Mastitis and Breast Engorgement - Causes, Symptoms and Treatment

Definition:

Mastitis (parenchymatous inflammation or the mammary glands) and breast engorgement (congestion) are disorders that may affect lactating females. Mastitis occurs postpartum in about 1%, mainly in primiparas who are breast-feeding. It occurs occasionally in non lactating females and rarely in males. All breast-feeding mothers develop some degree of engorgement, which is not an infectious process. The prognosis for both disorders is good.

Causes

Mastitis develops when a pathogen that typically originates in the nursing infant's nose or pharynx invades breast tissue through a fissured or cracked nipple and disrupts normal lactation. The most common pathogen of this type is Staphylococcus aureus; less frequently, it's Staphylococcus epidermidis or beta-hemolytic streptococci. Rarely, mastitis may result from disseminated tuberculosis or the mumps virus. Predisposing factors include a fissure or abrasion on the nipple; blocked milk ducts; and an incomplete let-down reflex, usually due to emotional trauma. Blocked milk ducts can result from a tight bra or prolonged intervals between breast­feedings. Causes or breast engorgement include venous and lymphatic stasis, and alveolar milk accumulation.

Signs and Symptoms

Mastitis may develop anytime during lactation but usually begins 1 to 2 weeks postpartum with fever (101° F [38.3° C] or higher in acute mastitis), malaise, and flu­like symptoms. The breast (or, occasionally, both breasts) becomes tender, hard, swollen, and warm.

Breast engorgement generally starts with onset of lactation (day 2 to day 5 postpartum). The breasts undergo changes similar to those in mastitis, and body temperature may be elevated. Engorgement may be mild, causing only slight discomfort, or severe, causing considerable pain. A severely engorged breast can interfere with the infant's capacity to feed because of his inability to position his mouth properly on the swollen, rigid breast.

Diagnosis

Diagnosis is usually made early, on clinical grounds. If pus is expressed from a nipple, a culture may be helpful in confirming the impression of mastitis. Differential diagnoses include abscess and inflammatory breast cancer.

Treatment

Antibiotic therapy, the primary treatment for mastitis, generally consists of oral cephalosporins, dicloxacillin or cloxacillin to combat staphylococcus. Azithromycin may be used for penicillin-allergic patients. Although symptoms usually subside 2 to 3 days after treatment begins, antibiotic therapy should continue for 10 days. Other appropriate measures include analgesics for pain and, rarely, when antibiotics fail to control the infection and mastitis progresses to breast abscess, incision and drainage of the abscess.

The goal of treatment for breast engorgement is to relieve discomfort and control swelling, and may include analgesics to alleviate pain, and ice packs and an uplift support bra to minimize edema.

Rarely, oxytocin nasal spray may be necessary to release milk from the alveoli into the ducts. To facilitate breast-feeding, the mother may manually express excess milk before a feeding so the infant can grasp the nipple properly.

Special Considerations

If the patient has mastitis:

• Isolate the patient and her infant to prevent the spread of infection to other nursing mothers. Explain mastitis to the patient and why isolation is necessary.
• Obtain a complete patient history, including a drug history, especially allergy to penicillin.
• Assess and record the cause and amount of discomfort. Give analgesics, as needed.
• Reassure the mother that breast-feeding during mastitis won't harm her infant because he's the source of the infection. Tell her to offer the infant the affected breast first to promote complete emptying of the breast and prevent clogged ducts. However, if an open abscess develops, she must stop breast-feeding with this breast and use a breast pump until the abscess heals. She should continue to breast-feed on the unaffected side.
• Suggest applying a warm, wet towel to the affected breast or taking a warm shower to relax and improve her ability to breast-feed.
• Instruct the patient to combat fever by getting plenty of rest, drinking sufficient fluids, and following prescribed antibiotic therapy.

Some Prevention Tips

To prevent mastitis and relieve its symptoms, teach the patient good health care, breast care, and breast-feeding habits. Advise her to always wash her hands before touching her breasts.

If the patient has breast engorgement:

• Assess and record the level of discomfort. Give analgesics, and apply ice packs as needed.
• Teach the patient how to express excess breast milk manually. She should do this just before nursing to enable the infant to get the swollen areola into his mouth. Caution against excessive expression of milk between feedings because this stimulates milk production and prolongs engorgement.
• Explain that because breast engorgement is due to the physiologic processes of lactation, breast-feeding is the best remedy for engorgement. Suggest breast-feeding every 2 to 3 hours and at least once during the night.
• Ensure that the mother wears a well-fitted nursing bra and be sure it is not too tight.