Breastfeeding challenges and its complications
Mastitis is the medical term for a secondary bacterial infection within breast tissues that predominates in women during breastfeeding. This complication may result from commonly derived skin bacteria called staphylococcus aureus that are normal in all of us and that we carry on the skin and in our nasal airways. It is also possible that the feeding infant may spread bacteria to the mother through nipple skin cracks that allow bacterial entry. Lactose-rich milk is also a perfect culture medium and permissive growth environment for bacteria. Nutrient rich milk produces rapid bacterial replication that is enhanced by stagnation of milk within dilated breast ducts, including the overproduction of milk.
“An important analogy is the rapidity at which milk left standing out on the kitchen counter goes off at room temperature”.
The basics of milk production relate to the muscle contraction around the nipple when the baby feeds that send a signal to the brain and the pituitary gland that is located between the eyes in the frontal brain lobe to increase the production of prolactin, the milk producing hormone whose blood levels increase during breastfeeding and pregnancy. Therefore, cessation of breastfeeding breaks this cycle and underpins the basis for the chemical cessation of prolactin in severe mastitis as an important treatment intervention.
The incidence of mastitis is about 1-10%, but may rise to as high as 33% in breastfeeding women. This rate peaks during the first few weeks after delivery. Clinically, mastitis presents with “flu-like” symptoms and signs of a breast infection: pain, warmth, firmness, swelling and redness with enlarged lumps in the armpits or axillae. It is important to exclude a breast abscess or a collection of pus at this stage. It is also recommended to take blood for bacterial culture and sensitivity to antibiotics in the event that the infection may be caused by bacteria that are unusual and unresponsive to standard antibiotics.
Usually, mastitis is localised to a single segment of the breast in keeping with an inflamed breast duct that may then spread to other segments or ducts. If left untreated, the infection spreads to other ducts and surrounding tissues. If left untreated, the mastitis or bacterial infection spreads and worsens to such an extent that it destroys tissues resulting in their death or necrosis to form a collection of pus called a breast abscess. An abscess is a collection of “dead tissues” that forms a capsule that is thickened and serves to wall off the pus, resulting from the bodies’ inflammatory response.
A breast abscess presents as a hard painful fluctuant lump in the peripheries of the breast, when mastitis remains untreated. It is diagnosed using breast ultrasound and is treated by withdrawing or aspirating the pus using a needle under ultrasound guidance. It is extremely important to send pus for isolation of bacteria and to test the sensitivity of these bacteria to a range of antibiotics.
Mastitis and up to 40% of breast abscesses may be caused by multiple bacteria that are important to diagnose in order to commence the correct antibiotic treatments.
Diagnosis using breast ultrasound is the mainstay and there is little place for mammograms in women 40 years and older until after the infection has settled. Consultations with Microbiologists may be crucial if initial antibiotic treatments are unsuccessful.
The principle underlying treatment is removal of milk that may involve continued breast feeding on antibiotics, however if things worsen, then this initial strategy should be reviewed. The choice of antibiotics should be reviewed with microbiology and repeat testing for bacterial sensitivities to an array of antibiotics is key. It is crucial to exclude MRSA or methicillin resistant staphylococcus aureus. The recommended sequence of oral antibiotics is: Flucloxacillin, followed by Co-amoxiclav or Clindamycin if there is no improvement. Failing this approach, intravenous Vancomycin is recommended. Most antibiotic regimens are recommended for 7-10 days.
One requires caution regarding antibiotics that may enter the breast milk and be harmful to the baby such as: Tetracycline, Ciprofloxacin and Chloramphenicol.
A breast abscess requires repeated ultrasound guided aspirations daily for 5-7 days to ensure complete drainage of pus, that is monitored by daily ultrasounds. Another important consideration is to cease prolactin production that stimulates milk production. This is achieved by prescribing the drug Cabergoline (Bromocriptine) daily for 2-5 days that stops milk production almost immediately. This treatment intervention should be accompanied by ceasing breastfeeding immediately, but pumping residual milk production. This approach aims to treat breast infections by addressing all predisposing factors.
Any pending skin damage or thinning with the appearance of skin death or necrosis requires an urgent referral to a breast surgeon. The recommended treatment in this instance is to incise the skin under local anaesthetic as an office procedure, in conjunction with daily antibacterial inadine dressings.
Breast changes during breastfeeding
Breast ducts are microscopic channels that are lined by cells called duct epithelial cells that are stimulated to secrete into the duct lumen by female sex hormones called oestrogen, progesterone and prolactin. The breast ducts dilate and age as a result of breastfeeding over time and can increase the formation of fluid filled lumps called cysts. Cysts can become filled with milk called galactoceles, that can also become secondarily infected to form an abscess.
This rich hormonal environment increases the growth and size of benign and normal breast lumps called Fibroadenomas that are not a risk factor for breast cancer, but any new or enlarged lump should be referred to a Consultant Breast Surgeon or see your GP.
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