Updated: 9/7/2020

Mastitis

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Snapshot
  •  A 29-year-old, G1P1, woman presents with a painful and erythematous right breast. Since the birth of her first son 3 weeks ago, she has been exclusively breastfeeding. Upon physical exam, there are visible small fissures around the nipple. The breast feels warm. Purulent discharge from the nipple is noted.
Introduction
  • Clinical definition
    • inflammation of the breast often associated with milk stasis during lactation
  • Epidemiology
    • incidence
      • 3-20% of lactating women
    • demographics
      • occurs in lactating women
      • any inflammatory breast in a post-menopausal woman is cancer until proven otherwise
      • often occurs within first 12 weeks post-partum
    • risk factors
      • lactation
      • injury to nipple
      • poor attachment of infant to breast
      • history of prior mastitis
  • Pathophysiology
    • pathophysiology
      • milk stasis, or accumulation of milk, may cause inflammatory response
      • milk stasis also creates favorable conditions for growth of bacteria
        • infection often starts from nipple fissures
        • often due to Staphylococcus aureus and Staphylococcus albus
        • can also be due to yeast, especially if infant has oral candidiasis or diaper dermatitis
  • Prognosis
    • prognostic variable
      • favorable
        • appropriate antibiotic treatment
    • survival with treatment
      • very good
Presentation
  • Symptoms
    • primary symptoms
      • tender, hot, and swollen breast
        • usually unilateral
      • flu-like myalgia
      • chills
      • fever
  • Physical exam
    • inspection
      • localized redness on the breast
        • often wedge-shaped
      • warmth and induration on the breast
      • cracked nipples or visible fissure
      • swollen lump may indicate breast abscess
      • may have purulent nipple discharge
    • suspect yeast mastitis if
      • pain out of proportion to clinical findings
        • shooting pain from nipple to chest wall
Imaging
  • Ultrasound
    • indications
      • if breast abscess is suspected
    • findings
      • fluid pocket seen inside breast
Studies
  • Labs
    • may see elevated white blood cell count
    • milk culture
      • indications
        • if no response to initial antibioitics
        • if recurrent or chronic mastitis
        • if there is presence of abscess
  • Diagnostic criteria
    • mastitis is typically diagnosed clinically based on physical exam
Differential
  • Engorgement
    • pain relief and resolution of symptoms with emptying of milk, ice packs, and analgesics 
  • Fibroadenoma
    • no signs of infection
Treatment
  • Conservative
    • continue breastfeeding
      • safe for infants
      • contraindicated in women with human immunodeficiency virus (HIV)
    • empty breasts of milk every 6 hours
      • indication
        • for mild symptoms lasting less than 1 day
      • outcomes
        • may shorten duration of mastitis
        • may improve rates of normal lactation
  • Medical 
    • dicloxacillin or cephalexin 
      • indications
        • symptoms persist after 1 day of effective, regular milk removal
        • milk culture indicates infection
        • visible nipple fissure
        • breast abscess
    • clindamycin or trimethoprim-sulfamethoxazole
      • indication
        • if methicillin-resistant Staphylococcus aureus (MRSA) is suspected    
    • fluconazole 
      • indication
        • if yeast mastitis is suspected
      • outcomes
        • successful if mother and infant are treated
  • Operative
    • surgical drainage       
      • indication
        • breast abscess is diagnosed
      • techniques
        • first-line
          • needle aspiration with or without ultrasound guidance
        • otherwise
          • incision and drainage for large abscesses
Complications
  • Breast abscess
    • 3-12% of women with mastitis develop breast abscess
    • treatment
      • surgical drainage
  • Vertical transmission of HIV infection from mother to infant
    • 10-20x higher load of HIV RNA in milk during mastitis
    • treatment
      • cessation of breastfeeding

 

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