Lactational or Puerperal Breast Abscesses

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Lactational or puerperal breast abscesses:
    • Occur in 0.4% to 11% of breastfeeding women
  • The objectives of management should include:
    • Resolution of the abscess
    • Relief of pain
    • Continuation of breastfeeding
  • Appropriate antibiotic coverage should include:
    • Coverage for Gram-positive organisms until cultures are available to guide therapy
  • The most common organisms isolated from cultures include:
    • Staphylococcus aureus
    • Staphylococcus epidermidis
    • Streptococci
  • Choice of interventional strategy is somewhat controversial:
    • As both needle aspiration and surgical I&D are highly effective in successfully treating the abscess and have similar recurrence rates
  • Needle aspiration:
    • Is associated with reduction of healing time, higher continuation of breastfeeding, and higher patient satisfaction, but the appropriate choice of management depends on the clinical situation
  • Aggressive pumping or overfeeding to empty the breast:
    • Can lead to hyperlactation and may contribute to further tissue damage and inflammation:
      • The patient should continue to breastfeed, if possible, or pump physiologic volumes of milk and empty the unaffected breast first
  • While mammary fistula (“milk fistula”) is the most common complication after breast abscess:
    • It is relatively rare, occurring in 1% to 3% of patients
    • They can develop spontaneously:
      • But more commonly occur after instrumentation of the breast (eg, needle biopsies, aspirations, surgery)
      • Not surprisingly, incidence of milk fistula after needle aspiration is significantly lower than surgical I&D for women with lactational breast abscesses (RR=0.21, p=0.013)
    • For patients undergoing surgery:
      • Incisions should be as small and as far from the nipple-areolar complex as possible
      • Placement of closed-suction drains or vacuum-assisted dressings should be avoided:
        • As they may promote fistula development due to granulation tissue formation:
          • Penrose drain or another non-suction drain should be used instead
      • While dopamine agonists have been shown to effectively cease lactation:
        • They are no longer routinely recommended
      • Continued breastfeeding is encouraged and can divert milk flow through the nipple, minimizing flow through the cavity
  • References:
    • Zhou F, Li Z, Liu L, et al. The effectiveness of needle aspiration versus traditional incision and drainage in the treatment of breast abscess: a meta-analysis. Ann Med. 2023;55(1):2224045. Published online June 23, 2023. doi: 10.1080/07853890.2023.2224045
    • Mitchell K, Johnson H, Rodriguez J, et al; Academy of Breastfeeding Medicine.  Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022.  Breastfeed Med. 2022;17(5):360-376. doi: 10.1089/bfm.2022.29207.kbm
    • Johnson HM, Mitchell KB.  Low incidence of milk fistula with continued breastfeeding following radiologic and surgical interventions on the lactating breast. Breast Dis. 2021;40(3):183-189. doi: 10.3233/BD-201000
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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