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

What Are Some Developmental Milestones for Solid Food Readiness?

Patient Presentation
A 6-month-old male came to clinic for his health supervision visit. The mother had no concerns. “A couple weeks ago I tried him with some cereal and he seemed to like it and last week at Thanksgiving dinner he grabbed my spoon so I gave him a taste of mashed up sweet potatoes. His eyes got really big and he got really excited and wanted more, so I gave him a few spoonfuls. I hope that is all right?” she inquired. The pertinent physical exam showed a happy infant sitting in his mother’s lap with excellent head control and easily manipulating a toy between hands and his mouth. Vital signs were normal with growth parameters around the 25%. His examination was normal including no head lag when pulled to a sitting position.

The diagnosis of a healthy 6 month old was made. The pediatrician inquired about any problems with tongue thrusting when feeding or choking which the mother denied. The pediatrician said, “He seems like he is really ready for starting solids. Continue the breastfeeding and half way through give him a few spoonfuls of the food and then finish the breastfeeding. The foods should be thin and easy to move in his mouth and don’t put too much in his mouth at once. He has to practice learning how to eat it. Only give him 1 new food every 2-3 days in case he has an allergy so then we can better know what it might be. Remember, breastmilk is his real food. Solids are desserts. They are for taste and texture but breastfeeding is the most important.”

Discussion
Introduction of solid, complimentary, foods for infants is a common question that health care providers are asked. The World Health Organization and the American Academy of Pediatrics and other organizations recommend exclusive breastfeeding until 6 months of age and then introduction of solid foods as the infant is developmentally ready. First foods generally are single-grain cereals but strained fruits or vegetables are also appropriate. Introduction of one new food every 2-3 days allows for potential food allergies to be more easily identified.

These may be the professional recommendations but the introduction of what types of foods and when to start them is highly dependent upon maternal beliefs which are influenced by cultural norms and by other individual family members such as grandmothers. In the U.S. 40% of infants are introduced to solid foods before 4 months of age. Early initiation of solid foods potentially increases the risk of obesity in later life as these infants have been found to consume more energy dense food. Formula fed infants or those feed formula and breastmilk are more likely to be fed solid food early than exclusively breastfed infants. Studies have found that mothers that are younger, less educated and have increased body weight tend to feed solid food earlier. Early introduction of solid foods has a higher rate of breastfeeding termination potentially putting children at risk for infections. A controlling or pressuring feeding maternal style is related to earlier solid feeding while a responsive style, following infant cues, is related to longer exclusive breastfeeding duration.

Infants that are more motorically active have also been correlated with earlier solid feeding. Potentially temperament (positive or negative reactivity) may also influence solid feeding with infants with negative reactivity being fed solid foods earlier. One study of young mothers found that “…infant diets mirror maternal diets and eating habits as early as 7 months of age.” This study and others found many poor feeding habits including excessive juice, inappropriate foods (i.e. french fries, pizza, macaroni and cheese, etc.), allergenic foods (i.e. eggs and peanut butter), and prechewing of table foods.

Learning Point
Breastfeeding or formula should be the main meals and calorie sources for infants during the first year. Solid food feeding is important for infant growth and development; they help the infant to learn about tastes and textures during the first year of life but initially should be used in small amounts like a dessert. There are development differences when infants are ready to take solid foods. In general infants should be able to:

  • Have no head lag when pulled from a reclined to seated position
  • Able to sit by self in a high chair or infant seat
  • Able to coordinate to move head and hands to be able to look for food and put it in the mouth
  • Responsively opens the mouth when food comes near
  • Able to move the food from the spoon into the mouth – does not have tongue thrust reflex
  • Able to swallow the food

There is a range of when infants are able to meet these milestones with some children as early as 4 months and others not until 10 months. Most infants are able to do so after 6 months of age. A table of infant and young children’s feeding skill milestones can be reviewed here.

Questions for Further Discussion
1. When can more textured infant foods be introduced?
2. What changes in stooling patterns occur after solid food introduction?
3. In a highly allergenic family, what changes to regular feeding patterns do you recommend?
4. When can children chew foods and eat foods that would be considered choking hazards such as nuts, chunks of meat, popcorn etc.?
5. What are the potential problems of homemade babyfood? A review is here.

