An Update on the Recognition and Management of Lactational Breast Inflammation

Christine M. Betzold, NP, CLC, MSN

Disclosures

J Midwifery Womens Health. 2007;52(6):595-605. 

In This Article

Associated Conditions

Blocked ducts usually present as tender lumps. Some mothers have plugs that are fatty, and others have those that are thought to be calcium stones.[17] Blocked ducts can be an underlying etiology of infectious and noninfectious mastitis. Close attention to the prevention of milk stasis is important for prevention and treatment. Other treatments include hot compresses, gentle massage, and steady compression[27] over the blocked area.[2,17,27] Therapeutic ultrasound is indicated when compresses and frequent milk removal do not resolve plugged ducts.[27] It can be performed by a sports medicine or physical therapy provider. Therapeutic ultrasound is basically a deep heat treatment.

Recurrent plugged ducts may be prevented by manually expressing milk before feeding, ingesting lecithin, limiting saturated fats,[17] avoiding holding the breast near the nipple (thus obstructing the flow of milk), getting adequate rest,[17] and using a well-fitting bra.[2,17] Rubbing lecithin into the nipple and areola has also been found beneficial.[17]

Nipple blebs are commonly associated with plugged ducts and manifest clinically as a white spot on the nipple. They are mainly treated by opening the pore with a sterile needle.[2,17] Anecdotally, Dr. Newman has found that using a mixture of mupirocin in combination with a topical antifungal, and a steroid cream for 7 to 10 days is helpful.[27]

A galactocele or milk cyst can develop as a result of a blocked duct.[2,17,27] Suspect infection (particularly Candida spp.[17]) and obtain cultures if the above treatment measures are ineffective and/or plugged ducts are persistent ( Table 3 ).

Although not technically defined as mastitis, mothers do develop infections of the mammary ducts. In contrast to mastitis (infectious or noninfectious), they usually present without any detectable objective findings. Instead, the woman will often complain of a deep burning, aching, or shooting breast pain during or after feedings, or occurring randomly.[2,3,11,12,17,31,32,33,34,35] Some mothers also experience a radiating pain across the back, pain down the arm, or a painful let-down. Women have prematurely weaned their infants because the pain from these infections was so agonizing. If the nipples are involved, the mother may complain of itchiness[33,35] or exquisite tenderness to very light touch.[33] Objective breast and nipple-areolar complex exam findings can be obscure or absent (i.e., without redness, induration, or tenderness), and mothers generally feel well and are afebrile.[3,11,34] If there are objective findings, they will be confined to the nipple-areolar complex, which may demonstrate increased pinkness or fiery redness, flakiness, shininess, or tissue breakdown. Moreover, the nipple may have purulent exudates or honey-colored crusts, which are indicative of bacterial infection (impetigo).[19] Alternatively, there may be creamy or caseous exudates that are indicative of Candida.[17,33] In one published case, the breast milk turned bloody and the milk culture revealed both Candida and S aureus.[12]

To date, S aureus and/or C albicans are considered the prime pathogens involved in ductal infections.[2,3,9,10,11,12,19,32,33,35] Nipple trauma of any etiology is probably the foremost risk factor.[35] Other predisposing factors include infant thrush, vaginal yeast infection during pregnancy, antibiotic treatment of mother or child, and pacifier use.[35] The positive predictive value that various signs and symptoms have in relation to a culture proven etiology of C albicans was done by Morrill et al.[9] and summarized in an article published in this journal by Weiner.[7]

To determine optimal therapy, the nipple-areola complex and the milk should be cultured separately.[12] Morrill's culturing techniques should improve the chances of identifying C albicans.[9] For treatment options see Table 3 .

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