An Update on the Recognition and Management of Lactational Breast Inflammation

Emerging insights of Staphylococcus spp. in human mastitis

Human mastitis represents a prevalent and intricate condition that significantly challenges breastfeeding women, often exacerbated by pathogenic bacteria such as Staphylococcus aureus. A deep understanding of the interplay between human mastitis, the breast milk microbiome, and causative agents is imperative. This understanding must focus on the bacterium's virulence and resistance genes, which critically influence the severity and persistence of mastitis. Current methods for detecting these genes, including Polymerase Chain Reaction (PCR), 16S rRNA gene sequencing, shotgun metagenomic sequencing, multiplex PCR, whole genome sequencing (WGS), loop-mediated isothermal amplification (LAMP), CRISPR-based assays, and microarray technology, are vital in elucidating bacterial pathogenicity and resistance profiles. However, advanced attention is required to refine diagnostic techniques, enabling earlier detection and more effective therapeutic approaches for human mastitis. The involvement of Staphylococcus aureus in human infection should be a prime focus, especially in women's health, which deals directly with neonates. Essential virulence genes in Staphylococcus species are instrumental in infection mechanisms and antibiotic resistance, serving as potential targets for personalized treatments. Thus, this review focuses on Staphylococcusaureus-induced mastitis, examining its virulence factors and detection techniques to advance diagnostic and therapeutic strategies.

Imaging enigma in mastitis: A comprehensive study of multifaceted causes, clinical and radiological presentations

BACKGROUND

Mastitis is an inflammatory condition of the breast which represents an array of underlying etiologies encompassing both infectious and non-infectious causes. Exacerbating factors include endemic infections, lack of awareness and suboptimal breastfeeding practices. Neglected cases lead to prolonged morbidity, recurrent episodes, and complications such as abscess or sinus formation, resulting in permanent breast disfigurement. Its overlapping clinical presentation with breast cancer necessitates an integrated multidisciplinary approach for diagnosis and treatment.

OBJECTIVES

The primary aim was to investigate demographic, radiological, and histopathological characteristics of mastitis. Objectives included correlating radiological and histopathological findings, classifying mastitis by etiology, identifying the clinical and imaging patterns across diverse clinical settings to enhance the understanding of mastitis.

MATERIAL AND METHOD

This is a retrospective observational study, analysing the clinical, radiological, and histopathological data from 65 patients with mastitis between February 2023 and February 2024.

RESULTS

The study included 65 patients, aged 18 to 65 years, with breast pain as the most prevalent clinical presentation. Cases were classified as infectious (47.6%) and non-infectious (52%). Acute puerperal mastitis (26.15%) and granulomatous mastitis (30%) were the most common subtypes. The commonest mammographic finding was focal asymmetry. On ultrasound, infectious mastitis showed oedema with other inflammatory changes, including diffuse skin thickening and collections; while non-infectious mastitis typically presented as solitary or multiple breast masses (p < 0.001). Surprisingly, idiopathic granulomatous mastitis constituted the largest percentage amongst various histopathological causes of mastitis in our study.

CONCLUSION

An integrated multidisciplinary approach with understanding of the pathogenesis is imperative for prompt diagnosis and optimizing treatment strategies, thereby improving patient outcome. Radiological imaging is critical for diagnosis, evaluating disease extent, conducting guided interventions, and monitoring treatment response.

Astragalus polysaccharide alleviates mastitis disrupted by Staphylococcus aureus infection by regulating gut microbiota and SCFAs metabolism

Polysaccharides, key bioactive compounds derived from Chinese herbs, are increasingly recognized for their therapeutic potential in modulating gut microbiota to treat various diseases. However, their efficacy in alleviating mammary inflammation and oxidative stress and protecting the blood-milk barrier (BMB) compromised by Staphylococcus aureus (S. au) infection remains uncertain. As evidence for the gut-mammary axis grows, identifying natural prebiotic components that affect this axis is crucial. This study reveals that Astragalus polysaccharide (APS), the primary active constituent of Astragalus, effectively mitigates S. au infection in murine mammary glands, suppresses inflammatory responses, reduces oxidative stress, and restores BMB integrity. The involvement of APS in modulating gut microbiota was substantiated through gut microbial depletion experiments and fecal microbiota transplantation (FMT). Notably, APS uniquely enriched Ruminococcus bromii (R. bromii) in the gut, facilitating the metabolism of short-chain fatty acids (SCFAs), particularly acetate and butyrate, which are pivotal to APS's protective effects. Collectively, these results propose a novel therapeutic approach for the treatment and prevention of S. au-induced mastitis, leveraging APS and R. bromii as prebiotics and probiotics, respectively.

