INFECTED GALACTOCELE IN A BREASTFEEDING WOMAN CAUSE BY THE TONGUE TIE AND LIP TIE OF THE BABY

Written by: Ernina Rahmatika Muis, MD

Case Report

Baby A, a female, was the firstborn child of Mr T and Mrs R. Baby A was born via pervaginam delivery with 2,750 grams (g) of birth weight, in a full-term pregnancy on October 3rd 2021. Mrs R exclusively breastfed her baby. During the early weeks of breastfeeding, Mrs R’s breasts became swollen, and then she had three sessions of lactation massages from a midwife. When Baby A was 5 months old, Mrs R frequently complained of marble-sized lumps on both breasts, that disappeared and recured. The lumps disappeared a few days while breastfeeding the baby and recured at a discrete spot.  Mrs R was a working mother. The Baby received expressed breastmilk from a teat bottle. Meanwhile, when she was at home after work or during days-off, the baby breastfed directly from the mother  or having direct breastfeeding (DBF).

Mrs R registered to the lactation clinic for the first time on 8 May 2022. She complained having a lump in her right breast that had existed for the past 2 months. Initially, the lump was about the size of a marble, then rapidly enlarged over several weeks to the size of a chicken egg and had remained to the date of first admission to the lactaion clinic. Mrs R also had a fever that subsided after taking paracetamol, while no antibiotics were taken. Based on the anamnesis, a family history of breast cancer was obtained from Mrs R’s grandmother, and she was worried that her lump might be a breast cancer.

Based on a physical examination, a lump of size 6x5x5 cm or about the size of a chicken egg on the right breast with a firm border was palpable at direction of 10 o’clock. The lump was mobile when the lactation doctor attempted to palpate the area. Redness or faint erythema appearance was present on the lump’s surface. There was minimal tenderness and minimal fluctuation.

BANNER 728 x 90

When the Baby was 7-month and 5-day old, her weight was 8,300 g and the weight gain was 25.81 g/day and the baby’s nutritional status was normo weight. The baby had complementary food, strained rice porridge, twice daily. The baby also had snacks three times a week. During a physical examination by a lactation medical doctor, it was found that the baby had tongue tie, the medial type, and lip tie, grade 4. Based on a direct breastfeeding observation, it was found that the baby’s suction reflex was not optimal, the baby latched poorly to the breast, and was easily distracted during breastfeeding. While breastfeeding, the baby often slipped from the breast, and finished breastfeeding before emptying the breast(s).

Based on the history taken and physical examination, the lactation doctor explained to the patient that the cause of the recurring lump (galactocele) was that the baby latched poorly and inadequately. Poor latching to the breast was caused by the baby’s  tongue tie and lip tie, and also by the use of a teat bottle during the working hours of the mother. For treating the tongue tie and lip tie,  the lactation doctor explained the procedure of simple frenotomy to both Mr T and Mrs R. The mother was prescribed painkiller, antibiotic, and Vitamin D3. An ultrasound examination of the breast was also required to rule out any possibility of breast abscess and cancer. The lactation doctor also counselled Mr T and Mrs R for complementary food in order for the baby to have the proper and subtle kind of complementary food.  It was also mandatory that the baby stop using teat bottle hence the parents had counselling session for working mothers. The counsellor also trained the caregiver to give expressed breastmilk using cup. 

Mrs R’s right breast lumps was 6x5x5 cm and at direction of 10 o’clock.  

The second admission to the lactation clinic was on May 10th 2022. The Baby was 7-month and 7-day old and the weight was 8300 g. The ultrasound examination was performed a day before the admission (9 May 2022). There were no additional complaints from Mrs R or the baby. Redness on the breast disappeared, also the lump size stayed the same. According to the ultrasound examination report, the following findings were obtained: Suggestive abscess formation at the superolateral quadrant of the right mammary, isoechoic lesion with a cystic component at the superomedial quadrant of the left mammary dd/galactocele and bilateral axillary reactive lymphadenopathy. At this visit, Mr T and Mrs R agreed to perform a simple frenotomy for the baby.  The mother learned how to do tongue and lip exercise, physical therapy done to the baby that is essential after frenotomy was performed. The lactation doctor also suggested a cold cabbage compression over the right breast to reduce the lump and the pain. The mother and baby dyad admitted to the ward for further treatments needed.

Ultrasound image,  May 9th, 2022 

                      Right breast                                                       Left breast

In ward, May 10th  2022, the surgeon visited the mother in ward. By the previous history taken, physical examination and ultrasound examination, it was decided to treat Mrs R as an outpatient. Mrs R was allowed to discharge and it was no longer necessary to carry out any surgery as there was a good response to the previous antibiotic treatment. The diagnosis was infected galactocele and it didn’t require any surgical treatment.  The surgeon also provided some further oral therapy as an outpatient care. It is essential that Mrs R continue to breastfeed her baby on both breasts, as the optimum suction of the baby would empty the breasts and thus shrink the galactocele. The lactation doctor also suggested applying a cold cabbage compression if it feels painful around the lump.

