How is Swimmer’s Itch Diagnosed?

Patient Presentation
A 4-year-old male came to clinic with a pruritic rash for 24 hours. He had been swimming in the local freshwater lake over the weekend. His mother had tried calamine lotion and over-the-counter strength hydrocortisone cream but said that “he just can’t stop itching.” The rash started on his legs but soon involved the area where his swimsuit had been. She denied any new soap, lotions, sunscreens, insect repellents or other new products. They were frequent users of this lake which was known to have swimmer’s itch and she said, “he just lives in the lake when we are there.” The mother said that she was also starting to itch around her ankles that morning. The past medical history was non-contributory.

The pertinent physical exam showed a healthy male who was rubbing his legs and groin. His vital signs were normal with growth parameters in the 50-90%. The rash was 2-3 mm macules with most having a papular component but no vesicles. The lesions were grouped especially in flexural areas of the ankles, knees, groin and buttocks. He had some distinct excoriations and some generalized erythema of the groups but it was difficult to tell if there was real erythema or it was secondary to rubbing. The mother’s ankles did not have any distinct lesions but did have general erythema because of her rubbing them.

The diagnosis of swimmer’s itch was made. The pediatrician recommended using an antihistamine and prescription strength topical hydrocortisone to help with the pruritis. “This usually takes a few days to go away but I think the medicines should help him be more comfortable. Swimmer’s itch often gets worse with more exposure so I would try to keep away from the lake if you can and swim elsewhere. If you go there, it helps to wash off right away and change clothes, so the bugs that cause this have less chance to get into his skin,” the pediatrician advised.

Discussion
Cercarial Dermatitis (CD) is known by many names throughout the world, but is commonly known as swimmer’s itch. It is a water-borne, non-communicable infectious disease that is caused by the larval stage (cercariae) of parasitic schistosomatid flukes. The cercariae causes an allergic maculopapular skin rash in humans that is usually self-limited (usually 4-10 days) but can cause problems for up to 20 days.

CD parasites are considered an emerging disease because of the increased distribution of the problem across the globe. Different parasite species cause the problem. In a normal life cycle that occurs mainly in fresh water but also brackish water, schistosome eggs invade various species of aquatic snails that act as an intermediary hosts. Within the snails, the schistosome eggs develop into schistosome cercariae. The schistosome cercariae migrate from the snail back into the water. In the water the schistosome cercariae encounters birds or mammals which are their definitive host. The cercariae penetrate the skin of the bird or mammal and travel within the host to a definitive organ (which depends on the species) where they develop into schistosome flukes. The schistosome flukes produces eggs which leave the definitive host usually through the intestinal tract usually, but occasionally through the bladder and urinary system. The schistosome eggs then start the cycle all over.

The usual intended definitive hosts are avian, especially waterfowl. Many different varieties of aquatic snails act as the intermediary host and of the more than 100 different schistosome species, 70% can cause CD. One of the most common species which causes CD is Trichobilharzia. Humans are incompatible species and are simply affected bystanders.

CD occurs in the warm weather when snails and bathers have their height of activity. Slow moving water, water near the edge of the water body, and being in the exposed water for longer increases the risk of acquiring CD. Children, especially 5-9 year olds, who play near the water’s edge for long periods of time have increased risk. It also appears that the children’s skin is more sensitive. The risk can be decreased by swimming in places where definitive hosts are not present or are present in fewer numbers, swimming farther out from the water’s edge especially in faster moving water, not swimming for long periods of time, and washing off and changing clothes after the potential exposure. Environmental mitigation includes drug treatment of definitive hosts, drug treatment of snails or manual removal of snails from the water. Use of waders, impermeable gloves and other protective clothing is a must for some recreational or professional uses.

