Assessing Breast Pain

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Assessing Breast Pain ~ Nancy Mohrbacher, IBCLC, FILCA Overview Possible causes of deep breast pain that is not mastitis The most likely causes Treatment options Many assume deep

1 Assessing Breast Pain ~ Nancy Mohrbacher, IBCLC, FILCA Overview Possible causes of deep breast pain that is not mastitis The most likely causes Treatment options Many assume deep breast pain between feedings that is not mastitis indicates ductal candidiasis Berens, et al. ABM Protocol #26. Breastfeed Med 2016; 11(2): Nancy Mohrbacher, IBCLC, FILCA 1

2 Research tells us Most likely causes of deep breast pain Symptoms & groups of symptoms provide clues to its cause CAUSES OF BREAST PAIN Yeast Yeast & Bacteria Bacteria Raynaud s phenomenon Other possible causes Bacterial infection 64% with moderate or severe nipple pain & nipple cracks (& babies <1 mo) cultured positive for Staph aureus Livingstone, et al. Can Fam Physician 1996; 42:654-59; N= Nancy Mohrbacher, IBCLC, FILCA 2

Bacterial infection Possible symptoms: Visible

Pain may increase, become intense Photo: The

J Hum Lact 1999; 15(3):241-46 Bacterial infection

burning breast pain & nipple vasospasm Vasospasm

Positive for S. aureus Livingstone, et al.

3 Bacterial infection Possible symptoms: Visible pus (exudate) Yellow scabs Slowed, no healing Pain may increase, become intense Photo: The Breastfeeding Atlas 9% Livingstone & Stringer. J Hum Lact 1999; 15(3): Bacterial infection & breast pain 5 of 84 had severe sore nipples, burning breast pain & nipple vasospasm Vasospasm associated with repeated nipple compression. Positive for S. aureus Livingstone, et al. J Hum Lact 1999; 15(3):241-46; N= Nancy Mohrbacher, IBCLC, FILCA 3

What resolved burning breast pain from infection & vasospasm? Treatment with cloxacillin (500 mg qid/10 days) Eliminating nipple compression Avoiding nipple exposure to cold Livingstone, et al.

Gynecol Obstet Invest 1996; 41:30-34 28 women with nipple pain (w/o mastitis) that often radiated into the breast 57% + S. aureus 0% + C. albicans Graves, et al.

4 What resolved burning breast pain from infection & vasospasm? Treatment with cloxacillin (500 mg qid/10 days) Eliminating nipple compression Avoiding nipple exposure to cold Livingstone, et al. J Hum Lact 1999; 15(3):241-46; N=84 Likely Cause of Ongoing Pain 52 lactating women with nipple &/or breast pain: 42% + S. aureus 19% + C. albicans Amir, et al. Gynecol Obstet Invest 1996; 41: women with nipple pain (w/o mastitis) that often radiated into the breast 57% + S. aureus 0% + C. albicans Graves, et al. Aust Fam Physician 2003; 32(7): Likely cause of breast pain Bacteria were found ~3x more often than yeast in the milk of mothers with deep breast pain We have prescribed fluconazole for 7 days to patients with deep, burning pain.the result has not been impressive. Thomassen, et al. Gynecol & Obstet Invest 1998; 46(2):73-74; N= Nancy Mohrbacher, IBCLC, FILCA 4

Misdiagnosis of breast pain 8 of 12 mothers with severe, throbbing

improvement Histories revealed all 12 suffered from Raynaud s

Pediatrics 2004; 113(4):e360-64 Breast pain occurred.

Pediatrics 2004; 113(4):e360-e364 Raynaud s phenomenon Episodic

5 Misdiagnosis of breast pain 8 of 12 mothers with severe, throbbing breast pain treated with repeated courses of diflucan saw no improvement Histories revealed all 12 suffered from Raynaud s phenomenon Anderson, et al. Pediatrics 2004; 113(4):e Breast pain occurred... In a cold environment After opening refrigerator door Anderson, et al. Pediatrics 2004; 113(4):e360-e364 Raynaud s phenomenon Episodic arteriospasm reducing blood flow to extremities Affects 20% of women of childbearing age More common with autoimmune disorders 2017 Nancy Mohrbacher, IBCLC, FILCA 5

