Mastitis - WHO

1 WHO/FCH/ : ENGLISHDISTR: GENERALM astitisCauses and ManagementDEPARTMENT OF CHILD AND ADOLESCENTHEALTH AND DEVELOPMENTW orld Health OrganizationGeneva2000 World Health Organization 2000 This document is not a formal publication of the World Health Organization (WHO),and all rights are reserved by the Organization. The document may, however, be freelyreviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or foruse in conjunction with commercial designations employed and the presentation of the material in this document do notimply the expression of any opinion whatsoever on the part of the Secretariat of theWorld Health Organization concerning the legal status of any country, territory, city orarea or of its authorities.

2 Or concerning the delimitation of its frontiers or views expressed in documents by named authors are solely the responsibility ofthose illustration adapted from a poster by permissionof the Ministry of Health, Time of Causes of Milk Breast Frequency of Attachment at the Preferred side and efficient Other mechanical Infecting Bacterial colonisation of the infant and Epidemic puerperal Routes of Predisposing Pathology and clinical Blocked Non-infectious Immune factors in Sub-clinical Infectious Breast Improved understanding of breastfeeding Routine measures

3 As part of maternity Effective management of breast fullness and Prompt attention to any signs of milk Prompt attention to other difficulties with Control of Blocked Breast Safety of continuing to Long term Management of Mastitis in women who are 1. Breastfeeding techniques to prevent and treat 2. Expression of 3. Suppression of authors of this review were Ms Sally Inch and Dr Severin von Xylander, with editorialassistance from Dr Felicity thanks are due to the following lactation experts for reviewing the document in draft andfor providing helpful constructive criticism.

4 Dr Lisa Amir (Australia), Ms Genevieve Becker (Eire), Ms Chloe Fisher (UK), Dr Arun Gupta(India), Dr Rukhsana Haider (Bangladesh), Ms Joy Heads (Australia), Dr Evelyn Jain (Canada),Dr Miriam Labbock (USA), Ms Sandra Lang (UK), Dr Verity Livingstone (Canada), Dr GroNylander (Norway), Dr Marina Rea (Brazil), Ms Janice Riordan (USA), Dr Anders Thomsen(Denmark), Ms Marsha Walker (USA) and Dr Michael Woolridge (UK). Ms Helen Armstrong (UNICEF) also reviewed the draft document and provided many also to members of WHO s Technical Working Group on Breastfeeding for helpfullyreviewing the manuscript: Dr Jose Martines, Ms Randa Saadeh, Dr Constanza Vallenas and DrJelka :Causes and Management1.

5 IntroductionMastitis is an inflammatory condition of the breast, which may or may not be accompanied byinfection. It is usually associated with lactation, so it is also called lactational Mastitis (67) orpuerperal Mastitis (1). It can occasionally be fatal if inadequately treated. Breast abscess, alocalised collection of pus within the breast, is a severe complication of Mastitis . Theseconditions form a considerable burden of disease and involve substantial costs (43; 112). Recentresearch suggests that Mastitis may increase the risk of transmission of HIV throughbreastfeeding (76; 150).

6 Awareness is growing that inefficient removal of milk resulting from poor breastfeedingtechnique is an important underlying cause, but Mastitis remains synonymous with breastinfection in the minds of many health professionals (11; 15; 93; 94). They are often unable tohelp a woman with the condition to continue to breastfeed, and they may advise herunnecessarily to stop (43).This review aims to bring together available information on lactational Mastitis and relatedconditions and their causes, to guide practical management, including the maintenance IncidenceMastitis and breast abscess occur in all populations, whether or not breastfeeding is the norm.

7 The reported incidence varies from a few to 33% of lactating women, but is usually under 10%(Table 1). Most studies have major methodological limitations, and there are no largeprospective cohort studies. The higher rates are from selected incidence of breast abscess also varies widely, and most estimates are from retrospectivestudies of patients with Mastitis (Table 2). However, according to some reports, especially fromdeveloping countries, an abscess may also occur without apparent preceding Time of occurrenceMastitis is commonest in the second and third week postpartum (29; 120; 122), with mostreports indicating that 74% to 95% of cases occur in the first 12 weeks (49; 122; 140; 167; 170).

8 However, it may occur at any stage of lactation, including in the second year (7; 140). Breastabscess also is commonest in the first 6 weeks post partum, but may occur later (18; 32; 43; 49;71; 74; 109; 119; 157).3 Table 1: Estimates of Incidence of MastitisAuthors:Year:Country:Method:Numb erof cases:CasedefinitionObservationperiod post-partum:Populationsize:Percentage ofmothersbreastfeeding at thetime of assessment:Percentagewithmastitis:Commen ts:Fulton (49)1945 UKPopulation based prospectivestudy156 Definiteevidence ofsuppuration2 years and 4months41,0001500 birthsnot (168)1946 UKRetrospective questionnaireamong post partum visitpatients3 Womenreportinghaving hadmastitis0 4 weeks5242% (62)1948 USAP rospective study in onehospital 121not indicated6 months1,730100%*7%* selectioncriterionMarshall (100)1975 USAP rospective study on womendelivering in one hospital 65 Actual orsuspectedbreast infection up to one year5,15549% * included onlywomen returningto the samehospital Prentice et al.

9 (131)1985 GambiaAnalysis of cases in a definedpopulation65 Diagnosis by ahealthprofessionalday 14 tocessation ofbreastfeedingnot indicated100%(presumed) ** Mean monthlyincidenceHughes et al. (67)1989 UKRetrospective analysis ofmedical recordsnotindicatedDiagnosis ofpuerperalbreast infectionnot indicated425not indicated4 - 10%** Annualincidence 1930 1988 Riordan & Nichols(140)1990 USA basedPostal retrospectivequestionnaire among abreastfeeding supportorganisation*60 Womenreportinghaving hadmastitisthe entirebreastfeedingperiod for each child180100%33%* Non-representativepopulationAmir (6)

10 1991 Australiaself-report questionnaire in abreastfeeding clinic and healthcentres*49not indicatedweek 1 to 2years98100 %50%* Non-representativepopulationKaufmann &Foxman (81)1991 USAR etrospective analysis ofmedical records30 Physician'sdiagnosis0 7 weeks96685% 1 (cont.): Estimates of incidence of MastitisAuthors:Year:Country:Method:Numb erof cases:CasedefinitionObservationperiod post-partum:Populationsize:Percentage ofmothersbreastfeeding at thetime of assessment:Percentagewithmastitis:Commen ts:Jonsson &Pulkkinen (78)1994 FinlandQuestionnaire distributed in aclinic, diagnosis made byhealth worker199 Based onclinicalpresentation5 12 weeks67085%24%** Methodologynot clearFoxman (48)1994 USASelf-administeredquestionnaire distributed atdischarge after formastitis0 9 days100100%*9%*RecruitmentconditionEvans (43)