Is AMR in Dairy Products a Threat to Human Health? An Updated Review on the Origin, Prevention, Treatment, and Economic Impacts of Subclinical Mastitis

Background

Bovine mastitis is the most frequent and costly illness impacting dairy herds worldwide. The presence of subclinical mastitis in dairy cows has an impact on the decreased output of milk and milk quality, culling of affected cows, mortality rate, as well as mastitis-related treatment expenses, generating significant financial loss to the dairy industry. The pathogenic bacteria invade through the mammary gland, which then multiply in the milk-producing tissues causing infection, and the presence of pathogenic bacteria in milk is concerning, jeopardizes human health, and also has public health consequences. Intervention to promote herd health is essential to protect public health and the economy.

Results

This review attempts to provide an overview of subclinical mastitis, including mastitis in different species, the effect of mastitis on human health and its pathogenic mechanism, the prevalence and incidence of subclinical mastitis, and current preventive, diagnostic, and treatment methods for subclinical mastitis. It also elaborates on the management practices that should be followed by the farms to improve herd immunity and health.

Conclusion

This review brings the importance of the threat of antimicrobial resistance organisms to the dairy industry. Furthermore, this review gives a glimpse of the economic consequences faced by the farmers and a futuristic mastitis market analysis in the dairy industry.

Scavenger receptor B1 facilitates the endocytosis of Escherichia coli via TLR4 signaling in mammary gland infection

SCARB1 belongs to class B of Scavenger receptors (SRs) that are known to be involved in binding and endocytosis of various pathogens. SRs have emerging role in regulating innate immunity and host-pathogen interactions by acting in co-ordination with Toll-like receptors.Query Little is known about the function of SCARB1 in milk-derived mammary epithelial cells (MECs). This study reports the role of SCARB1 in infection and its potential association in TLR4 signaling on bacterial challenge in Goat mammary epithelial cells (GMECs). The novelty in the establishment of MEC culture lies in the method that aims to enhance the viability of the cells with intact characteristics upto a higher passage number. We represent MEC culture to be used as a potential infection model for deeper understanding of animal physiology especially around the mammary gland. On E.coli challenge the expression of SCARB1 was significant in induced GMECs at 6 h. Endoribonuclease-esiRNA based silencing of SCARB1 affects the expression of TLR4 and its pathways i.e. MyD88 and TRIF pathways on infection. Knockdown also affected the endocytosis of E.coli in GMECs demonstrating that E.coli uses SCARB1 function to gain entry in cells. Furthermore, we predict 3 unique protein structures of uncharacterized SCARB1 (Capra hircus) protein. Overall, we highlight SCARB1 as a main participant in host defence and its function in antibacterial advances to check mammary gland infections. Video Abstract.

Integrated breast massage versus traditional breast massage for treatment of plugged milk duct in lactating women: a randomized controlled trial

BACKGROUND

Plugged milk duct during lactation is a common problem in breastfeeding. Traditional breast massage (TBM) has been performed in Thailand with reasonable outcomes, but several follow-up sessions are often required. A new massage technique, the integrated breast massage (IBM), was subsequently developed. This study aimed to compare resolution time, reduction in mass size, and pain score after breast massage between the IBM and TBM techniques.

METHODS

This randomized controlled trial was conducted at the Lactation Clinic of the Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during February 2019-July 2020. Women presenting with acute plugged milk duct were enrolled and randomly allocated to the IBM or TBM/control groups. Mass size in square centimeters (cm2) was calculated by multiplying the perpendicular axes of the mass. Pain score was self-scored by participants using a numerical rating scale. Median time (95% confidence interval [CI]) to resolution of plugged milk duct was derived using Kaplan-Meier survival analysis. Intention-to-treat analysis was performed.

RESULTS

Eighty-four women (42 per group) were included. All enrolled study participants completed the study and were included in the final analysis. Twenty-six (61.9%) and 25 (59.5%) participants from IBM and TBM, respectively, had mass diameter > 5 cm. The median (interquartile range [IQR]) mass size was 30 (20-48) and 20 (12-14) cm2 in IBM and TBM (p = 0.05), respectively. The median (95% CI) time to resolution of plugged duct was 0 (not available) and 1 (0.47-1.53) day in IBM and TBM, respectively (p < 0.01). After the first breast massage, the median (IQR) size of mass reduction was 30 (20-48) and 10 (10-26) cm2 in IBM and TBM, respectively (p = 0.01). The median (IQR) reduction in pain score was 8 (7-8) and 6 (4-7) in IBM and TBM, respectively (p = 0.01). No participants developed skin bruising or hematoma after breast massage.

CONCLUSIONS

The IBM technique resolved plugged milk duct significantly faster, with significantly less pain, and with significantly greater reduction in mass size after the first massage compared to TBM.

TRIAL REGISTRATION

Retrospectively registered in the Thai Clinical Trials Registry on 25 September 2019 ( TCTR20190925001 ).

