SYMPOSIUM S007 The Breast and Lactation Jenny Murase, MD July 28, 2017 Palo Alto Foundation Medical Group University of California, San Francisco I do not have any relevant relationships with industry.
Objectives Differential diagnosis and treatment of nipple dermatitis during lactation Chronic candidal mastitis Raynaud phenomenon of the nipple
Lactation consultants Assist with positioning head, body, and mouth to provide the best latch (problem in 95% of cases) The Lactation Consultant Directory: http://www.ilca.org/i4a/pages/index.cfm? pageid=3432
Problem with latch Breast Pain Underlying dermatologic problem (atopic dermatitis, psoriasis, or allergic contact dermatitis) Plugged ducts Fungal infection (Candida) Bacterial infection (Staph aureus) Vasospasm (Raynaud phenomenon)
Underlying dermatologic condition Contact allergy to bras or lanolin Tea bags (tannic acid), honey (spores of Clostridium botulinum), banana or papaya peels (high # microorganisms) http://chttp://www.accessmedicine.com/loadbinary.aspx?name= wolf&filename=wolf_2e-cd-27t.jpgontent.revolutionhealth.com/ contentimages/images-image_popup-ans7_breast_rash.jpg www.lactationconnection.com/detail.aspx?id=81
Blisters Critical to differentiate milk blisters from herpes simplex viral infection (life threatening, infant requires IV acyclovir) Recurrent milk blisters: -use lowest settings -verify breast shield size Milk blister (plugged lactiferous duct) http://mybreastpump.com/pumpsgalore.html http://www.mother-2-mother.com/images/milkblister.jpg Photo compliments of Dr. Honor Fullerton
Galactocele (milk cyst) Plugged duct 3-26% Milk stasis Mastitis (inflammation breast tissue) 5-10% Breast abscess (S. aureus) http://www.vashishtsurgicalservices.co.uk/images/pics/abscess2.gif http://www.vashishtsurgicalservices.co.uk/images/ pics/abscess2.gif Mastitis: fever and malaise; culture & rx amoxicillin, cephalosporins, clindamycin, erythromycin, or dicloxacillin 10-14 days; continue breastfeeding! No improvement 48 hrs, U/S for abscess; repeated aspirations
Axillary mammary tail http://www.imaios.com/en/e-anatomy/thorax-abdomen-pelvis/thoracic-wall-breast-illustrations
Mastitis (pt afebrile): A result of staph or candida? Burning, stabbing pain; flaky/shiny skin Most pts will be given diagnosis of candidal mastitis; 93% of MD s do not cx http://www.vashishtsurgicalservices.co.uk/images/pics/abscess2.gif
Recognizing candida in the infant 25% vaginally delivered infants are infected Half of infants (1 wk-18 mos) will culture positive, but only 25% exhibit sx Candida http://www.mycology.adelaide.edu.au/gallery/photos/candida01.gif Candida Epstein Pearls (on median palatal raphe) http://newborns.stanford.edu/photogallery/epsteinpearl2.html http://www.uptodate.com/online/content/images/prim_pix/candidal_diaper_dermatiti_a.jpg
Bacteria vs. Candida Baby s mouth: visual examination Bacterial culture of skin: swab any eroded areas, areola, on nipple, between breasts) Bacterial culture of breast milk Fungal cx not possible: requires special processing w/ iron to overcome effect of lactoferrin in milk. Morrill JF, Pappagianis D, Heinig MJ, et al. Detecting Candida albicans in human milk. J Clin Microbiol. 2003; 41: 475-78.
Truly candidal mastitis? 100 women/infants at 2 wks pp 23% colonized (23/100) 77% not colonized (77/100) 87% sx (20/23) 13% no (3/23) 16% sx (12/77) 84% no (65/77) Note: sx = pain, skin changes Clinically suggestive of mastitis 75% infant sx of thrush (15/20) 25% none (5/20) Most colonized w/ candida had sx of mastitis. Most not colonized w/ candida did not have sx of mastitis. Morrill JF, Heinig MJ, Pappagianis D, Dewey KG. Treatment of mammary candidosis among lactating women. JOGNN 2005; 34: 37-45.
Truly bacterial mastitis? 50% breast pain had positive staph culture If cx staph, treat with oral abx 4-6 wks Works better: 79% imp w/ oral vs. 16% topical Reduce risk of mastitis: 25% if not tx d, 5% if tx d Study of 69 women with deep breast pain 50% + cx, 50% - cx: both improved at same rate on antibiotics!! (ave. 6 wks abx, 94% resolution) 50% reported relief with antifungals (Are we treating the inflammation or infection?) Livingstone V, Stringer LJ. The treatment of infected sore nipples: a randomized comparative study. J Hum Lact. 1999; 15: 241-6.; Amir LH, Garland SM, Dennerstein L, Farish SJ. Candida albicans: is it associated with nipple pain in lactating women? Gynecol Obstet Invest 1996; 41(1): 30-4.; Eglash A, Plane MB, Mundt M. History, physical, and laboratory findings, and clinical outcomes of lactating women treated with antibiotics for chronic breast and/or nipple pain. J Hum Lact 2006; 22(4): 429-33.
