Meabh Cullinane

Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia

Objective To investigate Candida species and Staphylococcus aureus and the development of ‘nipple and breast thrush’ among breastfeeding women. Design Prospective longitudinal cohort study. Setting Two hospitals in Melbourne, Australia (one public, one private) with follow-up in the community. Participants 360 nulliparous women recruited at ≥36 weeks’ gestation from November 2009 to June 2011. Participants were followed up six times: in hospital, at home weekly until 4 weeks postpartum and by telephone at 8 weeks. Main outcome measures Case definition ‘nipple and breast thrush’: burning nipple pain and breast pain (not related to mastitis); detection of Candida spp (using culture and PCR) in the mothers vagina, nipple or breast milk or in the babys mouth; detection of S aureus in the mothers nipple or breast milk. Results Women with the case definition of nipple/breast thrush were more likely to have Candida spp in nipple/breast milk/baby oral samples (54%) compared to other women (36%, p=0.014). S aureus was common in nipple/breast milk/baby samples of women with these symptoms as well as women without these symptoms (82% vs 79%) (p=0.597). Time-to-event analysis examined predictors of nipple/breast thrush up to and including the time of data collection. Candida in nipple/breast milk/baby predicted incidence of the case definition (rate ratio (RR) 1.87 (95% CI 1.10 to 3.16, p=0.018). We do not have evidence that S aureus colonisation was a predictor of these symptoms (RR 1.53, 95% CI 0.88 to 2.64, p=0.13). Nipple damage was also a predictor of these symptoms, RR 2.30 (95% CI 1.19 to 4.43, p=0.012). In the multivariate model, with all three predictors, the RRs were very similar to the univariate RRs. This indicates that Candida and nipple damage are independent predictors of our case definition.

Nipple Pain, Damage, and Vasospasm in the First 8 Weeks Postpartum

BACKGROUND Nipple pain and damage are common in the early postpartum period and are associated with early cessation of breastfeeding and comorbidities such as depression, anxiety, and mastitis. The incidence of nipple vasospasm has not been reported previously. This article describes nipple pain and damage prospectively in first-time mothers and explores the relationship between method of birth and nipple pain and/or damage. SUBJECTS AND METHODS A prospective cohort of 360 primiparous women was recruited in Melbourne, Australia, in the interval 2009-2011, and after birth participants were followed up six times. The women completed a questionnaire about breastfeeding practices and problems at each time point. Pain scores were graphically represented using spaghetti plots to display each womans experience of pain over the 8 weeks of the study. RESULTS After birth, before they were discharged home from hospital, 79% (250/317) of the women in this study reported nipple pain. Over the 8 weeks of the study 58% (198/336) of women reported nipple damage, and 23% (73/323) reported vasospasm. At 8 weeks postpartum 8% (27/340) of women continued to report nipple damage, and 20% (68/340) were still experiencing nipple pain. Ninety-four percent (320/340) of the women were breastfeeding at the end of the study, and there was no correlation between method of birth and nipple pain and/or damage. CONCLUSIONS Nipple pain is a common problem for new mothers in Australia and often persists for several weeks. Further studies are needed to establish the most effective means of preventing and treating breastfeeding problems in the postnatal period.

Probiotics and mastitis: evidence-based marketing?

Probiotics are defined as live micro-organisms, which when administered in adequate amounts, confer health benefits on the host. Scientists have isolated various strains of Lactobacilli from human milk (such as Lactobacillus fermentum and Lactobacillus salivarius), and the presence of these organisms is thought to be protective against breast infections, or mastitis.Trials of probiotics for treating mastitis in dairy cows have had mixed results: some successful and others unsuccessful. To date, only one trial of probiotics to treat mastitis in women and one trial to prevent mastitis have been published. Although trials of probiotics to prevent mastitis in breastfeeding women are still in progress, health professionals in Australia are receiving marketing of these products.High quality randomised controlled trials are needed to assess the effectiveness of probiotics for the prevention and/or treatment of mastitis.

Detection of Candida spp. in the vagina of a cohort of nulliparous pregnant women by culture and molecular methods: Is there an association between maternal vaginal and infant oral colonisation?

Most studies describing vaginal Candida spp. in pregnancy focus on symptomatic vaginitis, rather than asymptomatic colonisation, and solely utilise microbiological culture. The extent to which asymptomatic vaginal carriage may represent a reservoir for infant oral colonisation has been highly debated.

