Breast Pain and Lactation. Overview. Overview. The 2 nd most common reason for terminating breastfeeding is breast pain 1

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1 Breast Pain and Lactation It s not always mastitis Sharon Wiener CNM MPH Associate Clinical Professor UCSF Department of Reproductive Sciences, Obstetrics and Gynecology Overview In 1971, only 25% of mothers initiated Breastfeeding. In 2005, approximately 72% of women initiated breastfeeding. Overview The 2 nd most common reason for terminating breastfeeding is breast pain 1 1 Amir L.Gynecol Obstet Invest 1996;41:30 1

2 Causes of Nipple and Breast Pain Infant Causes: incorrect sucking or attachment Trauma: incorrect use of breast pump, cracked nipples Lactational: galactocele, engorgement, blocked duct Causes of Nipple and Breast Pain Infection: mastitis, abscess, fungal Neuro-vascular: Raynaud s phenomenon Dermatological: eczema, psoriasis Mastitis Definition - non infective or bacterial, unilateral condition of the breast, usually associated with lactation. Diagnosis - symptoms that indicate infection: breast pain, localized erythema in a wedge-shaped area, chills, fever and myalgias. Diagnosis via phone. Mastitis: Epidemiology Reported incidence varies from 3 to 33% of lactating women. Rate variation is high. 2

3 Mastitis: Epidemiology Foxman, 2002: Longitudinal study from birth to 3 months or until breastfeeding stopped. 946 breastfeeding women from Nebraska and Michigan Interviews conducted at 3, 6, 9, and 12 weeks. Breastfeeding habits, pump use, depression, prior mastitis and demographic information was obtained. Mastitis: Epidemiology During 12 weeks: Highlights women reported at least 1 case of mastitis. 2. Incidence was highest in the first 3 weeks postpartum. 3. Mastitis was defined by self reporting after a diagnosis by a health provider via the phone. Mastitis: Epidemiology Diagnosis: 38% by ob/gyn, 21% by family practitioners, 23% by nurses and 18% by others. 64% did not have an examination. Antibiotics: 86% of women received cephalexin. Amox, ampi and augmentin were also used. Cultures were not taken, warm compresses and frequent feedings were recommended. Mastitis incidence, with the upper limits of the 95% confidence intervals shown by "whisker", by 3-week postpartum interval and mastitis history, Michigan and Nebraska, Foxman, B. et al. Am. J. Epidemiol : ; doi: /aje/ Copyright restrictions may apply. 3

4 Mastitis: Time of Occurrence Mastitis: Epidemiology Mastitis is most common in the 2 nd and 3 rd week post partum. Most reports in the U. S. indicate that 75%- 95% occur in the first 12 weeks post partum. SYMPTOMS Breast tenderness 98% Fever 82% Malaise 87% Chills 78% Redness 78% BREASTFEEDING Habits changed 50% Fed more often 38% Fed less often 11% Nursing hold 33% Foxman,2002 Mastitis: Associated Factors Mastitis incidence, with the upper limits of the 95% confidence intervals shown by "whisker", by 3-week postpartum interval and mastitis history, Michigan and Nebraska, Foxman, Prior history of mastitis: 24% risk for women with a prior history compared with 8% of first time breast feeders. Foxman, B. et al. Am. J. Epidemiol : ; doi: /aje/ Copyright restrictions may apply. 4

5 Mastitis: Associated Factors 36% of women reported cracks in the 1st week postpartum, 14% in the 2 nd week. Incidence of mastitis and nipple cracks or sores by week postpartum, Michigan and Nebraska, Prior hx. of mastitis: 3x more likely to get mastitis during the week of the cracked nipples. Without prior mastitis and cracks/sores: 6x more likely to get mastitis during the week of cracked nipples. Foxman, B. et al. Am. J. Epidemiol : ; doi: /aje/ Copyright restrictions may apply. 5