Nipple compression can cause vasospasm (23%) Nipple blanches after feeding Intense, shooting breast pain between feedings Photo: Jack Newman, MD Buck,

pagename=vid-vasosp Raynaud s phenomenon Other triggers include Cold Nicotine Caffeine Emotional stress Vibrating machinery Medications: Ergot

6 Nipple compression can cause vasospasm (23%) Nipple blanches after feeding Intense, shooting breast pain between feedings Photo: Jack Newman, MD Buck, et al. Breastfeed Med 2014; 9(2):56-62 Vasospasm Raynaud s phenomenon Other triggers include Cold Nicotine Caffeine Emotional stress Vibrating machinery Medications: Ergot alkaloids, beta blockers, oral contraceptives, stimulants, pseudoephedrine Hale & Berens. Clinical Therapy in Breastfeeding Patients, 2010 McGuiness & Cording. J Hum Lact 2013; 29(1): Nancy Mohrbacher, IBCLC, FILCA 6

Prevention Breastfeed in warm area Use blanket, wear warm clothing Apply dry heat after nursing, don t air-dry nipples Massage nipple Avoid cold & other triggers Treatment Warmth, massage 30 mg

Clinical Therapy in Breastfeeding Patients, 2010 Incidence of Candida infections At 2 wk, 23/100 positive for Candida infection, 8/23 symptomatic By 9 wk, 20/23 (87%) symptomatic No controls tested

7 Prevention Breastfeed in warm area Use blanket, wear warm clothing Apply dry heat after nursing, don t air-dry nipples Massage nipple Avoid cold & other triggers Treatment Warmth, massage 30 mg sustainedrelease nifedipine 1x/day for 2 wk Vitamin B mg bid for 2 wk Hale & Berens. Clinical Therapy in Breastfeeding Patients, 2010 Incidence of Candida infections At 2 wk, 23/100 positive for Candida infection, 8/23 symptomatic By 9 wk, 20/23 (87%) symptomatic No controls tested positive or developed symptoms Morrill, et al. JOGNN 2005; 34:37-45; N= control women; 100 lactating Candida infection Possible symptoms in mother: Plaque Redness Slowed/no healing Pain may be intense Possible symptoms in baby: White plaques in mouth Diaper rash Photo: Jack Newman, MD Walker. The Nipple and Areola in Breastfeeding and Lactation, Nancy Mohrbacher, IBCLC, FILCA 7

8 Candida as a cause of breast pain What are the odds? Francis-Morrill, et al. J Hum Lact 2004; 20(3): Is ductal candidiasis even possible? Hale, et al. Breastfeed Med 2009; 4(2): % of physicians do not use lab testing to diagnose Candida Brent. Clin Pediatr (Phila) 2001; 40: Nancy Mohrbacher, IBCLC, FILCA 8

New growth medium: CHROMA-gar Candida (CAC) Hale study 18 asymptomatic controls 16 mothers with symptoms Nipple trauma Stabbing, burning breast pain

9 Why? No Candida growth with lactoferrin Morrill, et al. J Clin Microbiol 2003; 41(1): But new methods of diagnosing Candida growth measure (1 3)-β-ᴅ-Glucan (comprises 40% yeast s cell wall, very sensitive) New growth medium: CHROMA-gar Candida (CAC) Hale study 18 asymptomatic controls 16 mothers with symptoms Nipple trauma Stabbing, burning breast pain Painful breastfeeding with no other diagnosis Hale, et al. Breastfeed Med 2009; 4(2):57-61 Areola & nipple washed & rinsed well to remove infant saliva Then pumped milk to culture Hale, et al. Breastfeed Med 2009; 4(2): Nancy Mohrbacher, IBCLC, FILCA 9

Hale, et al. Breastfeed Med 2009; 4(2):57-61 Results No elevated levels of (1 3)-β-ᴅ-Glucan found in control or symptomatic moms whether or not iron was added to milk.

