Thankyou Françoise, for referring to my paper (Mastitis in lactating women :
physiology or pathology ? C Fetherston. B Rev 2001 ; 9(1) : 5-12)
- in response to questions about about whether mastitis symptoms were
reflective of infection or inflammation.

As by way of explanation I would just like to say that treatment of mastitis
is often made very difficult as it is not always clear whether mastitis is
due to infection or inflammation. Clinically we observe many women who have
high temperatures and flu like symptoms (along with an inflamed area of the
breast or just early engorgement) who do resolve the episode with breast
drainage (and without antibiotics). We believe that these symptoms (in the
absence of infection) may be due to hormones present in the milk called
cytokines. Cytokines are proteins that regulate the immune system. Some of
these cytokines have pro inflammatory functions - it is their role to
orchestrate an inflammatory response which may be  reflected in symptoms
such as  hyperpyrexia, aching, headaches and shivering. Even in normal
conditions these pro inflammatory cytokines are in much higher
concentrations in milk than in blood and during mastitis they increase quite
substantially. Due to the increase in paracellular permeability during
mastitis it is probable that they leak out into the interstitium and induce
the systemic symptoms we commonly see in mastitis.

However great caution should be adopted with treating mastitis as the
sequalae of breast abscess and septicaemia are obviously so awful. If
symptoms are florid, soon after birth (where nosocomial infection risk is
high) or there are other risks for infection (eg: cracked nipples) the
episode should be treated immediately with antibiotics.

When the episode occurs later in lactation and is not obviously associated
with risk for infection they may be allowed a window before antibiotic
treatment is begun. Usually we treat with NSAIDS (ibuprofen) and breast
drainage (and hopefully identify and remove cause of the inflammation eg:
tight bra etc). Give a script to the patient and advise if there is no
improvement or symptoms worsen within the next 12-24 hours commence the
antibiotics. This protocol has been published by Lisa Amir:
Amir,L.H. (2000). Mastitis: Are we overprescribing antibiotics? Current
Therapeutics Online: http://www.ctonline.com.au/Feature99.asp?FArtld=40003

Anyone interested in the my paper but not able to easily access
Breastfeeding Review it is being republished in the June issue of MIDRS (in
a slightly abbreviated version).

Regards
Cathy Fethertson
Perth, Western Australia 

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