On the third admission , May 13th  2022,  the baby  was  7-month and 12-day old. Mrs R came to an internationally certified lactation consultant paediatrician. Mrs R felt the lump  shrunk. At this point, the baby weight gain was 13.33 g/day since her second visit. By the history taken, it was found that the lip exercise was not perfomed properly, hence the scar tissue was  formed and found at physical examination, causing her weight gain was insufficient. The baby subsequently underwent a re-incision (frenotomy) of the lip tie to achieve optimal suction and the weight gain would be optimal.

On the fourth admission, May 20th  2022, the baby was 7-month and 19-day old. Mrs R came for a follow-up visit. The baby did not gain anyweight, even by that time the weight reduced by 75 g since the third visit. The baby experienced fever, cough and runny nose over the past week. The baby was  prescribed Vitamin D3. The mother also continued taking Vitamin D3 and the lump decreased by size. Mrs R also said that her baby latched better and might be optimal as she felt her breasts emptied after breastfeeding sessions.

On the fifth admission, June 3rd  2022, the baby was 8-month and 3-day old. Mrs R came for a follow-up visit. At this time, the baby  weight was 8290 g, the weight gain was 1.78 g/day since the fourth visit. The lump on the mother left breast reduced almost to none. The baby A had stopped drinking from a teat bottle. When the mother was at work, the baby had expressed breast milk from a cup. However, the baby’s complementary food needed to be adjusted in terms of its texture and frequency. Therefore, the mother was counselled for a 4-star  complementary food WHO recommendations by the lactation doctor and was advised that the baby had aditional chicken egg in meal, known as egg therapy for the weight gain to be appropriate and optimal.

In the last follow-up session held by the lactation doctor, the baby was 11-month-old with a weight of 9700 gr (increased by 21.06 gr/day from the birth weight). Baby A had already consumed some complementary foods, which were textured as family meals. The main meal frequency was 3 times a day, while snacks were given once to twice a day. At this point, the mother fed the baby at least one chicken egg each day and did not neglect supplementary fat intake. The baby weight gain sufficiently increased every month. There was no breastfeeding and complementary feeding problem. Baby A was healthy with a good nutritional status, and still had only direct breastfeeding sessions when the mother stayed at home. When the mother was at work, the expressed breastmilk was given to the baby using cup adherently. As the father supports the mother continuously, the mother felt excited and optimistic to continue breastfeeding until the reached 2-year-old.

The baby weight graph

DISCUSSION

Galactocele is a benign lump that presents specifically within a female breast. It is a cyst filled with breast milk that occurs due to a blockage of the mammary duct or any obstruction at the lactiferous duct. 

A galactocele develops when ductal narrowing obstructs the flow of milk to the extent that a significant volume of obstructed milk collects in a cyst-like cavity. Galactoceles can range in size from small (1–2 cm) to very large (>10 cm). Galactoceles present as  moderately firm masses that gradually or rapidly increases in size over time. The size may fluctuate throughout the day, with a temporary decrease after breastfeeding. It may be uncomfortable, but is generally not as overtly painful as an abscess and does not have associated erythema or systemic symptoms unless it becomes infected galactocele. Ultrasound will show a simple or loculated cystic fluid collection. On occasion, image-guided aspiration may be performed to confirm the diagnosis. 2

In this case report, Mrs R’s lump was initially as large as a marble and persisted for 2 months and then rapidly enlarged over a week to the size of a chicken egg that persisted for 1 week. The lump was minimally painful upon pressure, had a faint red appearance on its surface, minimally fluctuated on pressure, and caused fever that lasted for a day. According to those findings, it leads to a conclusion that the lump was benign and  not a breast cancer (Ca mammae) since the lump was mobile when it was moved by hand and there were no typical signs of breast cancer such as peau d’orange, nipple retraction or pus and blood came out  of the nipple. Therefore, the diagnosis in this case was concluded as pre-abscess infected galactocele. 

The mechanism of direct breastfeeding for the baby to suckle the breast is a complex process. Initially, the baby must be able to seal the breast by folding the lips outwards, allowing no air flows into the mouth. Following that, the baby will grasp the breast by using the tongue and then press the breast towards the palate, the upper lining of the mouth cavity. Afterwards, in a rhythmic motion, the baby will continuously press the breast towards the palate and lower the tongue down to give it a relatively more negative vacuum, before finally the breastmilk comes out.3

Nevertheless, some babies with Tongue Tie and Lip Tie are unable to optimally empty the breast when they latch at the mother’s breast. That may cause a swollen breast or palpable lumps or bumps in certain areas of the breast. As per Mrs R’s case, due to Baby A’s non-optimal suction, the breast emptying was not optimal. As the result, Mrs R often experienced galactocele in certain areas of the breast. The cause of non-optimal suction in Baby A is due to the tongue tie and the lip tie.