Learning Point
The cercariae penetrate into human skin. If it is the initial contact, the cercariae may not cause a rash but can cause allergic sensitization. With subsequent exposure, there can be a prickling feeling with entry of the cercariae and then the rash becomes extremely pruritic. With recontact, a small macular-papular rash (1-2 mm initially) centered around the entry point of the cercariae happens within 12-48 hours. The macules can remit or become larger and vesicles can form on top of the papules. There can be surrounding erythema of the rash area. Pustules can occur if there is bacterial superinfection and pigmented spots can persist after resolution of the papules. The rash usually resolves within 4-10 days but can last for up to 20 days. Acute systemic reactions such as generalized limb swelling, nausea, diarrhea and fever can occur with subsequent exposure. The diagnosis is usually clinical-based but if needed, the organism can be identified on skin biopsy. Criteria include contact with water, rash appearance within 12-48 hours of exposure, and lesions on the body only where the water was in contact. Treatment of the rash is usually with antihistamines and/or topical steroids. The differential diagnosis includes insect bites, contact dermatitis, bacterial dermatitis, and skin reactions to larval cnidarians such as sea anemones or thimble jellyfish (if in appropriate location).

Questions for Further Discussion
1. What other parasites affecting humans are water-bourne?
2. What do you recommend for summer safety?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Parasitic Diseases and Water Safety (Recreational).

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Cercarial Dermatitis or Cercariosis: What’s in a Name?
Morley NJ. Trends Parasitol. 2016 Feb;32(2):92-3.

Pinto HA. Cercarial Dermatitis’ and ‘Cercariosis’: Very Broad Terms.
Trends Parasitol. 2016 May;32(5):351-2.

Horak P, Mikes L, Lichtenbergova L, Skala V, Soldanova M, Brant SV. Avian schistosomes and outbreaks of cercarial dermatitis.
Clin Microbiol Rev. 2015 Jan;28(1):165-90.

Kolarova L, Horak P, Skírnisson K, Mareckova H, Doenhoff M.
Cercarial dermatitis, a neglected allergic disease.
Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Long Do Concussive Symptoms Last?

Patient Presentation
An 11-year-old male came to clinic approximately 20 hours after falling off some school playground equipment. The fall was witnessed by adults but not the parent. The parent was told the child fell approximately 4 feet onto a wood-chip covered surface but hit his head more than once. The adults got to him quickly and did not report loss of consciousness. He says he remembers playing and being picked up by the adults, but not actually hitting his head. His mother took him home and said that during the evening he seemed quieter, tired and ate less. He complained of a headache and she gave him some acetaminophen. In the morning, his mother had to awaken him but he woke up easily. He complained of continued top of his head and frontal headache without radiation. He held his left eye closed because “otherwise I see 2 of things and I don’t like it.” He also complained of light and noise sensitivity. He also had some problems walking but his mother wasn’t sure if it was his balance or because of his eyes. She reported that he seemed to have his normal personality but was tired and wanted to rest throughout the day. The review of systems was negative for any memory loss, or emesis/nausea.

The pertinent physical exam showed a healthy appearing male who answered questions easily and without delay. His vital signs were normal including a blood pressure of 98/56. Visual acuity was 20/30 with each eye and was 20/20 with both eyes. He had a small contusion along his forehead hairline and he reported that his headache was centered around this spot without much radiation. He consistently would close his left eye throughout the examination. His pupils were 3 mm, symmetric and responded appropriately to light and accommodation. He complained of light sensitivity but when visual fields were checked with decreased ambient lighting they were normal for individual eyes and when tested together. He complained of seeing 2 of everything. His retina exam was brief, but discs appeared sharp on partial exam. Neurologically his cranial nerves were intact with normal DTRs bilaterally. He was slower with rapid alternative movements of his hands, and had some past pointing with finger to nose test. Romberg was positive when he closed his eyes and he was not able to do a tandem gait. His gait was normal but slower with his eyes open. He had no balance issues when sitting.

The diagnosis of a concussion was made, but because of the onset after the event of the visual symptoms and the consistent closing of one eye, the pediatrician contacted the neurologist. The neurologist felt that this was consistent with concussion symptoms but felt that he should be seen by ophthalmology and themselves the following day. He was sent home with head injury and strict brain rest instructions.

The patient’s clinical course showed that he still had some double vision and light sensitivity the next day but it was improving and ophthalmology did not see any structural problems. The family reported to neurology that his headache was improving and he was less fatigued but still was sleeping more. On examination they found similar balance problems but his mother said they were improved from the previous day.

