Mastitis

SURENDRA SINGH, 318

Mastitis
An acute inflammation of the interlobular connective tissue within the mammary gland

Mastitis
Normal breast architecture

Outline
Epidemiology Presentation Predisposing factors Microbiology Treatment Complications Effect on breast milk

Epidemiology
Incidence 2-33%
ACOG reports 1-2% in U.S. Most common worldwide <10%

Most common 2nd-3rd week postpartum

74-95% in first 12 weeks Can occur anytime in lactation

Presentation
Systemic illness: Chills, myalgias Fever of 38.5 Tender, hot, swollen wedge-shaped erythematous area of breast Usually one breast

Differential Diagnosis
Fullness: bilateral, hot, heavy, hard, no redness Engorgement: bilateral, tender, +/- fever, minimal diffuse erythema Blocked Duct: painful lump with overlying erythema, no fever, feel well, particulate matter in milk

Differential Diagnosis
Galactocele: smooth rounded swelling (cyst) Abscess: tender hard breast mass, +/fluctuance, skin erythema, induration, +/fever Inflammatory Breast Carcinoma: unilateral, diffuse and recurrent, erythema, induration

Causes
Milk Stasis
Stagnant milk increases pressure in breast leading to leakage in surrounding breast tissue Milk, itself, causes an inflammatory response

+/- Infection
Milk provides medium for bacterial growth

Causes
3 groups
Milk stasis (bacteria<10^3, leuk<10^6) Noninfectious inflammation (bacteria <10^3, leuk >10^6) Infectious (bacteria >10^3, leuk>10^6)

Randomized treatment
No intervention Systematic emptying of breast Infectious group with 3rd intervention: antibiotics (PCN, Amp, Erythro) and systematic emptying

Causes
Poor results
Milk stasis (10) 3 recurrences, 7 impaired lactation Noninfectious (20) 13 recurrences Infectious (76 only 2 in Abx group) 6 abscesses, 21 recurrences

Could not clinically tell difference between the groups without lab data. Conclusion: Treat with antibiotics

Predisposing factors
Improper nursing technique
Timing of feeds Poor attachment

Oversupply of milk
Overabundant milk supply Lactating for multiples Rapid weaning Blocked nipple pore or duct

Pressure on Breast
Tight Bra Car seatbelt (yes, this is actually listed) Prone sleeping position

Predisposing factors
Damaged nipple (nipple fissure) Primiparity Previous history of mastitis Maternal or neonatal illness Maternal stress Work outside the home Trauma Genetic

Microbiology
Detection of pathogens difficult
Usually nasal/skin flora Difficult to avoid contamination

Milk culture
Encouraged in hospital acquired, recurrent mastitis, or no response in 2 days

Microbiology
Staph Aureus Coag neg staph Also, Group A and B hemolytic Strep, E Coli, H. flu MRSA Fungal infections TB where endemic 1% of cases

Fungal infections
Based on case reports that anti-fungal cream improves sx Case reports of cyptococcal infection Most common: Candida Albicans
Genital tract Newborn oral colonization

May lead to nipple fissure Thought to be associated with deep, shooting pains and nipple discomfort Most commonly treated with fluconozole to , oral nystatin to infant

Candida Infection

Treatment
Supportive Therapy
Rest, fluids, pain medication, anti-inflammatory agents, encouragement

Continue breast feeding Antibiotics that cover Staph and Strep

Culture results Severe symptoms Nipple fissure No improved after 12-24 hours of milk removal

Treatment (ACOG)
Dicloxicillin 500 mg qid Erythromycin if PCN allergic If resistant to treatment penicillinaseproducing staph, then vancomycin or cefotetan until 2 days after infection subsides Minimum treatment 10-14 days

Treatment (Alternative)
Therapeutic U/S Accupunture Bella donna, Phytolacca, Chamomilla, sulphur, Bellis perenis Cabbage leaves Avoid drinks like coffee with methylxanthines, decreasing fat intake

Complications
(Other bad things related to mastitis)

Breast Abscess

Breast Abscess

Breast abscess with early skin necrosis

Abscess
Most common in first 6 weeks 5-11% of mastitis cases Affect future lactation in 10% of affected No differences b/t groups by age, parity, localization of infection, cracked nipples, + milk cultures, mean lactation time Duration of symptoms: only independent variable favoring abscess development

Breast Abscess

Inflammatory breast cancer

Other Complications
Distortion of breast Chronic inflammatio

Granulomatous Mastitis
Noncaseating granulomas in a lobular distribution Differential Diagnosis
TB mastitis Foreign body Fat necrosis Autoimmune: sarcoid, erythema nodusum, polyarthritis

Presentation
Unilateral Breast lump No infection identified at presentation

Granulomatous Mastitis
Can mimic Breast Ca on clinical, radiological, and cytological exams Diagnosis: Histology Treatment:
Antibiotics not helpful Corticosteroids Excision biopsy

Limited literature, but no clear association with breast feeding, OCPs

Neonatal Mastitis

Neonatal Mastitis
Occurs up to 5 weeks of age Girls outnumber boys 2 : 1 Etiology: 85% S. aureus, also E. coli, group D Streptococcus Treatment:
Prompt antibiotics (IV?) Careful needle aspiration if abscess

Effect on Milk

Immune Factors
IgA is predominant in milk Increased immune factors from both plasma and local epithelial cells No adverse events documented in peds
Poor growth documented likely related to poor milk production Contradictory studies showing benefit or harm

Interest in pediatric vaccine development

Michie 2003, Filteau 2003

Increased HIV transmission risk

Alternating breast/bottle increased risk Role of free virus vs cell bound virus unclear If must breast feed, then pump on affected breast (pasteurize) and feed on unaffected

Michie 2003, Filteau 2003

Mastitis