Supporting breastfeeding In Local Communities (SILC) in Victoria, Australia: a cluster randomised controlled trial

Objectives Breastfeeding has significant health benefits for mothers and infants. Despite recommendations from the WHO, by 6 months of age 40% of Australian infants are receiving no breast milk. Increased early postpartum breastfeeding support may improve breastfeeding maintenance. 2 community-based interventions to increase breastfeeding duration in local government areas (LGAs) in Victoria, Australia, were implemented and evaluated. Design 3-arm cluster randomised trial. Setting LGAs in Victoria, Australia. Participants LGAs across Victoria with breastfeeding initiation rates below the state average and > 450 births/year were eligible for inclusion. The LGA was the unit of randomisation, and maternal and child health centres in the LGAs comprised the clusters. Interventions Early home-based breastfeeding support by a maternal and child health nurse (home visit, HV) with or without access to a community-based breastfeeding drop-in centre (HV+drop-in). Main outcome measures The proportion of infants receiving ‘any’ breast milk at 3, 4 and 6 months (womens self-report). Findings 4 LGAs were randomised to the comparison arm and provided usual care (n=41 clusters; n=2414 women); 3 to HV (n=32 clusters; n=2281 women); and 3 to HV+drop-in (n=26 clusters; 2344 women). There was no difference in breastfeeding at 4 months in either HV (adjusted OR 1.04; 95% CI 0.84 to 1.29) or HV+drop-in (adjusted OR 0.92; 95% CI 0.78 to 1.08) compared with the comparison arm, no difference at 3 or 6 months, nor in any LGA in breastfeeding before and after the intervention. Some issues were experienced with intervention protocol fidelity. Conclusions Early home-based and community-based support proved difficult to implement. Interventions to increase breastfeeding in complex community settings require sufficient time and partnership building for successful implementation. We cannot conclude that additional community-based support is ineffective in improving breastfeeding maintenance given the level of adherence to the planned protocol. Trial registration number ACTRN12611000898954; Results.

Breastfeeding Support in the Early Postpartum: Content of Home Visits in the SILC Trial

Abstract Background The Supporting breastfeeding In Local Communities (SILC) cluster randomized controlled trial evaluated whether a home visit focussed on infant feeding early in the postpartum period increased the percentage of infants breastfeeding at 4 months in low socioeconomic areas of Victoria, Australia. The visits were offered to women identified as at risk of early breastfeeding cessation after discharge home with a new baby. This paper describes the content of the home visits. Methods SILC visited 1,043 women from September 2012 to March 2013, and completed a data sheet for each visit documenting topics discussed, as well as what support and resources were offered. Frequencies and percentages are presented. Results Home visits most commonly included the provision of reassurance to women (91%). Topics discussed included general breastfeeding information (83%), supply and demand (83%), positioning (79%), and feeding frequency (78%). Newborn feeding/behavior (57%), expression of breastmilk (54%), nipple pain (41%), low breastmilk supply (41%), and the use of nipple shields (18%) were also prominent topics. The issues and support needs of women were similar across locations (rural, regional or metropolitan) and regardless of maternal parity or age. There was some variation in the resources suggested in different localities. Conclusions New mothers require help and reassurance independent of whether this is their first or subsequent child, reinforcing the need for support, breastfeeding information, and education about normal neonatal behavior. Key aspects of support are reassurance, normalization of infant behavior, and education.

In Response to “Microbial Diversity in Milk of Women With Mastitis: Potential Role of Coagulase-Negative Staphylococci, Viridans Group Streptococci, and Corynebacteria”:

To the Editor, We read with interest the article by Mediano and colleagues, “Microbial Diversity in Milk of Women With Mastitis: Potential Role of Coagulase-Negative Staphylococci, Viridans Group Streptococci, and Corynebacteria” (Mediano et al., 2017). The authors conducted an extensive microbial characterization of milk samples from women described as suffering from mastitis to determine the etiology of this condition. Although the findings were of interest, the study has a number of failings. The inclusion criteria for mastitis were either “both local (breast redness, pain, and engorgement) and systemic symptoms (fever or flu-like symptoms) or only local symptoms (pain, engorgement, reduced milk secretion)” (p. 310). We believe that local symptoms only do not indicate mastitis. In most instances, breast symptoms are relieved with more frequent feeding or expressing, massaging, using hot/cold compresses, etc. Consensus guidelines define mastitis as when a woman has systemic symptoms in addition to local inflammatory breast symptoms (Amir & The Academy of Breastfeeding Medicine Protocol Committee, 2014). Local breast symptoms only are diagnosed as engorgement or a blocked duct (Berens, 2015; Witt, Bolman, Kredit, & Vanic, 2016). Therefore, we believe that milk samples collected from women with local breast symptoms only may not indicate mastitis. Furthermore, milk samples were analyzed from both breasts, even if only one was affected. Since breasts produce milk independently and women commonly experience mastitis in one breast only (Jahanfar, Ng, & Teng, 2013), we believe that analysis of milk from unaffected breasts was inappropriate. However, our greatest concern is the lack of milk samples from women without mastitis to serve as a comparison group. Whereas staphylococci, streptococci, and corynebacteria were the most prevalent bacterial groups reported, how can we be sure that these groups are not also present in comparable ratios in milk samples from women without mastitis? The authors concluded that the identified bacteria may be important etiologic agents of mastitis. Although this may be true, we believe that the absence of a control group precludes any conclusion. Human milk is not a sterile substance, and several hundred bacterial species have been identified in human milk (Cabrera-Rubio et al., 2012); therefore, the presence of bacterial species may not necessarily be indicative of infection. It is concerning that the authors argue that “a proper diagnosis of mastitis requires a microbiological analysis of milk” (p. 316). However, in practice, the lactating mother with mastitis is an unwell woman with a clear clinical diagnosis based on history (febrile symptoms and breast pain) and examination (redness and hardness of part of the breast) (Amir & Lumley, 2006; Iatrakis et al., 2013), and it is impractical to wait for microbiological confirmation. This contrasts with veterinary medicine, where greater reliance on investigations may be standard practice. Another point that we would like to make relates to the comments about the isolation of Candida spp. The authors are confused when they say “human mastitis cases have been frequently misdiagnosed as mammary candidiasis” (p. 316). Although we agree that some women with breast pain (e.g., cases of nipple vasospasm) are misdiagnosed as having a Candida infection, this condition presents as radiating breast pain in a normal looking breast (Amir et al., 2013) and never presents as redness, lump, or fever; therefore, the differential diagnosis of mastitis is never Candida infection of the breast. In conclusion, we hope that readers understand that the absence of a control group is a fatal flaw in this article. We look forward to seeing appropriately conducted studies in which standard demographic characteristics are collected and samples of milk are clearly defined, that is, milk from the affected breast of women with mastitis according to the standard definition, in addition to milk from women without mastitis for comparison.

Implementation and evaluation of community-based drop-in centres for breastfeeding support in Victoria, Australia

BackgroundWhile Australia has high breastfeeding initiation, there is a sharp decline in the first weeks postpartum and this continues throughout the first year. Supporting breastfeeding In Local Communities (SILC) was a three-arm cluster randomised controlled trial to determine whether early home-based breastfeeding support by a maternal and child health nurse (SILC-MCHN), with or without access to a community-based breastfeeding drop-in centre, increased the proportion of infants receiving any breast milk at three, four and six months. The trial was conducted in ten Local Government Areas (LGAs) in Victoria, Australia.The primary aim of this paper is to describe the three drop-in centres established during the trial; and the profile of women who accessed them. The secondary aim is to explore the views and experiences of the drop-in centre staff, and the challenges faced in establishing and maintaining a breastfeeding drop-in centre in the community.MethodsEvaluation of the three LGAs with drop-in centres was multifaceted and included observational visits and field notes; data collected from attendance log books from each drop-in centre; a written survey and focus groups with maternal and child health (MCH) nurses who ran the drop-in centres; and semi-structured interviews with MCH coordinators of the participating LGAs.ResultsThe three LGAs developed and ran different models of breastfeeding drop-in centres. They reported challenges in finding convenient, accessible locations. Overall, attendance was lower than expected, with an average of only one attendee per session. Two global themes were identified regarding staff views: implementation challenges, encompassing finding accessible, available space, recruiting volunteers to provide peer support, and frustration when women did not attend; and the work of SILC-MCHNs, including themes of satisfying and rewarding work, juggling roles, and benefits to women, babies and the community.ConclusionProviding community-based breastfeeding support was satisfying for the drop-in centre staff but proved difficult to implement, reflected by the lower than anticipated attendances at all of the drop-in centres. Interventions to increase breastfeeding in complex community settings require sufficient time to build partnerships with the existing services and the target population; to understand when and how to offer interventions for optimum benefit.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12611000898954.