- Email: [email protected]
Puerperal mastitis: Causes, prevention, and management
PUERPERAL MASTITIS: Causes, Prevention, and Management
Janet Bostrom Ezra& C.N.M., M.S., and Helen Gordon, C.N.M., M.S.
ABSTRACT Breast infection can be a pathologically based negative influence on breast feeding. There are basically five types of lactational mastitis: subclinical mastitis, acute puerperal mastitis (cellulitis and adenitis), supperative mastitis, mammay infection with uncommon organisms, and virus infection in mammary neoplasms. The first three types are seen most often. Mastitis patients present, along with fever, a rapid pulse, and hot, reddened, tender areas on one or both breasts. Symptoms are most severe in supperative mastitis. In these cases, the developing breast abscess may be clearly identifiable. Nipple trauma and engorgement are thought to be predisposing factors to mastitis. Nipple trauma may lead to fissured nipples, thereby facilitating entry of bacteria into the connective tissue of the breast and development of acute cellulitic mastitis. Engorgement leads to stasis of milk and plugged milk ducts, which may create a setting condusive to development of acute adenitis. Nurse-midwives should be actively involved in prevention and early detection of mastitis. Prevention may include instruction in hand expression and breast massage; encouragement of early, unrestricted nursing; identification of mothers with increased risk of nipple trauma and engorgement; instruction in signs and symptoms of infection; identification of support and information sources; and scheduling of early postpartum clinic visits. Treatment of mastitis includes rest in bed, increased oral fluids, temperature monitoring, and either continuation of breast feeding or discontinuation with binding of breasts and application of ice packs. Research seems to indicate that continuation is preferable. Treatment with antibiotics, usually antistaphylococcal drugs, is also necessary.
Lactation
is known
physiological
process.
to be a natural, For thousands
of years infants have been nourished through breast feeding. Yet, since the early 1930’s the practice of breast feeding has declined. What has led to this decline? Kathleen Auerbach. in her article
Address correspondence to: Janet Ezra& 5543 Somerset Way, Salt Lake City, Utah 84117.
Journal
of Nurse-Midwifery
??
“Where Have All The Nursing Mothers Gone?” identified and classified several factors that she feels have negatively influenced the practice of breast feeding.’ The types of influences she considered contributoy were:
paraphernalia necessary for artificial feeding, the provision of work for women away from the home, the concomitant lack of provision for care of children at work site, and the advertising of artificial foods.
1. Ecological. Includes those environmental factors which set the stage for a particular behavior within the culture, such as industrialization, hospitalization for childbirth, mass production of
Refers to the particular 2. Clinical. treatment of women in childbirth and the postpartum period, including the use of maternal anesthesia in childbirth, separation of the mother and infant after deliv-
Vol. 24, No. 6, November/December
1979
3
ery, the initiation of delayed feedings and/or supplemental feedings of artificial formula, and the training of medical professionals in formula use and management without comparable training of those same personnel in the management of normal lactation. 3.
Sociological. Related to factors that include maternal age and parity, the mother’s socioeconomic level, the child’s gender, information and attitude of medical professionals about breast feeding and the support of the woman’s desire to breast feed by these, as well as the extent to which the woman herself is informed about breast feeding and how to go about it.’
Another category not mentioned is “pathological.” Although a recent study reported that the physical health status of a nursing mother is not usually a major impediment to breast feeding,2 it must be recognized that this type of factor does sometimes adversely affect the breast‘feeding experience. This article will explore one such physical impediment to breast feeding: mastitis. The term mastitis refers to any inflammation of the breasL3 Although chronic mastitis may occur at any rime, to either sex,4 the more common, acute mastitis, usually occurs during the postpartum period and during lactation. It is sometimes
Janet Bostrom
Ezrati is an instructor in
the nurse-midwifery versity of Utah.
of Science degree Utah in 1978
program
at the Uni-
She receiued the Master at the University of
and the Bachelor
of Sci-
ence degree at the University of Rochester in 1975. Helen
Gordon
graduated
uersity of Utah in 1978, Master
of Science degree
specialization
4
the Unithe
in nursing with
in nurse-midwifery.
received the Bachelor from
from
receiving
She
of Science degree
the University of Arkansas in 1974.
called lactational mastitis,“ or puerperal mastitis,5 when it presents postpartally. Approximately 2.5% of breast feeding women develop mastitis according to statistics derived from a study by Marshall and others.6 It is much less common in bottle feeding women.’ Mastitis and its possible sequela, breast abscess, represent the most serious complication of both early and late lactation.* Newbould identified five types of lactational mastitis. They are subclinical (asymptomatic) mastitis, acute puerperal mastitis, supperative mastitis (breast abscess), mammary infection with uncommon organisms, and virus infection in mammary neoplasms.9 Subclinical mastitis is characterized by a tender breast and occasional low-grade fever (below 38°C). During the first 10 days of the puerperiurn, 92% of women with subclinical mastitis produce milk that contains Staphylococcus aureus. The infection is asymptomatic as long as there is adequate drainage of the breast. Acute puerperal mastitis has been recognized in two forms: acute puerperal mammary cellulitis and acute puerperal mammary adenitis.” The basic difference between the two is in the location of the inflammation. Cellulitis occurs in the connective tissues located between the lobes of the breast (see Figure 1). Adenitis occurs within the ducts and lobes of the breast (see Figure 2). These differences in location are reflective of type-specific etiologies and manifest themselves in particular ways (see Figure 3). Mammary cellulitis usually occurs as a result of the introduction of bacteria through a cracked or fissured nipple. lo Because fissuring of nipples is most common at the onset of breast feeding, cellulitis is most likely to occur early in the puerperium. Typically, cracks in the nipples repeatedly heal and then reappear. When cellulitis occurs, the infected breast becomes hot, flushed, painful and hard, often in a localized
Journal of Nurse-Midwifery
??
