Treatment of breast infection

Having warned us that we should treat breast infections early for
fear of complications and medicolegal consequences the authors
unfortunately fail to offer any guidance for primary care on how to
distinguish between breast duct engorgement and infection.
I do not believe that every red breast segment is always infected in
lactating women, and indeed many settle down quietly and quickly without
ever coming to our attention. I have tended to treat women who are become
systemically unwell or have local signs of breast changes other than just
erythema, but otherwise not used antibiotics first line. Would the authors
agree, or would they prefer all breast redness to be treated with
antibiotics?

Many thanks for publishing this very useful clinical review. However
there seem to be sequencial errors in the reference numbers within the
text, at least in the printed BMJ 342 p484-489 (published 26/2/11). For
example on p485 the review of 946 cases of lactational mastitis in the USA
is surely reference 8, not 9? Similarly, in the section headed "How to
treat mastitis" on the same page reference 13 should be 12, 14 should be
13, 15 should be 14 & 16 should be 15.

I have not checked through all of the references in the review but it
does also look like the reference as to the cause of intertrigo on p488
should be ref 20, not 21 as stated.

In view of this I wonder if it is worth checking back through the
numbering of all the references in this article.

We are often asked to prescribe high dose oral antifungals to mothers
for a diagnosis made by health visitors and midwives of 'fungal
mastitis'. The core symptoms we are advised are severe needle like pains
in the breast during feeding. There are rarely any signs in the woman but
she has been persuaded by her care providers that this is the diagnosis
and given an information sheet of this 'disease' and the neeeded
treatment (high dose oral antifungals much higher than the bnf recommends)
to present to her GP. We are then left with a dilema, is this real
disease, is there a fungal component or is this similar to gut
candidiasis as a cause of chronic fatigue synmdrome.

Of course anybody could find a photograph in media records of the
doctor involved in the Baby P case (and everybody now knows he too has a
name). But it is surprising to find her photograph published in BMJ when
it is not common practice to publish them. When making these decisions
there is a danger of either overt or unconscious desires to be punitive.
Perhaps even more so in this case, not just because of the horrible
consequences of mistakes made, not only by this doctor but a whole network
of health and social workers who have not had their photographs published,
but because she is a woman, from a non British ethnic group,wearing a
headscarf. And she has flouted the disciplinary proceedings of the medical
world and the inevitable further humiliation, by resigning from the GMC
before her case is heard. But does the medical world really need to
distance themselves from terrible mistakes by hounding one health worker?