Construct validity and internal consistency of the Breast Inflammatory Symptom Severity Index in lactating mothers with inflammatory breast conditions

Background

Inflammatory Conditions of the Lactating Breast (ICLB) affect more than one in five lactating mothers, yet no fully validated outcome measures exist to aid clinicians in their patient-centred care of women with ICLB. The Breast Inflammatory Symptom Severity Index (BISSI) is an ICLB-specific clinician administered patient-reported outcome measure, currently used by Australian clinicians, who treat mothers with ICLB. To date the BISSI has undergone partial psychometric development. This study, therefore, aimed to undertake the next stage of psychometric development by determining the construct validity and internal consistency of the BISSI.

Methods

A retrospective audit was conducted on patient records of 160 mothers who were treated for ICLB, at a private physiotherapy practice in Melbourne, Australia. An electronic data capture tool was used to collate BISSI scores and associated ICLB assessment variables. Construct validity was determined through factor analysis and discriminant performance. Reliability was determined by assessing measures of internal consistency.

Results

Factor analysis established that BISSI items (n = 10) loaded on to four factors, Wellness, Pain, Physical Characteristics of Affected Area (PCAA), and Inflammation, which together, explained 71.2% of variance. The remaining item (‘Wellness/sickness unspecified’) did not load. Wellness, Pain, PCAA and Inflammation factors individually and collectively displayed the ability to discriminate symptom severity, as scores were significantly higher in mothers with high symptom severity (assessed via AUC close to or >0.7 and P value <0.005 for each factor). The BISSI demonstrated internal consistency with an overall Cronbach alpha of 0.742.

Conclusions

The BISSI has adequate construct validity, demonstrating behaviour consistent with theoretical constructs of inflammation severity, via its dimensionality and ability to discriminate symptom severity. The BISSI also has adequate internal consistency demonstrating reliability. Therefore, clinicians can have confidence that the BISSI is valid, the individual item scores are correlated, and the concepts are consistently measured.

Diseases and complications of the puerperium

BACKGROUND

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

METHODS

This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

RESULTS

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

CONCLUSION

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.

Benign Breast Disease in Women

BACKGROUND

Most clinical breast changes in women are benign; in only 3% to 6% of cases are they due to breast cancer. How- ever, there is a lack of up-to-date, evidence-based treatment recommendations for the various benign differential diagnoses.

METHODS

Selective literature search of PubMed from 1985 to May 2019, including current national (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [Association of Scientific Medical Societies in Germany]) and inter- national guidelines.

RESULTS

Mastalgia and fibrocystic changes are common (around 50% of all women over the age of 30). Fibroadenomas occur in 25% of women; they are the most common benign tumors of the breast and do not require treatment. With most benign breast changes the risk of dedifferentiation is very low. However, it is important in the differential diagnosis to distinguish between such benign changes and breast cancer or changes that carry a risk of malignancy. Complex cysts, for example, carry a risk of malig- nancy of 23% to 31%, papillary lesions 16% , and radial scars 7%. Where there is doubt, histological confirmation should be sought by means of percutaneous biopsy.

CONCLUSION

Benign breast changes can be definitively distinguished from malignant lesions through the selective use of avail- able diagnostic investigations and interdisciplinary collaboration. When lesions of uncertain malignant potential are found (B3 in the biopsy classification), complete excision is indicated. Prospective studies on the early diagnosis of breast cancer in lesions carrying a risk of malignancy are desirable.

Development of a novel patient focussed symptom severity index for use in assessing and treating inflammatory conditions of the lactating breast: a Delphi study

AIM

To investigate the content and face validity of a patient-reported outcome measure used by Australian physiotherapists in the assessment of inflammatory conditions of the lactating breast.

METHODS

Sixty one experts representing 'women who previously had inflammatory conditions of the lactating breast' (48%), 'clinicians' (38%) and 'academics' (8%) interested in women's health and 7% unidentified participants were invited to complete a three round Delphi study.

RESULTS

Ninety five percent of participants agreed that overall, the patient-reported outcome measure was appropriate for use in assessing and treating inflammatory conditions of the lactating breast. The item 'impact' was added to ensure the appropriate assessment of functional aspects of daily life. The item terminology used in the patient-reported outcome measure was simplified to 'pain', 'redness', 'hardness/tightness', 'temperature of affected area', 'sickness/wellness' and 'affected area. A clinician script was developed to ensure the patient-reported outcome measure has utility and consistency regardless of the experience of the women presenting with inflammatory conditions of the lactating breast or the clinician.

CONCLUSION

The resultant Breast Inflammatory Symptom Severity Index (BISSI) is a patient-reported outcome measure for use in the diagnosis and monitoring of clinical changes of symptoms associated with inflammatory conditions of the lactating breast including engorgement, blocked ducts and mastitis. It utilizes person-centred language and assesses symptoms considered important to both patient and clinician. The development of the clinician script facilitates utility regardless of the experience of either the woman with the inflammatory condition or the treating clinician.

