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 Key Points - Case Study E
Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
- Topic 5.1: Sore nipples
- Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.
What other conditions may contribute to nipple damage occurring in the first week postpartum?
- Topic 5.2: Factors causing nipple damage
- Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.
After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
- Topic 5.3: General treatment for sore nipples
- The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.
Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?
- Topic 5.4: Further causes of nipple pain
- Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.
Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?
- Topic 5.5: Mastitis – diagnosis
- Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.
What would be the appropriate treatment to give her now?
- Topic 5.6: Mastitis – treatment and complications
- Good breast drainage is an essential component of the treatment of mastitis. Antibiotics may be required, especially if the mother has moderate to severe local or systemic symptoms, that she has cracked nipples, or the symptoms have been present for more than 12 hours without improving. Recurrent infection, Candida and a breast abscess are complications of mastitis.
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