FIGURE 1 Mammary Cellulitis Infection
of the
connective
tissue be-
tween the lobes of the breast.
FIGURE 2 Mammary Adenitis Infection within the lobes and ducts of the breast.
area. l”,ll The patient becomes febrile, with a temperature of 38°C (100.4“F) or more, and has a rapid She may develop chills, pulse. malaise, and headache.” Occasionally, the cellulitis will spontaneously resolve in one to two days. More often, if not treated, it will lead to the formation of a breast abscess.” Mammary adenitis results from the introduction of bacteria into the ducts of the breast.‘O It occurs in the ab-
Vol. 24, No. 6, November/December
1979
Fragile Skin Improper
Missed Feedings
Breaking
Poor Positioning I
Interval Between Nursing Too Long I
1
I
I
I
NIPPLE TRAUMA
L Pain
I
-
Impaired
Let-down
.
I
4 ENGORGEMENT
Cracked’Nipples
1
Stasls\f
1 Entry for Bacteria
Milk
1 Plugged Ducts MAShTIS
I
t No Treatment
Tre&ment
1 L Improper
Treatment
1
4
PROBL!EM RESOLVED
4
BREAST ABSCESS
FIGURE 3
sence of cracked or fissured nipples. Often, pus can be expressed from the nipple of the infected breast, a finding not present in cellulitic infections. The symptoms of mammary adenitis are similar to those of mammary celThe lulitis, but often are less severe. infectious process has an insidious onset and exists in a mild to moderate form longer than will a cellulitis infection. lo Unlike the localization of cellulitis infections, several areas of the breast, or even both breasts, may be involved in an adenitis infectionlO This diffusion is the result of simultaneous infection of several breast ducts. Adenitis usually occurs two or more weeks after delivery, when the It has occurred mother is at home. earlier, in epidemic form, in some hospital settings, however. I3 Both types of acute puerperal mastitis are most often caused by infection with S. aureus. I2 In mammary cellulitis, it is thought that staphylococci are introduced into a nipple fissure when an infected staff member touches the breast, when an infected baby nurses, or when the mother herself transmits staphylococci from another part of her body to her breast. There is some question about how staphylococci
Journal of Nurse-Midwifery
??
are introduced into the breast ducts in mammary adenitis. One of the most probable theories is that staphylococci in the nasopharynx of an infant are introduced into the breast when the infant nurses. I3 Colbeck, in a study of a hospital epidemic of mastitis, proposed that the initial introduction of staphylococcus into the ward was caused by the infected staff members. They infected the infants, who, in turn, passed the infection on to their mothers. He found that in almost staphylococci were every case, present in the nasopharynges of the infants of infected mothers, and that, in most cases, infant throat cultures were positive before or at the time the mothers developed mastitis. I3 Breast abscesses, or suppurative mastitis. can occur at any time and may be chronic or acute. Acute breast abscesses occur most commonly in breast feeding women or in those who have recently discontinued breast feeding. I4 Typically, acute puerperal mastitis occurs first. If treatment is delayed or inappropriate, one or more abscesses may develop.‘” Several abscesses separated by the fibrous septa of the
Vol. 24, No. 6, November/December
1979
FIGURE 4 Suppurative
Mastitis
Abscesses separated of the breast.
by the fibrous septa
breast are the most usual findings.“’ (See Figure 4.) The most frequent causal organism is again S. aureus, although S. epidermidis and beta hemolytic streptococci are occasionally cultured from abscesses.9 The patient with suppurative mastitis develops the usual signs and symptoms of acute infection: malaise, fever, diaphoresis, headache, and muscle pain. The affected
breast is enlarged, painful, red, and hot. If the abscess is far advanced, “pointing” may be seen. This appears as a very localized, shiny, white spot with pus just under the surface of the skin.‘” The fourth and fifth types of breast infection identified by Newbould are rare and will only be discussed briefly. Infection with an uncommon organism occurs when microorganisms that have invaded another part of the body are transferred to the breast. Mastitis may develop in the breast of a lactating woman with mumps, for example, as a result of the transfer of that infecting organism. Virus infection in a mammary neoplasm, the fifth category of mammary infection, was idtlitified when particles with all the attributes of viruses were demonstrated not only in cancerous mammary tissue, but also in milk produced by women with and without cancer. 9 The most important task of a nurse-midwife in dealing with mastitis is prevention of infection. The following are key points in the prevention of mastitis: 1. Instruction in hand expression and gentle breast massage during the antepartum period.16J7 The main value of this practice is that through touching her breasts before delivery, a woman may be more comfortable with the touching required for breast feeding after delivery. 2. Encouragement of early and unrestricted nursing following delivery. This practice encourages the flow of milk and will help prevent engorgement.18 3. Identification of mothers with increased risk of nipple trauma and engorgement (see Figure 3). When specific risk factors are identified, a care plan can be devised for that mother which will focus on eliminating or minimizing her particular risk factors.
