Mastitis Joe Breuner, M.D.. Thanks to Doug Trotter, who gave this talk 18 months ago

MastitisMastitis

Joe Breuner, M.D.Joe Breuner, M.D.

Thanks to Thanks to

Doug Trotter, who gave Doug Trotter, who gave this talk 18 months agothis talk 18 months ago

Case PresentationCase Presentation

Healthy 25 year-old woman, Healthy 25 year-old woman, G2P2, with a 6 week-old infantG2P2, with a 6 week-old infant

Infant is fully breast-fedInfant is fully breast-fed Patient is fatigued due to Patient is fatigued due to

caring for 2 young childrencaring for 2 young children Husband is Boeing engineer, Husband is Boeing engineer,

stressed because of likely stressed because of likely upcoming layoffupcoming layoff

At 6 week visit, she reports 2 At 6 week visit, she reports 2 episodes of moderately episodes of moderately painful swelling in upper painful swelling in upper inner quadrant of R breast; inner quadrant of R breast; it occurred once in L breastit occurred once in L breast

It usually resolves, but she It usually resolves, but she wants to know why it wants to know why it happens, and what to dohappens, and what to do


Exam: Exam: AfebrileAfebrile Looks tired but otherwise wellLooks tired but otherwise well Normal nipple and breast; no Normal nipple and breast; no

lumps or indurated areaslumps or indurated areas No skin changes or No skin changes or

lymphadenopathylymphadenopathy


Exam: Exam: AfebrileAfebrile Looks tired but otherwise wellLooks tired but otherwise well Normal nipple and breast; no Normal nipple and breast; no

lumps or indurated areaslumps or indurated areas No skin changes or No skin changes or

lymphadenopathylymphadenopathy Dx: Milk stasis or “plugged Dx: Milk stasis or “plugged

duct”duct”


Risk factors for milk stasis:Risk factors for milk stasis: Fatigue, stressFatigue, stress Infrequent feedingInfrequent feeding Incomplete emptying of breastIncomplete emptying of breast Ill-fitting braIll-fitting bra Pumps, shieldsPumps, shields Prior breast trauma or Prior breast trauma or

infectioninfection

Milk stasisMilk stasis

Treatment for milk stasis:Treatment for milk stasis: Heat applicationHeat application Massage toward nippleMassage toward nipple Frequent, relaxed nursingFrequent, relaxed nursing Change position to promote Change position to promote

emptyingemptying Avoid pumps, shieldsAvoid pumps, shields

Milk stasisMilk stasis

Pt calls you Sunday afternoon, Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum3 PM, now 7 weeks postpartum

Had recurrent swelling of Had recurrent swelling of upper inner quadrant R breast upper inner quadrant R breast yesterday, but didn’t resolveyesterday, but didn’t resolve

Now 2 hrs of fever, chills, Now 2 hrs of fever, chills, increased tendernessincreased tenderness


Pt calls you Sunday afternoon, Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum3 PM, now 7 weeks postpartum

Had recurrent swelling of Had recurrent swelling of upper inner quadrant R breast upper inner quadrant R breast yesterday, but didn’t resolveyesterday, but didn’t resolve

Now 2 hrs of fever, chills, Now 2 hrs of fever, chills, increased tendernessincreased tenderness

Dx: Acute mastitisDx: Acute mastitis


Incidence: 2 - 3% of Incidence: 2 - 3% of lactating womenlactating women

MastitisMastitis


More common at 2 - 6 weeks More common at 2 - 6 weeks post-partum, but can occur post-partum, but can occur at any timeat any time

MastitisMastitis


More common at 2 - 6 weeks More common at 2 - 6 weeks post-partum, but can occur post-partum, but can occur at any timeat any time

More common in primiparas, More common in primiparas, but probably due to biasbut probably due to bias

MastitisMastitis

Incidence: 2 - 3% of lactating Incidence: 2 - 3% of lactating womenwomen

More common at 2 - 6 weeks post-More common at 2 - 6 weeks post-partum, but can occur at any timepartum, but can occur at any time

More common in primiparas, but More common in primiparas, but probably due to biasprobably due to bias

Risk factors: milk stasis, age > Risk factors: milk stasis, age > 30, stress, fatigue, professional 30, stress, fatigue, professional employment of mother employment of mother oror father father