Acupoint-tuina therapy promotes lactation in postpartum women with insufficient milk production who underwent caesarean sections

Breast milk is recognized and strongly recommended by the World Health Organization (WHO) as the optimal feeding for all babies. Breastfeeding is associated with better nutritional and non-nutritional outcomes when compared to formula feeding, and has proven health benefits to both infants and their mothers. This clinical research is to examine the feasibility and efficacy of Acupoint-Tuina therapy in treating postpartum women who underwent C-sections and suffered from insufficient milk production.The patients in the control group received standard medical care, while the patients in the Tuina group received Tuina therapy during the next 48 hours in addition to standard care, given once daily for 2 days. To evaluate the efficacy of Tuina therapy, patients of both groups were assessed for surface temperature of breasts, volume of breasts, volume of breast milk production, serum PRL level, and uterus recovery at various time points.Tuina therapy significantly increased the milk production when compared to the control group, for as much as 13-fold and 10-fold of that in the control group on the third and fourth postpartum days. In addition, Tuina therapy also significantly increased the full breast enlargement and the serum PRL level change, and decreased the breast surface temperature rise. Last but not the least, Tuina therapy also accelerated the post-surgery recovery of uterus.During the early postpartum days, Tuina therapy increases the milk production and promotes other physiological changes supporting lactation for postpartum women with C-section delivery and insufficient breast milk production. The novel intervention is warranted for further investigation and validation.

Breast abscesses in lactating women: evidences for ultrasound-guided percutaneous drainage to avoid surgery

BACKGROUND

Surgical incision with drainage remains the first-line therapy recommendation for breast abscesses greater than 5 cm.

PURPOSE

To determine recovery with ultrasound guided (US-guided) procedures for treatment of lactational breast abscesses without surgical incision for drainage.

MATERIAL AND METHODS

Institutional review board approval and written informed patient consent were obtained for this retrospective study. From May 1, 2009, to June 1, 2018, 92 consecutive women (mean age 30 years, range 18-45) with 105 abscesses were treated with oral antibiotics and US-guided percutaneous drainage under local anesthesia. A total number of 202 US-guided procedures were performed. Three techniques were used: needle aspiration (diameter 18 to 14G), pigtail catheter insertion (diameter 5 to 7F), and/or vacuum-assisted biopsy/aspiration (diameter 10G). When using needle aspiration or pigtail catheter, a saline irrigation of the cavity was performed according to pus viscosity.

RESULTS

The median diameter of abscesses was 4.5 cm (range 1-15), 82/105 (78%) were larger than 3 cm and 40/105 (38%) larger than 5 cm. US-guided management was successful for 101/105 (96%; 95% CI, (91-99%)) abscesses regardless the size. After the first round of procedures, 49/105 (47%) abscesses were recovered, 56/105 (53%) needed more than one drainage with a median number drainages of 2.6 (2-6). In 4/105 cases (4%), women underwent additional surgery under general anesthesia. By excluding abscesses which occurred in the weaning phase (n = 17), breastfeeding carried on for 68/75 (91%) women.

CONCLUSION

Unlike previous studies, US percutaneous guided management of lactational abscesses is effective even for abscesses greater than 5 cm and allows continued breastfeeding.

Breast infections - Microbiology and treatment in an era of antibiotic resistance

INTRODUCTION

Primary breast abscesses occur in <1% of non-lactating women, rising to 11% in women with lactational mastitis. In patients undergoing breast cancer surgery, the inflammatory response to post-operative surgical site infection (SSI) has been implicated in recurrence. Anti-microbial resistance increasingly hampers treatment in each group.

AIMS

Describe the demographic and predisposing characteristics of patients with primary breast abscesses and secondary infections, identify the microbial and antimicrobial patterns and formulate an evidence-based protocol for treating breast infections.

METHODS

Retrospective cohort study of all breast infections (primary and post-operative) treated at UHL from 2014 to 2017. Data collected from microbiology databases and patient records was analysed using Minitab V18.

RESULTS

537 cultures from 108 patients were analysed. 47 (43.5%) had primary abscesses, 12 (11.1%) were lactational and 49 (45.4%) were post-operative SSI. For primary infections, the mean age was 41.9 (±12.2) and reinfection rate 33%. For SSIs the mean age was 51.8 (±14.52) and reinfection rate 11.8%. Overall, 29.3% were smokers, 6.4% diabetic and 2.9% pregnant. 60 (43%) patients required radiological drainage and 2 (1%) surgical drainage. 57.5% had mixed growth. The most common isolate was Staphylococcus aureus; cultured in 16.7% of primary abscesses and 24% of SSIs. 13 empiric antibiotic regimes were prescribed before 26.4% of patients changed to 12 different targeted regimes.

