Mastitis

Mastitis is inflammation of the breast, which may or may not be accompanied by infection. Mastitis is more common in the lactational phase affecting one in five breastfeeding women. 74% to 95% cases of mastitis occur in the first 12 weeks after child birth especially in the second and third week postpartum. It is one of the reasons for early discontinuation of breastfeeding, which provides optimal infant nutrition

When mastitis occurs during lactation, it is called lactation or puerperal mastitis and in non-lactating women it is called periductal mastitis. Untreated infective mastitis can lead to breast abscess, which is localized collection of pus within the breast. Breast abscess is also common in the first six weeks’ post-partum, but may occur later.

The risk of mastitis can be reduced by providing ongoing support to maintain frequent, complete emptying of the breast and proper breastfeeding technique during lactational phase by health care providers.

References-

apps.who.int/iris/bitstream/handle/10665/66230/WHO_FCH_CAH_00.13_

www.acog.org/Patients/FAQs/Benign-Breast-Problems-and-Conditions

www.ncbi.nlm.nih.gov/pmc/articles/PMC4048576/

 

Breast pain is the primary symptom of mastitis. Other symptoms and signs of mastitis are:

  • Breast swelling
  • Skin redness, often in a wedge-shaped pattern
  • Breast tenderness, or warmth to touch
  • Pain or a burning sensation continuously or while breast-feeding
  • Feeling ill
  • Fever of 101 F (38.3 C) or greater
  • Hard lump in breast
  • Discharge from nipple

References-

www.healthline.com/health/mastitis#symptoms

 

Milk stasis and infection are two important causes of mastitis. Milk stasis is usually the primary cause, which may or may not be accompanied by or progress to infection.

Milk stasis occurs when baby is not sucking properly, and milk is collected within the breast tissue of lactating woman, that may lead to non-infectious inflammation (or non-infectious mastitis). As the stagnant milk provides a suitable environment for the bacteria to grow (without effective removal of milk) non-infectious mastitis may progress to infectious mastitis, and further to formation of an abscess.

Various reasons for milk stasis may be:

  • Poor attachment of the infant at the breast;
  • ineffective suckling;
  • restriction of the frequency or duration of feeds;
  • a blocked milk duct;
  • an overabundant milk supply;
  • lactating for twins or higher multiples.
  • Cracked nipple: Fissured or painful nipples may lead to avoidance of feeding on the affected breast and thus predispose to milk stasis. The commonest cause of trauma is poor attachment at the breast. Bacteria from women’s skin or baby's mouth can enter the milk ducts through a crack in the skin of nipple or through a milk duct opening.
  • A short frenulum (tongue-tie) in the infant has been observed clinically to interfere with attachment at the breast, and may cause cracked nipple.
  • Use of a pacifier or a bottle and teat may be associated with poor attachment at the breast, sore nipples, and reduction in breastfeeding frequency and duration. Pacifiers may thus interfere with milk removal and predispose to milk stasis.
  • Tight clothing, and prone sleeping position are other mechanical factors that have been observed in connection with mastitis.
  • Mastitis may occur in the breast opposite to the preferred side for lactation.

The commonest organisms found in mastitis and breast abscess are coagulase-positive Staphylococcus aureus but less commonly, Streptococcus or        Escherichia coli may be found.

References-

apps.who.int/iris/bitstream/handle/10665/66230/WHO_

www.ncbi.nlm.nih.gov/pmc/articles/PMC4048576/

 

Most cases of mastitis are diagnosed clinically. Medical care provider/doctor will ask about the various symptoms fever, pain, lactational history, and any medicinal intake. On clinical examination of the breast he/she will focus on looking for signs of inflammation (erythema, localised tenderness, heat, engorgement and swelling) and nipple damage.

Breast abscess is characterized by symptoms similar to mastitis, with the additional sign of a discrete tender lump, which may be tense or fluctuant. The mass may have overlying skin necrosis suggesting that the abscess is ‘pointing’ (abscess is sitting close to the surface of the skin).

Examination of the infant and attachment to the breast: The infant should be examined for anatomical conditions such as cleft palate or tongue-tie which may interfere with attachment.

Investigation- Mastitis is a clinical diagnosis and investigations are not indicated in the initial assessment. If symptoms don’t improve few days after proper management following investigations may be advised.

  • Ultrasound: Breast infection that does not improve with a course of appropriate antibiotics should be investigated with breast ultrasound.
  • Mammography: It is not a first line investigation in lactating women but is indicated if clinical, sonographic or biopsy features are suspicious for malignancy.
  • Bacteriological examination: Breastmilk for culture may be obtained by collecting a hand-expressed midstream clean-catch sample into a sterile container (i.e., a small quantity of the initially expressed milk is discarded to avoid contamination of the sample with skin flora, and subsequent milk is expressed into the sterile container, taking care not to touch the inside of the container). Cleansing the nipple prior to collection may further reduce skin contamination and minimize false-positive culture results.

Reference-

apps.who.int/iris/bitstream/handle/10665/66230/WHO_FCH_CAH_00.13_eng.pdf?sequence=1&isAllowed=y

 

Management of mastitis consist of effective milk removal and antibiotics if infection is suspected.

Simple analgesics like oral paracetamol and nonsteroidal anti-inflammatory drugs which are safe in breast feeding can be used to relieve pain.

Support for continued breastfeeding: In addition to effective treatment and control of pain, a woman needs emotional support. Continued breastfeeding should be encouraged in the presence of mastitis and generally it does not pose a risk to the infant. She needs reassurance about the value of breastfeeding that it is safe to continue breastfeeding and milk from the affected breast will not harm her infant.

