Condition	Presentation	Treatment
Dermatoses
Bacterial infection	Erythema, purulent discharge	Most cultures are positive for Staphylococcus
		Topical mupirocin (Bactroban) applied three times per day
Candidiasis	Salmon-colored nipples, flaky or shiny skin with associated itching or burning within the duct during feeding	Topical or oral antifungals
		Oral fluconazole (Diflucan; two 150-mg doses given 48 hours apart or 100 mg per day for 10 days) is more effective than oral nystatin
		Topical mupirocin applied three times per day for five to seven days can be considered because it may have antifungal properties and help prevent secondary bacterial infections
		Gentian violet can be used with caution because of the risk of infant mucosal ulcerations: gentian violet 1% is applied to the nipple with a cotton swab (this is messy and will stain clothing and skin) followed by a feeding at the treated breast, then this is repeated on the other side; this process is continued daily for three or four days, and up to seven days if there is improvement
Dermatitis/eczema	Pruritic, erythematous, scaly rash	Remove offending agent
		Rinse older infant's mouth between eating solids and breastfeeding
		Class IV medium-potency topical corticosteroid, such as hydrocortisone valerate 0.2%, triamcinolone 0.1%, or fluocinolone 0.025% (Synalar) applied twice per day for seven days
Nipple damage	Erythema, broken skin, ulcerations, bruising	Adjustment of latch and infant position or pump flange size to stop trauma to the nipple
		Expressed breast milk applied to the nipple after feedings and as needed between feedings
		Lanolin, all-purpose nipple ointment, breast shells, or glycerin pads can be used but are no more effective than expressed breast milk; hydrogel dressings have been shown to manage pain more effectively than lanolin
Milk flow issues
Blocked milk ducts	Tender nodule confined to one or more ducts	Check breast pump flange sizes (during expression phase of pumping, the nipple and a small amount of areola should be pulled into the tunnel; the nipple should be centered and move freely in the tunnel)
		Check the latch of the infant
		Massage area or apply vibration (e.g., with an electric toothbrush or massager)
		Improve/increase drainage of the breast by removing constricting clothing (e.g., underwire bras, tight sports bras), increasing the frequency of feedings, or pumping more often or between feedings; hand express to focus on one area for complete emptying
		Dangle feeding: the breast is dangled over the infant, often with the infant lying flat or inclined and the mother leaning over the infant so that milk flows forward by gravity
		Heat therapy: apply warm compresses or a heating pad to the breast for 20 minutes
		Feed with the chin toward the blockage to increase suction on that area and improve drainage (this may require assistance from a support person to hold the infant in position or can be done with dangle feeding)
		Reduce pain and inflammation with nonsteroidal anti-inflammatory drugs such as ibuprofen, 600 to 800 mg three times per day
		The herbal remedy lecithin, 1,200 mg three or four times per day, can be considered for recurrence
		Evaluate for milk blebs
		Rest and hydration
Engorgement	Full, tender breasts; breasts are edematous and shiny, and nipples and areolae may appear similar to inverted nipple; difficulty with latching	Hot or cold packs, acupuncture, application of cabbage leaves, and massage therapy may be helpful to reduce discomfort
		Reverse pressure softening (positive pressure applied around the nipple and areola temporarily moving interstitial fluid deeper into the breast away from the areola, making the areola softer and more pliable) decreases edema around the nipple and areola to help the infant latch more easily; a video of this method is available at https://m.youtube.com/watch?t=15s&v=2_RD9HNrOJ8
		Feed infant in a reclined position to reduce flow to infant
		Hand express or pump just enough to soften the breast and provide relief but not completely drain the breast
Milk blebs	Milk-filled blisters on the nipple	Soak the breast in warm salt water for five to 10 minutes, and then gently rub the nipple with a washcloth to abrade it and unroof the blister; if this is ineffective, a sterile 18-gauge needle can be used to unroof the blister
Oversupply	Forceful let down; infant may pull away from or clamp down on the breast while feeding; infant may have loose, green stools with some mucus	Follow recommendations for engorgement
		Reduce feedings or pumping sessions slowly to reduce milk production
		Block feeding: allow infant to feed off same breast for all feedings until supply regulates; this should be done with supervision of a physician and lactation consultant to ensure weight gain of infant and to prevent mastitis
Serious infections
Breast abscess	Tender, fluctuant nodule; erythema; induration; warmth	Ultrasonography for diagnosis
		Incision and drainage plus appropriate antibiotic therapy based on culture results
	Usually associated with the systemic symptoms of mastitis	Because of the risk of sinus tract formation, referral to a breast surgeon or interventional radiologist for incision and drainage should be considered
Mastitis without systemic symptoms	Tender nodule within a duct plus erythema and warmth	Treat for blocked ducts, including massage, warm compresses, rest, hydration, and nonsteroidal anti-inflammatory drugs, for 24 hours
		If there is no improvement after 24 hours, start dicloxacillin, 500 mg four times per day for five days; add an additional five days if inflammation is still present
Mastitis with systemic symptoms	Symptoms of mastitis plus malaise, fatigue, and fever greater than 101°F (38.3°C)	Follow recommendations for mastitis without systemic symptoms
		If symptoms do not resolve in 48 hours, a milk sample should be cultured; most cultures are positive for Staphylococcus
		If there is a concern for methicillin-resistant Staphylococcus aureus, the patient should be treated accordingly
		If symptoms are unresolved or there is an area of fluctuance, breast ultrasonography should be performed to evaluate for abscess
Vascular issues
Vasospasm	Breast pain after feeding	Prevent or reduce cold exposure; warm the nipples
	Raynaud phenomenon: nipple blanches white after feeding, and then may flush purple-blue to red a few minutes later; similarsymptoms in hands or feet	Treat causes of nipple trauma
		Avoidance of vasoconstrictive products, including caffeine
		Nifedipine, 30 mg per day for two weeks, can minimize pain and is safe in breastfeeding women