mastitis

and Sabine Schrör, medical journalist Updated on

Florian Tiefenböck studied human medicine at the LMU Munich. In March 2014, he joined as a student and has supported the editorial team with medical articles ever since. After receiving his medical license and practical work in internal medicine at the University Hospital Augsburg, he has been a permanent member of the team since December 2019 and, among other things, ensures the medical quality of the tools.

Mastitis: description

Mastitis is inflammation of the mammary gland (mammary gland = mamma). It is mainly caused by bacteria. However, other factors such as blocked breasts during breastfeeding, stress or hormonal fluctuations can also lead to breast infections. Mastitis almost always occurs unilaterally.

Doctors differentiate between puerperal mastitis and non-puerperal mastitis:

Puerperal mastitis is an inflammation of the breast that occurs during the puerperium and breastfeeding. It affects between 1 and about 25 percent of all women who have recently given birth - depending on which definition the corresponding studies are based on, for example whether a milk blockage is already listed as mastitis.
Non-puerperal mastitis is inflammation of the mammary gland outside of breastfeeding.

Appearance of mastitis

Mastitis is a typical disease affecting fertile women. Therefore, most often 20- to 40-year-olds develop breast infections. Only ten percent of all cases of non-puerperal mastitis are found after menopause.

It is very rare for men to develop mastitis. The disease can also occur in newborns. In this case, doctors speak of mastitis neonatorum. It usually develops between the fourth and sixth day after birth.

Mastitis: symptoms

There are a number of typical mastitis symptoms. The signs of puerperal mastitis differ only slightly from non-puerperal mastitis:

Usually the breast is swollen and hardened in the inflamed area. In this area, there is often a noticeable reddening. The inflamed chest feels considerably warmer than the unaffected one. Palpation of the inflamed area is typically painful. A pain in the nipple area is also a possible symptom of mastitis.

In about half of those affected, the lymph nodes below the armpit swell. Usually this enlargement is painful.

In the case of breast inflammation in the puerperium, the patients often also suffer from general physical complaints. These include chills, malaise and fever with temperatures above 38.4 degrees Celsius. Affected people feel tired, exhausted and very sick. The secreted milk is changed. It tastes salty, so many infants refuse to breastfeed.

Usually the upper area on the outside of the chest is inflamed. If mastitis is not treated in a timely manner, the inflammation can spread to the entire breast. In some cases, the inflammation is encapsulated. A large amount of pus accumulates (abscess). Experts call this process abscessing. Patients can feel the abscesses as a lump that gives way under pressure and is very painful.

Passages may form from the abscess to the nipple or to the surface of the skin. Doctors refer to these tube-like connections to the surface of the body as fistulas.

Neonatal mastitis: symptoms

Breast inflammation in newborns is also associated with typical mastitis symptoms. As in adults, only one breast is usually affected, reddened and hot. Sick babies cry noticeably often because of the pain, especially when the inflamed breast is touched. Mastitis neonatorum is usually preceded by swelling of the breast. In many cases, milk, also called witch's milk, leaks from the affected breast.

Do not try to use pressure to drain a swollen chest in your child, as this increases the risk of infection.

Mastitis: causes and risk factors

Bacterial puerperal mastitis

By far the most common pathogen causing postpartum mastitis is the bacterium Staphylococcus aureus. At almost 95 percent, it can be detected much more frequently in this breast inflammation than in non-puerperal mastitis. Other germs such as streptococci, Proteus bacteria, pneumococci or Klebsiella are less common.

The pathogens get into the baby's nose and mouth from the mother or other people in the immediate vicinity (relatives, caregivers). During breastfeeding, the germs are then transferred to the mother's breast:

Breastfeeding causes small tears in the skin (rhagades) in the area of the nipple. They are the gateway through which the bacteria usually first enter the lymphatic system of the mammary gland. In this case, doctors speak of interstitial mastitis, i.e. an inflammation of the breast in the spaces between the glandular tissue.

Under certain circumstances, however, the bacteria can also get directly into the milk ducts. This so-called parenchymatous mastitis is particularly favored by a milk congestion. The milk ducts are then significantly widened by the accumulated secretion and thus more accessible to germs.

