Ellie, who is breastfeeding five-week-old Harry, develops a breast abscess. Part 2
Ellie didn't have an abscess when I first saw her but was admitted to hospital one week later for intravenous antibiotics and abscess drainage
Fortunately, Ellie's ultrasound didn't show an abscess, and by phone the next day I recommended that she continue the antibiotics and continue with the steps that we'd discussed. She was also in close contact with her own GP.
My heart dropped when Ellie told me down the phone that she'd had a great night's sleep and was feeling better, that James had got up to Harry and she had slept for eight hours. I knew that this was dangerous for her breast. But Ellie was feeling unwell and had weighed things up for herself and decided that sleep was more important.
She was also not removing milk from the affected breast more often during the day, because of the cracks and nipple pain.
In a confusing health system environment, parents simply make their own path through as best they can, and my role is to offer information and support Ellie's own carefully weighed-up decisions.
Five days after the first clear ultrasound, Ellie's GP sent her up to the hospital for intravenous antibiotics. Ellie had woken that morning feeling awful, with painfully swollen lymph glands in the armpit on the affected side of her body. A second ultrasound in hospital now showed an abscess.
Ellie was admitted for intravenous antibiotics, drainage of the abscess, and for therapeutic ultrasound. When I spoke with her by phone, Ellie wanted to know if this might have been prevented if she had started antibiotics earlier, and if she'd had therapeutic ultrasound from the start, too.
"Ellie, I know this is very confusing," I responded, cautiously. "But there is no reason to think that starting antibiotics earlier, say 12 or 24 hours after your mastitis started - which is what you often hear - would have prevented the abscess forming. The research tells us that regardless of when we start antibiotics, about the same percentage of women with mastitis go on to develop abscess."
"Ok," Ellie said. "It's just hard, because I did wait five days or so."
"I know, but waiting for a number of days, even when you were feverish, was the right thing to do. Our job as health professionals is to make sure you know about the things that you can be doing which might help."
Ellie was happy to accept that. Then she continued: "My next question is about the therapeutic ultrasound. It kind of felt good, as if it was helping, especially when the milk started flowing, and I was wondering why no-one had told me about it sooner?"
"Yes it does feel right and healing when the milk is flowing, doesn't it!" I replied. "That's the best part of the ultrasound - when the probe is covered with the warmed up lubricant and the gentle movement of it over the breast triggers a letdown!"
"I know, it just felt right," Ellie said, again.
"But the problem is that the best way to get a letdown is to have your baby breastfeeding. The second best way to get a letdown is gentle hand expressing or pumping of your breast, if your baby doesn't want to breastfeed or there's nipple damage, like you had. If the pumping worsens the nipple pain, then hand expressing is the way to go. The evidence doesn't show benefit to therapeutic ultrasound and also there's no convincing scientific rationale to explain why ultrasound of your breast tissue might actually heal up the inflammation." I took a deep breath. I knew Ellie wanted to know the facts and my perspectives, so I decided to go on.
"This is why physiotherapists have largely stopped using therapeutic ultrasound for tissue strain and injury. Once, they were using it all the time! I can tell you from my own experience with my son, who was sporty, that the physios 20 years ago were right into ultrasound, but then the evidence started to show it wasn't effective. Now, it's being used on women's inflamed breast during lactation - and the concern is that if used too vigorously it might even apply pressure over the very sensitive inflamed tissues which makes inflammation worse. At best, it is not likely to help - beyond the wonderful benefits of having letdowns, as many as possible. The warm gel and gentle rolling sensation of the ultrasound probe stimulates letdowns."
"Right," Ellie said, rather doubtfully. "It's really upsetting that there's so much conflicting advice! How can you know what to do when everyone claims that what they are doing is evidence-based?"
"I know," I said quietly. I had no answer to this. "It is really hard."
Will Ellie continue breastfeeding? At this point in Ellie's story, I couldn't know. Our health system has quite accidentally conspired to make breastfeeding much harder for Ellie than many parents would consider acceptable. These parents most definitely want the very best for their baby's health and wellbeing, but they weigh up the costs against the benefits, and decide it's just not worth the suffering and distress which they have been experiencing around the clock.
The decision to stop breastfeeding is not due to a woman's lack of persistence. It's also not due to lack of knowledge about the downsides of formula use. It's a pragmatic decision about how to navigate a very rocky patch in their family's life, in a way that feels responsible and manageable.
Our health system blind spots made it very hard or impossible for breastfeeding to work for Ellie and her baby
When I saw Ellie next, two weeks after she'd been admitted for intravenous antibiotics and drainage of the abscess, the baby was taking 800 mls of formula in a 24-hour period - that is, was receiving all or most of his necessary calories from formula.
Ellie was gamely putting Harry to the breast as often as he would take it. He usually suckled away for a while and drowsed off into sleep. The lump in her left breast was still there, but smaller and soft, not at all tender, and gradually disappearing.
"It's too stressful trying to increase the amount of breastmilk he is getting," she said. "It's affecting my mental health and James is very worried about me. I keep worrying that Harry is getting nothing but I can't tell. I keep feeling like I should try to re-lactate. I feel incredibly guilty that I'm not giving him more of my breastmilk, but I just can't bear the stress. I stopped pumping a week ago because I just couldn't keep it up."
I nodded quietly. I completely understood. By the end of our consultation, I believe Ellie had a number of things clear in her own mind.
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Ellie didn't want to try to drive up her milk supply either through pumping or trying to make breastfeeding work.
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Ellie wanted to keep using her breast as a 'tool' for dialling little Harry down whenever she felt like it, and she might still offer the breast before the bottle to see what happens.
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Ellie had done her very best to make breastfeeding work, and she would practice a deep self-compassion, knowing this. She also knew that much has been out of her control. For instance, she had received lots of conflicting advice from the health professionals and 'evidence-based' sources that she turned to.
Although I didn't say this to Ellie, hers is a story about how the advice she received from kind and caring health professionals when she struck problems to do with breastfeeding and sleep made things harder for Ellie than they needed to be. The advice she received made it very difficult or impossible for her to continue breastfeeding, and resulted in her needing to predominantly formula feed her little one.
This is the way our health system fails women and their families. In advanced economies, we can no longer blame the formula companies. Our health system in advanced economies fails women and their families because of a historic lack of investment into research exploring how best help with breastfeeding challenges and how best to help parents and their babies in sync. We focus a lot more now on the mental health fallouts, without considering how effective help for breastfeeding and resultant unsettled baby behaviour helps prevent family distress and postpartum anxiety or depression.
This is no-one's fault - it is a health system problem. Advice that is definitely not evidence-based is taught to, or written into guidelines for, health professionals as if it is research-based. This includes advice to not change your breastfeeding patterns if you have mastitis, or to use therapeutic ultrasound, or massage, or probiotics, or lecithin, as if these approaches, which are costly, will help heal mastitis. But they don't. Many businesses have sprung up specialising in the treatment of mastitis, using approaches recommended by scientifically flawed guidelines.
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