6
in the signs and 4. Instruction symptoms of a possible infection before delivery and review before discharge from the health care facility. The mother may then be able to recognize early indications of a problem and seek help before mastitis progresses. of a telephone 5. Establishment call-in system that clients may utilize for support and information needs. Names of La Leche League leaders or women from the local Nursing Mothers’ Council can also be offered to help meet this need. These resource people may be able to reinforce and supplement the services offered by health care providers. 6. Scheduling of the first postpartum visit 2-3 weeks after delivery. This is a peak time for mastitis, as well as for the emotional needs of the mother. Should efforts fail in the area of mastitis prevention, action must be taken to manage the problem and prevent development of a breast abscess. While little controversy over identification and diagnosis of mastitis is seen in the literature, two different types of management are proposed. Some clinicians and researchers advise the discontinuation of breast feeding, at least on the affected breast. 4~11~19~20They believe that with less stimulation of the breast, recovey is quicker and recurrence less likely. Other health care providers recommend that their patients continue nursing, with special emphasis on emptying the affected breast:’ ,6,8, =*I6 They feel that discontinuation of breast feeding leads to stasis of milk and distention of breast tissue, factors which exacerbate mastitis. They also note that discontinuation of breast feeding deprives the infant of its benefits. Some of the promoters of continued breast feeding do recommend pumping the breast,
Journal of Nurse-Midwifery
??
and discarding the milk while the woman is febrile, however.21 In one comparative investigation of these two treatments, by Marshall and others, one group of mastitis patients (41 subjects) continued breast feeding and another (15 subjects) weaned their infants.6 In the first group, four subjects had a recurrence of the infection. In the latter group, three subjects developed breast abscesses. No infants in either group developed illness. They concluded that continued breast feeding is preferable. Outlined below are the two currently recommended plans for management when the patient presents with localized breast tenderness. Plan I 1. Rest in bed until symptoms subside. 2. Increased oral fluids. 3. Temperature monitoring every four hours. 4. Frequent emptying of the affected breast, through nursing or manual expression. Plan II. This includes steps 1 through 3 of Plan 1 and the following: 1. Discontinuation of breast emptying. 2. Binding of the breasts and application of cold packs. 3. Nourishment of infant by formula feeding. If symptoms of infection persist for more than 24 hours, antibiotic therapy should be initiated in all cases. Deveraux reported in his study of 71 cases of mastitis that when true febrile mastitis developed and no supportive or specific treatment was instituted within 24 hours, abscess was the usual outcome.‘5 Several different antibiotics are recommended in the literature, including sulfisoxazole,” penicillin G,” penicillin V,6 doxycycline,’ and novobiocin8 Because most breast infections are caused by S. aureus, an antistaphylococcal drug is usually
Vol. 24, No. 6, November/December
1979
TABLE l* UsualAdult Daily Dose
Drug
Comments
Penicillin G
4- 10 mega units IM or IV
Not effective against penicillinase
Methicillin
4 g IM or IV
Effective against penicillinase
organisms.
Cloxacillin
2 -4 g PO. IM, or IV Effective against penicillinase
organisms.
Dicloxacillin
2-4
Effective against penicillinase good absorption orally.
organisms.
Flucloxacillin
Effective against penicillinase good absorption orally Effective against penicillinase
organisms.
Oxacillin
250 mg q6” PO or IM 2 g PO. IM. or IV
Nafcillin
1-2
g PO. IM or IV Effective against penicillinase unreliable oral -absorption.
organisms, -
Cephalothin
2-4
g IM or IV
Cephaloridine
l-2gIM
Clindamycin
600-1200
Lincomycin
1.5 g PO. l-l.5 g IV infusion
Can be used in penicillin allergic patients, but not drug of 1st choice.
Erythromycin
l-2gPO. l-4gIV
Effective against penicillinase organisms. useful if allergic to penicillin.
Fucidic Acid
500 mg tid PO
Not effective against fucidin-resistent staphylococci.
Chloramphenicol
l-4gPO also IM or IV
Questionable
Vancomycin
2 g IV infusion
Indicated only in resistent infections.
* Adapted
from Antibiotics
g PO
organisms.
given IV, useful
Useful if allergic to penicillin. mg PO
in Clinical Practice
indicated. Table 1 lists the major antistaphylococcal drugs in use at this time. Both Deveraux15 and Newton* point out that when choosing an antibiotic, caution must be taken. Many S. aureusstrains encountered in mastitis are penicillin resistant. Another consideration, when prescribing to a patient who is continuing breast feeding, should be the amount and effect of the antibiotic in the breast milk. Figure 3 illustrates the possible causes, course, and outcomes of mastitis. A typical clinical situation might involve a new mother who is nursing an infant for the first time. This factor alone can predispose the patient to nipple trauma. If this mother receives inadequate or inap-
Journal of Nurse-Midwifery
Painful IM injection-usually if allergic to penicillin.
organisms.
??
