Mastitis Joe Breuner, M. D.
Thanks to Doug Trotter, who gave this talk 18 months ago
Case Presentation v Healthy 25 year-old woman, G 2 P 2, with a 6 week-old infant v Infant is fully breast-fed v Patient is fatigued due to caring for 2 young children v Husband is Boeing engineer, stressed because of likely upcoming layoff
Case Presentation v At 6 week visit, she reports 2 episodes of moderately painful swelling in upper inner quadrant of R breast; it occurred once in L breast v It usually resolves, but she wants to know why it happens, and what to do
Case Presentation v Exam: Ø Afebrile Ø Looks tired but otherwise well Ø Normal nipple and breast; no lumps or indurated areas Ø No skin changes or lymphadenopathy
Case Presentation v Exam: Ø Afebrile Ø Looks tired but otherwise well Ø Normal nipple and breast; no lumps or indurated areas Ø No skin changes or lymphadenopathy v Dx: Milk stasis or “plugged duct”
Milk stasis v Risk factors for milk stasis: Ø Fatigue, stress Ø Infrequent feeding Ø Incomplete emptying of breast Ø Ill-fitting bra Ø Pumps, shields Ø Prior breast trauma or infection
Milk stasis v Treatment for milk stasis: Ø Heat application Ø Massage toward nipple Ø Frequent, relaxed nursing Ø Change position to promote emptying Ø Avoid pumps, shields
Case Presentation v Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum v Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve v Now 2 hrs of fever, chills, increased tenderness
Case Presentation v Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum v Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve v Now 2 hrs of fever, chills, increased tenderness v Dx: Acute mastitis
Mastitis v Incidence: 2 - 3% of lactating women
Mastitis v Incidence: 2 - 3% of lactating women v More common at 2 - 6 weeks post- partum, but can occur at any time
Mastitis v Incidence: 2 - 3% of lactating women v More common at 2 - 6 weeks post- partum, but can occur at any time v More common in primiparas, but probably due to bias
Mastitis v Incidence: 2 - 3% of lactating women v More common at 2 - 6 weeks post- partum, but can occur at any time v More common in primiparas, but probably due to bias v Risk factors: milk stasis, age > 30, stress, fatigue, professional employment of mother or father
Mastitis Normal breast architecture
Mastitis v 1970 Series: Ø 71 cases of acute lactational mastitis Ø Peak incidence at 2 -3 weeks postpartum Ø No infants weaned; none became ill Ø 11% developed abscesses; 75% of those required surgical drainage Ø Abscess more likely if antibiotics delayed Ø 8% developed mastitis in a later pg
Mastitis v 1975 Series: Ø 65 cases in 2, 534 women: 2. 5% incidence Ø Average onset 5 weeks postpartum Ø 14% had missed feed or rapidly weaned Ø 12% had nipple fissure beforehand Ø 74% had been nursing normally Ø 5% developed abscesses, all in pts who chose to wean
Mastitis v 1978 Series: Ø Similar results to prior studies Ø No abscesses if prompt antibiotic treatment and continued nursing
Mastitis v Etiology: Ø 50% or more: S. Aureus Ø Other organisms: E. Coli S. pyogenes ,
Mastitis v Etiology: Ø 50% or more: S. Aureus Ø Other organisms: E. Coli S. pyogenes , v Source: infant nasopharynx (? )
Mastitis v Etiology: Ø 50% or more: S. Aureus Ø Other organisms: E. Coli S. pyogenes , v Source: infant nasopharynx (? ) v Mechanism: via milk ducts or nipple fissure
Mastitis v Treatment: Ø Prompt antibiotics: Ø PO: Dicloxacillin, cephalexin, erythromycin Ø IV: Nafcillin, cefazolin Ø Continued frequent nursing Ø Heat application Ø Massage toward nipple Ø Antipyretics
Mastitis v In non lactating or pregnant women, consider early referral, as cancer is much more common.
Breast Abscess
Breast Abscess Breast abscess with early skin necrosis
Breast abcess v Consider diagnosis in mastitis which fails to respond to antibiotics after 2 -3 d (may not feel fluctuant) v refer to breast surgeon for incisional drainage and biopsy-v 10 -15% of breast carcinomas in women<40 are found during pregnancy or lactation
Breast Abscess Inflammatory breast cancer
Neonatal Mastitis
Neonatal Mastitis v Occurs up to 5 weeks of age v Girls outnumber boys 2 : 1 v Etiology: 85% S. aureusalso E. coli , , group D Streptococcus
Neonatal Mastitis v Occurs up to 5 weeks of age v Girls outnumber boys 2 : 1 v Etiology: 85% S. aureusalso E. coli , , group D Streptococcus v Treatment: Ø Prompt antibiotics (IV? ) Ø Careful needle aspiration if abscess
Candida Infection
Candida Infection v Burning pain with nursing v Mild erythema & pruritis of nipple; findings may be subtle v Associated with thrush in the baby v May be intraductal
Candida Infection v Treat mother and baby with topical antifungals or Gentian violet v May be recurrent v If no response to topical therapy, may use oral fluconazole 150 mg qd X 5 d
Mastitis
