @  x  <A ??? H  0޽h ? ̙33  \T(  x  c $4<P  < r  S < <    f<gֳgֳ 5%5%? BThe dilemma of prescribing  Z  N<gֳgֳ ? b  Recommendations for a lactating mother are probably over-cautious and mothers who need treatment should not be prevented from breastfeeding if the drug is likely to be safe J $$  x  <A ??? 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