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

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mastitis
Mastitis

Joe Breuner, M.D.

thanks to

Thanks to

Doug Trotter, who gave this talk 18 months ago

case presentation
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
case presentation1
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
case presentation2
Case Presentation
  • Exam:
    • Afebrile
    • Looks tired but otherwise well
    • Normal nipple and breast; no lumps or indurated areas
    • No skin changes or lymphadenopathy
case presentation3
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”
milk stasis
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
milk stasis1
Milk stasis
  • Treatment for milk stasis:
    • Heat application
    • Massage toward nipple
    • Frequent, relaxed nursing
    • Change position to promote emptying
    • Avoid pumps, shields
case presentation4
Case Presentation
  • Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum
  • Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve
  • Now 2 hrs of fever, chills, increased tenderness
case presentation5
Case Presentation
  • Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum
  • Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve
  • Now 2 hrs of fever, chills, increased tenderness
  • Dx: Acute mastitis
mastitis1
Mastitis
  • Incidence: 2 - 3% of lactating women
mastitis2
Mastitis
  • Incidence: 2 - 3% of lactating women
  • More common at 2 - 6 weeks post-partum, but can occur at any time
mastitis3
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
mastitis4
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
mastitis5
Mastitis

Normal breast architecture

mastitis6
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
mastitis7
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
mastitis8
Mastitis
  • 1978 Series:
    • Similar results to prior studies
    • No abscesses if prompt antibiotic treatment and continued nursing
mastitis9
Mastitis
  • Etiology:
    • 50% or more: S. Aureus
    • Other organisms: E. Coli, S. pyogenes
mastitis10
Mastitis
  • Etiology:
    • 50% or more: S. Aureus
    • Other organisms: E. Coli, S. pyogenes
  • Source: infant nasopharynx (?)
mastitis11
Mastitis
  • Etiology:
    • 50% or more: S. Aureus
    • Other organisms: E. Coli, S. pyogenes
  • Source: infant nasopharynx (?)
  • Mechanism: via milk ducts or nipple fissure
mastitis12
Mastitis
  • Treatment:
    • Prompt antibiotics:
      • PO: Dicloxacillin, cephalexin, erythromycin
      • IV: Nafcillin, cefazolin
    • Continued frequent nursing
    • Heat application
    • Massage toward nipple
    • Antipyretics
mastitis13
Mastitis
  • In non lactating or pregnant women, consider early referral, as cancer is much more common.
breast abscess1
Breast Abscess

Breast abscess with early skin necrosis

breast abcess
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 women<40 are found during pregnancy or lactation
breast abscess2
Breast Abscess

Inflammatory breast cancer

neonatal mastitis1
Neonatal Mastitis
  • Occurs up to 5 weeks of age
  • Girls outnumber boys 2 : 1
  • Etiology: 85% S. aureus, also E. coli, group D Streptococcus
neonatal mastitis2
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
candida infection1
Candida Infection
  • Burning pain with nursing
  • Mild erythema & pruritis of nipple; findings may be subtle
  • Associated with thrush in the baby
  • May be intraductal
candida infection2
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