Mastitis

An acute inflammation of the interlobular

connective tissue within the mammary gland
Normal breast
architecture
Mastitis
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 2
nd
-3
rd
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 3
rd
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 penicillinase-
producing 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 with
early skin
necrosis
Breast Abscess
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


Inflammatory
breast cancer
Breast Abscess
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

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