10 Hale, et al. Breastfeed Med 2009; 4(2):57-61 Results No elevated levels of (1 3)-β-ᴅ-Glucan found in control or symptomatic moms whether or not iron was added to milk. When pure Candida samples were added to the milk, it grew both with & without added iron It is possible that this symptom constellation represents a different pathology or multiple pathologies. Hale, et al. Breastfeed Med 2009; 4(2):57-61 Long-term nipple & breast pain Chart review of 64 mothers over 5 yr w/chronic breast &/or nipple pain that is not mastitis 50% of 60 cultured positive for pathogenic bacteria None grew Candida Eglash, et al. J Hum Lact 2006; 22(4): Nancy Mohrbacher, IBCLC, FILCA 10

Combination of S. aureus & C. albicans implicated in persistent, relapsing infections Symptoms Chronic nipple lesions do not heal Deep breast pain Tender breasts Eglash, et al.

11 Combination of S. aureus & C. albicans implicated in persistent, relapsing infections Symptoms Chronic nipple lesions do not heal Deep breast pain Tender breasts Eglash, et al. J Hum Lact 2006; 22(4): % had been treated for breast candidiasis 43% of this group reported antifungals had partly relieved their pain Eglash, et al. J Hum Lact 2006; 22(4): Antibiotics taken 3-6 wk; choice based on allergy, frequency preference, milk culture results & cost: Cephalexin 500 mg qid Dicloxacillin 500 mg qid Clindamycin 300 mg qid Erythromycin 333 mg tid Amoxicillin/clavulanate 875 mg bid Eglash, et al. J Hum Lact 2006; 22(4): Nancy Mohrbacher, IBCLC, FILCA 11

May take weeks of antibiotics to clear Chronic nipple lesions, deep breast pain, tender breasts Sendi & Proctor.

12 Average duration of antibiotic treatment: 5.7 wk Those with negative milk cultures improved at same rate Pain resolution: 94% Eglash, et al. J Hum Lact 2006; 22(4): Small colony variants of Staph Aureus Slow-growing, colony one-tenth the size Implicated in persistent, relapsing, antibiotic-resistant infections May take weeks of antibiotics to clear Chronic nipple lesions, deep breast pain, tender breasts Sendi & Proctor. Trends in Microbiology 2009; 17(2):54-58 The role of biofilm Coating grown to protect bacteria colony May be stimulated by saliva Highly resistant to topical & oral antibiotics Harriott & Noverr. Antimicrob Agents Chemother 2009; 53(9): Nancy Mohrbacher, IBCLC, FILCA 12

Amir, et al. Pregnancy and Childbirth 2011; 11:54 http.//www.biomedcentral.

nose, baby s nose & mouth Culture not widely available Oral anatomy not checked

BMJ Open 2013; 3(3) 79% reported nipple pain 54% breast pain, radiating & not 42%

13 Amir, et al. Pregnancy and Childbirth 2011; 11:54 http.// Birth to 8 wk 6 questionnaires 6 cultures from nipple, breast & nose, baby s nose & mouth Culture not widely available Oral anatomy not checked Breastfeeding not observed Amir, et al. BMJ Open 2013; 3(3) 79% reported nipple pain 54% breast pain, radiating & not 42% burning nipple pain Burning nipple pain & radiating breast pain can be caused by nipple damage Amir, et al. BMJ Open 2013; 3(3) 2017 Nancy Mohrbacher, IBCLC, FILCA 13

Weeks 2-8, significant relationship between pain & presence of Candida Link between Candida & pain independent of trauma or

BMJ Open 2013; 3(3) At 4 weeks, >50% with & without symptoms were colonized with Staph aureus clinicians should be cautious

BMJ Open 2013; 3(3) Comparing approaches Conservative (CTX) Improve latch Topical ointment Oral antibiotics (OTX) CTX failed

14 Weeks 2-8, significant relationship between pain & presence of Candida Link between Candida & pain independent of trauma or Staph aureus Pain of Candida Persistent, mild to severe Not relieved by nipple shields, pumping, heat Amir, et al. BMJ Open 2013; 3(3) At 4 weeks, >50% with & without symptoms were colonized with Staph aureus clinicians should be cautious about diagnosing infection (whether fungal or bacterial) in every woman with nipple damage. Amir, et al. BMJ Open 2013; 3(3) Comparing approaches Conservative (CTX) Improve latch Topical ointment Oral antibiotics (OTX) CTX failed Narrow-spectrum antibiotic chosen based on culture results & allergies/sensitivities Witt, et al. Breastfeed Med 2014; 9(2): Nancy Mohrbacher, IBCLC, FILCA 14