6 Mastitis: Associated Factors Frequency of feedings: can lead to fissures, cracked nipples. Mastitis Foxman, 2002 Not associated with: Duration of the feeding is NOT associated with mastitis. Breast pain when latching on, nursing or not nursing, is associated with increased rate of mastitis. Age Ethnicity Education Work Bottle feeding Washing breasts Nursing pads Nursing bra Support group Breast pump hand held Mastitis: Causes Mastitis: Causes Milk stasis: usually the primary cause, which may or may not be accompanied by or progress to infection. Milk is not removed from the breasts efficiently. Predisposition to milk stasis: poor attachment of the infant, ineffective suckling, frequency of feedings, blockage of milk ducts, over abundant milk supply. Thomsen, et al., 1984 randomized study categorized 339 mastitis cases into 3 groups: milk stasis, non infectious inflammation, and infectious mastitis. Counted leukocytes and bacteria in breast milk. 6

7 Milk Leukocytes and Bacterial Counts Bacterial Mastitis Bacti: <10(3)ml milk Bacti: >10(3)ml milk Leukocytes <10(6)/ml milk Milk Stasis Thomsen AC, et a.,l Am J of Ob Gyn 1984,149:493 Leukocytes >10(6)/ml milk Non-infectious mastitis Infectious mastitis Organisms: staph aureus, coagulasenegative staph, Group A and B hemolytic streptococci, E coli. Bacterial studies are complicated by the difficulty of avoiding contaminants from skin bacteria. Even with careful collection, only 50% of cultures may be sterile. Route of Infection Nipple fissure : Livingston, 1996 in a prospective RCT, found that women with fissures who were treated with antibiotics were 4-5 times less likely to develop mastitis, than women treated with topical preps or improved breastfeeding techniques. Contributing Factors Intrinsic prior episode Trauma Immune Genetic milk stasis MASTITIS Feeding Issues engorgement suck Nutritional positioning 7

8 Mastitis: Management Consensus that lactation should be continued. Supportive therapy: bed rest, fluids, analgesics, warm compresses, breastfeeding in various positions, pumping. Antibiotic Therapy No consensus on antibiotic use days is usually recommended. No RCTs in the literature. Most treatment studies were conducted over 20 years ago and focused on emptying the breast and the timing of treatment, i.e.: fever >100.8 Various classes of antibiotics which cover staphylococci and streptococci are usually prescribed. Mastitis: Management SFGH: Between August 2004 and March 2005 reported a mastitis rate of 2.1%. 811 patients were followed and 17 had mastitis based on symptoms and milk culture. 53% of the patients with mastitis had MRSA. Breast Infection: SFGH 04/ /2005 Mastitis with breast milk culture sent (n=15) Breast abscess with culture sent (N=3) MSSA MRSA Coag neg staph 6 2 Neg culture

9 Management-SFGH Take milk cultures on women with severe disease, with abscess and not responding to beta-lactum therapy. Antibiotics active against MRSA should be used initially in high risk patients - trimethoprim/sulfamethoxazole, clindamycin. Management-SFGH High Risk Factors: prior abscess, IVDU, previous culture for MRSA, significant use of antibiotics, exposure to the health care system. Mastitis: Symptomatic Treatment Analgesic Rest and fluids Application of warm compresses No real evidence that applying cabbage leaves, avoiding coffee, and restricting fat intake are effective treatment. Mastitis: Complications Breast Abscess Recurrent infections Truncation of breast feeding Depression 9

10 Prevention: is it possible? If breastfeeding is managed appropriately from the beginning to prevent milk stasis and if early signs of engorgement, blocked ducts and nipple cracks are treated promptly then mastitis and abscesses could be prevented. 10

11 Raynaud s Phenomenon of The Nipples Definition: vasospasm of the nipples with concurrent pain prenatally or post partum while nursing. Case reports only. Raynaud s: Literature Gunther, Descriptive report used the term psychosomatic sore nipples. Coates, First to suggest that a vasospasm of the nipple may be related to Raynaud s syndrome. Lawlor-Smith, Case report of 5 breastfeeding women. 11