After one week of brain rest, followup with the pediatrician showed resolution of all symptoms but he still was fatigued and sleeping more. His mother said that he seemed to take longer to do some activities. The pediatrician recommended slow reintroduction to activities and school and followup in another week which he did not come for. At his well child appointment 3 months later, his mother said that he got better so she didn’t bring him to that appointment.

Discussion
Concussion as defined by the International Conference on Concussion in Sport in 2012 is “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.” It results in quick onset of signs and symptoms of physical and cognitive impairment. Concussion is sometimes referred to as mild traumatic brain injury (TBI) as mild TBI refers to “…concussions that are generally not life threatening despite the potential for short-term disability and serious ongoing sequelae.” Concussion symptoms are usually categorized as:

  • Cognitive – confusion, difficulty remembering, difficulty thinking or concentrating, mentally foggy, delayed motor or verbal responses or “feeling slow”
  • Emotional – irritability, volatility, nervous, depression or sadness
  • Physical/somatic – headache, dizziness, balance problems, nausea/emesis, blurry vision, light sensitivity, sound sensitivity
  • Sleep disturbance – increased sleep duration, prolonged sleep latency, drowsiness

Headache is the most commonly reported initial symptom (93%) followed by dizziness and confusion.

Concussion is a clinical diagnosis based on reported symptoms, mental status examination and physical examination.

Learning Point
The duration of concussive symptoms are very individual. A 2015 systemic review and meta-analysis of high school and collegiate athletes found that in general high school athletes report more physical symptoms and cognitive problems than collegiate athletes. High school athletes compared to college athletes report slower recovery for physical symptoms (15 days vs 6 days) and for cognitive recovery (7 days vs 5 days). Especially as the cognitive recovery seems to be about the same for both groups, collegiate athletes may be underreporting their physical symptoms deliberately (because wanting to return to play or pressure to return to play) or are not attributing the symptoms to the concussion.

A 2014 study of the post-concussion symptom duration of 280 teenagers and young adults ages 11-22 years (median 14 years), who came to the emergency room within 72 hours of the concussion, found that initially patients presented with headache, dizziness, fatigue and taking longer to think, but in the followup period new symptoms developed especially cognitive and emotional symptoms including sleep problems, fatigue, forgetfulness and frustration. Visual symptoms were initially reported and occurred after initial assessment included blurry vision (32% and 5.4%), double vision (13.2% and 2.1%) and light sensitivity (42.5% and 10.7%). For all symptoms, 77% had some symptoms on day 7, 32% on day 28 and 15% on day 90. The median days for all symptom duration was 13 days. For all symptoms evaluated the median days of symptoms duration was 14 or less with the exception of sleep disturbance and irritability which was 16 days.

So, many patients have resolution of all symptoms by 2 weeks, but there will be some patients who continue to have some symptoms even several weeks later. Cognitive symptoms were often present initially, developed later in other patients and were more likely to last longer.

Some risk factors for prolonged concussion recovery time include age < 18 years, prior history of concussions, duration of symptoms with those concussions, timing of the concussions relative to each other and the current incident, having migraine headache, depression, attention deficit disorder, learning disabilities and sleep disorders.

Questions for Further Discussion
1. How is acute concussion managed? When can an athlete return to play? When can a child return to learning? For a review click here.
3. How are prolonged concussive symptoms managed?
4. What screening tools can be used to help screen for concussion?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Concussion

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Consensus statement, SCAT3. Br J Sports Med 2013;47:5 259.

Consensus statement, Child SCAT3, Br J Sports Med 2013;47:5 263.

Eisenberg MA, Meehan WP 3rd, Mannix R. Duration and course of post-concussive symptoms. Pediatrics. 2014 Jun;133(6):999-1006.

Williams RM, Puetz TW, Giza CC, Broglio SP. Concussion recovery time among high school and collegiate athletes: a systematic review and meta-analysis. Sports Med. 2015 Jun;45(6):893-903.