Well absorbed
orally.
ing of infant, technique of breaking infant suction, nipple hygiene (including avoidance of any cleansing agent that could dry or irritate nipples), air drying breasts, etc. 3. Rest in bed. 4. Increased
fluids
Follow-up care to ascertain that the mastitis has resolved and that those breast feeding problems that were contributing to nipple trauma. have been resolved is necessary. Nurse-midwives should be familiar with all aspects of the problem of mastitis, but the greatest impact can be made in prevention of infection by identification of predisposing factors and elimination or minimization of their effect, and in the recognition’of early signs and symptoms of mastitis so that prompt treatment can be initiated. By focusing on these areas we can decrease the chance of at least pathologically based breast feeding failure.
use in nursing mothers, can cause grey baby syndrome in infants. staphylococcal REFERENCES 1. Applebaum RM: Abreast of the Times. Miami. Applebaum, 1969
by Hillas Smith
propriate breast feeding assistance, her chances of developing cracked nipples increases. The fissured nipples provide an entry into the connective tissue of the breasts. The mother appears in clinic with the typical signs and symptoms of mammary cellulitis: elevated temperature, rapid pulse, and hot, reddened, painful areas in one or both breasts. At this time, treatment is imperative. One possible course of management might include the following:
1. Prescription of cloxacillin every six hours.
500 mg
2. Continuation of breast feeding, with special emphasis on position-
Vol. 24, No. 6, November/December
1979
2. Ladas AK: How to help mothers breastfeed. Clin Ped 9: 702-705, 1970 3. Reeder SR, Mastroiannin Martin LL, et al: Maternity Nursing. ed New York, Lippincott, 1976 4. Haagensen, Breast. 2nd ed. Saunders, 1971
CD: Diseases Philadelphia.
5. Puerperal mastitis. Med J, April, 1976
LR. 13th of the W.B.
Editorial in Br
6. Marshall BR, Hepper JK, Zirbel C: Sporadic puerperal mastitis: an infection that need not interrupt lactation. JAMA
233:1377-1379, 1975 7. Greenhill J, Friedman E: Biological Principles and Modern Practice of Obstetrics. ders, 1974
Philadelphia.
W.B.
Saun-
8. Newton M: Human lactation, The Mammary Gland and its Secretion. Vol 1. Edited by SK Kwon, AT Cowie. New York, Academic Press, 1961
7
9. Newbould FHS: Microbial diseases of the mammary gland, Lactation-A Comprehensive Treatise. Edited by BL Larson, VR Smith. New York, Academic Press, 1974 10. Gibberd GR: Sporadic and epidemic puerperal breast infections: a contrast in morbid anatomy and clinical signs. Am J Obstet Gynecol 65:1038-
1041, 1953 11. Pritchard JA, Macdonald Williams Obstetrics. 15th York, Appleton-Century-Crofts, 12. Myles MF: Textbook wives. 8th ed. Edinburgh, Livingstone, 1975
PC: ed. New 1976 for MidChurchill
13. Colbeck JC: An extensive outbreak of staphylococceal infections in maternity units. Can Med ASSOC J 61:557-68, 1949
18. Newton M: Mammary effects. In: DB Jelliffe, EP Jelliffe: The uniqueness of human milk. Am J Clin Nutr 24:987990, 1971
14. Richardson WW: Breast Nurs Times 66432-3, 1977
19. Pillitter A: Nursing Growing Family. Boston, and Company, 1976
abscess.
15. Devereux WP: Acute puerperal mastitis-evaluation of its management. AM J Obstet Gynecol 108:1, 1970
Care of the Little, Brown
20. Joseph S, Peck R: Postpartum needs of the family, MaternityNursing Today. Edited by J Clausen et al. New York, McGraw-Hill, 1973
16. LaLeche League International: Sore breast: what, why, and what to do. Information Sheet #12 (revised), 1975
21. Ziegel E, Van Blarcom C: Obstetric Nursing. 6th ed. New York, Macmil-
17. LaLeche League International: The Womanly Art of Breastfeeding. 2nd ed. Franklin Park, LaLeche League International, 1963
lan, 1972 22. Smith, H: Antibiotics in Clinical Practice. 3rd ed. Baltimore, University Park Press, 1977
-
Legislation regarding CNM practice has been introduced in the New Jersey Assembly. Walter Kern introduced the liberal proposal, Assembly Bill 3245, in early May 1979 in response to the restrictions on midwifery practice being imposed by the New Jersey Board of Medical Examiners. The bill has been assigned to committee, and the New Jersey CNMs are beginning to mobilize consumer and professional support for the bill. Major points of the bill include: 1. refers to CNMs only; no provision for or against empirical midwives; 2. establishes a Nurse-Midwives Examining Committee under the state Board of Medical Examiners, but with explicit powers listed in the legislation. The Committee membership would
include 4 CNMs, 1 OB-GYN, and 2 public members. The Committee would license CNMs in the state, certify programs for academic nurse-midwifery within the state, and prescribe the standards of practice for CNMs within the state. 3. includes, under Standards of Practice, an extensive list of allowed CNM activities, including episiotomy repair and IUD insertion, two of the issues the New Jersey midwives have contested with the Board of Medical Examiners. Irene Sabatini, the chairperson of the New Jersey Chapter of NurseMidwives, can provide current information on the status of the legislation. The Chapter address is 100 Bergen Street, Newark, NJ 07103. Journal of Nurse-Midwifery
8 Comght 0
1979 by the American College of Nurse-Midwives
??
*
*
*
*
An organization in Washington D.C. that promotes many issues of interest to CNMs is the National Women’s Health Network. The Network lobbies congressional and executive agencies and publishes a bimonthly newsletter for its members. A sampling from their April-May newsletter shows the wide variety of issues the Network monitors; unnecessary mastectomies, sterilization abuse, depo-provera, grants for allied health professions, breast feeding in public, and poisoning from the herbal abortifacient pennyroyal are some of the items included. Individual membership is $25 and Health/Women’s Group membership is $35. Local chapters of ACNM might consider such group membership. The Network is located at 2025 I Street N.W., Washington, DC 20006. Vol. 24, No. 6, November/December
1979
Janet Bostrom Ezra& C.N.M., M.S., and Helen Gordon, C.N.M., M.S.
