II. Epidemiology

  1. Incidence: 9-33% of lactating women
  2. Most common in first few weeks and nearly all cases within first 3 months

III. Pathophysiology

  1. Generally occurs in Lactation several weeks postpartum
  2. Bacteria enter through a cracked nipple

V. Symptoms

  1. Fatigue
  2. Malaise
  3. Myalgias
  4. Headache

VI. Signs

  1. Fever
  2. Unilateral Breast inflammation
    1. Warmth
    2. Tenderness
    3. Erythema
  3. Observe for signs of Breast Abscess
    1. Requires needle aspiration

VII. Labs: Milk Culture

  1. Indications (not routine)
    1. Severe Mastitis
    2. Refractory despite optimal antibiotics for at least 48 hours
    3. Hospital acquired infection
  2. Technique
    1. Cleanse nipple
    2. Hand express small quantity of Breast Milk and discard
    3. Hand express a sample into a sterile container

VIII. Differential Diagnosis

  1. Inflammatory Breast Cancer

IX. Management: General Measures

  1. Tylenol or Ibuprofen
  2. Ensure adequate hydration
  3. Apply local massage
  4. Apply cool compresses
    1. Warm packs are frequently recommended, but may worsen symptoms
  5. Alternate feeding positions
  6. Antifungals (Monilial Infection)
    1. Topical Antifungals on Breast
    2. Oral Nystatin for infant
  7. Continue with frequent Breastfeeding (except if Breast Abscess present)
    1. Avoid over-feeding or over-pumping (may increase milk production and worsen symptoms)
    2. Risk of Breast Abscess if Breast engorgement occurs
    3. Ensure proper technique (see prevention below)
    4. Safe for infant to continue to feed despite infection with following exceptions
      1. Mother HIV positive
      2. Breast Abscess
        1. Discard Breast Milk for the first 24 hours on antibiotics
        2. Resume Breast Feeding after the first 24 hours on antibiotics

X. Management: Antibiotics

  1. Course: 10 to 14 days
  2. Coverage: Staphylococcus aureus (or as directed by culture)
  3. May observe localized Breast redness, tenderness without systemic symptoms or abscess for 24 hours
    1. For first 24 hours may use general measures above and hold antibiotics
    2. Start antibiotics by 24 hours if not improving, systemic symptoms, other risks
  4. Antibiotics: Nursing Mothers
    1. Amoxacillin-Clavulanate (Augmentin) 875 mg orally twice daily
    2. Cephalexin (Keflex) 500 mg orally four times daily
    3. Dicloxacillin 500 mg orally four times daily
    4. Clindamycin 300 mg orally four times daily (for MRSA)
  5. Antibiotics: Non-Breast Feeding women
    1. Trimethoprim-sulfamethoxazole (Septra) 160mg/800 mg orally twice daily (for MRSA)
      1. May be used in Lactation after first 2 months of life

XI. Management: Breast Abscess

  1. Obtain Bacterial culture
  2. Needle aspiration under Ultrasound guidance (preferred, 60% effective)
    1. Attempt to irrigate the abscess via the same needle used for aspiration
    2. May repeat up to 3 times if fails to resolve (then incise in drain if still refractory)
  3. Incision and Drainage
    1. Indicated in refractory cases (after 3 attempted needle aspirations)
    2. Also first-line measure in very superficial lesions, with skin thinning over the abscess
  4. References
    1. Sacchetti in Herbert (2016) EM:Rap 16(5): 1

XII. Follow-up

  1. Early antibiotics prevent abscess formation
  2. If not better in 48 hours examine Breast for abscess
    1. Consider Incision and Drainage

XIII. Prevention

  1. Optimal Breast Feeding Technique with good latch-on by infant
  2. Address predisposing factors early
    1. Sore nipples suggest problems
      1. Correct latch-on problems
      2. Address dry nipples with lanolin
      3. Avoid plastic-backed Breast pads
      4. Evaluate infant for anatomic problems (e.g. short frenulum, Cleft Palate)
    2. Cracked nipples colonized with Staphylococcus aureus should be treated
      1. Oral antibiotics (e.g. Dicloxacillin) are preferred
      2. Livingstone (1999) J Hum Lact 15:241-6 [PubMed]
    3. Blocked milk ducts should be unblocked
      1. Blocked ducts will appear with a bleb overlying a tender, red area adjacent to nipple
      2. Remove bleb with moist cloth
    4. Yeast infection should be treated (both infant and mother)
      1. Infant: See Thrush for management options
      2. Mother
        1. Topical agents: Nystatin or Ketoconazole
        2. Oral agents: Fluconazole 400 mg on day #1, then 200 mg orally daily for 10 days
        3. Chetwynd (2002) J Hum Lact 18:168-71 [PubMed]

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