Mastitis Joe Breuner, M.D.

Thanks to Doug Trotter, who gave this talk 18 months ago

Case Presentation  Healthy 25 year-old woman, G2P2, with a 6 week-old infant  Infant is fully breast-fed  Patient is fatigued due to caring for 2 young children  Husband is Boeing engineer, stressed because of likely upcoming layoff

 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  It usually resolves, but she wants to know why it happens, and what to do Case Presentation

 Exam:  Afebrile  Looks tired but otherwise well  Normal nipple and breast; no lumps or indurated areas  No skin changes or lymphadenopathy Case Presentation

 Exam:  Afebrile  Looks tired but otherwise well  Normal nipple and breast; no lumps or indurated areas  No skin changes or lymphadenopathy  Dx: Milk stasis or “plugged duct” Case Presentation

 Risk factors for milk stasis:  Fatigue, stress  Infrequent feeding  Incomplete emptying of breast  Ill-fitting bra  Pumps, shields  Prior breast trauma or infection Milk stasis

 Treatment for milk stasis:  Heat application  Massage toward nipple  Frequent, relaxed nursing  Change position to promote emptying  Avoid pumps, shields Milk stasis

 Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum  Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve  Now 2 hrs of fever, chills, increased tenderness Case Presentation

 Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum  Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve  Now 2 hrs of fever, chills, increased tenderness  Dx: Acute mastitis Case Presentation

 Incidence: 2 - 3% of lactating women Mastitis

 More common at weeks post- partum, but can occur at any time Mastitis

 Incidence: 2 - 3% of lactating women  More common at weeks post- partum, but can occur at any time  More common in primiparas, but probably due to bias Mastitis

 Incidence: 2 - 3% of lactating women  More common at weeks post- partum, but can occur at any time  More common in primiparas, but probably due to bias  Risk factors: milk stasis, age > 30, stress, fatigue, professional employment of mother or father Mastitis

Normal breast architecture Mastitis

 1970 Series:  71 cases of acute lactational mastitis  Peak incidence at 2-3 weeks postpartum  No infants weaned; none became ill  11% developed abscesses; 75% of those required surgical drainage  Abscess more likely if antibiotics delayed  8% developed mastitis in a later pg Mastitis

 1975 Series:  65 cases in 2,534 women: 2.5% incidence  Average onset 5 weeks postpartum  14% had missed feed or rapidly weaned  12% had nipple fissure beforehand  74% had been nursing normally  5% developed abscesses, all in pts who chose to wean Mastitis

 1978 Series:  Similar results to prior studies  No abscesses if prompt antibiotic treatment and continued nursing Mastitis

 Etiology:  50% or more: S. Aureus  Other organisms: E. Coli, S. pyogenes Mastitis

 Etiology:  50% or more: S. Aureus  Other organisms: E. Coli, S. pyogenes  Source: infant nasopharynx (?) Mastitis

 Etiology:  50% or more: S. Aureus  Other organisms: E. Coli, S. pyogenes  Source: infant nasopharynx (?)  Mechanism: via milk ducts or nipple fissure Mastitis

 Treatment:  Prompt antibiotics:  PO: Dicloxacillin, cephalexin, erythromycin  IV: Nafcillin, cefazolin  Continued frequent nursing  Heat application  Massage toward nipple  Antipyretics Mastitis

Mastitis  In non lactating or pregnant women, consider early referral, as cancer is much more common.

Breast Abscess

Breast abscess with early skin necrosis Breast Abscess

Breast abcess  Consider diagnosis in mastitis which fails to respond to antibiotics after 2- 3d (may not feel fluctuant)  refer to breast surgeon for incisional drainage and biopsy--  10-15% of breast carcinomas in women<40 are found during pregnancy or lactation

Inflammatory breast cancer Breast Abscess

Neonatal Mastitis

 Occurs up to 5 weeks of age  Girls outnumber boys 2 : 1  Etiology: 85% S. aureus, also E. coli, group D Streptococcus 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 Neonatal Mastitis

Candida Infection

 Burning pain with nursing  Mild erythema & pruritis of nipple; findings may be subtle  Associated with thrush in the baby  May be intraductal Candida Infection

 Treat mother and baby with topical antifungals or Gentian violet  May be recurrent  If no response to topical therapy, may use oral fluconazole 150 mg qd X 5d Candida Infection

Mastitis