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Infant & Toddler Feeding Case Files
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August 2019

Breast Pain Without A Lump

Dr FUNG Wai Han
General Practitioner

Case History

Ms. Lovely, with good past health, had an uneventful delivery of her second baby. She resumed work while continuing with direct breastfeeding, supplementing with pumping and bottle-feeding. At about 6 months postpartum, she began to experience bilateral breast pain. The pain was deep and shooting, scoring 7 out of 10 in severity. It occurred soon after milk removal and lasted for an hour. She was afebrile and without other flu-like symptoms. She consulted a doctor 2 weeks later. Breast examination was essentially normal. There was no local tenderness or palpable lump. Further exploration revealed that she had completed a course of an antibiotic due to a urinary tract infection a week before onset of the pain. The baby was otherwise well, without oral or perineal thrush. Observation of her breastfeeding showed good positioning and attachment. Based on the clinical presentation, she was diagnosed Intraductal Candidiasis, likely triggered by antibiotics. Topical anti-fungal treatment (2% miconazole cream) for the mother with prophylactic treatment (Nystatin suspension) for her baby were prescribed.

After 2 weeks’ treatment, the breast pain got worse. The areolae were swollen and slightly abraded (Fig. 1). Further enquiry revealed that Ms. Lovely had switched to a larger breast shield for a week after heeding her friend’s advice that the breast pain might have been due to an under-sized breast shield. Observation of her pumping showed that the breast shield was actually over-sized. Too much areola was pulled into the tunnel resulting in areolar swelling and abrasion, which might have aggravated the Intraductal Candidiasis. She was advised to use an appropriate-sized breast shield to prevent further nipple trauma. DaktacortÒ (2% miconazole cream and 1% hydrocortisone) and topical mupirocin ointment were prescribed. Follow-up a week later showed good healing of the areolar lesion but her breast pain reduced only slightly. A 2-week course of oral anti-fungal (fluconazole) treatment was given after which she had complete recovery.


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Key Messages:

1. Early identification with timely management of breast pain can prevent early cessation of breastfeeding.

2. Diagnosis and management of Intraductal Candidiasis is a controversial issue. Diagnosis relies more on the clinical presentation than microbiological testing.

3. To minimize over- or under-treatment of Intraductal Candidiasis, a systematic approach to excluding other differential diagnoses of breast pain is important.

4. Mother with Intraductal Candidiasis is safe to breastfeed.

Editor-in-Chief: Dr Shirley Leung
Illustration: Ms Iris Leung, 草屋 Iris's Workshop - 畫公仔的草

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