Mastitis in newborns

Mastitis in newborns is an inflammation of the mammary gland in a child in the first month after birth. This process also occurs in older children, but more often in newborns due to the peculiarities of the structure and functioning of the mammary gland. Any inflammatory process in such a baby threatens serious complications and generalization of inflammation, which is why the problem of mastitis is so important for timely diagnosis.

Epidemiology

The epidemiology of mastitis in newborns is such that about 65% of all babies in the first month of life suffer from physiological mastopathy, and about 30% of cases are complicated by purulent mastitis. Mortality from purulent mastitis is 1 in 10 cases of the disease, which is an incredibly large figure, despite the availability of new modern treatment methods. About 92% of mastitis cases are primary, caused by exogenous penetration of the pathogen through cracks or scratches of the nipple. Such data allow preventing the disease by simple conversations with parents about the rules of child care, which will reduce the number of mastitis.

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Causes neonatal mastitis

Mom is the first person to notice any changes in her baby's health. Mastitis develops very quickly in such a child, so it is sometimes difficult to accurately determine its cause. But it is imperative to know about all possible factors that influence the development of mastitis, so that the mother can prevent their development.

The mammary glands of a newborn baby have their own anatomical and physiological features. The mammary gland consists of glandular tissue, loose connective tissue and milk ducts. In newborns, it lies on a large "fat pad" consisting of connective tissue with a loose structure. The milk ducts themselves are not very developed, but they have a small branching in the radial direction. Under the influence of mother's hormones, there may be activation of the synthesis of myocytes and connective tissue cells just before childbirth, which some time after birth gives clinical manifestations of physiological engorgement of the mammary glands. This process is considered normal and is not accompanied by inflammation. A small amount of secretion - colostrum - may even be released from the nipple, which is also not a pathology. But often, due to inexperience or simply carelessness, parents injure the gland or try to somehow treat engorgement by squeezing out the secretion. This is often the main cause of mastitis, as a primary complication of physiological mastopathy.

The pathogenesis of the inflammatory process is that with the slightest cracks on the nipple or areola, bacteria that are on the skin surface enter the gland tissue. This leads to the activation of immune protection and leukocytes are activated at this site of bacterial penetration. After this, an active immune response begins and the inflammatory process causes symptoms. But a feature of the structure of the mammary gland of newborns is a large amount of loose connective tissue, which in turn allows the inflammatory process to instantly spread further with rapid damage to other tissues. Such features of the pathogenesis of mastitis lead to the early appearance of complications, which must be taken into account during timely diagnosis.

Another common cause of mastitis in newborns can be considered improper care of the baby's skin. This group of reasons includes not only insufficient hygiene measures, but also excessive care. This term implies that mothers often massage the baby incorrectly, or try to wash him thoroughly, wiping the skin with a washcloth. All this is an additional factor of trauma, and as a consequence - an entry point for infection. Therefore, a healthy newborn child does not need such measures, light bathing in water without rubbing is enough.

Mastitis can be caused not only by a local inflammatory reaction, but also by a systemic one. For example, if a child has a sore throat or otitis that is not diagnosed in time, the infection may spread through the lymphatic or hematogenous route. In this case, against the background of weakened immunity or in premature babies, the infection may generalize with the development of mastitis secondary to the sore throat.

When talking about the causes of mastitis in newborns, it is necessary to highlight the main etiological factors in children of this age. The cause is most often streptococci, staphylococci, enterococci. This is important not only for diagnostic purposes, but also for choosing treatment tactics.

The causes of mastitis in newborns are pathogenic bacteria that cause an inflammatory process. Today, the etiological significance in the development of mastitis is group B streptococci (which are a common cause of mastitis in newborns), group C (they are the cause of sepsis in newborns). Since the 80s, the number of diseases, pyogenic infections caused by coagulase-negative strains of staphylococci St. epidermidis, St. saprophiticus, St. hemoliticus, St. xylosus has increased, that is, the species composition of staphylococci changes. Therefore, the division of staphylococci into "pathogenic" and "non-pathogenic" is currently conditional. The pathogenic action of staphylococci is explained by their ability to secrete toxins (lethal toxin, enterotoxin, necrotoxin, hemotoxin, leukocidin) and aggressive enzymes (coagulase, fibrinolysin, hyaluronidase), which significantly facilitate the spread of the pathogen in the tissues of the infant's body. In addition, most pathogenic strains secrete penicillinase, cephalosporinase, which destroy penicillins, cephalosporins in normal therapeutic doses.