ABSTRACT Breast infection can be a pathologically based negative influence on breast feeding. There are basically five types of lactational mastitis: subclinical mastitis, acute puerperal mastitis (cellulitis and adenitis), supperative mastitis, mammay infection with uncommon organisms, and virus infection in mammary neoplasms. The first three types are seen most often. Mastitis patients present, along with fever, a rapid pulse, and hot, reddened, tender areas on one or both breasts. Symptoms are most severe in supperative mastitis. In these cases, the developing breast abscess may be clearly identifiable. Nipple trauma and engorgement are thought to be predisposing factors to mastitis. Nipple trauma may lead to fissured nipples, thereby facilitating entry of bacteria into the connective tissue of the breast and development of acute cellulitic mastitis. Engorgement leads to stasis of milk and plugged milk ducts, which may create a setting condusive to development of acute adenitis. Nurse-midwives should be actively involved in prevention and early detection of mastitis. Prevention may include instruction in hand expression and breast massage; encouragement of early, unrestricted nursing; identification of mothers with increased risk of nipple trauma and engorgement; instruction in signs and symptoms of infection; identification of support and information sources; and scheduling of early postpartum clinic visits. Treatment of mastitis includes rest in bed, increased oral fluids, temperature monitoring, and either continuation of breast feeding or discontinuation with binding of breasts and application of ice packs. Research seems to indicate that continuation is preferable. Treatment with antibiotics, usually antistaphylococcal drugs, is also necessary.
Lactation
is known
physiological
process.
to be a natural, For thousands
of years infants have been nourished through breast feeding. Yet, since the early 1930’s the practice of breast feeding has declined. What has led to this decline? Kathleen Auerbach. in her article
Address correspondence to: Janet Ezra& 5543 Somerset Way, Salt Lake City, Utah 84117.
Journal
of Nurse-Midwifery
??
“Where Have All The Nursing Mothers Gone?” identified and classified several factors that she feels have negatively influenced the practice of breast feeding.’ The types of influences she considered contributoy were:
paraphernalia necessary for artificial feeding, the provision of work for women away from the home, the concomitant lack of provision for care of children at work site, and the advertising of artificial foods.
1. Ecological. Includes those environmental factors which set the stage for a particular behavior within the culture, such as industrialization, hospitalization for childbirth, mass production of
Refers to the particular 2. Clinical. treatment of women in childbirth and the postpartum period, including the use of maternal anesthesia in childbirth, separation of the mother and infant after deliv-
Vol. 24, No. 6, November/December
1979
3
ery, the initiation of delayed feedings and/or supplemental feedings of artificial formula, and the training of medical professionals in formula use and management without comparable training of those same personnel in the management of normal lactation. 3.
Sociological. Related to factors that include maternal age and parity, the mother’s socioeconomic level, the child’s gender, information and attitude of medical professionals about breast feeding and the support of the woman’s desire to breast feed by these, as well as the extent to which the woman herself is informed about breast feeding and how to go about it.’
Another category not mentioned is “pathological.” Although a recent study reported that the physical health status of a nursing mother is not usually a major impediment to breast feeding,2 it must be recognized that this type of factor does sometimes adversely affect the breast‘feeding experience. This article will explore one such physical impediment to breast feeding: mastitis. The term mastitis refers to any inflammation of the breasL3 Although chronic mastitis may occur at any rime, to either sex,4 the more common, acute mastitis, usually occurs during the postpartum period and during lactation. It is sometimes
Janet Bostrom
Ezrati is an instructor in
the nurse-midwifery versity of Utah.
of Science degree Utah in 1978
program
at the Uni-
She receiued the Master at the University of
and the Bachelor
of Sci-
ence degree at the University of Rochester in 1975. Helen
Gordon
graduated
uersity of Utah in 1978, Master
of Science degree
specialization
4
the Unithe
in nursing with
in nurse-midwifery.
received the Bachelor from
from
receiving
She
of Science degree
the University of Arkansas in 1974.
called lactational mastitis,“ or puerperal mastitis,5 when it presents postpartally. Approximately 2.5% of breast feeding women develop mastitis according to statistics derived from a study by Marshall and others.6 It is much less common in bottle feeding women.’ Mastitis and its possible sequela, breast abscess, represent the most serious complication of both early and late lactation.* Newbould identified five types of lactational mastitis. They are subclinical (asymptomatic) mastitis, acute puerperal mastitis, supperative mastitis (breast abscess), mammary infection with uncommon organisms, and virus infection in mammary neoplasms.9 Subclinical mastitis is characterized by a tender breast and occasional low-grade fever (below 38°C). During the first 10 days of the puerperiurn, 92% of women with subclinical mastitis produce milk that contains Staphylococcus aureus. The infection is asymptomatic as long as there is adequate drainage of the breast. Acute puerperal mastitis has been recognized in two forms: acute puerperal mammary cellulitis and acute puerperal mammary adenitis.” The basic difference between the two is in the location of the inflammation. Cellulitis occurs in the connective tissues located between the lobes of the breast (see Figure 1). Adenitis occurs within the ducts and lobes of the breast (see Figure 2). These differences in location are reflective of type-specific etiologies and manifest themselves in particular ways (see Figure 3). Mammary cellulitis usually occurs as a result of the introduction of bacteria through a cracked or fissured nipple. lo Because fissuring of nipples is most common at the onset of breast feeding, cellulitis is most likely to occur early in the puerperium. Typically, cracks in the nipples repeatedly heal and then reappear. When cellulitis occurs, the infected breast becomes hot, flushed, painful and hard, often in a localized
Journal of Nurse-Midwifery
??