MastitisMastitis

Normal Normal breast breast architecturearchitecture

MastitisMastitis

1970 Series:1970 Series: 71 cases of acute lactational mastitis71 cases of acute lactational mastitis Peak incidence at 2-3 weeks Peak incidence at 2-3 weeks

postpartumpostpartum No infants weaned; none became illNo infants weaned; none became ill 11% developed abscesses; 75% of 11% developed abscesses; 75% of

those required surgical drainagethose required surgical drainage Abscess more likely if antibiotics Abscess more likely if antibiotics

delayeddelayed 8% developed mastitis in a later pg8% developed mastitis in a later pg

MastitisMastitis

1975 Series:1975 Series: 65 cases in 2,534 women: 2.5% 65 cases in 2,534 women: 2.5%

incidenceincidence Average onset 5 weeks postpartumAverage onset 5 weeks postpartum 14% had missed feed or rapidly 14% had missed feed or rapidly

weanedweaned 12% had nipple fissure beforehand12% had nipple fissure beforehand 74% had been nursing normally74% had been nursing normally 5% developed abscesses, all in pts 5% developed abscesses, all in pts

who chose to weanwho chose to wean

MastitisMastitis

1978 Series:1978 Series: Similar results to prior studiesSimilar results to prior studies No abscesses if prompt No abscesses if prompt

antibiotic treatment and antibiotic treatment and continued nursingcontinued nursing

MastitisMastitis

Etiology:Etiology: 50% or more: 50% or more: S. AureusS. Aureus Other organisms: Other organisms: E. ColiE. Coli, , S. S.

pyogenespyogenes

MastitisMastitis


pyogenespyogenes Source: infant nasopharynx Source: infant nasopharynx

(?)(?)

MastitisMastitis


pyogenespyogenes Source: infant nasopharynx Source: infant nasopharynx

(?)(?) Mechanism: via milk ducts Mechanism: via milk ducts

or nipple fissureor nipple fissure

MastitisMastitis

Treatment:Treatment: Prompt antibiotics:Prompt antibiotics:

PO: Dicloxacillin, cephalexin, PO: Dicloxacillin, cephalexin, erythromycinerythromycin

IV: Nafcillin, cefazolinIV: Nafcillin, cefazolin Continued frequent nursingContinued frequent nursing Heat applicationHeat application Massage toward nippleMassage toward nipple AntipyreticsAntipyretics

MastitisMastitis

MastitisMastitis

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

Breast AbscessBreast Abscess

Breast Breast abscess abscess with early with early skin skin necrosisnecrosis


Breast abcessBreast abcess

Consider diagnosis in mastitis Consider diagnosis in mastitis which fails to respond to which fails to respond to antibiotics after 2-3d (may not antibiotics after 2-3d (may not feel fluctuant)feel fluctuant)

refer to breast surgeon for refer to breast surgeon for incisional drainage and biopsy--incisional drainage and biopsy--

10-15% of breast carcinomas in 10-15% of breast carcinomas in women<40 are found during women<40 are found during pregnancy or lactationpregnancy or lactation

InflammatorInflammatory breast y breast cancercancer


Neonatal MastitisNeonatal Mastitis

Occurs up to 5 weeks of ageOccurs up to 5 weeks of age Girls outnumber boys 2 : 1Girls outnumber boys 2 : 1 Etiology: 85% Etiology: 85% S. aureusS. aureus, also , also

E. coliE. coli, group D , group D StreptococcusStreptococcus


Occurs up to 5 weeks of ageOccurs up to 5 weeks of age Girls outnumber boys 2 : 1Girls outnumber boys 2 : 1 Etiology: 85% Etiology: 85% S. aureusS. aureus, also , also

E. coliE. coli, group D , group D StreptococcusStreptococcus Treatment:Treatment:

Prompt antibiotics (IV?)Prompt antibiotics (IV?) Careful needle aspiration if Careful needle aspiration if

abscessabscess


Candida InfectionCandida Infection

Burning pain with nursingBurning pain with nursing Mild erythema & pruritis of Mild erythema & pruritis of

nipple; findings may be nipple; findings may be subtlesubtle

Associated with thrush in Associated with thrush in the baby the baby

May be intraductalMay be intraductal


Treat mother and baby with Treat mother and baby with topical antifungals or topical antifungals or Gentian violetGentian violet

May be recurrentMay be recurrent If no response to topical If no response to topical

therapy, may use oral therapy, may use oral fluconazole 150 mg qd fluconazole 150 mg qd XX 5d 5d


MastitisMastitis

Documents

Mastitis Joe Breuner, M.D.. Thanks to Doug Trotter, who gave this talk 18 months ago