Non-puerperal bacterial mastitis

With a good 40 percent, the Staphylococcus aureus germ is the most common cause of bacterial breast inflammation outside of breastfeeding. The globular bacterium Staphylococcus epidermidis causes an inflammatory reaction in the mammary gland just as often. Other bacteria that can cause non-puerperal mastitis are Escherichia coli, Proteus bacteria, Fusobacteria and streptococci. Breast inflammation occurs much less often as part of another infectious disease - such as tuberculosis, syphilis (syphilis), leprosy, radiation fungal disease or typhoid.

The germs get into the breast tissue through injuries to the breast and the nipple or through small tears in the skin. There they can settle and multiply. The body's defenses take action against the intruders - the chest becomes infected.

It is very rare for the bacteria to spread through the bloodstream. Only in the case of additional purulent diseases such as furunculosis is the risk of germ colonization increased. Boils are a painful, purulent inflammation of the hair root and occur more frequently on the chest, neck and groin.

Non-bacterial non-puerperal mastitis

In most cases of non-bacterial (abacterial) breast infections, blocked breasts are the direct cause of mastitis. In the process, the mammary gland produces too much milk that cannot flow out quickly enough - for example, because the breast tissue has scarred changes due to previous inflammations or injuries. Due to the accumulated secretion, the milk ducts (ductus lactiferi) widen and the milk penetrates into the surrounding tissue between the mammary gland lobules. There the secretion is fought like an intruder - the chest becomes inflamed. In the further course germs can settle and multiply in the inflamed breast area. This is how an abacterial mastitis becomes bacterial.

High blood levels of the messenger substance prolactin trigger increased milk production. This hormone is responsible for breast growth and milk production. It is made in the pituitary gland and is normally secreted during pregnancy and while breastfeeding. Outside of this time, stress, thyroid disorders, medication (e.g. metoclopramide) or tumors in the pituitary gland can lead to an increased release of prolactin. In some cases, the cells of the mammary gland are very sensitive to the hormone. Then even small amounts of prolactin cause the mammary gland to secrete more milk.

Other risk factors for non-puerperal mastitis

There are numerous factors that can favor non-puerperal mastitis:

Women who have already breast-fed a child or have injured their breasts or nipples are more likely to develop breast infections.
Medicines can also cause mastitis: contraceptive pills with a high proportion of the female sex hormone estrogen (estrogen-based ovulation inhibitors for contraception), sedatives and preparations for menopausal symptoms make women more susceptible to breast infections.
In addition, there are some breast diseases in which non-puerperal mastitis occurs more frequently. One example of this is what is known as fibrocystic mastopathy. Large cavities filled with fluid form in the breast tissue. These cysts can be more easily colonized by bacteria.
Cycle-dependent breast pain (mastodynia) and particularly large breasts (macromastia) also promote breast inflammation.
Nipples that are turned inward (sagging or inverted nipples) are also considered a risk factor.
Studies have also shown that non-puerperal mastitis recurs more often, especially in heavy smokers.

Mastitis neonatorum

The mother's hormones are still active in the body of some newborns - including prolactin, which stimulates milk production. In this case, the infant's breasts may swell and release a milky fluid. This secretion is also called witch's milk. If it builds up, the child's chest can become inflamed - especially when trying to squeeze out the milk. Hormones from the placenta and direct bacterial infections can also trigger mastitis in newborns.

Mastitis: diagnosis and examination

A doctor can usually recognize mastitis quickly. First, he asks about the symptoms that arise:

What has changed in your chest?
Is your chest hurting?
Do you feel sick and exhausted?
Do you have chills or a fever?
What medications are you taking?
Have you recently given birth?
Have you already had a breast infection?
Are you currently breastfeeding?

The typical symptoms of mastitis - redness, overheating and swelling of the breast - are easy to identify on the subsequent physical examination. The doctor will also palpate the breast and the surrounding lymph nodes. If a swelling in the breast can be easily depressed, this indicates an abscess.

Imaging

Usually, the doctor will also do an ultrasound scan of the breast. This can be used to identify abscesses in the breast and to better assess the extent of the mastitis. Foci of pus appear as irregular, dark lumps on the ultrasound image.

After treatment with antibiotics, the doctor usually arranges for an x-ray of the breast (mammography). This is to rule out a malignant disease of the breast. In particular, if the symptoms do not improve with antibiotic therapy, there is a suspicion of inflammatory breast cancer (inflammatory breast cancer).

If in doubt, the gynecologist will take a piece of tissue from the breast as part of a biopsy and have it examined for degenerate cells.