CONCLUSION

Breast infections are frequently polymicrobial with a wide variety of organisms isolated, suggesting the need for broad spectrum coverage until culture results become available. Based on our local culture results, the addition of clindamycin to flucloxacillin would provide excellent empiric coverage for all categories of breast infection. An evidence-based treatment guideline is required and should be formulated in close collaboration with microbiology specialists.

Breast Infection: A Review of Diagnosis and Management Practices

Mastitis is a common condition that predominates during the puerperium. Breast abscesses are less common, however when they do develop, delays in specialist referral may occur due to lack of clear protocols. In secondary care abscesses can be diagnosed by ultrasound scan and in the past the management has been dependent on the receiving surgeon. Management options include aspiration under local anesthetic or more invasive incision and drainage (I&D). Over recent years the availability of bedside/clinic based ultrasound scan has made diagnosis easier and minimally invasive procedures have become the cornerstone of breast abscess management. We review the diagnosis and management of breast infection in the primary and secondary care setting, highlighting the importance of early referral for severe infection/breast abscesses. As a clear guideline on the management of breast infection is lacking, this review provides useful guidance for those who rarely see breast infection to help avoid long-term morbidity.

The microbiology and treatment of human mastitis

Mastitis, which is generally described as an inflammation of breast tissue, is a common and debilitating disease which frequently results in the cessation of exclusive breastfeeding and affects up to 33% of lactating women. The condition is a primary cause of decreased milk production and results in organoleptic and nutritional alterations in milk quality. Recent studies employing culture-independent techniques, including metagenomic sequencing, have revealed a loss of bacterial diversity in the microbiome of mastitic milk samples compared to healthy milk samples. In those infected, the pathogens Staphylococcus aureus, Staphylococcus epidermidis and members of corynebacteria have been identified as the predominant etiological agents in acute, subacute and granulomatous mastitis, respectively. The increased incidence of antibiotic resistance in the causative species is also a key cause of concern for treatment of the disease, thus leading to the need to develop novel therapies. In this respect, probiotics and bacteriocins have revealed potential as alternative treatments.

The Postpartum Maternal and Newborn Microbiomes

Biological and environmental changes to maternal and newborn microbiomes in the postnatal period can affect health outcomes for the mother-baby dyad. Postpartum sleep deprivation and unmet dietary needs can alter commensal bacteria within the body and disrupt gut-brain communication. Perineal injury and breast infections also change microbial community composition, potentiating an environment favoring pathogen growth. The gut microbiome refers to the collection of microorganisms working in harmony. Disruptions within the gut microbiome and gut-brain communication may lead to postpartum depression, a potentially devastating sequela. Postnatal newborn changes to the gut and skin microbiome materialize quickly after birth and are profoundly influenced by mode of birth, feeding method, and bathing and skin care practices. During the newborn period, infant microbiomes are highly vulnerable and susceptible to multiple influences. Maternal-newborn nurses have a valuable role in helping mothers and newborns promote healthy microbiomes. Factors that influence the rapidly changing postnatal microbiome of the mother and her newborn, and the role nurses have to positively influence immediate and long-term health outcomes are presented.

Breast Abscessed Cancer in Nonlactating Women in Tropical Environment: Radiological, Bacteriological, and Anatomopathological Features about 3 Cases

The association of breast cancer and abscess is rare in daily practice. The authors report a short series of 3 cases of cancer of the breast in nonlactating women presented as breast abscess, reviewing aspects in radiology (ultrasound and mammography), correlating them with the histopathology findings and the bacteriological profile of the isolated germs.

Lactational mastitis caused by Streptococcus lactarius

Human infections caused by Streptococcus lactarius have not been previously reported. In the present report, we describe a lactational mastitis caused by this organism. The infection occurred in a 28-year-old breast-feeding female, with a 10-days history of moderate pain on the right breast. The patient was cured after antibiotic treatment with levofloxacin for 21 days. Our case shows that S. lactarius should be considered as a cause of lactational mastitis. The introduction of molecular microbiology techniques can be extremely useful for knowing the implication of streptococci in lactational mastitis.

Chronic Mastitis, Mastalgia, and Breast Pain

Whereas the management of acute mastitis seems clear, there is little scientific evidence to support management of chronic mastitis/breast pain. This article reviews bacteriological findings, their possible meanings, and their use in clinical settings. Clinical experience, newer and more accurate microbiological techniques, and the growing knowledge about our metagenome have many insights to offer.

Severe lactational mastitis: particularities from admission

OBJECTIVE

to identify characteristics of women who have suffered severe lactational mastitis.

METHOD

a descriptive, retrospective, documentary, quantitative study was performed. Data were collected from patient records of 114 hospitalized women from January of 2009 to December of 2013. Data were analyzed by using descriptive statistics.