McGinley AD, Master CL, Zonfrillo MR. Sports-Related Head Injuries in Adolescents: A Comprehensive Update. Adolesc Med State Art Rev. 2015 Dec;26(3):491-506.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Can Parents Do To Help Their Junior High or High School Student Start Off Right?

Patient Presentation
A 12-year-old male came to clinic for his health maintenance examination. He was going to start junior high school in the fall and was excited to talk about trying out for the cross country and track teams. “There’s going to be a lot more kids though so I don’t know if I’ll get to run,” he offered. The past medical history showed a healthy male with no previous athletic injuries.

The pertinent physical exam showed a happy young tween with normal vital signs and growth parameters. His examination was normal. The diagnosis of a healthy male was made. The pediatrician discussed that many sports and other activities at the junior high level were open for all students to be a part of. “Oh, that’s good because I want to be with my friends. I just don’t know if I will be good enough,” the tween said. “You just start doing some running now – a little at a time every day and you’ll be surprised how much you will improve,” the pediatrician offered. He went on, “I also recommend that you practice learning to use a combination lock this summer too because you will have to do that at school too. Sounds like you will have some friends to have lunch with when you start but try to make some new friends too in class and on the teams. There’s always room for more friends in your life. And if you have problems with your classes, just remember to talk with your Dad or with your teachers. They are there to help you.”

Discussion
Starting junior high and high school are big moments for teenagers. They are milestones on the way to adulthood. They require the student to take additional steps toward independence. The schools are usually physically larger at each step and require the student to interact with more teachers, school personnel and other students. Students start to independently engage within the larger community by participation in after school activities such as sports, music, volunteering, etc. Junior high and high school are excellent times to try different activities. Before junior high, many adult relationships the students have are extensions of the parents or families’ relationships. The students in junior high and high school now have more opportunities to create their own relationships with adults on a separate and equal basis.

Learning Point
Ways that parents can help their teenager start junior high, senior high or even a new school year include:

  • Location
    • Often transitioning to junior high and high school involves changing school buildings. This may also involve taking new or different modes of transportation such as the bus or maybe driving to school. The bus route should be reviewed including the times and location of pickup and dropoff. Students who drive to school should practice their route including parking locations and any specific local parking rules. Plan for alternatives if the school day starts late or ends early. What will the student do?
  • School supplies and clothing
    • Schools will often have a list of needed school supplies but often the list changes once the student is in the classroom. Consider purchasing a limited amount of general supplies before school. Similarly clothing should make the student feel comfortable and is serviceable. Know the school dress code rules and allow the student to choose the clothes they want to wear within reason. Consider purchasing a limited amount of clothing before school and then seeing what might be more fashionable and accepted after the school year begins and purchasing other clothing then.
  • Combination locks
    • The idea of not being able to open their locker can be scary for many students, especially for new junior high students. Sometimes students are so afraid that will carry all their books and belonging and become “walking lockers.”Getting a combination lock and practicing before school starts can help students. After a locker is assigned, having the student open the locker a couple of times with a parent or older sibling available also helps with this fear. Remember that students often have more than one locker that they use including their regular locker, gym locker, athletic locker, and musical instrument locker. It’s not surprising that this can be a little overwhelming for them even at the high school level with many other things to remember.
  • Friends
    • Having a “buddy” for the first few days of school can help with the transition as the student often feels more comfortable with a friendly face and knows they won’t be “alone” for lunch, the bus ride, or during class.
    • Students should be encouraged to continue good relationships with their friends but also to try to meet new friends. If the student is afraid they won’t have friends asking questions such as “Do you know anyone from your old school?” is a good starting place. “I know you had friends at your old school. What do you think could happen if you didn’t make new friends?” or “What made those friendships successful?” can help the student think about the situation and what they could do to help themselves.
  • Multiple classes and being late to class
    • Taking a tour of the school building to learn the location of classrooms, lockers, restroom and lunch room helps to get the student off to a good start.
    • Once classes are assigned, walking around the school to find the classrooms will help with the worries that many students have about getting to class on time. An older student often has many tips to get from class to class effectively.
    • If the schedule changes from day to day, going over the schedule the night before can be helpful especially at the beginning of the year, especially for junior high students.
  • Increased Academic Work
    • As students advance though their school career, the expectations also increase. They have to master the content but also have to learn from multiple teachers who may have different teaching styles than they are used to.
    • Many teachers have syllabi that give an overview of their classroom expectations for homework, grading, how to contact the teacher and how to get extra help if needed. Reading the syllabi, by both students and parents, can help the student to know more about the class at the beginning of the year. Keep it for a reference for when the student needs to get extra help or to contact the teacher. Students should be their own advocate and contact the teacher themself at first. If there is a problem then the parent can work with the student to help contact the teacher and get the necessary help.
    • Identifying a “study buddy” for each class is a great way for students to have someone to contact if they miss an assignment or to clarify an assignment.
    • Create a homework place for the student to do their homework that is well lit, comfortable and has necessary supplies close at hand. Students have been sitting in desks all day so some student will want to work on their bed or on the floor. This is okay if they are efficient and able to complete the work in a reasonable amount of time and learn the material. Distractions such as televisions, computers, and phones should be kept out of the homework space if possible. They can be used as a “study break” for a short period of time while homework is being completed. Internet use for school is common and it is recommended that all Internet use occur in a common place of the home such as the kitchen so parents can appropriately monitor its use.
    • A general rule for homework is about 10 minutes per year of school. While there will be daily differences, if the student is consistently spending a long time doing homework, talk with them about if they are having problems organizing the work, efficiently completing the work, problems understanding the work in general or in a specific subject. This may help the student and the parent understand if there is a time management or prioritization problem or if the students needs additional help in a particular subject or even has an underlying attention or learning problem.
  • Time management and school planners
    • Using time wisely is one of the most important skills that junior high and high school students need to learn.
    • Using a paper or electronic school planner or calendar (or even a small notebook) is a must for students. Recording daily homework assignments, longer-term project deadlines and school and home activities in one place helps them to learn to plan and prioritize their time wisely. This is a necessary skill and parents may need to help them to learn to use their planner.
    • As different people like to record this information in different ways, different planners can be tried. Paper planners are inexpensive and easy to use, but may not be in the right location all the time or can be lost. Electronic planners are easily backed up so are less likely to be lost. An electronic student planner can be linked to a teacher’s electronic class calendar so the information doesn’t have to be copied. Electronic planners require Internet access though and may not be available during the school day or at other times.
    • Whatever planner is used it should be readily available and easy for the student to use. Parents can help the students by showing or reviewing with students reviewing different ways to use a planner.
  • Setting priorities
    • Balancing busy schedules can be difficult for students.
    • Students need to remain healthy which means that physiologic needs should come first when planning their general daily schedule. Regular sleep (and enough sleep ~8-10 hours/day) and meal times should be the first priority for planning a regular daily schedule. As school is the student’s occupation and is a large component of their day, planning the school day and homework is usually the next priority. After this students should schedule family, extracurricular and other personal time as a third priority. While there will be day-to-day and week-to-week variations, a general daily schedule helps students prioritize the important parts of their days in a healthy way.
    • Parents can help the students by enforcing regular sleep and eating schedules, and helping students learn to prioritize all of their daily activities.
    • Extracurricular activities at the junior high levels often allow all or most students to participate. At the high school level, some activities, such as sports, may require tryouts or auditions. Usually there are many other activities for students to participate in, if they do not “make the team” in one activity.
  • Technology
    • Technology can improve the educational opportunities for students in and out of the classroom. It can also improve communication among teachers, coaches, parents, peers and students. Technology has to be used wisely though.
    • Technology and the learning environment need to both be respected. In general, computers, phones and other devices should be put away while in class and doing homework. Study breaks or passing time between classes usually are appropriate opportunities to use the devices. Expectation for social media use should be discussed and rules enforced by parents and teachers. Student often do need access to a cellphone (their own, parent or peer) as many schools do not have pay phones and offices are locked at off times. Students can be in contact with parents about after school activities and to check in about their location at home or school. Students should remember that having and using a cellphone or other device is a privilege and with that goes the responsibility of appropriate use.
  • Communication
    • Teenagers are trying to become adults during their adolescent years. They may not communicate the way they did as school agers or as an adult would. Parents should continue to talk with their teenager, even if answers are not as forthcoming and discussions are short. Asking open-ended questions can often be helpful because it allows the students to better describe how their day was, or what they did in class. Parents do not need to offer solutions to every problem a students has as often students, like adults, often just need a person to talk to about an issue. Listening by parents should not be underestimated.
    • Parents should keep listening and talking with their student even if they think the student isn’t listening. Family meals or even a beverage break can be good times to talk with students. Car rides may not be a good time as students are often tired after school and activities. It may also be the first time since the morning that there has been some quiet too because school is a noisy place.
  • Stress
    • All people have some type of stress in their life and teenagers are no different. Being upset about not understanding the English assignment, hearing a nasty comment by another student, messing up on the choir audition or just even forgetting a school supply can cause stress. Students who are doing well in school, have several friends they talk about, are able to eat meals regularly and getting sleep regularly probably are doing well. Students who may not be handling their stress well may need professional help. Talking with the school guidance counselor, medical professional or spiritual counselor may offer some ideas about how to help the student.
    • Indications that students may not be doing well include:
      • Poor sleep pattern, poor eating pattern or poor grooming
      • Personality changes such as being more angry or violent, being withdrawn, moodiness, or irritability
      • Having anxiety or panic attacks or sadness or depression or becoming violent
      • Loss of friends or abrupt change in the group of friends
      • Any indications the student may be using tobacco or drugs
      • Physical symptoms such as headaches, abdominal pain or chest pain
      • Constantly talking about being hassled or hurried
    • It is understandable that some of these signs occur for short time periods such as around final exams or other stressful times. But if they occur most days, are getting worse, or extend beyond a reasonable time period, students usually should get some professional help.