Blood draw and smear

There are some levels in the blood that are generally elevated when there is inflammation in the body. Typically, these are the number of white blood cells (leukocytes) and the sedimentation rate (abbreviation: blood sedimentation). Above all, an increased concentration of the hormone prolactin can be determined by means of blood analysis.

If the nipple secretes milk, the doctor can take a smear and examine it for possible pathogens.

Mastitis: treatment

Mastitis symptoms should be clarified by a doctor at an early stage. This prevents the inflammation from melting down. When it melts, the inflamed tissue dies and liquefies. A purulent abscess forms.

Cooling and relieving the chest

In the early phase of mastitis, the focus is on cooling the inflamed breast. Ice packs or quark compresses are suitable for this.

In order to calm the inflamed breast, the bra should be tight. Tying up the affected breast also has a relieving effect. Breastfeeding mothers are advised to empty their breasts at regular intervals, for example by stroking or using a breast pump. This also relieves the glandular tissue.

Antibiotics

In the case of bacterial non-puerperal mastitis, the doctor immediately prescribes antibiotics.

Breastfeeding mothers with puerperal mastitis, on the other hand, are initially attempted to be treated without antibiotics. To do this, the chest is cooled and relieved. If the mastitis symptoms do not improve within a day, it is very likely that it is a bacterial form of puerperal mastitis. Then the doctor will prescribe appropriate antibiotics that are compatible with breastfeeding and safe for mother and child.

Breast inflammation - breastfeeding is still possible

Breastfeeding mothers with mastitis usually do not need to take a break from breastfeeding. You should only interrupt breastfeeding if you have breast inflammation caused by streptococci.

Even if the child is taking antibiotics, the breast can still be given. Antibiotics can only be found in breast milk in very small amounts. Very rarely do they disturb the intestinal lining of the child, which can lead to diarrhea.

An exception are premature babies, who are particularly sensitive. With them, the mother should refrain from breastfeeding in the event of bacterial mastitis.

Be sure to talk to your doctor if you plan to take a break from breastfeeding. He will advise you on the correct way to wean.

More medication

Non-puerperal mastitis that is not caused by bacteria is usually based on an excessively high blood concentration of the hormone prolactin. In this case, antibiotic therapy is not helpful. Rather, doctors try to curb milk production by giving so-called prolactin inhibitors. For breastfeeding mothers with puerperal mastitis, however, prolactin inhibitors are no longer recommended today so that the mothers can continue to breastfeed their children.

Anti-inflammatory drugs (non-steroidal anti-inflammatory drugs) such as ibuprofen help against breast pain caused by mastitis.

Abscess treatment

If the doctor detects an accumulation of pus on the ultrasound, it must be surgically removed. First, the inflamed breast is irradiated with warming red light. This promotes the liquefaction and encapsulation of the inflamed breast tissue. The pus fluid is then sucked off with a syringe.

For larger abscesses, the doctor will make a small incision on the affected breast and use a liquid to flush the pus out. In particularly severe cases, a small tube is placed during this surgical procedure. The following pus can drain through such a catheter and the doctor can rinse again if necessary.

Mastitis: disease course and prognosis

The prognosis for a breast infection is very good. In some cases it resolves itself or disappears quickly with simple measures. Bacterial mastitis heals quickly, especially with early and correct treatment with appropriate antibiotics.

With some breast infections, a purulent abscess forms. This can either be directly under the skin (subcutaneous abscess) or the nipple (subareolar abscess).Deeper abscesses or fistulas within the mammary gland usually need to be drained and treated by surgery.

Mastitis outside the breastfeeding period can recur and turn into chronic mastitis. Contact a doctor as soon as you notice the first symptoms of mastitis. The inflammatory process can then be stopped early. Take the prescribed medication long enough to avoid the recurrence of non-puerperal mastitis. If you smoke: By not using tobacco products, you can also reduce the risk of a new breast infection.

Mastitis: prevention

Breast infections can never be prevented one hundred percent. However, the right breastfeeding technique lowers the risk of puerperal mastitis. Talk to friends, doctors, lactation consultants and midwives. Useful information can also be found in books and journals. In this way, you effectively avoid sore nipples, which are an ideal entry point for germs, or prevent milk congestion, which increases the risk of mastitis.

Here are the most important tips on how proper breastfeeding can prevent breast infections:

>> Provide a relaxed breastfeeding position!
Sit or lie down relaxed. If you have chosen to breastfeed while seated, your arms and back should be well supported. The baby is lying with their tummy against yours and their head tilted back a little to keep their nose free.