Further, next to staphylococcal infection, which occurs in newborns in 45-50% of mastitis and other skin infections, the proportion of gram-negative flora increases. Outbreaks caused by Escherichia coli, Klebsiella, Serratia, Proteus, Pseudomonas aeruginosa (in 30-68%), their association begin to appear. Gram-negative opportunistic flora has pronounced biological plasticity, which allows them to adapt to different ecological niches. Some of them: Escherichia coli, Klebsiella, Proteus, Enterobacter are representatives of normal human microflora, others Serratia, Pseudomonas are mainly found in the environment. They can cause various pathological processes in newborns in addition to mastitis omphalitis, enteritis, pneumonia, conjunctivitis, meningitis, sepsis. Hospital strains are especially dangerous, as they are formed in hospitals as a result of the widespread, often irrational use of broad-spectrum antibiotics. As a result, strains with high resistance to antibiotics and disinfectants are formed.

Another feature of the etiological flora of mastitis is the presence of pathogenicity factors (enterotoxigenicity, adhesiveness), aggressive enzymes (proteases, DNAases), hemolytic activity in bacteria, which enhance their pathogenic potential. A feature is their resistance in the external environment (their ability to stay and reproduce in the external environment for a long time at low temperatures). Moist places are especially favorable for them: toilets, sinks, soap dishes, hand wash brushes, resuscitation equipment. All this contributes to their widespread distribution in hospital conditions and is a risk factor for the development of mastitis in a child if he is infected while still in the hospital.

Thus, the cause of mastitis in newborns are bacteria that can represent the normal flora of the child or can be infected with them from the external environment. But in this case, a prerequisite for the development of inflammation in the baby's mammary gland is the presence of an entry gate for infection. This can be a scratch or damage to the skin of the mammary gland, a crack in the nipple with physiological engorgement, which allows the pathogen to get under the skin and contributes to the further development of the inflammatory process.

The causes of mastitis in newborns are directly related to external factors, so proper care of the baby during this period is very important.

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Risk factors

Risk factors for developing mastitis:

1. a premature baby has a reduced protective function of the immune system, which allows the purulent process to spread faster;
2. physiological engorgement of the mammary glands can be a prerequisite for the development of mastitis;
3. injury to the skin of the mammary gland or nipple;
4. previous operations in a child with a long hospital stay and contact with hospital flora;
5. unfavorable obstetric history: long-term infertility, somatic diseases, extragenital pathology;
6. pathological course of pregnancy, threat of miscarriage, urogenital diseases, acute respiratory viral infections, exacerbation of chronic foci, prolonged hypoxia;
7. pathological course of labor, premature birth, prolonged anhydrous period, obstetric interventions, etc. during labor;
8. need for resuscitation and intensive care, artificial ventilation, intubation, catheterization of the main vessels, nutrition;
9. artificial feeding from the first days.

Thus, mastitis can develop in an absolutely healthy baby without signs of pathology after birth, and the main factor in this case is infection with bacterial flora.

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Pathogenesis

The pathogenesis of inflammation of the mammary gland in a newborn child is based on the peculiarities of the development of the gland in children after birth. In each child after birth, all organs and systems adapt to environmental conditions. One of such states of adaptation of the child is a sexual crisis. The appearance of a hormonal crisis is caused by the action of the mother's estrogen hormones, which, starting from the 7th month of gestation, are transferred from the mother to the fetus in utero.

One of the manifestations of the sexual crisis is symmetrical swelling of the mammary glands, which appears on the 2nd-4th day of the child's life, and reaches its maximum size by the 6th-7th day. This phenomenon is observed in both girls and boys. The mammary glands, as a rule, slightly increase in size, sometimes they swell to the size of a walnut. The skin above them tenses, can become hyperemic. When pressed, a whitish liquid resembling colostrum is released from the glands. Mastitis mainly develops against this background. For this, the mandatory condition for the inflammation process must be the penetration of pathogenic bacteria into the mammary gland tissue. Only this implies the further development of mastitis against the background of physiological mastopathy.

Susceptibility to infections in newborns is high, which is predetermined by the anatomical and physiological characteristics of the skin of the newborn and their reduced immunological reactivity, imperfection of the non-specific defense system:

1. Low phagocytic activity of leukocytes, complement activity, low lysozyme levels impair the permeability of the epithelial-endothelial barrier protection
2. Specific protection is provided by the humoral and cellular links of immunity, which also have their own characteristics that contribute to the development of mastitis in newborns:
   1. low synthesis of own Ig G, secretory Ig A;
   2. predominance of the synthesis of Ig M macroglobulin, which, due to its structure, does not have sufficient protective properties;
   3. low cytotoxic activity of T-lymphocytes, cellular link insufficiency.

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Symptoms neonatal mastitis

The first signs of mastitis in a newborn may appear against the background of physiological mastopathy. Then there is a disturbance in the general condition of the child, capriciousness or even severe anxiety. After a few hours, you can already see objective symptoms of mastitis. The gland itself increases significantly in size, the skin above it becomes red or even with a blue tint. If you try the baby's breast, he will immediately react, since this is accompanied by severe pain. If an abscess has formed, you can feel how the pus moves under your fingers during palpation - a symptom of fluctuation. This process is usually one-sided. Discharge can also be from the nipple on the affected side in the form of green or yellow pus. These are the main symptoms that indicate a local inflammatory process. They develop very quickly, sometimes over several hours. But such changes can not always be detected. Sometimes the first symptom can be a significant increase in body temperature. Then the child screams, sometimes there can be convulsions against this background.

