Cathy Fetherston 9/2/2008

Breast and Nipple Conditions During Lactation 1

Cathy Fetherston RM PhD IBCLC

Diagnosing

Breast and Nipple

Conditions

During Lactation

Trauma

� Poor Attachment

� Unrelieved negative pressure• Early days, low volume

� Anatomical Anomalies• Tongue tie, inverted nipples,

Nipple Pain

Anatomical Variations

Large nipple

Large breasts

Tongue Tie

micrognathia

Inverted nipple

Nipple Pain

Trauma and Infection

� Nipple trauma with moderate severe nipple pain where infant is < 1 month

� 64% chance of +ve bacterial skin culture

� 54% chance of S. aureus

� Mastitis developed in

� 30% (BF advice alone) and

� 12% (BF advice + topical A/B group) compared to

� 5% (BF advice + systemic antibiotics).

Livingstone & Stringer, 1999

J Human Lact 15(3): 241-46

Nipple Pain

Photo Courtesy of Barbara Wilson-Clay

Candida sp.

� Graves et al., 2003 Aust Fam Physician 32(7): 570-71

� Tender nipples/ “breast thrush” (N=28)

� 57% nipple swabs +ve for S. aureus

� 48% milk cultures +ve for S. aureus

� None +ve for candida sp.

� Morrill et al., 2004

J Hum Lact 20(3) 288-295

� Incidence of candida sp. 23% using lactoferrin inhibition on culture

� PPV highest >3 S&S present or

� If shiny/flakey areola and breast pain

Nipple Pain

DermatitisNipple Pain

Paget’s Disease

Taylor et al. 2001 The Breast. 10:442-446.

Cathy Fetherston 9/2/2008

Breast and Nipple Conditions During Lactation 2

Vasospasm (Raynaud’s Phenomenon)

� nipple and/or breast pain

� triphasic colour change (white, blue, red)

� precipitated by cold, stress, trauma and pain

� associated with previous breast surgery

�Rx� avoid smoking, caffeine, cold

� aerobic exercise, biofeedback, Ca, Mg & B6 supps, evening

primrose & fish oil, breast warmers

� nifidipine

Nipple Pain

Nipple Discharge

� Blood� Cracked nipple

� Breast trauma

� Rusty-pipe syndrome (epithelial hyperplasia)

� Pathology (ductal ectasia, papilloma, Ca)

� Pigmental staining of breastmilk (green, orange, yellow)� Vitamins, seaweed, food dyes, drugs

� Flavour programming (culturally determined flavour preferences)

� (amniotic fluid, breastmilk)

Breast Pain (Mastalgia)

� affects up to 70% women during a lifetime

(cyclical, non-cyclical, chest wall, 30-50yrs)

� poorly understood

� increased duct dilatation

� 20-50% resolve spontaneously

� In lactation:

� More likely to be bacterial than fungal (Thomassen et al., 1998)

� Consider underlying conditions

(Feeding problems, Vasospasm, Fibromyalgia, Tietze syndrome)

� Cancer rare (0.5% will have localised continuous pain)

Benign Lumps and Bumps

� blocked duct/s

� R/T milk stasis

� Poorly understood

(diet, immune status,

infection and

anatomical variance

may be implicated)

� galactocele

� Form as a result of ductal obstruction

� Smooth, tender mobile mass

� Most common following weaning

� Aspiration is curative

Blocked nipple pore

� accessory tissue� lactating adenomas

� Painless sizable well-

demarcated mass

Benign Lumps & Bumps

Photo courtesy of Denise Fisher

Gigantomastia

(1:100,000 pregnancies)

Growth abnormalitiesPoland’s Syndrome

Hypoplasia

Cathy Fetherston 9/2/2008

Breast and Nipple Conditions During Lactation 3

Mastitis (inflammation of the mammary gland)

Aetiology

�Blockage of milk ducts

�Trauma

�Microbial Invasion

Clinical Presentation

�Pyrexia

�Flu like symptoms

�Inflammation of the

breast

Aetiology

Milk stasis Inflammatory mastitis Infective mastitis

continuum?

Mastitis

� Non infective

� Related to milk stasis (poor milk transfer, tight

bras/clothing, missed/dropped feeds, oversupply)

� Relieved by effective drainage

� Infective

� Related to nipple trauma, oversupply and early post

partum period

� Requires antibiotic treatment

� Severe sequelae (abscess)

AetiologyMastitis

Bacteriology

�Osterman & Rahm, 2000. J Hum Lact 16(4):297-302

� 62% (n=25) normal skin flora (80% CNS)

� 38% (n=16) pathogens

S. aureus (81%), haemolytic strep. poor outcomes

�Fetherston (n=13)

� 2 episodes S. aureus -hyperacute symptoms

� Remaining episodes CNS and Strep. Viridans

Mastitis

Paracellular pathway

Milkspace

Apical Membrane

Tight Junctions

Basement Membrane

(zonulae occludentes)

Paracellular Pathway

plasma proteinssodium cells

Open duringpregnancy, involvution, milkstasis andinflammation

lactosealpha lactalbuminCapillary

Mastitis Mastitis

Cathy Fetherston 9/2/2008

Breast and Nipple Conditions During Lactation 4

serumlactocytes

milk space

sodium

chloride

lactose

serum albumin

Paracellular pathway

MastitisCurrent Management Guide

continue breast drainagescript for A/B if no

improvement in 12 hoursNSAIDS

present < 24 hours

Consider IV A/Bsbroad spectrum A/Bs

if no better in 48 hours

complete course of A/Bs

if improving

if lump or rednesspersistsDx U/S

continue A/Bsfor 10 days

if breast still red or hardafter 5 days

Antibiotic treatmentdicloxacillin/flucloxacillin

cephalexinclindamycin

present > 24 hours

systemic symptoms

Mastitisred hard tender area

heat, rest and drain the breast

Adapted from Amir, Current Therapeutics April 2000

Mastitis

Abscess

Photo Courtesy of Barbara Wilson-Clay

Incidence: 3% women with mastitis

Rx: needle aspiration or

excision and drainage(Amir et al., 2004. BJOG 111:1378-81)

Photos by Chao-Huei Chen, M.D