Questions for Further Discussion
1. What other advice would you offer to students starting junior high or high school?
2. How can young adults keep themselves safe at college? A review is here.

3. What does a child need to be ready to go to kindergarten? A review is <a href="https://pediatriceducation.org/2015/08/03/what-does-a-child-need-to-do-to-be-ready-to-go-to-kindergarten/

“>here.
4. What does the literature say about the best school starting times for junior or senior high school students?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: School Health

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

GreatSchools.org. Getting Ready for Middle School. Available from the Internet at http://www.greatschools.org/gk/articles/getting-ready-for-middle-school/ (rev. 2016 cited 8/31/16).

Secondary Sara. 5 Ways to Prepare Your Students for Middle School. Available from the Internet at http://minds-in-bloom.com/2015/02/5-ways-to-prepare-students-for-middle.html (rev. cited 8/31/16).

Scholastic. Preparing for Middle School. http://www.scholastic.com/parents/resources/article/what-to-expect-grade/preparing-middle-school (cited 8/31/16).

Scholastic. Kids’ Biggest Middle School Fears. Available from the Internet at http://www.scholastic.com/parents/resources/article/back-to-school/kids-biggest-middle-school-fears (cited 8/31/16).

Scholastic. Making the Transition. Available from the Internet at http://www.scholastic.com/parents/resources/article/back-to-school/making-transition (cited 8/31/16).

HealthyChildren.org. Helping Your Teen Succeed in School. Available from the Internet at https://www.healthychildren.org/English/ages-stages/teen/school/Pages/Helping-Your-Teen-Succeed-In-School.aspx (rev. 11/21/15, cited 8/31/16).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Causes Neonatal Mastitis?

Patient Presentation
A 15-day-old full-term female came to clinic with left breast swelling. Her mother said that the baby had some symmetric breast swelling after birth but that it had been resolving. She noticed the left breast swelling about 12 hours before and said that it seemed tender as the infant fussed more when it was touched. She denied any nipple discharge, fever, irritability, or feeding problems. There were no sick contacts. The past medical history showed a full-term infant born after an uneventful pregnancy and delivery. Maternal laboratories were negative and the infant received all routine care after delivery. She was exclusively breastfeed.