 The lingual frenulum is a mucous membrane connecting the underside of the tongue with the floor of the mouth. This tissue has various appearances, can be thin or thick, long or short. When the lingual frenulum is short, fibrous, tight, or positioned too far forward, it limits the normal range of motion of the tongue and affects oral function. In such cases, ankyloglossia, or tongue tie is identified. 4

In addition to tongue tie, breastfeeding problems can also be caused by lip tie. Lip tie is a string or frenulum at the top of the lip that attaches to the upper jaw. This frenulum has no muscles and only consists of a membrane. If the frenulum is attached to the bone or upper gum, it can cause limited movement of the lips during breastfeeding. Flange-out lip position is needed in the breastfeeding process so that the baby’s mouth can create a vacuum or high negative pressure so that the baby can suck well and the transfer of the milk can be optimal. Flange-out lips also stimulate the oxytocin chain release, which causes the optimal release of breast milk from the mother’s breast. A baby’s lips that are not engorged when feeding to the breast can cause breastfeeding complaints, such as pain and sore nipples.5

Parents received a full explanation about tongue tie and frenotomy and gave written informed consent prior to the procedure. In preparation for frenotomy, the baby was swaddled to immobilize the arms and legs and laid supine on the examination table. An assistant helped

by holding the head still while the operator lifted the tongue with a finger to locate the frenulum.6

The frenulum was then snipped with blunt-ended sterile scissors, and sterile gauze was used to stop the bleeding. The tongue-tie was assessed as completely released if a neat diamond shape was visible with no palpable tissue remaining to restrict tongue movement. We favored not using general anesthesia to perform the procedure because this is likely to add delays in breastfeeding. Immediately after frenotomy, the mother was asked to breastfeed her baby for reevaluation of latch and improvement. The mother was taught how to perform tongue exercises to prevent reattachment. A follow-up visit was scheduled 3 days later to assess for complications and to evaluate the baby weight gain. A further review was scheduled 1 week later and continued every week after as necessary until the breastfeeding dyads’ course was considered as satisfactory.7

Following the frenotomy performed on Baby A, Mrs R’s felt that  the lump was reduced in size, the faint redness appearance diminished and the breast became painless. Mrs R felt that her baby had a stronger suction and was able to empty the breast(s) after breastfeeding sessions. The  complementary food and the additional egg therapy also affected the baby’s growth and development. The  complementary food appliance is in accordance to WHO recommendations. Baby A’s weight gain was also favoured and was found to be in a good nutritional status until the last follow-up visit. 

The following are 10 principles of infant complementary feeding according to WHO recommendations, (1) Breastfeed for 6 months, then give complementary feeding while continuing to breastfeed the baby. (2) Continue to breastfeed the baby until 2 years of age (on demand). (3) Implement active-responsive feeding (4) Ensure food hygiene and proper food storage. (5) Start the feeding with a small amount and gradually increase it. (6) Gradually adjust the texture of the food as the baby grows. (7) Increase the frequency of feeding as the baby grows. (8) Provide a variety of foods to fulfil the baby’s nutritional intake. (9) If indicated, use fortified foods or supplements. (10) Consider the feeding method if the baby is unwell. 8

In this particular case, we can conclude that galactocele, which is frequently experienced by mothers, is often caused by tongue tie and lip tie in infants. Through a simple frenotomy on the baby, along with the mother’s oral therapy and complementary feeding according to WHO standards, the baby can grow and develop optimally and the mother can continue to breastfeed for up to 2 years of age.

BIBLIOGRAPHY

  1. De jong, Sjamsuhidajat. Buku Ajar Ilmu Bedah. EGC. Jakarta. 2010
  2. Mitchell K, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. 2022 ; 365
  3. Praborini A, Wulandari RA. Anti Stres Menyusui. Kawan Pustaka. Jakarta. 2019
  4. Clay W, Hoover. The Breastfeeding Atlas Sixth Edition. United States of America. 2013 : 14
  5. Cole M. Tongue and Lip Tie: A Comprehensive Approach to Assessment and Care. Powerpoint presentation. 2017
  6. Sunil Kumar, P., Raja Babu, p., Jagadish Reddy, G., & Uttam, A. (2011). Povidone iodine – Revisited. Indian Journal of Dental Advancements, 3 (3). 617-620
  7. Praborini A, Purnamasari H, Munandar A, Wulandari RA. Early Frenotomy Improves Breastfeeding Outcomes for Tongue-Tied Infant. United States Lactation Consultant Association. 2015; 6 (1): 9-15.
  8. Direktorat Gizi Masyarakat Ditjen Kesehatan Masyarakat Kementrian Kesehatan Republik Indonesia. Manajemen Makanan Pendamping ASI. 2016

Leave a Reply

Your email address will not be published.