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: Infant and Newborn Nutrition

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.

Arvedson JC. Swallowing and feeding in infants and young children. GI Motility online (2006) Available from the Internet at: http://www.nature.com/gimo/contents/pt1/full/gimo17.html (rev. 5/16/2006, cited 8/29/16).

Turck D. History of complementary feeding. Arch Pediatr. 2010 Dec;17 Suppl 5:S191-4.

Cattaneo A, Williams C, Pallas-Alonso CR, Hernandez-Aguilar MT, Lasarte-Velillas JJ, Landa-Rivera L, Rouw E, Pina M, Volta A, Oudesluys-Murphy AM. ESPGHAN’s 2008 recommendation for early introduction of complementary foods: how good is the evidence? Matern Child Nutr. 2011 Oct;7(4):335-43.

Karp SM, Lutenbacher M. Infant feeding practices of young mothers. MCN Am J Matern Child Nurs. 2011 Mar-Apr;36(2):98-103.

American Academy of Pediatrics. Starting Solid Foods.
Available from the Internet at https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx (rev. 2/1/12, cited 8/28/16).

Doub AE, Moding KJ, Stifter CA. Infant and maternal predictors of early life feeding decisions. The timing of solid food introduction. Appetite. 2015 Sep;92:261-8.

American Academy of Pediatrics. Working Together: Breastfeeding and Solid Foods.
Available from the Internet at https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Working-Together-Breastfeeding-and-Solid-Foods.aspx (rev. 11/21/15, cited 8/29/16).

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

Creepy Crawlie Therapy?

Patient Presentation
A pediatrician heard a radio story on the news about using worms to try to treat Crohn’s disease. She also was reading a book at the time where blood letting through cuts in the skin or leeches was a common medical treatment. She thought it was a good time for a quick review of organisms used for medical therapies that usually were thought of as potentially harmful creepy crawlies.

Discussion
Humans are only one species among the multitudes that inhabit the earth. While many species are used by humans for food, clothing or shelter, as a higher evolved organism, humans are particularly aware of other species that move as they could be a potential predator or cause injury. This wariness is protective, but moving animal species can be domesticated (e.g. dogs, horses), farmed (e.g. cattle, goats) or harvested (e.g. fish, silk) for human use for food, clothing or shelter and also for medicinal use.

Learning Point
Medical leeches have been used since ancient times. The most commonly used leech is Hirudo medicinalis named by Linneaus in 1758. It attaches to the host with a posterior sucker, bites with 3 jaws, and feeds on ~2-20 ml of blood usually within 10-30 minutes. Its saliva has several anticoagulants which allows for continued blood oozing up to 48 hours. It is the oozing effect that is the most useful to help in the treatment of large soft tissue hematomas (e.g. tongue), and especially for venous congestion after surgery for tissue flap reconstructions or reimplantation after amputations. Venous congestion can cause many problems in various surgical repairs and is a common reason for tissue flap failures. Hirudotherapy (or use of medical leeches) is considered an adjuvant after determining that there is not an arterial problem or venous congestion problem that is amenable to further surgery. Hirudotherapy can also be used if additional surgery is contraindicated. Medical leeches are grown specially for medical use. After feeding they are sacrificed in 70% alcohol and disposed of as a biohazard. As the gut of the leech is directly exposed to the patient, prophylactic antibiotics are usually given. The most common leech intestinal flora organism is Aeromonas hydrophilia. The various bioactive anticoagulants in leeches’ saliva and its body are also being researched. While there are several agents, 2 of the more common ones being evaluated are hirudins and hyaluronidase. Hirudins are being invested for antithrombotic effects in venous thrombosis and acute coronary syndromes. Hyaluronidase is being evaluated to increase permeability to improve absorption of fluids.