The pertinent physical exam showed an alert and responsive infant. Her weight was 3.960 kg (50%), length of 49 cm (25%) and head circumference of 34.5 cm (50%). She was afebrile. Her anterior fontanelle was soft and non-bulging. She had mild neonatal acne on both cheeks. Her right breast had a 1 cm breast bud that was palpable without overlying erythema. Her left breast had overlying erythema of a 3 cm symmetric mass centered under the nipple. The nipple was slightly retracted and purulent fluid was expressed. The area was warm. No axillary lymph nodes were palpable. The infant cried with palpation of the area but easily calmed. The diagnosis of neonatal mastitis was made and the infant was admitted for parenteral antibiotics and observation.

The laboratory evaluation showed a white blood cell count of 13.8 x 1000/mm2 with a 30% left shift. The C-reactive protein was < 0.5 mg/dl. Blood cultures were eventually negative. The nipple discharge gram stain showed gram-positive organisms and eventually grew only a few colonies of Staph. epidermidis. The patient’s clinical course after admission revealed that she continued to look and act well. She remained afebrile and was treated with 3 days of parenteral antibiotics. She was switched to oral antibiotics and monitored before being discharged. Over time she had marked resolution of the breast swelling and surrounding erythema and at 1 week followup she had a 1 cm left breastbud that was similar to the right breast.

Discussion
Breast hypertrophy secondary to maternal hormones is common in neonates but neonatal mastitis is uncommon and relatively little is written in the literature. One study says “[m]ajor pediatric institutions can expect to see one to three cases per year.” Neonatal mastitis usually occurs between 2-8 weeks after birth in full term infants. Some studies report a peak occurence at 2-3 weeks and others at 4-5 weeks. It generally does not occur in preterm infants and this is thought to be because of underdeveloped breast tissue. Most studies report a higher incidence in females.

Symptoms include redness, swelling, induration, fluctuance, purulent nipple discharge and lymph node enlargement on the same side. Irritability as only sign has also been documented. Infants are often well appearing but may have fever and laboratory testing may show signs of infection such as increased white blood cell counts, and C-reactive protein levels.

Neonatal patients have an increased risk of abscess formation occurring in 40-50% of patients in some studies. Bacteremia has been reported in ~4% of patients. Bacterial meningitis is reportedly low, but lumbar puncture may be performed because of neonates age and symptoms.

Treatment is variable but most people recommend hospitalization and parenteral antibiotics especially because of the age and risk of abscess formation. Total antibiotic duration is variable but studies report 7-14 total days. Ultrasound examination for potential abscess and abscess treatment is commonly used. Surgical treatment for abscess formation includes a risk of decreased breast tissue, and scar formation.

Learning Point
The mechanism of neonatal mastitis is not fully understood but is thought to occur because of skin-colonizing bacteria migrating into the breast parchenyma. Staphylococcus aureus (methicillin-resistant and methicillin-sensitive) is the most common organism. A variety of other organisms have also been reported including S. epidermidis, E. coli, Klebsiella, Proteus, Pseudomonas and Aceinetobacter.

Questions for Further Discussion
1. What are indications for lumbar puncture?
2. How does sepsis and/or bacteremia present in neonates?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Breast Diseases.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Brown L, Hicks M. Subclinical mastitis presenting as acute, unexplained, excessive crying in an afebrile 31-day-old female. Pediatr Emerg Care. 2001 Jun;17(3):189-90.

Stricker T, Navratil F, Sennhauser FH. Mastitis in early infancy. Acta Paediatr. 2005 Feb;94(2):166-9.

Montague EC, Hilinski J, Andresen D, Cooley A. Evaluation and treatment of mastitis in infants. Pediatr Infect Dis J. 2013 Nov;32(11):1295-6.

Mohr EL, Berhane A, Zora JG, Suchdev PS. Acinetobacter baumannii neonatal mastitis: a case report. J Med Case Rep. 2014 Sep 25;8:318.

Stromps JP, Na HS, Grieb G, Orlikowsky T, Kuhl C, Pallua N. Surgical treatment of neonatal mastitis by periareolar drainage. Curr Pediatr Rev. 2014;10(4):304-8.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital