Mastitis ( Lactational)): Causes and Symptoms, Diagnostic study, Medication

LACTATIONAL MASTITIS

Mastitis is an infection of one or more ductal complexes of the breast, generally associated with breastfeeding and potentially causing significant morbidity if not recognized and aggressively treated. 2%-10% of women who are breastfeeding after delivery.

Predominant age; Reproductive age; 2-6 weeks after delivery.

Etiology and Pathogenesis

Causes: Infection comes from organisms carried in the nose and mouth of a nursing infant, most commonly Staphylococcus aureus and streptococcus species. Common agents include B-hemolytic streptococci, Haemophilus influenzae, H.parainfluenzae, Escherichia coli, and Klebsiella pneumoniae.

Signs and Symptoms of lactational mastitis

• Firm, sore, red, and tender portion of the breast, most commonly in the upper outer quadrant.
• High fever, tachycardia, headache, anorexia, and malaise
• Axillary nodes tender or enlarged
• In patients who are not breastfeeding a palpable, recurrent mass, accompanied by a multicoloured discharge from the nipple or adjacent to a Montgomery follicle.

Diagnostic approach for mastitis

• Breast abscess
• Blocked duct
• Breast engorgement
• Galactocele

Associated Condition: Breast engorgement.

Workup and Evaluation 

Laboratory: A complete blood count documents an elevated white blood cell count but is not required for diagnosis. Cultures of the mother's milk and the infant's nose and mouth may be helpful but are not required.

Imaging; No imaging indicated 

Special Tests: None indicated

Diagnosis Procedures: History and physical examination combined with the knowledge of the condition of the breast at or before delivery.

Pathologic Findings

Swelling and obstruction of the involved ducts with inflammation. When present in nonpregnant and postmenopausal women, it may be accompanied by squamous metaplasia. When well established ductal, thickening may lead to nipple retraction.

Management of  mastitis

General Measures: Mild fluid restriction, analgesics, ice packs, and support ( well-fitting brassiere). In mild cases, it is not necessary to cease breastfeeding.

Specific Measures: Prompt and aggressive antibiotic therapy is indicated. Breastfeeding from the opposites side or pumping or expression of the involved breast may be helpful. If tenderness or fever do not promptly decrease, abscess must be suspected and prompt surgical drainage, usually under general anaesthesia, is required. 

Diet: No specific dietary changes indicated.

Activity: No restriction.

Medications for  mastitis

Dicloxacillin 500 mg PO four times daily or cephalexin 500 mg PO four times daily. Cefaclor 250 mg PO three times a day or amoxicillin/clavulanate 250 mg PO three times a day may also be used.

Contraindications: Known or suspected allergy.

Precautions: If the response to therapy is not prompt, surgical drainage is required.

Alternative Drugs

• Penicillin G or erythromycin 250-500 mg PO four times a day
• Erythromycin ethylsuccinate 400 mg PO four times a day for 10 days.
• The level of erythromycin achieved in milk is very high.
• In severe infections, empiric inpatient therapy with vancomycin 15-20 mg/kg/dose every 8-12 hours ( not to exceed 2 g per dose ) may be indicated

Follow-up of  mastitis

Patient Monitoring: Normal health maintenance. Watch for the development of an abscess.

Prevention/Avoidance: Attention to normal hygiene practices during breastfeeding ( handwashing avoid drying agents). Avoid cracking or fissuring of nipples. Use breast or nipples. 

Possible Complications: Progression of infection, abscess formation, squamous metaplasia, ductal ectasia.