FIGURE 1 Mammary Cellulitis Infection
of the
connective
tissue be-
tween the lobes of the breast.
FIGURE 2 Mammary Adenitis Infection within the lobes and ducts of the breast.
area. l”,ll The patient becomes febrile, with a temperature of 38°C (100.4“F) or more, and has a rapid She may develop chills, pulse. malaise, and headache.” Occasionally, the cellulitis will spontaneously resolve in one to two days. More often, if not treated, it will lead to the formation of a breast abscess.” Mammary adenitis results from the introduction of bacteria into the ducts of the breast.‘O It occurs in the ab-
Vol. 24, No. 6, November/December
1979
Fragile Skin Improper
Missed Feedings
Breaking
Poor Positioning I
Interval Between Nursing Too Long I
1
I
I
I
NIPPLE TRAUMA
L Pain
I
-
Impaired
Let-down
.
I
4 ENGORGEMENT
Cracked’Nipples
1
Stasls\f
1 Entry for Bacteria
Milk
1 Plugged Ducts MAShTIS
I
t No Treatment
Tre&ment
1 L Improper
Treatment
1
4
PROBL!EM RESOLVED
4
BREAST ABSCESS
FIGURE 3
sence of cracked or fissured nipples. Often, pus can be expressed from the nipple of the infected breast, a finding not present in cellulitic infections. The symptoms of mammary adenitis are similar to those of mammary celThe lulitis, but often are less severe. infectious process has an insidious onset and exists in a mild to moderate form longer than will a cellulitis infection. lo Unlike the localization of cellulitis infections, several areas of the breast, or even both breasts, may be involved in an adenitis infectionlO This diffusion is the result of simultaneous infection of several breast ducts. Adenitis usually occurs two or more weeks after delivery, when the It has occurred mother is at home. earlier, in epidemic form, in some hospital settings, however. I3 Both types of acute puerperal mastitis are most often caused by infection with S. aureus. I2 In mammary cellulitis, it is thought that staphylococci are introduced into a nipple fissure when an infected staff member touches the breast, when an infected baby nurses, or when the mother herself transmits staphylococci from another part of her body to her breast. There is some question about how staphylococci
Journal of Nurse-Midwifery
??
are introduced into the breast ducts in mammary adenitis. One of the most probable theories is that staphylococci in the nasopharynx of an infant are introduced into the breast when the infant nurses. I3 Colbeck, in a study of a hospital epidemic of mastitis, proposed that the initial introduction of staphylococcus into the ward was caused by the infected staff members. They infected the infants, who, in turn, passed the infection on to their mothers. He found that in almost staphylococci were every case, present in the nasopharynges of the infants of infected mothers, and that, in most cases, infant throat cultures were positive before or at the time the mothers developed mastitis. I3 Breast abscesses, or suppurative mastitis. can occur at any time and may be chronic or acute. Acute breast abscesses occur most commonly in breast feeding women or in those who have recently discontinued breast feeding. I4 Typically, acute puerperal mastitis occurs first. If treatment is delayed or inappropriate, one or more abscesses may develop.‘” Several abscesses separated by the fibrous septa of the
Vol. 24, No. 6, November/December
1979
FIGURE 4 Suppurative
Mastitis
Abscesses separated of the breast.
by the fibrous septa
breast are the most usual findings.“’ (See Figure 4.) The most frequent causal organism is again S. aureus, although S. epidermidis and beta hemolytic streptococci are occasionally cultured from abscesses.9 The patient with suppurative mastitis develops the usual signs and symptoms of acute infection: malaise, fever, diaphoresis, headache, and muscle pain. The affected
breast is enlarged, painful, red, and hot. If the abscess is far advanced, “pointing” may be seen. This appears as a very localized, shiny, white spot with pus just under the surface of the skin.‘” The fourth and fifth types of breast infection identified by Newbould are rare and will only be discussed briefly. Infection with an uncommon organism occurs when microorganisms that have invaded another part of the body are transferred to the breast. Mastitis may develop in the breast of a lactating woman with mumps, for example, as a result of the transfer of that infecting organism. Virus infection in a mammary neoplasm, the fifth category of mammary infection, was idtlitified when particles with all the attributes of viruses were demonstrated not only in cancerous mammary tissue, but also in milk produced by women with and without cancer. 9 The most important task of a nurse-midwife in dealing with mastitis is prevention of infection. The following are key points in the prevention of mastitis: 1. Instruction in hand expression and gentle breast massage during the antepartum period.16J7 The main value of this practice is that through touching her breasts before delivery, a woman may be more comfortable with the touching required for breast feeding after delivery. 2. Encouragement of early and unrestricted nursing following delivery. This practice encourages the flow of milk and will help prevent engorgement.18 3. Identification of mothers with increased risk of nipple trauma and engorgement (see Figure 3). When specific risk factors are identified, a care plan can be devised for that mother which will focus on eliminating or minimizing her particular risk factors.