RESULTS

a higher percentage of severe lactational mastitis was found in young, primiparous women who had completed high school, who had no partner, and did not have a job; 96.5% of women had breast complications before admission and remained hospitalized an average of 4.4 days; at discharge, 23.7% of women had weaned their infants.

CONCLUSION

this study showed that severe lactational mastitis can cause great harm to the woman and the baby.

Invited review: Cessation of lactation: Effects on animal welfare

The forced cessation of milk production, or dry-off, is a routine management practice in dairy cattle, sheep, and goats. This practice initiates a dry period, during which the animal is not milked. Milking begins again after parturition. Most of the literature on the dry period has focused on how various drying-off strategies affect milk production and disease; little work to date has addressed how dry-off affects the overall welfare of the dairy animal. The first aim of this review was to present an overview of the importance of dry-off and how it is commonly achieved. Our review shows that much scientific progress has been made in improving health status between lactations. The second aim was to identify important gaps in the literature, of which 2 key research disparities have been identified. We find that much of the work to date has focused on cattle and very little research has examined dry-off in dairy sheep and goats. We also find a lack of research addressing how common dry-off methodologies affect animal welfare on more than just a biological level, regardless of species.

Six-Step Recanalization Manual Therapy: A Novel Method for Treating Plugged Ducts in Lactating Women

BACKGROUND

Plugged ducts are a common, painful condition in lactating women, but no standard treatment is currently available.

OBJECTIVE

This study aimed to evaluate the clinical efficacy of a newly established 6-step recanalization manual therapy (SSRMT) for treating plugged ducts.

METHODS

This observational study included 3497 lactating women with plugged ducts. The SSRMT comprised the following well-defined steps: (1) preparation, (2) clearing the plugged duct outlets, (3) nipple manipulation, (4) pushing and pressing the areola, (5) pushing and kneading the breast, and (6) checking for residual milk stasis. The response to the treatment was graded as I (complete resolution), II (marked improvement), III (improvement), or IV (no response).

RESULTS

Of the 3497 patients, the mean age was 26.7 years and 3284 (93.9%) patients were primiparas. Fever was present in 1231 (35.2%) patients. After a single SSRMT treatment, 3189 (91.2%), 173 (4.9%), and 83 (2.4%) patients achieved grade I, II, and III responses, respectively, with only 52 (1.5%) showing unresponsiveness. For the 308 (8.8% of total) non-grade I patients, a second SSRMT given 3 days later resulted in grade I, II, and III responses in 267 (7.6% of total), 28 (0.8% of total), and 13 (0.4% of total) patients, respectively, and none were absolutely unresponsive. No complications with clinical significance were observed.

CONCLUSION

Based on this large-scale clinical observation, SSRMT appears to be a useful, safe, low-cost treatment for postpartum plugged milk ducts.

Case-control study of risk factors for infectious mastitis in Spanish breastfeeding women

Background

The purpose of this study was to identify potential predisposing factors associated with human infectious mastitis.

Methods

We conducted a case–control study among breastfeeding women, with 368 cases (women with mastitis) and 148 controls. Data were collected by a questionnaire designed to obtain retrospective information about several factors related to medical history of mother and infant, different aspects of pregnancy, delivery and postpartum, and breastfeeding practices that could be involved in mastitis. Bivariate analyses and multivariate logistic regression model were used to examine the relationship between mastitis and these factors.

Results

The variables significantly- and independently-associated with mastitis were cracked nipples (P < 0.0001), oral antibiotics during breastfeeding (P < 0.0001), breast pumps (P < 0.0001), topical antifungal medication during breastfeeding (P = 0.0009), mastitis in previous lactations (P = 0.0014), breast milk coming in later than 24 h postpartum (P = 0.0016), history of mastitis in the family (P = 0.0028), mother-infant separation longer than 24 h (P = 0.0027), cream on nipples (P = 0.0228) and throat infection (P = 0.0224).

Conclusions

Valuable factors related to an increased risk of infectious mastitis have been identified. This knowledge will allow practitioners to provide appropriate management advice about modifiable risk factors, such as the use of pumps or inappropriate medication. They also could identify before delivery those women at an increased risk of developing mastitis, such as those having a familial history of mastitis, and thus develop strategies to prevent this condition.

