Recurring abscesses and multi-drug resistance in mothers of babies who have tongue-tie and lip-tie Novita Adelina,MD and Regia Puspa Astari, MD, CIMI Mrs. D, 30 years old, came to the emergency room with a swollen right breast for two weeks. There were also breast pain and fever. Mother was breastfeeding her 17 days old male baby (Baby K). The baby’s suckling was often detached. Due to this difficulty and eversince the mother enters the emergency room, the mother usually gave pacifier and her expressed breast milk using a bottle to the baby. While in the emergency room the mother was diagnosed with the right breast abscess. The procedure for a maternal abscess incision was performed the next day at around three in the afternoon. During the day after the mother had entered the emergency room, before the operation of the mother’s abscess, the baby came to lactation clinic with the father. At the clinic, physical examination has shown that the baby has a tongue-tie and lip-tie. This condition contributed to the improper baby’s sucking ability and a nipple blister on the mother’s breast. This blister was an entry for germs into the mother’s breast and influencing the formation of abscess. The lactation team helped the baby to drink the mother’s expressed breastmilk using the glass or cupfeeder, which was hold by the father, in order to avoid nipple confusion and other disadvantages from artificial teat. The cup was only used during the operation procedure for the breast abscess. Once the procedure was over, the baby was allowed to be breastfed directly from the mother’s breast, including the breast with post-operative abscesses. Through adequate breast emptying by the baby’s suckling, the breast was supposed to heal faster. During the hospitalization period after the mother’s first abscess surgery, a holistic management was done for both the mother and baby. The pediatrician did a simple incision (frenotomy) on the tongue-tie and lip-tie. After the procedure, the baby was able to latch correctly on the breast. The mother and baby were hospitalized for three days.BANNER 728 x 90 Figure 1. Right breast abscess after first surgery- covered with sterile gauze Figure 2. Breast abscess after first surgery After one month post-operative abscess, Mrs. D came to the lactation clinic with complaints of swelling and pain in the right breast. After the previous post-operative care, the mother did not come to see the surgeon, in order to get a proper wound care and follow up examination. The ultrasound examination was done for the breast. It was shown a mastitis with the formation of an abscess in the right breast. Figure 3. Recurring Breast abscess on right breast Mrs. D, her husband and the family agreed to underwent the second hospitalization. At the inpatient department, Mrs. D and baby K were in the care of a team consisting of a pediatrician, lady doctors as lactation consultants, and a surgeon. During treatment, the intravenous Ceftriaxone (antibiotics), painkillers were administered and the baby was breastfed directly on both breasts. There was no improvement in maternal complaints after four days. During the fourth day of treatment, the results of antibiotic resistance examination of the pus and the pus culture on the first breast abscess treatment shown that the mother had a resistance to several antibiotics, MRSA (Methicilin-resistant Staphylococcus Aureus). This resistance to some of these antibiotics could cause recurring complaints despite the proper standard antibiotics use. A switch from Ceftriaxone to Levofloxacin (which is considered ‘sensitive’ according to the pus examination) was decided and recommended the mother to undergo a surgery. After the second surgery, the mother was assisted by lactation consultants to keep breastfeeding directly at both breasts, including the right breast. The right breast had shown improvement, and the mother was able to breastfeed the baby comfortably so that the mother was allowed to go home and continued to outpatient care. During post-operative care, the mother came routinely to the surgery clinic to get a routine wound care and follow up. She also came to the pediatrician and lactation consultants to optimize breastfeeding as well as monitoring child growth and development. At the first outpatient visit after surgery, the baby was two months and five days, with a bodyweight of 4675 grams. The mother had no complaint about breastfeeding. The mother routinely got a follow-up for post-operative abscess care and took medicine according to doctor’s orders. She came back to work in a month. The lactation team helped the mother in expressing her breast milk by hand and also helped the nanny learning to give the expressed milk to the baby with a glass cup. At the second visit, the baby was two months and 21 days, with a bodyweight of 5380 (gaining 44 g / day from the previous visit), the mother and baby had no complaints of breastfeeding, while the breasts also felt comfortable. Discussion Most breast abscesses are complications of mastitis in breastfeeding mothers that are not well managed. The management of breast abscess is the incision of the abscess and drainage of the pus contained in the abscess. The mother must keep breastfeeding her baby directly at both breasts before and after the incision. Termination of the production of breast milk is contraindicated. Methicillin-Resistant Staphylococcus aureus (MRSA) is a Staphylococcus aureus that is immune to methicillin type antibiotics. MRSA experiences resistance due to the genetic changes caused by irrational exposure to antibiotic therapy. Transmission of bacteria moves from one patient to another through a medical device that does not pay attention to its sterility. The transmission can also be by air or by room facilities, such as blankets or bedding (Nurkusuma, 2009). Risk factors for MRSA include environment, population, sports contact, personal hygiene, treatment history, history of surgery, history of infection and disease, treatment history, and medical conditions (Biantoro, 2008). In this case, the mother has a strong determination to breastfeed the child. Husband and the family support make mothers stronger. Good holistic care and simultaneous care between lactation counselors, pediatricians, and surgeons make the treatment of breast abscess and baby with slow weight gain work well without stopping the breastfeeding process. Antibiotic resistance can be one of the causes of recurrent breast abscesses. Antibiotic resistance occurs multi-causally, partly because of the irrational use of drugs. In this case, the long period of waiting for the result of the pus examination makes the process of inflammation can be repeated in a fast period, therefore a routine evaluation control should be done. References Kataria. K, Srivasta. A, Dhar, A. Management of Lactational Mastitis and Breast Abscesses: Review of Current Knowledge and Practice. Indian J Surg. 2013. 75 (6): 430-5 Biantoro, I. 2008. Metichillin-Resistant Staphylococcus aureus (MRSA). (Tesis). Universitas Gajah Mada. Yogyakarta. 7-26 pp. Nurkusuma, D. 2009. Faktor yang berpengaruh terhadap Metichillin-Resistant Staphylococcus aureus (MRSA) pada kasus infeksi luka pasca operasi di ruang perawatan bedah Rumah Sakit Dokter Kariadi Semarang. Tesis. Universitas Diponegoro. Semarang.