Breast infection and nipple fissures are not uncommon occurrences among women of all age groups. In this article, we will be discussing the risks associated with breast infection and how to prevent it. 

Breast tissue is made up of fatty connective tissue, ducts and plays a vital role in milk production as a mammary gland. The tissue is prone to developing infections, usually within the first three months after childbirth.

New mothers need to be aware of the risks, symptoms, treatments and prevention of these infections. The recurrent occurrence of infections eventually leads to complications.

What is a nipple fissure?

A nipple fissure is a small crack or sore on the nipple surface. It is commonly found in breastfeeding women due to multiple reasons. One of the reasons is an entry point for bacteria from a cracked nipple. (ncbi)

Etiology of nipple fissure³

Let us discuss the causes of these occurrences:

Poor breastfeeding techniques 

Improper latching and poor feeding position techniques contribute to the formation of nipple fissures. It is very important for the new mothers to be aware of the proper way to breastfeed 

Dry or sensitive skin

One cannot deny the importance of emollients and good moisturisers when it comes to cracked nipples and fissure formation. Well-moisturised skin helps to prevent cracks on the nipple and thus prevent bacteria from entering the tissues

Mechanical trauma 

Trauma due to an infant bite or breast pump machines can also lead to the formation of fissures. Hence, breastfeeding mothers are more prone to developing mastitis.

Pre-existing dermatological conditions 

Some dermatological conditions, like eczema and psoriasis, can also contribute to the list, as bacteria can enter the skin as a result of these skin conditions.  

Pathophysiology of infection

Bacterial entry via fissures

Common pathogens: Staphylococcus aureus and Streptococcus spp enter the body via fissures and thereby trigger inflammation within the parenchymal tissue of the breast, i.e. mastitis

Immune response

Inflammatory reaction in breast tissue is triggered once the pathogen enters the breast, and this response includes redness, swelling, erythema and edema, all causing localised  pain

Progression to mastitis²

Mastitis is an infection of the breast tissue.

Definition and clinical features

Redness, swelling, warmth, pain, and systemic symptoms (fever, malaise) are the common symptoms of breast mastitis

Role of nipple fissures in initiating mastitis

It is the port of bacterial entry, as it enters within the surface of the breast skin and releases toxins. This leads to inflammation and infection

Types of mastitis

Infective vs. non-infective (e.g. due to milk stasis)

While mastitis is commonly caused by fissures and cracks and bacterial superinfection, it can also be caused by breast milk engorgement due to stasis of breast milk due to improper or incomplete milk drainage.

Complication: breast abscess

The pathway from untreated mastitis

Mastitis, if left untreated, can progress into a collection of pus, debris and bacteria within the breast and skin surface. This is called a breast abscess.¹

Clinical signs

The most common signs and symptoms of mastitis are as follows: 

• Fever 
• Pain 
• Redness
• Swelling 
• Edema

Risk factors

The delayed treatment, immunocompromised state, like pregnancy, autoimmune conditions, untreated breast mastitis, improper drainage of  breast milk and recurrent breast infections  are all risk factors that contribute to the formation of an abscess

Diagnosis

Clinical examination

The first step towards the diagnosis of infection of the breast is done by thorough breast examination

Ultrasound imaging

Ultrasound is used to detect an abscess after examination findings suggest an abnormality

Milk culture (in select cases)

Sometimes, a breast secretion culture test is also done to detect the bug causing the infection and to start the antibiotic therapy accordingly 

Management

The following treatment options are available:³

Prevention of fissures

Proper breastfeeding techniques: This is the most important part in preventing the formation of fissures. Nipple care (lanolin, air drying, hygiene) pre- and post-feeding is equally important

Treatment of fissures

Topical antibiotics; emollients are usually the first-line treatment options available for fissure treatment

Mastitis management

• Continued breastfeeding/pumping: the first line treatment options are continued breast pumping, feeding, to prevent breast engorgement, followed by antipyretic medication to reduce fever
• Antibiotics (e.g., flucloxacillin) are the antibiotic of choice for mastitis management

Abscess management

• Needle aspiration or surgical drainage. This is done under local anaesthetic as a minor surgical operation, as it has complications associated with it
• Once the pus is drained, topical or systemic antibiotics are administered to prevent further spread of infection

Prognosis

With early detection and management

With early detection through follow-ups, examinations and treatment options, generally, outcomes are good as complications are prevented.

Delayed treatment risks

Recurrent infections and cessation of breastfeeding are the common complications associated with a delayed treatment plan. Hence, an early diagnosis management plan is essential.

Summary

To conclude, nipple fissures and infections are common in women of all ages. Hence, appropriate measures to ensure the prevention of complications like breast mastitis and abscesses are critical. Educating mothers and women regarding preventative techniques like breastfeeding techniques, the use of appropriate moisturisers and breast hygiene is equally important. 

Frequently asked questions 

Can breast mastitis occur in non-lactating women? 

Breast mastitis is usually divided into lactation and non-lactation. In lactating women, the usual cause is breast trauma or milk stasis. However, in non-lactating women, the common site of infection occurs in the areola (the tissue surrounding the nipple). Interestingly, women who smoke are at a high risk of developing periareolar mastitis.¹

 What is the difference between a fissure and a fistula?

A fissure is a wound or crack on the surface of the skin of the breast; however, a fistula is an abnormal tract that connects the breast duct with the skin(2).

Are antibiotics necessary to treat mastitis? 

Antibiotics play a significant role when Mastitis is diagnosed early. Immediate intervention with antibiotics leads to a better prognosis and better outcome. 

Are women at risk of developing cancer once diagnosed with breast mastitis

It is important to understand the age and other risk factors when women of reproductive and menopausal age are presented with symptoms of mastitis, as imaging studies like ultrasound and mammography should be done to rule out the possibility and risk of cancer.²

Risk of recurrent mastitis and MRSA infection 

It is important not to miss MRSA when talking about recurrent mastitis, as frequent infections and mastitis not able to be treated by antibiotics raise a suspicion for MRSA and hence, empirical antibiotics should be considered in such cases. 

What is the difference between breast engorgement and breast abscess?

Breast engorgement is when the ducts of the breast are dilated and enlarged due to insufficient pumping of the breast milk. However, mastitis is an inflammation which includes systemic illness, like swelling, redness of the breast, along with rise in temperature. 

What is the right age to get a mammogram? 

The recommended age to undergo a mammogram of breast mammogram is 40 years. Before that, an ultrasound scan is recommended to rule out abnormal growth within the breast. 

Can I breastfeed during a breast infection? 

It is recommended to continue breastfeeding during infection as it helps to unclog the mammary ducts and thus prevents breast engorgement.