Your child should not fall asleep while breastfeeding, as this can damage the nipple more easily - the risk of mastitis increases.

>> Make sure that the child accepts the breast correctly!
In order to be able to suckle properly, the baby must have the nipple and areola correctly in the mouth. If your child only sucks on part of the wart, it can quickly become sore.

The baby's tongue lies over the lower tooth bar when sucking and the lips are turned outwards. If you want to change position and your child does not let go of the nipple, gently slide a finger into the corner of their mouth to release the negative pressure in the child's mouth.

>> Take physical characteristics into account!
There are a number of factors that can make proper breastfeeding technique difficult. These include flat or inwardly turned nipples of the mother, but also a wrong position of the tongue, a short ligamentous ligament or jaw and palate malformations in the child. In these cases, pay particular attention to the correct positioning of your child.

>> Clean your breasts before breastfeeding!
Good hygiene prevents mastitis from developing. First of all, clean your nipples and areola areas with warm water. Also, wipe your child's mouth before breastfeeding to reduce the number of possible pathogens.

>> Avoid sore nipples!
Small cracks in the skin in the area of the nipples make it easier for germs to enter. Do not use paraffin-based ointments, creams and alcoholic liquids on the chest area, as they can dry out the skin and thus promote cracks. It's better to let your nipples air dry after breastfeeding. Use nursing pads, change them regularly and pay attention to breathable materials when buying.

If you already have sore nipples, there are a number of treatment options. A few drops of breast milk or pure lanolin (wool wax) applied to the nipples have a proven soothing effect. Breast compresses, applied tea bags or soft laser therapy are sometimes mentioned as measures against sore nipples. However, there is insufficient evidence that these procedures are effective, so that treatment guidelines do not recommend them. This also applies to the use of nipple shields.

If the nipples are already reddened and painful, the likelihood of mastitis is high. In this case, consult your doctor quickly.

>> Watch out for increased swelling of the mammary glands after the birth!
After giving birth, the blood flow in the breasts increases. In addition, more and more milk collects. As a result, lymphatic water and venous blood can be evacuated more poorly. Fluid leaks from the bloodstream, accumulates in tissues, and causes edema. In addition, the messenger substance oxytocin, which controls the flow of milk, finds it more difficult to reach its place of action, namely the muscle cells of the mammary glands. Stress, lack of sleep and fears also limit milk supply. Some experts recommend cooling the swollen breast when a woman is not breastfeeding to prevent mastitis.

Cabbage leaves, cooling pads and quark toppings have proven their worth. The guidelines for the use of Retterspitz, acupuncture and special massages do not make any recommendations. So far, there are no proven studies in this regard that can confirm their benefits. Only the so-called low pressure massage can reduce the symptoms of swollen breasts. The accumulated fluid is pressed in the direction of the lymphatic system in order to achieve a natural drainage. Make absolutely sure that it is carried out correctly! Otherwise the risk of a breast infection from the smallest injuries increases.

>> Make sure that milk is emptied regularly!
Breast eight to twelve times in the first few days after the birth so that the milk that has accumulated is emptied. If you are not breastfeeding your child, empty your breasts by hand stroking or using a breast pump. When doing this, warm your breasts before breastfeeding or expressing to facilitate milk delivery.

The so-called "Reverse Pressure Softening" technique is helpful for severe swelling of the breasts. Gentle pressure creates slight indentations around the nipple so that your child can suckle the breast more easily. Let trained professionals such as midwives or lactation consultants show you the technique. Avoid painful massages or injuries at all costs - they significantly increase the risk of mastitis.

>> At the beginning, keep the duration of breastfeeding limited!
Only breastfeed your child for five to ten minutes at a time for the first few days. In this way you can avoid skin tears in the area of the nipples and prevent puerperal mastitis.

Breastfeeding causes an increased release of the messenger substances oxytocin and prolactin, which stimulate milk production and milk flow. This creates mature breast milk after two to three weeks. Then have your child drink one breast empty (approximately twenty minutes). Just let the other breast drink and start with this side the next time you breastfeed.

If you have complaints, see a doctor quickly!

If you have chest pain or you notice other changes such as red, hot patches of skin on your chest, contact your doctor as soon as possible. Early treatment can prevent complications such as abscesses. If you are breastfeeding, however, you should try to continue to do so to avoid congestion. It increases the risk of breast inflammation and promotes the access of germs and thus the development of bacterial mastitis.

Tags: Diseases menshealth organ systems