What we don't yet know about mastitis would fill a book.  The incidence
varies widely, depending on who is reporting.  In the medical literature,
the incidence hovers around 2.5% to 9% (Marshall, 1975, Kaufman and Foxman,
1991, and Foxman, 1994).  However, Riordan and Nichols reported 33%
incidence in retrospective recall questionaires in American women.
Fetherston (1995) found 24% of women reported mastitis in the first 12 weeks
postpartum in her Australian sample.  Clearly, asking women to recall their
experiences is less beneficial than to have a prospective cohort, which is
research that is begging to be done.  Amir really tries to get at this by
the chart review in the study we are discussing,.  The limitations are that
it was done in an ER where the diagnosis may or may not have been entirely
accurate, and where the management was almost entirely based on antibiotics
rather than management.  It is also hard to extrapolate to the population at
large.

Amir's article brings out one point very interesting to me in the sense that
the ER docs were relying a lot of the report of deep pain rather than
febrile sx as a reliable indicator of mastitis.  Clinically, I see a fair
amount of women with symptoms of pain only who describe themselves as having
to be half dead before they typically run a fever.  They don't run fever
with other infections, and they often find it difficult to get treatment in
the absence of this symptom.  Yet, when finally they are treated with
antibiotic, they recover.  Now antibiotics have good antiinflammatory
symptoms, so is this the mechanisms by which improvement is achieved?

Thomsen's work on bacteriological counts in milk samples gives us a schema
for looking at the gradations between inflammatory and infectious mastitis,
but in my city, milk cultures are seldom done when nursing women report
breast pain.  Often, thrush is the first thing suspected, and yet the baby
and the mother are often asymptomatic except for the mother's pain.  Many
women I see are treated aggressively for fungal infections for weeks with no
results.  Are these undiagnosed cases of mastitis?  Can infectious mastitis
hover at a sub-clinical level for a while in otherwise healthy women
creating only deep pain as a symptom?  Is the early marker of fissured
nipples an important fact to tease out?  Are we dealing with hospital
acquired strains of staph in women stricken with mastitis in the first few
weeks postpartum ( a period of time which seems to manifest the most
frequent reports of mastitis)?


Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates, Austin, Texas
http://www.lactnews.com

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