12 Hardwick, et al., Case report of an antenatal patient with vasospasm that was resolved after delivery-no problem with breastfeeding. Garrison, Case report. Pt. Had a strong family hx of Raynaud s and mother had migraines. Stammler, Antenatal case report associated with anti-phospholipid syndrome. Anderson, Case reports on 12 women. 8 out of 12 women had received prior treatment for candida of the breast. Page, Case report, multipara without prior history who was treated successfully with nifedipine. Wiener, Not published case report of an antenatal patient on first visit. Raynaud s: Signs and Symptoms Pain: Usually bilateral, severe and throbbing, spasm like. Discoloration of the nipple: white, blue, purple to red. No signs of infection, no cracks or fissures. 12

13 Associated Factors Medical conditions: rheumatologic diseases, endocrine diseases, and autoimmune disease. Behaviors: cigarette use and caffeine intake. Raynaud s: Diagnosis Take a good history. Evaluate latch - lactation consultant. Apply cold compress/ice to nipple to observe phenomenon. Raynaud s: Treatments Nifedipine, a calcium channel blocker. Avoid cold exposure, vaso-constricting medications, nicotine and caffeine. Mild cases: warm compresses, showers. Topical nitroglycerine: effective 50% of the time. Candida of The Nipple/Breast The diagnosis of candida of the nipple and breast is one of exclusion, based primarily on history and symptoms. 13

14 Candida: Diagnosis Brent NB, 2001 Survey of members of the Academy of Breastfeeding medicine and lactation consultants. Response rate was 72%. They relied on history and physical exam of the baby, not the mother to make the diagnosis of candida. Candida: Diagnostic Criteria Francis-Morrill J, et al Prospective cohort study: positive predictive value of signs and symptoms of candida. N=200 nipples/breasts cultures of skin and milk. Candida: Diagnostic Criteria Sensitivity: cases identified correctly with SS and culture. Burning nipples 83% Sore nipples 81% Stabbing pain in the breast 78% Shiny nipples 42% Flaky nipples 39% Candida: Diagnostic Criteria Specificity: cases correctly identified as NOT having candida. Sore nipples 51% Burning 69% Pain 84% Stabbing pain 79% Shiny nipples 91% Flaky nipples 90% 14

15 Candida: Diagnostic Criteria PPV: percentage of cases with SS that have colonization. Sore 23% Burning 32% Pain 46% Stabbing 42% Shiny 43% Candida: Diagnostic Criteria Francis-Morrill, J: PPV >70% is considered to be of clinical importance. PPV for candida colonization with a combination of 2 or more SS is likely to yield a positive culture. PPV of Signs and Symptoms Pain + Skin Changes + Stabbing 100 Pain + Skin Changes + Stabbing + Sore + Burning 100 Pain + Skin Changes + Stabbing + Burning 100 Pain + Skin Changes + Sore + Burning Pain + Skin Changes + Burning Pain + Stabbing + Sore + Burning 74 Pain + Stabbing + Burning 63 Milk Cultures How accurate are culture results? What should we culture? Will it change our management? Pain + Stabbing 57 15

16 Candida: Treatment Regimes Candida: Treatment No treatment guidelines in the literature. No documentation of efficacy and safety of the treatments that are prescribed. Many recommendations, many variations on the same theme. Nipple: topical: antifungal, antibacterial, steroid Wash hands, pumps, pacifiers. Treat infant if mom is treated. Breast: ideally treat systemically after culture is taken. Oral fluconazole load 200mg-400mg x one dose, then mg x 14 days. Treat infant. Breastfeeding Management: WHO Goals: Feed the infant adequately Keep the breasts healthy Keep the breasts healthy Important Points: Breastfeed within an hour or so of delivery. Make sure infant is well attached to the breast. Decrease distractions. Breastfeed exclusively for 4-6 months. 16

17 Author N Type of study Thomassen 1998 Chetwynd 2002 Graves, 2003 Candida: Studies Culture Candida 20 Prospective Yes 5/20 milk 5/20 nipple Staph 14/20 m 9/20 n 1 Case Report No Yes Not Reported 28 Control Yes 0/28 57% nipple 48% milk Andrews, Prospective cohort Yes 6/20 5/20 Author n Type of Study Amir 1991 Candida: Studies Culture Candida Staph 2 Case Report No Yes Not reported Amir 1991 Tanquay 1994 Bodley Questionnaire No Yes Not Reported 27 Retrospective Case No Yes Not Reported 1 Case Report No Yes Not Reported 17