Management of Common Complications of Lactation – Milk Fistula

• Milk Fistula:
  • Myth:
    • Procedures should be avoided on the lactating breast due to the risk of milk fistula
  • Science:
    • Milk fistula is rare if lactation and surgical interventions are managed appropriately
    • After a procedure:
      • Patients should not avoid breastfeeding:
        • In fact, the preferential flow of breastmilk through the nipple will decrease the flow through a needle or incision tract
      • On the other hand, patients should not be counseled to “pump to empty” their breasts or breastfeed more frequently on the affected breast:
        • As this will cause increase in milk production:
          • Which will promote fistula persistence
  • Treatment:
    • Large surgical incision and drainage:
      • Should be avoided in lactation patients
    • Any incision made should be as small as possible, and as distant from the nipple areolar complex as possible
    • If a distal incision is not possible:
      • It should be made outside the region where an infant latches or pump flanges contact the skin:
        • Periareolar incisions, although cosmetic, are particularly high risk due to the potential for latch or pump trauma.
  • Patients should feed physiologically after a procedure:
    • Local anesthetic agents are not absorbed orally by the infant, and blood is safe for the infant to ingest
  • A transient fistula will form after any procedure but is expected to close within a week if lactation is managed appropriately:
    • Should a persistent, high-output fistula develop:
      • A distal diverting drain can be placed to hasten closure (Figure)
      • Milk passing through a fistula tract may be collected and is safe to feed to the infant
      • Absorbent dressings may be used to prevent skin maceration from moisture but should be removed before breastfeeding:
        • As they are potential choking hazards and/or may interfere with latch
        • Wound vacuum systems should not be used on the lactating breast, as this will promote chronic fistulization and maintain tract patency

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