Raynaud Phenomenon WHITE (pallor) TRIPHASIC BLUE (cyanosis) TRIPHASIC RED (rubor) http://www.riversideonline.com/source/images/ image_popup/ans7_raynaudsdisease.jpg http://www.visualdxhealth.com/images/dx/webadult/ raynaudsdisease_34289_lg.jpg BIPHASIC www.hakeem-sy.com/main/files/raynauds-disease.jpg Reported in up to 20% of women of childbearing age in the hands and feet Of those presenting to a dermatology lactation referral center with nipple pain, 25% of women were diagnosed with Raynaud phenomenon
Raynaud Phenomenon Barrett ME, Heller MM, Fullerton-Stone H, Murase JE. Raynaud Phenomenon of the Nipple in Breastfeeding Mothers: An Underdiagnosed Cause of Nipple Pain. JAMA Dermatology 149 (3): 300-306, 2013.
Raynaud Phenomenon Diagnostic criteria Chronic deep breast pain (> 4 weeks) that responded to therapy for Raynaud phenomenon and had at least 2 of the following: 1. Observed or self-reported color changes of the nipple, especially with cold exposure (white, blue, or red) 2. Cold sensitivity or color changes of the hands or feet with cold 3. Failed therapy with oral antifungals. Nifedipine 30 mg SR tab qhs in 2 wk courses, often require a few courses Side effects: postural hypotension, headaches Avoid cold, caffeine, and tobacco
History for nipple dermatitis Seen lactation consultant for latch? History of Atopy? Psoriasis (Koebnerize)? Any substances applied to breast (lanolin, tea bags) Temperature sensitivity (Raynaud s symptoms)? Increase risk factors for candidal infection: History of gestational diabetes? On multiple antibiotics recently? Diaper rash in infant or thrush in mouth? Increase risk factors for bacterial infection
Quality of Pain Let down pain: mild pain first few mins, then 12-15 mins after nursing; improves over weeks FEED Candida: moderate pain worst w/ latch, throughout nursing, radiating/hot w/ refill; dramatic relief 1-3 days w/ oral antifungals FEED Raynaud s: moderate pain before/during/after nursing, throbbing, possibly color change FEED REFILL REFILL REFILL
http://www.lirmm.fr/bib-icons/stanford/smile.frown.gif Multifactorial etiology: Dermatologists are in an excellent position to diagnose, manage, and treat! Atopic dermatitis Allergic contact dermatitis Raynaud s Candidal infection Plugged duct Bacterial infection Concept courtesy of Dr. Honor Fullerton
Pain management Warm water compresses superior in reducing pain (vs. lanolin or applying breast milk) Ibuprofen 400 mg q4h (max 2400 mg/day) Hydrogels (glycerin breast pads) Replace every 1-3 days, clean with soap/water Soothies, Comfort Gel http://images.google.com/images?hl=en&q= Soothies&um=1&ie=UTF-8&sa=N&tab=wi
Management: topical therapy If suspect infection Gentian violet 3-7 days [max 0.5%] or 1 ml nystatin susp baby s mouth each feed Wash linens and bras in hot water/1 cup vinegar daily
Management: oral therapy Continue breastfeeding as pain allows even if infection is present Fungal infection: Fluconazole 400 mg x 1 then 100 mg bid for at least 2 wks Bacterial infection: Cephalexin (or amoxicillin) for 2 wks Raynaud: Nifedipine 30 mg SR tab qhs for 2 wks
Resources Comprehensive review article and patient questionnaire. Heller MM, Fullerton-Stone H, Murase JE. Caring for new mothers: diagnosis, management, and treatment of nipple dermatitis in breastfeeding mothers. Int J Dermatol 2012 Oct: 51(10): 1149-61.
Pregnancy-Associated Hyperkeratosis of the Nipple Physiologic change of pregnancy May be symptomatic and persist postpartum Photos courtesy of Dr. George Kroumpouzos Editor of Atlas of Obstetric Dermatology, JAMA Dermatol. 2013 Jun;149(6):722-6.
Take-home points Not possible to culture candida of breast milk in commercial lab ( chronic candidal mastitis ) Consider candida, staph, and Raynaud phenomenon in cases of chronic mastitis.
Mastitis Articles References Heller MM, Stone HF, Murase JE. Caring for New Mothers: Diagnosis, Management, and Treatment of Nipple Dermatitis in Breastfeeding Mothers. International Journal of Dermatology, 51: 1149-61, 2012. Barrett ME, Heller MM, Stone HF, Murase JE. Dermatoses of the breast in lactation. Dermatologic Therapy. 26: 331-6, 2013. Lactation Consultant Reference Text Medications and Mothers Milk. Thomas W. Hale. 12 th ed 2006. ISBN-10: 0-9772268-3-2
Disclaimer This presentation material is intended to serve as an initial reference resource and not as a complete reference resource. It does not include information concerning every therapeutic agent, laboratory, or diagnostic test or procedure available. It is intended for physicians and other competent healthcare professionals who will rely on their own discretion and judgment in medical diagnosis and treatment.