Hot and cold packs to breast: As milk stasis is often the initiating factor in mastitis, mother can apply heat (warm compresses or a warm shower)) to the breast prior to feedings.

Effective milk removal: This is the most essential part of management of mastitis. Antibiotics and symptomatic treatment may make a woman feel better temporarily, but unless milk removal is improved, the condition may become worse or relapse despite the antibiotics.

Mother should be encouraged to breastfeed more frequently, as often and as long as the infant is willing, without restrictions starting on the affected breast. If necessary express breast-milk by hand or with a pump, until breastfeeding can be resumed.

Infant should be well attached to the breast during breastfeeding and if there is any problem with attachment, mother should be helped by health care provider/ caregiver. If attachment is painful, a breast pump can be used to drain the breast until the pain decreases enough to allow the baby to feed from the breast.

Massaging the breast during the feed with an edible oil or nontoxic lubricant on the fingers may also be helpful to facilitate milk removal. Massage, by the mother or a helper, should be directed from the blocked area moving toward the nipple.

Antibiotic therapy: Health care provider may advise for antibiotic therapy in following situations:

  • cell and bacterial colony counts and culture of breast milk are available and indicate infection,
  • symptoms are severe from the beginning, or
  • a nipple fissure is visible, or
  • symptoms do not improve after 12-24 hours of improved milk removal.

The chosen antibiotic must be given for an adequate length of time. (Tetracycline, ciprofloxacin and chloramphenicol are not advised as they are unsafe for use in lactating women.)

Identification and drainage of breast abscess:

If an abscess has formed, it needs pus removal. This can be done by surgical incision and drainage under general anesthesia. Pus can also be removed by aspiration, guided by ultrasound, if available. This procedure is less painful and can be done under local anesthesia. Systemic treatment with appropriate antibiotics is also required along with aspiration of pus.

Mother should be encouraged for breastfeeding and should be reassured that milk is safe for her baby when she is taking appropriate antibiotic.

References-

www.racgp.org.au/download/documents/AFP/2011/December/

www.ncbi.nlm.nih.gov/pmc/articles/PMC4048576/

 

Breast abscess- In about 3% of women with mastitis, breast abscess may occur.  A diagnostic breast ultrasound will identify a collection of fluid. The collection can often be drained by needle aspiration. Fluid or pus aspirated can be sent for culture. Systemic treatment with appropriate antibiotics is also required along with aspiration of pus. Mother should be encouraged for breastfeeding and reassured that milk is safe for her baby when she is taking appropriate antibiotic.

Reference-

www.ncbi.nlm.nih.gov/pmc/articles/PMC4048576/

 

Mastitis and breast abscess are preventable. If breastfeeding is managed appropriately from the beginning to prevent situations which give rise to milk stasis and if early signs such as engorgement, blocked duct and nipple soreness are treated promptly, mastitis can be prevented.

Skilled help to promote/support breastfeeding- Women and those who care for them (mother and child) should know about effective breastfeeding management as it is beneficial for both- to feed the infant adequately and to keep the breasts healthy. Breastfeeding should be managed appropriately from the beginning to throughout the first two years of life to prevent situations which give rise to milk stasis.

Important points are:

  • Mother should start to breastfeed within an hour of delivery;
  • make sure that the infant is well attached to the breast, taking care to prevent irritation and cracking of the nipple;
  • breastfeed with no restrictions, in either the frequency or duration of feeds, and let the baby finish the first breast first, before offering the other;
  • exclusive breastfeeding up to six months of age (the infant only receives breast milk without any additional food or drink, not even water);
  • encourage breastfeeding ‘on demand’ (as often as the child wants, day and night);
  • no use of bottles, teats or pacifier.
  • Mothers should be taught to hand-express when the breasts are too full for the infant to attach or the infant does not relieve breast fullness. A breast pump may also be used, if available, for these purposes.
  • During the time of weaning, mother should wean the baby over several weeks instead of suddenly stopping breast feeding.

In addition to facilitating breastfeeding and bonding, early skin-to-skin contact of a mother with her infant, and rooming-in, are the most natural and efficient ways to prevent the spread of infection, including the spread of organisms responsible for mastitis.

Prompt attention to any signs of milk stasis: A woman should know how to care for her breasts and about early signs of milk stasis.

  • Mothers should be taught to check their breasts for pain, redness or lumps.
  • If the mother notices any signs of milk stasis, she needs to rest, increase the frequency of breastfeeding, apply heat to the breast prior to feedings, and massage lumpy areas.
  • Mother should contact healthcare provider if symptoms are not improving within 24 hours.
  • Nipple soreness should be treated promptly.

Rest: As fatigue is often a precursor to mastitis, healthcare providers should encourage breastfeeding mothers to obtain adequate rest and to remind family members that breastfeeding mothers may need more help and encourage mothers to ask for help as necessary.

Good hygiene: It is important for hospital staff, new mothers, and their families to practice good hand hygiene during breast feeding.

MAA (Mothers’ Absolute Affection) Programme: Ministry of Health and Family Welfare, Government of India has launched a national breastfeeding promotion programme as MAA (Mothers’ Absolute Affection) to improve the breastfeeding and child feeding practices in the country. 

To know more about MAA click at nhm.gov.in/MAA/

Infographics to encourage breastfeeding- .who.int/topics/breastfeeding/infographics/en/

Know how to breast feed your baby- unicef.org/nutrition/files/Brochure_how_to_breastfeed.

References-

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4048576/

http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/

 

  • PUBLISHED DATE : Aug 01, 2018
  • PUBLISHED BY : NHP Admin
  • CREATED / VALIDATED BY : Dr. Aruna Rastogi
  • LAST UPDATED ON : Aug 01, 2018

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