Mastitis

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Here’s the RoshReview Question of the Week:

A 30-year-old woman presents to the office with right-sided breast swelling and pain. She is 8 weeks postpartum from a spontaneous vaginal delivery of a term infant and is currently breastfeeding. She states her right breast is very painful, swollen, and red, and she has had a fever for the last 2 days. Which one of the following is the most appropriate next step for this patient?

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For more on breastfeeding, see our prior breastfeeding episodes (Part I and Part II) with Dr. Erin Cleary 

Before we get into mastitis… Breastfeeding is challenging!

  • There are many benefits to breastfeeding

    • Decrease in breast cancer, ovarian cancer, diabetes, HTN, heart disease 

    • Recommendation for breastfeeding for first 6 months of life or longer 

    • Benefits to the infant as well 

  • However in the US, as high as 45% of women report early, undesired weaning

    • Can be because of many things; nipple pain, perception of low milk supply, difficulty with latch

    • Other social factors, ie. limited access to maternity leave, barriers to breastfeeding in the workplace  

    • Depression, previous negative breastfeeding experiences 

  • Also, many things can occur in breastfeeding that can be a challenge 

What can look like mastitis? 

  • Engorgement

  • Physiologic breast fullness that often occurs between day 3-5 postpartum 

  • Typically reassuring sign that mature milk is being secreted 

  • However, can cause symptoms of distention, pain, tenderness, firmness and even fever (usually lower fever) - which can make it easy to confuse with mastitis 

  • Slightly swollen and tender lymph nodes 

  • Can sometimes be very pronounced and there should be anticipatory guidance 

  • Treatment:

    • Overall, data on prevention is limited

    • Can try acupuncture, hot and cold packs, cabbage leaves - but all from systematic reviews have found insufficient evidence to recommend a particular treatment regimen 

    • Can use milk expression to relieve some symptoms 

  • Persistent breast pain with feeding

    • Can be caused by many things  

      • Nipple damage from baby or with overuse/misuse of pump

        • Infant with tight lingual frenulum “tongue tie” - can get frenotomy or frenectomy 

        • Can help observe pumping session and adjust level of suction or fit of flange with lactation consultants  

      • Psoriasis, eczematous conditions - need to apply emollient and reduce identifiable triggers 

      • Candida infections - topical azole and antifungal ointment or cream are ok, or even oral fluconazole 

      • Herpes simplex or zoster - can be seen a small, clustered tender vesicles

        • Treatment with oral antiviral therapy 

        • Stop breastfeeding on that side temporarily 

  • Galactocele - milk retention cyst 

    • Usually just a collection of fluid that is caused by obstructed milk duct - usually soft cystic masses 

https://creogsovercoffee.com/notes/2019/6/16/breastfeeding-part-ii-facts-and-myth-busting

  • Infant’s chest rests against maternal body

  • Infant’s chin touches the breast, tongue is down 

  • Lips flanged outward

  • Little or no areola is visualized 

  • Rhythmic sucking present 

  • Audible swallowing present

  • Latch is not uncomfortable or painful and nipple is not injured or misshapen after breastfeeding  

What is mastitis? 

  • Defined as inflammation of the breast 

    • Can occur spontaneously, but today we’re talking just about mastitis in the context of breastfeeding 

  • Can occur in about 10% of patients who are breastfeeding 

    • Is especially problematic because it can lead to discontinuation of breastfeeding 

  • Risk factors:

    • Infant attachment issues - ie. short frenulum, cleft lip/palate

    • Cracked nipples, local milk stasis 

    • Missed feedings 

    • Poor maternal nutrition 

    • Previous mastitis 

    • Primiparity

    • Use of breast pump 

    • Yeast infection 

  • Diagnosis

    • Usually is made clinically 

    • Presentation usually is:

      • Localized, unilateral breast tenderness + erythema 

      • Fever - usually high! >101.0F (38.5C)

      • Can also have malaise, fatigue, body aches, headache 

      • Rarely will need to have culture to identify organism 

    •  On exam: will find redness, tenderness on one aspect of a breast (can be in different quadrants)

      • Be sure to examine for fluctuance - is there an abscess?  

    • When to get imaging:

      • If you suspect abscess on physical exam 

      • If symptoms are not improving despite medical management 

      • Usually can diagnose via ultrasonography  

  • Treatment

    • Breastfeeding technique

      • Lactation consultation to improve technique 

      • Counsel that patient should not stop breastfeeding or pumping on that side, as stopping can lead to milk stasis and more likely to develop abscess 

      • Can continue breastfeeding!  

      • Usually, the baby is already colonized by the same organism 

    •  Medical management

      • Antibiotics are usually needed for 10-14 days

      • Possible treatments include:

        • Augmentin 875 mg BID 

        • Keflex 500 mg 4x/day (hard to do 4x/day meds) 

        • Clindamycin 300 mg 4x/day - can be used against MRSA 

        • Dicloxacillin 500 mg 4x/day 

        • Bactrim DS (160mg/800 mg) BID - can be used against MRSA, but usually may want to avoid in patients with preterm infants 

  • When to refer

    • Abscess

      • Usually needs to be drained 

      • Can often be done at the bedside, and usually will not need to refer to breast surgery if you feel comfortable 

      • However, can depend on individual provider’s level of comfort  

    •  Abnormal presentation/lack of response to treatment

      • Most mastitis should resolve after initial treatment, and recurrence is not common, but can result from inappropriate or incomplete antibiotic therapy 

      • Most abscesses do not recur 

      • Inflammatory breast cancer can resemble mastitis at times, but may be differentiated by skin thickening as well as axillary lymphadenopathy