Unfortunately I haven't been able to catch up with lactnet since my first
posting about HIV and subclinical mastitis but its very interesting to catch
up with all your subsequent discussions. There's a couple of things I want
to comment on.

 Firstly, Barbara's Mum with Strep (?group/type) cultured in milk. The
comment about "not being enough to cause a problem" is interesting and also
difficult to know what he means by this. Streptococcus species are generally
not something you would normally find in any amount in breastmilk, unless he
is intimating that it is a normal commensal contaminant from collection (in
which case there should be present numerous other species of normal
commensals). Presuming this is not the case you are probably fortunate that
you found any bacteria as even when present, you can not be assured that you
will express milk from the infected area and have a subsequent positive
culture. Even when bacteria are present their concentration may be diluted
out by milk being simultaneously expressed from other sectors that may not
contain the bacteria. We should also perhaps take into consideration the
immune factors present in milk may well disturb the bacterial count prior to
culture. I think treatment in this women is indicated,if the bacteria are
not contaminants from collection, especially considering her other symptoms.
We know so little, it is naive of us to presume all women will present with
the classical symptoms we currently accept for infective mastitis.

Some of the current studies available on sodium(Na) levels and subclinical
mastitis - I have real problems with their methodology, especially some that
have used raised Na as a sole indicator for their definition of mastitis
(not to mention mixing left and right breast samples before analyses)
without taking into consideration, or observing for, local and systemic
physical symptoms. Other considerations such as mixed feeding (that weren't
commented on) could also lead to raised Na and lactoferrin -  as involution
of the gland may be occuring. As patients studied were HIV positive, and if
the paracellular pathway permeability was increased due to involution, I
don't think we can be sure that some of the raised levels of inflammatory
cytokines seen in the milk of these women were not produced in the breast
but were serum derived and were in fact not an indicator of breast
infection, sub clinical or otherwise.

A quick comment on breast pain - I think if there appears to be no breast
related causes, or risk factors, - we sometimes need to look for other
causes. A few mothers I have found have also presented with generalized
tenderness of the rib cage and/or costochondral joints and a history of back
pain. When the back problems were treated the breast pain resolved. There
are perhaps several other differential diagnoses for this symptom that we
are not aware of, both physical and psychological in origin.

Cathy Fetherston
Perth Western Australia

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