Gradual cessation of milking reduces milk leakage and motivation to be milked in dairy cows at dry-off

The effects of gradual versus abrupt cessation of milking at dry-off in dairy cows are not well understood, but gradually reducing milk production in human mothers is known to reduce discomfort and milk leakage. This study compared the effects of abrupt versus gradual cessation of milking on milk leakage and dairy cow behavior. Holstein dairy cows were housed in groups of 6 and randomly assigned to either abrupt milk cessation (i.e., dry-off on d 0) or gradual milk cessation (i.e., skipped milkings beginning on d 0; dry-off on d 5). Four replicates were performed over time, for a total of 24 cows (mean ± SD; parity=2.3±1.2; milk production the day before d 0=24±5 kg/d). Intramammary antibiotic, internal teat sealer, and external teat sealant were administered at dry-off. Measurements were taken from d -3 to 8 relative to dry-off. Three periods were identified for behavior data: baseline (d -3 to 1), period 1 (abrupt cows dry, gradual cows milking; d 0-4), and period 2 (all cows dry; d 5-8). Lying time was recorded with data loggers. Video scan samples (5-min intervals) were used to measure feeding time and motivation to be milked (i.e., standing at the pen's exit gate). Milk leakage was monitored every 20 min during the 2-h period following the milking times of 0500 and 1500 h after complete cessation of milking (period 1 for abrupt vs. period 2 for gradual). Composite milk samples were taken before dry-off (d -1, 0, and 5) and at the start of the next lactation (colostrum, 24h and 7-10 d postcalving) to determine somatic cell score (SCS) and conduct bacteriological examinations in clinical mastitis cases. Regardless of treatment, dry-off resulted in reduced lying time [14.1 vs. 13.2h/d; standard error of the difference (SED)=0.2], reduced lying bouts (10.7 vs. 8.3 bouts/d; SED=0.2), increased lying bout duration (1.4 vs. 1.7h/bout; SED=0.03) and increased feeding time (5.0 vs. 5.9h/d; SED=0.2). Compared with baseline, the odds of standing at the gate increased for abrupt cows (period 1: odds ratio=6.2; 95% CI: 2.7-14.4; and period 2: odds ratio=5.2; 95% CI: 1.8-14.6). No increase in time spent standing at the gate was noted in gradual cows. Frequency of leakage was greater in abrupt versus gradual cows (75 vs. 27%). Although the gradual treatment showed an increase in SCS over the 5 d of reduced milking frequency, both treatments showed an increase in SCS at calving and both returned to pre-experiment levels within 7 to 10 d after calving. This work demonstrates that gradually reducing milking frequency in high-producing cows results in reduced time spent anticipating milking and reduced milk leakage after dry-off.

Ultrasound as a treatment of mammary blocked duct among 25 postpartum lactating women: a retrospective case series

OBJECTIVE

The purpose of this case series is to report the outcomes of 25 postpartum women who were experiencing difficulties with breastfeeding and were treated using therapeutic ultrasound.

METHODS

Case files of postpartum women who presented to a chiropractic clinic between 2005 and 2011 with difficulties with breastfeeding due to blocked ducts were identified.

RESULTS

Twenty-five cases were retrospectively identified of women who presented with a breast lump that was consistent with a blocked duct. Eight women experienced recurrent blocked ducts (5 had multiple episodes while nursing the same child; 3 women experienced episodes with more than 1 child). Patients had been treated with therapeutic ultrasound, receiving between 1 and 7 treatments (average, 3.3) to experience improvement in their presenting symptoms. A majority of the patients reported improvements in breastfeeding and symptoms after treatment. No adverse reactions were identified in the patient records.

CONCLUSION

For women reported in this case series, chiropractic management including ultrasound therapy was a beneficial treatment for women presenting with blocked ducts and difficulties breastfeeding.

Results of microbial testing exploring the etiology of deep breast pain during lactation: a systematic review and meta-analysis of nonrandomized trials

INTRODUCTION

Controversy over the etiology of deep or burning breast pain during lactation continues to persist, despite a long history of published studies and case reports. This article reviews the literature exploring the etiology of deep breast pain, summarizes the results, and identifies possible explanations for the controversies surrounding this disorder.

METHODS

A clinical query and a librarian-assisted search of MEDLINE were used to find articles published between 1896 and 2010. Inclusion criteria consisted of comparing microbial testing results from symptomatic and asymptomatic lactating women. Cases were restricted to those experiencing deep or burning breast pain when possible.

RESULTS

Prospective studies consisting of 1 unmatched case-control and 6 cohorts were found. Trials typically detected higher microbial levels in the milk or nipple(s) or both of symptomatic women, irrespective of the detection method or type and range of microbes (bacterial, yeast, or fungal) studied. Case milk samples were positively associated with finding Staphylococcus aureus (relative risk ratio [RR] 7.29; 95% confidence interval [CI], 3.25-16.36) or Candida (RR 8.45; 95% CI, 3.96-18.06). Moreover, recent reports about small-colony variants and biofilm-producing organisms may explain the atypical symptoms unique to this disorder.

DISCUSSION

In lactating women reporting deep breast pain, evidence consistent with infection is persistently found, and explanations exist for the disorder's atypical characteristics. Although lactating women with deep breast pain are more likely to test positive for Candida, the risk of testing positive for S aureus is also present. Thus, these women should have cultures done. Management options include treating immediately while awaiting results or waiting until results are available to guide treatment. With either approach, providers must consider the risk of falsely negative tests.