Helminths or parasite worms are common parasites which in the past affected almost all people. Today they still affect an estimated 2 billion people globally. Helminths appear to have an immunomodulating effect on the human immune system. It is thought that because of helminthic infestations, the human immune system is actively suppressed to allow continued viability of both organisms. Unfortunately, the human host is also less reactive to some other infectious agents such as tuberculosis or malaria and hosts have decreased vaccine responses. The potential advantage for the human host is to be less responsive which can help effects of immune-mediated diseases such as atopy, rheumatoid arthritis, Crohn’s disease, etc.. Pig whipworm, Trichuris suis is one of the most common medically used helminths. There are currently ongoing clinical trials for allergies, inflammatory bowel disease, rheumatoid arthritis and multiple sclerosis using helminth-modulated macrophage therapy. Experimental laboratory therapy is also ongoing for diabetes and sepsis. With helminth therapy it is important to note that there is a balance in trying to regulate an individual’s immune system. As one author said: “Because parasitism is on balance detrimental, administration of live helminths is itself a balancing act, attempting to maximize any beneficial effects against a deleterious backdrop. Where the fulcrum of that balance sits will very much vary according to the genetic makeup of the individual.”

While leeches and helminths are creepy crawlies that can be seen, newer research is looking at a much smaller scale. A microbiome are microorganisms that can be commensal, symbiotic or pathogenic and which inhabit our body spaces during health and disease. Common places to have microbiomes are the mouth, gut, vagina, lung and skin. There are many factors which affect an individual’s microbiome including genetics, antibiotics, diet, and environmental exposure (e.g. family, pets, soil, etc.). Studies are providing more information about how the microbiome in prenatal and early life can affect potential disease especially immune-related diseases such as allergies and asthma, inflammatory bowel disease, and also weight gain and obesity and infections. As the science associated with microbiomes is relatively new yet may potentially provide important understanding of normal and disease states, the National Institute of Health has undertaken the Human Microbiome Project as one of several international large scale scientific efforts to better understand human microbiomes.

Questions for Further Discussion
1. What other examples of medical uses of potential harmful species can you think of?
2. What potential side effects do some of these species have?

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 Complementary and Integrative Medicine.

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.

Porshinsky BS, Saha S, Grossman MD, Beery I PR, Stawicki SP. Clinical uses of the medicinal leech: a practical review. J Postgrad Med. 2011 Jan-Mar;57(1):65-71.

Zaidi SM, Jameel SS, Zaman F, Jilani S, Sultana A, Khan SA. A systematic overview of the medicinal importance of sanguivorous leeches. Altern Med Rev. 2011 Mar;16(1):59-65.

O’Dempsey T. Leeches–the good, the bad and the wiggly. Paediatr Int Child Health. 2012 Nov;32 Suppl 2:S16-20.

Maizels RM. Parasitic helminth infections and the control of human allergic and autoimmune disorders. Clin Microbiol Infect. 2016 Jun;22(6):481-6.

Steinfelder S, O’Regan NL, Hartmann S. Diplomatic Assistance: Can Helminth-Modulated Macrophages Act as Treatment for Inflammatory Disease? PLoS Pathog. 2016 Apr 21;12(4):e1005480.

Tamburini S, Shen N, Wu HC, Clemente JC. The microbiome in early life: implications for health outcomes. Nat Med. 2016 Jul 7;22(7):713-22.

National Institutes of Health. Human Microbiome Project Overview. Available from the Internet at http://commonfund.nih.gov/hmp/overview (rev. 5/16/16, cited 7/19/16).

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

Family Meals: They Do Everyone Good

Patient Presentation
An 18-month-old male came to clinic for his health maintenance visit. His dietary history showed he drank ~45 ounces of milk a day mainly from a bottle that he was allowed to have during most of the day. His mother complained that he didn’t eat much solid food, and wouldn’t sit down to eat. She noted that she didn’t really stop to eat herself. She would just drive through a fast-food restaurant and eat in the car even if she was not pressed for time. “It’s just something I do,” she said. He was doing well with normal development. The past medical history showed a healthy male. The social history showed him living with his employed mother. There was maternal family support locally. The family did not receive governmental assistance and the mother felt she had adequate resources from her employment. The pertinent physical exam revealed a smiling male with normal vital signs and growth parameters in the 25-50%. His examination was normal including normal appearing teeth.

The diagnosis of a healthy male with inappropriate food intake and behaviors was made. The pediatrician counseled the mother to decrease the total milk intake to 16 ounces/day and to put this into a sippy-cup or regular cup. “Any other fluid he wants can be up to 4 ounces of juice a day or water. All of it should be in a cup. He also should not be walking around with the cup. If he fills up on fluid he won’t eat. He should have 3 meals and a couple of snacks a day and he needs to sit down whenever he eats or drinks. It really does only take a few minutes and you both can have a nice time together talking and eating. It’s also a good break for you during the day. Even if you do have some fast-food, you should eat it as a family, sitting down together. He’ll learn what is expected of him at the dinner table too.” The laboratory evaluation showed a low hemoglobin and hematocrit so he was started on elemental iron.