6
in the signs and 4. Instruction symptoms of a possible infection before delivery and review before discharge from the health care facility. The mother may then be able to recognize early indications of a problem and seek help before mastitis progresses. of a telephone 5. Establishment call-in system that clients may utilize for support and information needs. Names of La Leche League leaders or women from the local Nursing Mothers’ Council can also be offered to help meet this need. These resource people may be able to reinforce and supplement the services offered by health care providers. 6. Scheduling of the first postpartum visit 2-3 weeks after delivery. This is a peak time for mastitis, as well as for the emotional needs of the mother. Should efforts fail in the area of mastitis prevention, action must be taken to manage the problem and prevent development of a breast abscess. While little controversy over identification and diagnosis of mastitis is seen in the literature, two different types of management are proposed. Some clinicians and researchers advise the discontinuation of breast feeding, at least on the affected breast. 4~11~19~20They believe that with less stimulation of the breast, recovey is quicker and recurrence less likely. Other health care providers recommend that their patients continue nursing, with special emphasis on emptying the affected breast:’ ,6,8, =*I6 They feel that discontinuation of breast feeding leads to stasis of milk and distention of breast tissue, factors which exacerbate mastitis. They also note that discontinuation of breast feeding deprives the infant of its benefits. Some of the promoters of continued breast feeding do recommend pumping the breast,
Journal of Nurse-Midwifery
??
and discarding the milk while the woman is febrile, however.21 In one comparative investigation of these two treatments, by Marshall and others, one group of mastitis patients (41 subjects) continued breast feeding and another (15 subjects) weaned their infants.6 In the first group, four subjects had a recurrence of the infection. In the latter group, three subjects developed breast abscesses. No infants in either group developed illness. They concluded that continued breast feeding is preferable. Outlined below are the two currently recommended plans for management when the patient presents with localized breast tenderness. Plan I 1. Rest in bed until symptoms subside. 2. Increased oral fluids. 3. Temperature monitoring every four hours. 4. Frequent emptying of the affected breast, through nursing or manual expression. Plan II. This includes steps 1 through 3 of Plan 1 and the following: 1. Discontinuation of breast emptying. 2. Binding of the breasts and application of cold packs. 3. Nourishment of infant by formula feeding. If symptoms of infection persist for more than 24 hours, antibiotic therapy should be initiated in all cases. Deveraux reported in his study of 71 cases of mastitis that when true febrile mastitis developed and no supportive or specific treatment was instituted within 24 hours, abscess was the usual outcome.‘5 Several different antibiotics are recommended in the literature, including sulfisoxazole,” penicillin G,” penicillin V,6 doxycycline,’ and novobiocin8 Because most breast infections are caused by S. aureus, an antistaphylococcal drug is usually
Vol. 24, No. 6, November/December
1979
TABLE l* UsualAdult Daily Dose
Drug
Comments
Penicillin G
4- 10 mega units IM or IV
Not effective against penicillinase
Methicillin
4 g IM or IV
Effective against penicillinase
organisms.
Cloxacillin
2 -4 g PO. IM, or IV Effective against penicillinase
organisms.
Dicloxacillin
2-4
Effective against penicillinase good absorption orally.
organisms.
Flucloxacillin
Effective against penicillinase good absorption orally Effective against penicillinase
organisms.
Oxacillin
250 mg q6” PO or IM 2 g PO. IM. or IV
Nafcillin
1-2
g PO. IM or IV Effective against penicillinase unreliable oral -absorption.
organisms, -
Cephalothin
2-4
g IM or IV
Cephaloridine
l-2gIM
Clindamycin
600-1200
Lincomycin
1.5 g PO. l-l.5 g IV infusion
Can be used in penicillin allergic patients, but not drug of 1st choice.
Erythromycin
l-2gPO. l-4gIV
Effective against penicillinase organisms. useful if allergic to penicillin.
Fucidic Acid
500 mg tid PO
Not effective against fucidin-resistent staphylococci.
Chloramphenicol
l-4gPO also IM or IV
Questionable
Vancomycin
2 g IV infusion
Indicated only in resistent infections.
* Adapted
from Antibiotics
g PO
organisms.
given IV, useful
Useful if allergic to penicillin. mg PO
in Clinical Practice
indicated. Table 1 lists the major antistaphylococcal drugs in use at this time. Both Deveraux15 and Newton* point out that when choosing an antibiotic, caution must be taken. Many S. aureusstrains encountered in mastitis are penicillin resistant. Another consideration, when prescribing to a patient who is continuing breast feeding, should be the amount and effect of the antibiotic in the breast milk. Figure 3 illustrates the possible causes, course, and outcomes of mastitis. A typical clinical situation might involve a new mother who is nursing an infant for the first time. This factor alone can predispose the patient to nipple trauma. If this mother receives inadequate or inap-
Journal of Nurse-Midwifery
Painful IM injection-usually if allergic to penicillin.
organisms.
??