Breast inflammation: clinical examination, aetiological pointers

Red, hot, and painful breast inflammation can have a large number of causes. The history of the condition and clinical observations usually give a pointer to the aetiological diagnosis, which is based on the classic triad of clinical, radiological and histopathological examinations, and guide the choice of additional investigations for rapid therapeutic management of this breast emergency. In breastfeeding women, the cause is often mastitis or, more rarely, an abscess; in non-breastfeeding women, the problem may be mastitis or a periareolar abscess, inflammatory lesions sometimes with secondary infection, or more rarely a real abscess, regardless of a catalogue of various causes. In all cases, the possibility must be considered of inflammatory breast cancer.

Exclusive breastfeeding, maternal HIV disease, and the risk of clinical breast pathology in HIV-infected, breastfeeding women

OBJECTIVE

The objective of the study was to examine the relationship between breastfeeding patterns, markers of maternal human immunodeficiency virus (HIV) disease, and woman's breast pathology.

STUDY DESIGN

Secondary data analysis from a randomized breastfeeding trial including 947 HIV-infected women (n = 5982 visits) from breastfeeding initiation until 6 months postpartum; 1 month after breastfeeding cessation; or loss to follow-up or death. Generalized estimating equations assessed the effects of breastfeeding pattern and maternal HIV status on breast pathology.

RESULTS

One hundred ninety women (20.1%) had a breast problem; 86 (9.1%) had mastitis; and 31 (3.3%) had abscess. After confounder adjustment, nonexclusively breastfeeding women had an increased risk of breast problems (odds ratio, 1.98; 95% confidence interval, 1.33-2.95) and mastitis (odds ratio, 2.87, 95% confidence interval, 1.69-4.88) compared with exclusive breastfeeders. Women with a CD4 count less than 200 cells/μL tended to have an increased risk of abscess.

CONCLUSION

Nonexclusive breastfeeding significantly increased the risk of breast pathology. Exclusive breastfeeding is not only optimal for infant health but it also benefits mothers by reducing breast problems.

Serotonin transport and metabolism in the mammary gland modulates secretory activation and involution

CONTEXT

Serotonin [5-hydroxytryptamine (5-HT)] is an important local regulator of lactation homeostasis; however, the roles for the serotonin reuptake transporter and monoamine oxidase have not been known.

OBJECTIVE

The aim of the study was to determine whether drugs that impact 5-HT affect human lactation physiology.

DESIGN AND SETTING

We conducted laboratory studies of human and animal models and an observational study of the onset of copious milk secretion in postpartum women at a university medical center.

PARTICIPANTS

We studied women expecting their first live-born infant; exclusion criteria were: referred to the medical center for another medical condition, known contraindication to breastfeed, and less than 19 yr of age and unable to obtain parental consent.

INTERVENTION(S)

The mothers were interviewed. The cell and animal studies consisted of a variety of biochemical, pharmacological, and genetic interventions.

MAIN OUTCOME MEASURE(S)

The human subjects outcome was prevalence of delayed onset of copious milk secretion. The cell and animal outcomes were physiological and morphological.

RESULTS

Inhibiting serotonin reuptake in mammary epithelial cells altered barrier function, and the effects were amplified by coadministering a monoamine oxidase inhibitor. Direct delivery of fluoxetine by slow-release pellets caused localized involution. TPH1 knockout mice displayed precocious secretory activation. Among a cohort of 431 women, those taking SSRI were more likely (P = 0.02) to experience delayed secretory activation.

CONCLUSIONS

Medications that perturb serotonin balance dysregulate lactation, and the effects are consistent with those predicted by the physiological effects of intramammary 5-HT bioactivity. Mothers taking serotonergic drugs may need additional support to achieve their breastfeeding goals.

Toward a clarification of the concept of mastitis as used in empirical studies of breast inflammation during lactation

The objective of this study is to clarify use of the term mastitis in empirical studies of lactational mastitis. Eighteen articles published between 1998 and 2008 were critically analyzed, and a concept clarification of the term mastitis was carried out. Four articles suggested that mastitis was an infection, 4 made no mention of the etiology of symptoms, and 10 articles described mastitis as an inflammation or an infection. Eight studies made no use of distinctions between milk stasis, noninfectious mastitis, and infectious mastitis. Bacterial cultivation was used in 5 articles, and 1 article measured leukocytes and C-reactive protein. Several different causes were cited. Antibiotics were suggested as appropriate treatment in 4 articles. Use of the concept of mastitis in empirical studies remains inconsistent and may do so until the etiology of symptoms is understood. Understanding is also needed as to why some women who present with symptoms suggesting septic reaction recover without antibiotic therapy.