The patient’s clinical course at 3 month followup found the mother to be proud of having started some of the interventions. She reported that he was only using a sippy-cup and taking only 24 ounces of milk a day. “He cries so much for the milk that I give him more than I should,” she said. “We are sitting down more together though – at least for dinner and most of his snacks when I am with him. When we are at my mom’s house, we have started to have him sit with us for part of our dinner too,” she remarked.

Discussion
Family meals (FM) are “…occasions when food is eaten simultaneously in the same location by more than 1 family member.” Overall, more frequent family meals are protective for healthy physical and psychosocial functioning across socioeconomic status, race/ethnicity and gender. Why FMs have these protective effects (possibly related to family connectedness) is unclear and additional research is ongoing.

Factors associated with increased FMs include:

  • Increased parental education
  • Gender – adolescent boys report more FM than adolescent females
  • Race/ethnicity – Asian-Americans have more FM than whites who have more than African-Americans. Hispanics have more FMs.
  • Children’s ages – younger children have more FMs than older children and adolescents
  • Parenting style – mothers who are authoritative have more FMs

The ideal FM environment is one that is positive, without arguments if possible and encourages communication among the family members. There should be no television or other electronic devices (including phones) in the room. Quiet music can help to set a positive mood for the meal. FMs do not have to be long and can be as short as 20 minutes.

Barriers to FMs often cited are work and school/extracurricular schedules, lack of meal planning, not having a regular time set for meals, picky eaters, young children not able to sit through the meal, and family members being hungry at different times. Ways to overcome this include setting the expectations that FMs will occur and family members are expected to participate, making grocery lists, making meals ahead of time for use later, and use of time saving devices such as microwave ovens and slow-cookers. Additional ways to keep the FM a popular and daily event include keeping the conversation fun and light, involving the children in meal preparation and serving foods that the children enjoy. FMs also can expand the types of foods children enjoy and the FM should not turn into a short-order restaurant to prepare separate meals for each person’s tastes.

Learning Point
Eating more frequent family meals has better physical and psychosocial outcomes for children including:

  • Increased/Improved
    • Consumption of good nutrition including appropriate calories, “… protein, fiber, calcium, iron, folate, and vitamins A, B-6, B-12, C and E….”, and increased servings of fruits, vegetables, grains and calcium-rich foods.
    • Healthy body weight
    • Body image perception
    • Self-esteem
    • Academic grade point averages, commitment to learning, language skills
    • Family relationships (e.g., perceived family support, communication, and parental involvement), and connectedness
    • Effective communication
  • Decreased
    • Consumption of poor nutrition including soda consumption and saturated fats
    • Disordered eating including less obesity and eating disorders
    • Alcohol and substance abuse (including tobacco and marijuana)
    • Depression and suicidal thoughts
    • Violent behavior

Questions for Further Discussion
1. How often do you personally have family meals?
2. How could you include family meal counseling into your preventative care discussions?

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: Family Issues and Child Nutrition.

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.

Berge JM, Rowley S, Trofholz A, Hanson C, Rueter M, MacLehose RF, Neumark-Sztainer D. Childhood obesity and interpersonal dynamics during family meals. Pediatrics. 2014 Nov;134(5):923-32.

Martin-Biggers J, Spaccarotella K, Berhaupt-Glickstein A, Hongu N, Worobey J, Byrd-Bredbenner C. Come and get it! A discussion of family mealtime literature and factors affecting obesity risk. Adv Nutr. 2014 May 14;5(3):235-47.

Harrison ME, Norris ML, Obeid N, Fu M, Weinstangel H, Sampson M. Systematic review of the effects of family meal frequency on psychosocial outcomes in youth. Can Fam Physician. 2015 Feb;61(2):e96-106.

DeGrace BW, Foust RE, Sisson SB, Lora KR. Benefits of Family Meals for Children With Special Therapeutic and Behavioral Needs. Am J Occup Ther. 2016 May-Jun;70(3):7003350010p1-6.

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