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?

Check your answer and get a special discount at the link above!

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 

Breastfeeding Part II: Facts and Myth-busting

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Today we (finally!) sit down with Part II of our breastfeeding special with Dr. Erin Cleary to cover myths, facts, and advantages of breastfeeding.

There are only three main contraindications to breastfeeding:
1. In infants with galactosemia.
2. In mothers who are HIV+ in high-resource settings.
3. In mothers with human T-cell lymphoma virus.

There are a number of relative contraindications to breastfeeding:

  • In a mother with Hepatitis A until she receives gamma globulin.

  • In a mother with Hepatitis B until the infant receives HBIG and HepB vaccine.

  • In a mother with Hepatitis C if coinfections present, such as HIV.

  • In a mother with Varicella zoster (Chicken pox) while mother is infectious.

  • In a mother with Active TB until mother has received 2+ weeks treatment

  • In a mother with influenza

    • if the mother has been afebrile without antipyretics for >24 hours, and the mother is able to control her cough and respiratory secretions.

    • Oseltamivir or Tamiflu is poorly excreted in breastmilk

  • In patients abusing IV drugs.

  • In patients using marijuana:

    • (THC), the main compound in marijuana, is present in human milk up to eight times that of maternal plasma levels, and metabolites are found in infant feces, indicating that THC is absorbed and metabolized by the infant

    • Several preclinical studies highlight how even low to moderate doses during particular periods of brain development can have profound consequences for brain maturation, potentially leading to long-lasting alterations in cognitive functions and emotional behaviors

    • Breastfeeding mothers should be counseled to reduce or eliminate their use of marijuana to avoid exposing their infants to this substance and advised of the possible long-term neurobehavioral effects from continued use

Common Breastfeeding Myths/Misconceptions:

Infectious:

  • You should breastfeed if you have mastitis, emptying the breast prevents stasis of milk

You can breastfeed in setting of acute respiratory, urinary, GU infections, continuation of BF acceptable

Imaging Sudies

  • You can breastfeed if… You need medical imaging.

    • XRays do not affect milk

    • Mammograms may be harder to interpret when a patient is lactating, but this should not be a reason to defer recommended diagnostic imaging

    • CT/MRI with or without contrast do not impact breastmilk

    • XRays with contrast dye or imaging with radioactive material are also OK

    • Exception: thyroid scan using I-131

      • I-131 concentrates in breastmilk and at high levels can suppress baby’s thyroid function (or even destroy the thyroid) and increase risk of thyroid cancer.

      • Therefore it is important that breastfeeding be discontinued until breastmilk levels are safe (this depends upon the dose and ranges from 8 days to 106+ days). The half-life for I-131 is 8.1 days.

      • Hale recommends that when I-131 is used, breastmilk samples should be tested with a gamma (radiation) counter before breastfeeding is resumed to ensure that radiation in the milk has returned to safe levels.

  • You can breastfeed if… You are pregnant!  

    • Increasing progesterone will decrease supply and cause breast/nipple sensitivity.  

    • Mature milk will be replaced by colostrum in the 2nd trimester.

    • Tandem feeding includes breastfeeding a newborn and toddler

  • You can breastfeed if… You’ve had general anesthesia.  As soon as you are awake enough to hold the baby, the medication has metabolized and breastfeeding is safe.

  • You can breastfeed if… You are on maintenance medications such as methadone and buprenorphine

    • There is a reduction in severity and duration of treatment of NAS when mothers on these medications breastfeed

  • You can breastfeed if… You have an occasional alcoholic beverage

    • Alcohol concentration in the blood is in steady state with the milk, so delaying nursing or pumping until more alcohol is metabolized can limit exposure

  • If direct breastfeeding is interrupted due to temporary separation of mother and child for any reason, the breastfeeding mother should be encouraged and supported to regularly express her milk.

    • Expression and storage of milk allows the infant to continue to receive milk if appropriate, and prevents stasis of milk and mastitis

In the setting of infection, prior to expressing breast milk, mothers should wash their hands well with soap and water and, if using a pump, follow recommendations for proper cleaning.

Breastfeeding Part I

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Today we start a two part series on breastfeeding with Dr. Erin Cleary, Assistant Professor of Obstetrics and Gynecology and Clinician Educator at the Warren Alpert Brown School of Medicine. She’s also the incoming MFM fellow at the Ohio State University — so look out for her in July, Buckeye listeners!

Also, thank you Dr. Daniel Ginn, our first Patreon sponsor — and apologies for the dad joke with your name!

We start today with a discussion of the anatomy of the breast, and in particular with lactation. At the bottom of this post is a corresponding Netter image to guide your listening.

The physiology of lactation is somewhat confusing, but in bulleted summary:
Lactogenesis I Early in pregnancy, human placental lactogen, prolactin, and chorionic gonadotropin contribute to maturation of the breast tissue to prepare for lactogenesis.

  • In the second trimester, secretory material which resembles colostrum appears in the glands.  A woman who delivers after 16 weeks gestation can be expected to produce colostrum.

  • Differentiated secretory alveolar cells develop at the ends of the mammary ducts under the influence of prolactin.  Progesterone acts to inhibit milk production during pregnancy. This makes sense from a viewpoint of energy expenditure- grow your baby first in utero, then switch to focus on growing it with milk.

Lactogenesis II is the onset of copious milk production at delivery.  In all mammals, it is associated with a drop in progesterone levels; in humans, this occurs during the 1st 4 days postpartum, with “milk coming in” by day 5

  • During the next 10 days, the milk composition changes to mature milk.  Establishing this supply is Lactogenesis III, and is NOT a hormonally-driven process like Lactogenesis I or II. Rather, this is supply/demand-driven with expression of milk

  • When the milk is not removed, the increased pressure lessens capillary blood flow and inhibits the lactation process.  Lack of sucking stimulation means lack of prolactin release from the pituitary.

Next week, we’ll be back again with Dr. Cleary discussing breastfeeding myths and contraindications, so stay tuned!

Netter’s Anatomy. Copyright Elsevier texts.