Neonatal mastitis is an infection of the breast tissue that occurs in full-term neonates with a peak incidence in the third week of life. Females are affected more often than males in a 2:1 distribution.
Clinical Signs and Symptoms: Clinically, it manifests as swelling, induration, erythema, warmth, and tenderness of the affected breast. The ipsilateral axillary lymph nodes may be swollen. Approximately two-thirds have palpable fluctuance. In some cases, purulent discharge may be expressed from the nipple. Fever may be present in 25% of affected patients. Other systemic symptoms (irritability, decreased appetite, and vomiting) are less common but indicate a more severe infection if present. Bacteremia is rare.
Pathology: Staphylococcus aureus is the most common pathogen, causing 75% to 85% of cases. Rarely, gram-negative organisms or group B or D Streptococcus are the cause. If treatment is delayed, mastitis may progress rapidly with involvement of subcutaneous tissues and subsequent toxicity. In the initial stages, neonatal mastitis may mimic mammary tissue hypertrophy owing to maternal passive hormonal stimulation. Minor trauma, cutaneous infections, and duct blockage may precede this infection.
Management
- Immediate treatment is important to avoid cellulitic spread and breast tissue damage.
- In cases of mild cellulitis with no associated fluctuance in an otherwise well-appearing, afebrile neonate, culture of nipple discharge (if present) and oral antibiotics (antistaphylococcal penicillin or first-generation cephalosporin) with close outpatient follow-up are sufficient.
- Adjustment of coverage can be made once results of cultures or Gram stain are available, especially in the presence of gram-negative bacilli.
- In cases involving systemic signs of infection, rapid subcutaneous spread, or toxic appearance, a complete sepsis workup should be performed followed by hospitalization.
- If no organism is seen on Gram stain, a parenteral antistaphylococcal penicillin plus an aminoglycoside or cefotaxime alone should be used.
- In cases of palpable fluctuance, prompt surgical consultation should be obtained to assess the need for needle aspiration or incision and drainage.
- Conservative treatment with intravenous (IV) antibiotics often results in resolution of the fluctuance without surgical intervention.
- Recovery is usually within 5 to 7 days
Points to Remember:
1. Antibiotic choice should include coverage for S aureus.
2. Maintain a low threshold for initiating a sepsis workup and IV antibiotics.
3. Delays in the diagnosis and treatment may lead to distortion of the nipple, impairment of the secretory capacity of the breast, and reduction in the size of the adult breast
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