Latch fix reduced pain less With OTX, pain dropped quickly At 6-12 weeks, groups comparable CTX group had no more

15 Witt, et al. Breastfeed Med 2014; 9(2):63-72 Witt, et al. Breastfeed Med 2014; 9(2):63-72 Failed CTX if pain not reduced 5 days In those who failed CTX: Greater pain at first Latch fix reduced pain less With OTX, pain dropped quickly At 6-12 weeks, groups comparable CTX group had no more complications Pain levels low Breastfeeding rates equal Median length of antibiotics: 14 days Witt, et al. Breastfeed Med 2014; 9(2): Nancy Mohrbacher, IBCLC, FILCA 15

Assessment Baby s age Breast (lumps, firm areas, red streaks, fever) Nipple (trauma, pus, discharge) History (nipple trauma, color changes [fingers], breast surgery) Location of pain (one breast,

from breast surgery/injury Ruptured breast implant Galactocele Ductal ectasia Breast cancer In both breasts Engorgement (if baby 2 wk) Strong milk ejection Premenstrual pain Muscle strain from large

16 Assessment Baby s age Breast (lumps, firm areas, red streaks, fever) Nipple (trauma, pus, discharge) History (nipple trauma, color changes [fingers], breast surgery) Location of pain (one breast, both) Location & timing of pain Breast Pain Occurs During Feedings Between Feedings In one breast Nipple trauma Mastitis Infection (bacterial or fungal) Referred pain from elsewhere Internal scarring from breast surgery/injury Ruptured breast implant Galactocele Ductal ectasia Breast cancer In both breasts Engorgement (if baby 2 wk) Strong milk ejection Premenstrual pain Muscle strain from large breasts Mohrbacher. Breastfeeding Answers Made Simple, 2010 Referred pain from nipple trauma Mastitis Infection (bacterial or fungal) Referred pain from elsewhere Internal scarring from breast surgery/injury Ruptured breast implant Galactocele Ductal ectasia Referred pain from nipple trauma Raynaud s/vasospasm Muscle strain from large breasts Unusual causes of breast pain Strong milk ejection Premenstrual pain History of pain disorder (allodynia) Muscle strain from large breasts 2017 Nancy Mohrbacher, IBCLC, FILCA 16

Mammary Constriction Syndrome http://www.breastfeedinginc.ca/product.php?

the tightening of chest muscles leading to a lack of blood flow to the breast and nipples.

Edith Kernerman, IBCLC, The Pain Algorithm for Sore Nipples & Breasts prodid=42 Kerneman & Park.

17 Mammary Constriction Syndrome A still hypothetical and newly described set of symptoms that address breast and nipple pain caused by the tightening of chest muscles leading to a lack of blood flow to the breast and nipples. May be treated with Pectoral Muscle Massage. Edith Kernerman, IBCLC, The Pain Algorithm for Sore Nipples & Breasts Mammary Constriction Syndrome Kerneman & Park. J Hum Lact 2014; 30(3): Unusual causes of breast pain Referred pain from injury elsewhere Galactocele: Movable lump Ductal ectasia: Multi-colored discharge 2017 Nancy Mohrbacher, IBCLC, FILCA 17

Referred pain from nipple trauma 2. Bacterial infection 3. Raynaud s phenomenon 4.

18 Unusual causes of breast pain Internal scarring from breast surgery Ruptured breast implant Breast cancer Inflammatory Paget s disease Other types Deep Breast Pain: Most Likely Causes 1. Referred pain from nipple trauma 2. Bacterial infection 3. Raynaud s phenomenon 4. Fungal infection Overview Possible causes of deep breast pain that is not mastitis The most likely causes Treatment options 2017 Nancy Mohrbacher, IBCLC, FILCA 18

Questions? nancy@nancymohrbacher.com ~ www.nancymohrbacher.com www.naturalbreastfeeding.com Facebook.

19 Questions? ~ Facebook.com/NancyMohrbacherIBCLC Nancy Mohrbacher, IBCLC, FILCA 19

Systematic Review and Meta-analysis. Nothing to Declare

Systematic Review and Meta-analysis Nothing to Declare 1. Breast Fullness 2. Engorgement: Milk and/or Vascular 3. Plugged Duct w/ or w/out a Bleb 4. Galactocoele (Milk Cyst) 5. Non-Infectious Mastitis