Q.  In researching information on mastitis for telephone protocols at our public
health agency, I feel like I don't have the latest info, even though I have
consulted the usual resources. Would you experts out there please define
mastitis for me. Are the categories of adenitis and cellulitis still
accurate? How does one tell one type from another? Is is OK for mothers to
treat themselves conservatively first ( rest, heat, massage). How long can
one wait before seeing the doctor?

A.  Mastitis, by the book, is defined as inflammation of the breast.  There
are many causes of inflammation including bacterial infection, infiltration
with neoplastic cells, inflammation because of extravasation of milk in an
engorged breast and so on.

Most often the term mastitis is used to refer to an infectious mastitis.  I
believe that breaking this down into adenitis and cellulitis is a good
clinical approach.  Adenitis is an infection in the duct.  Cellulitis is an
infection in the supporting connective tissues.

Cellulitis can be further broken down to a cellulitis with only local
effects (redness, tenderness, swelling etc) and cellulitis with systemic
effects (all of the local effects plus fever, malaise, myalgia etc).  These
can also be called non toxic and toxic cellulitis, respectively.  Still with
me?

I rarely see adenitis.  I have had only two in over 300 patients at the
breastfeeding clinic.  One was from a cracked nipple and one was from a
bite.  They present with a tender, hard lump with some overlying redness.
The two patients I saw had lumps under 3 cm in diameter.  When you massage
the lump, you can express pus from the duct.  It is worth culturing this and
I started antibiotics immediately in these patients while waiting for the
antibiotic sensitivity to be done.

The cellulitis patients have more of a diffuse area of tenderness.  They can
have hardly any redness to a flaming red hot breast.  They tend to have a
fullness in the affected area but no distinct lump.  If there is a really
well defined lump, rule out abscess.  They can have overlying dimpled skin
(peau d'orange).  You cannot express obvious pus from the breast.

If the mother had a non toxic cellulitis, is reliable and agreeable, I send
her home with a prescription for antibiotics and instruct her to go to bed
and nurse and pump or express as much as possible for 24 hours.  If she
develops a fever or feels unwell or if she is not a lot better in 24 hours,
I get her to start the antibiotics.  If she has a fever, I immediately start
the antibiotics.  I like to see these patients again in 48 hours.

Another way to approach infectious mastitis is described in an article by
Thomsen et al. (Am. J. Obstet. Gynecol 1984;  149(5):492)  He talks about
milk stasis, non infectious inflammation of the breast and infectious
mastitis.  He divides patients up by the number of white blood cells and the
amount of bacteria in the breast milk.  Unfortunately these tests can take a
while to set up and don't help you make immediate decisions.   The paper
showed that half of the patients with noninfectious inflammation went on to
develop infectious mastitis and that failure to treat infectious mastitis
often resulted in a poor outcome (sepsis and abscess formation).  The
problem with the paper is that the mothers were nursing followed by pumping
only every 6 hours.  Perhaps they would have had much better outcomes if
these mothers had been nursing on a more "normal" schedule.

I like to see patients with mastitis on the same day.  These women need
effective treatment, pain relief, good advice and close supervision.

Hope this helps,

Shirley Gross
_________________________________________

M. Shirley Gross M.D.,C.M., C.C.F.P., I.B.C.L.C.
Director, Edmonton Breastfeeding Clinic
Edmonton, Alberta, Canada
E mail at  <  [log in to unmask]  >
_________________________________________