Mastitis

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Mastitis
Joe Breuner, M.D.
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Thanks to

• Doug Trotter, who gave this talk 18 months ago

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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

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Case Presentation

• 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

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Case Presentation

• Exam
• Afebrile
• Looks tired but otherwise well
• Normal nipple and breast no lumps or indurated
  areas
• No skin changes or lymphadenopathy

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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

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Milk stasis

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

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Milk stasis

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

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Case Presentation

• Pt calls you Sunday afternoon, 3 PM, now 7 weeks
  postpartum
• Had recurrent swelling of upper inner quadrant R
  breast yesterday, but didnt resolve
• Now 2 hrs of fever, chills, increased tenderness

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Case Presentation

• Pt calls you Sunday afternoon, 3 PM, now 7 weeks
  postpartum
• Had recurrent swelling of upper inner quadrant R
  breast yesterday, but didnt resolve
• Now 2 hrs of fever, chills, increased tenderness
• Dx Acute mastitis

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Mastitis

• Incidence 2 - 3 of lactating women

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Mastitis

• Incidence 2 - 3 of lactating women
• More common at 2 - 6 weeks post-partum, but can
  occur at any time

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Mastitis

• Incidence 2 - 3 of lactating women
• More common at 2 - 6 weeks post-partum, but can
  occur at any time
• More common in primiparas, but probably due to
  bias

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Mastitis

• Incidence 2 - 3 of lactating women
• More common at 2 - 6 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

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Mastitis

• Normal breast architecture

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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

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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

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Mastitis

• 1978 Series
• Similar results to prior studies
• No abscesses if prompt antibiotic treatment and
  continued nursing

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Mastitis

• Etiology
• 50 or more S. Aureus
• Other organisms E. Coli, S. pyogenes

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Mastitis

• Etiology
• 50 or more S. Aureus
• Other organisms E. Coli, S. pyogenes
• Source infant nasopharynx (?)

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Mastitis

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

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Mastitis

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

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Mastitis

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

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Breast Abscess
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Breast Abscess

• Breast abscess with early skin necrosis

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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 womenduring pregnancy or lactation

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Breast Abscess

• Inflammatory breast cancer

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Neonatal Mastitis
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Neonatal Mastitis

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

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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

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Candida Infection
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Candida Infection

• Burning pain with nursing
• Mild erythema pruritis of nipple findings may
  be subtle
• Associated with thrush in the baby
• May be intraductal

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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

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Mastitis
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