Well absorbed
orally.
ing of infant, technique of breaking infant suction, nipple hygiene (including avoidance of any cleansing agent that could dry or irritate nipples), air drying breasts, etc. 3. Rest in bed. 4. Increased
fluids
Follow-up care to ascertain that the mastitis has resolved and that those breast feeding problems that were contributing to nipple trauma. have been resolved is necessary. Nurse-midwives should be familiar with all aspects of the problem of mastitis, but the greatest impact can be made in prevention of infection by identification of predisposing factors and elimination or minimization of their effect, and in the recognition’of early signs and symptoms of mastitis so that prompt treatment can be initiated. By focusing on these areas we can decrease the chance of at least pathologically based breast feeding failure.
use in nursing mothers, can cause grey baby syndrome in infants. staphylococcal REFERENCES 1. Applebaum RM: Abreast of the Times. Miami. Applebaum, 1969
by Hillas Smith
propriate breast feeding assistance, her chances of developing cracked nipples increases. The fissured nipples provide an entry into the connective tissue of the breasts. The mother appears in clinic with the typical signs and symptoms of mammary cellulitis: elevated temperature, rapid pulse, and hot, reddened, painful areas in one or both breasts. At this time, treatment is imperative. One possible course of management might include the following:
1. Prescription of cloxacillin every six hours.
500 mg
2. Continuation of breast feeding, with special emphasis on position-
Vol. 24, No. 6, November/December
1979
2. Ladas AK: How to help mothers breastfeed. Clin Ped 9: 702-705, 1970 3. Reeder SR, Mastroiannin Martin LL, et al: Maternity Nursing. ed New York, Lippincott, 1976 4. Haagensen, Breast. 2nd ed. Saunders, 1971
CD: Diseases Philadelphia.
5. Puerperal mastitis. Med J, April, 1976
LR. 13th of the W.B.
Editorial in Br
6. Marshall BR, Hepper JK, Zirbel C: Sporadic puerperal mastitis: an infection that need not interrupt lactation. JAMA
233:1377-1379, 1975 7. Greenhill J, Friedman E: Biological Principles and Modern Practice of Obstetrics. ders, 1974
Philadelphia.
W.B.
Saun-
8. Newton M: Human lactation, The Mammary Gland and its Secretion. Vol 1. Edited by SK Kwon, AT Cowie. New York, Academic Press, 1961
7
9. Newbould FHS: Microbial diseases of the mammary gland, Lactation-A Comprehensive Treatise. Edited by BL Larson, VR Smith. New York, Academic Press, 1974 10. Gibberd GR: Sporadic and epidemic puerperal breast infections: a contrast in morbid anatomy and clinical signs. Am J Obstet Gynecol 65:1038-
1041, 1953 11. Pritchard JA, Macdonald Williams Obstetrics. 15th York, Appleton-Century-Crofts, 12. Myles MF: Textbook wives. 8th ed. Edinburgh, Livingstone, 1975
PC: ed. New 1976 for MidChurchill
13. Colbeck JC: An extensive outbreak of staphylococceal infections in maternity units. Can Med ASSOC J 61:557-68, 1949
18. Newton M: Mammary effects. In: DB Jelliffe, EP Jelliffe: The uniqueness of human milk. Am J Clin Nutr 24:987990, 1971
14. Richardson WW: Breast Nurs Times 66432-3, 1977
19. Pillitter A: Nursing Growing Family. Boston, and Company, 1976
abscess.
15. Devereux WP: Acute puerperal mastitis-evaluation of its management. AM J Obstet Gynecol 108:1, 1970
Care of the Little, Brown
20. Joseph S, Peck R: Postpartum needs of the family, MaternityNursing Today. Edited by J Clausen et al. New York, McGraw-Hill, 1973
16. LaLeche League International: Sore breast: what, why, and what to do. Information Sheet #12 (revised), 1975
21. Ziegel E, Van Blarcom C: Obstetric Nursing. 6th ed. New York, Macmil-
17. LaLeche League International: The Womanly Art of Breastfeeding. 2nd ed. Franklin Park, LaLeche League International, 1963
lan, 1972 22. Smith, H: Antibiotics in Clinical Practice. 3rd ed. Baltimore, University Park Press, 1977
-
Legislation regarding CNM practice has been introduced in the New Jersey Assembly. Walter Kern introduced the liberal proposal, Assembly Bill 3245, in early May 1979 in response to the restrictions on midwifery practice being imposed by the New Jersey Board of Medical Examiners. The bill has been assigned to committee, and the New Jersey CNMs are beginning to mobilize consumer and professional support for the bill. Major points of the bill include: 1. refers to CNMs only; no provision for or against empirical midwives; 2. establishes a Nurse-Midwives Examining Committee under the state Board of Medical Examiners, but with explicit powers listed in the legislation. The Committee membership would
include 4 CNMs, 1 OB-GYN, and 2 public members. The Committee would license CNMs in the state, certify programs for academic nurse-midwifery within the state, and prescribe the standards of practice for CNMs within the state. 3. includes, under Standards of Practice, an extensive list of allowed CNM activities, including episiotomy repair and IUD insertion, two of the issues the New Jersey midwives have contested with the Board of Medical Examiners. Irene Sabatini, the chairperson of the New Jersey Chapter of NurseMidwives, can provide current information on the status of the legislation. The Chapter address is 100 Bergen Street, Newark, NJ 07103. Journal of Nurse-Midwifery
8 Comght 0
1979 by the American College of Nurse-Midwives
??
*
*
*
*
An organization in Washington D.C. that promotes many issues of interest to CNMs is the National Women’s Health Network. The Network lobbies congressional and executive agencies and publishes a bimonthly newsletter for its members. A sampling from their April-May newsletter shows the wide variety of issues the Network monitors; unnecessary mastectomies, sterilization abuse, depo-provera, grants for allied health professions, breast feeding in public, and poisoning from the herbal abortifacient pennyroyal are some of the items included. Individual membership is $25 and Health/Women’s Group membership is $35. Local chapters of ACNM might consider such group membership. The Network is located at 2025 I Street N.W., Washington, DC 20006. Vol. 24, No. 6, November/December
1979