Mastitis in newborn girls and boys is equally common and the symptoms are also the same. But there are stages of the inflammatory process that differ in their manifestations. It is not always possible to track the dynamics of the stages in newborns, since the process quickly moves from one to another.

Serous mastitis is an inflammation characterized by initial changes in the tissue of the mammary gland and accumulation of serous secretion. This stage is characterized by initial manifestations of the disease in the form of a violation of the general condition and swelling of the gland. There may not yet be a change in skin color, but the body temperature may increase.

The infiltrative stage occurs when the active immune response in the gland tissue is accompanied by infiltration and the formation of a diffuse focus. This already manifests itself in reddening of the skin, pain, high body temperature. Then the foci of infiltration merge and the number of dead leukocytes forms pus, which leads to the next stage.

Purulent mastitis in newborns is characterized by an extreme degree of severity of symptoms against the background of a massive infectious process that can easily spread to deeper tissues.

Forms

Types of mastitis are classified according to stages, which is sometimes difficult to distinguish due to the rapid dynamics of such children. Therefore, the main task of the mother is to promptly contact the doctor if there are symptoms of redness or enlargement of one gland with a violation of the general condition of the child.

Symptoms of mastitis in a newborn depend on the stage of the disease. There are several types of inflammation of the mammary gland.

1. According to the clinical course.
   1. Spicy:
      1. stage of serous inflammation;
      2. infiltrative (phlegmonous) form;
      3. abscess formation stage;
      4. gangrenous.
   2. Chronic:
      1. non-specific;
      2. specific.
2. By localization:
   1. Subareolar
   2. Antemamar (premamar).
   3. Intramammary:
      1. parenchymatous
      2. interstitial.
   4. Retromamarni.
   5. Panmastitis.

In newborns, one mammary gland and the whole one at once are often involved in the process, therefore we are talking about panmastitis. The first signs of the disease are manifested by local symptoms. The onset of the disease is usually acute. In most cases, the disease begins with the appearance of hardening of the mammary gland, rapidly increasing pain. The pain is intense, can be pulsating, does not radiate, and intensifies with palpation of the gland. Such an inflammatory process causes an early increase in body temperature to high numbers (39-40). As a result of the inflammatory process, weakness, anxiety of the baby, and a piercing cry develop. Then there is pronounced hyperemia and fluctuation of the skin over the site of inflammation. The general condition is disturbed, intoxication syndrome is expressed, appetite is reduced, and sucking is sluggish. Going through successive stages of the disease, at the stage of formation of the gangrenous or phlegmonous process, the child's condition can significantly worsen. The body temperature rises quickly, which cannot be reduced. The child begins to refuse food, he can constantly sleep or, on the contrary, scream. The skin may show a dark gray or blue color of the inflammatory process, which may show through the baby's thin skin. The inflammatory process spreads very quickly and the baby's condition may worsen in a few hours. Therefore, purulent mastitis in a newborn is most common when the process quickly moves from the serous stage to the purulent inflammation stage. This plays a huge role in the treatment and choice of tactics at each stage of the disease.

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Complications and consequences

Complications of mastitis can be generalization of the infection with the development of sepsis literally in a matter of hours, so it is simply necessary to begin treatment immediately after diagnosis. The consequence of the operation may be lactation disorders in the future, if it is a girl, but such consequences are not comparable with the health of the baby. The prognosis can be very serious, so it is necessary to prevent such pathology.

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Diagnostics neonatal mastitis

Mastitis diagnostics are not complicated, even by external characteristics. First, you need to listen to all the mother's complaints and find out how the symptoms developed. High body temperature, acute onset of the disease, and deterioration of the child's condition indicate mastitis.

During examination, diagnostic signs of pathology are very simple - an enlarged hyperemic mammary gland is visible, sometimes the local temperature may be elevated. During palpation, it can be noted that the child begins to cry and fluctuation or uneven consistency can be felt due to accumulation of pus.

As a rule, the diagnosis is not in doubt if such objective symptoms are present. Additional research methods for a newborn child can be complex. Therefore, if the child was previously healthy, then general clinical tests are limited. Changes can be characteristic of a pronounced bacterial infection with high leukocytosis and increased ESR. But the absence of changes in the blood test does not exclude acute bacterial inflammation, since due to the immaturity of the immune system, there may not be a pronounced reaction.

Instrumental diagnostics of mastitis is not often used, since there is no need for it in the case of pronounced clinical symptoms. Therefore, ultrasound examination can be performed only for the purpose of differential diagnostics.

Thermography: zones with local temperature increase are formed.

Invasive examination with biopsy of the inflammation site and laboratory examination of exudate, determination of microflora sensitivity to antibiotics is one of the most specific methods for further conservative diagnostics. This allows to accurately determine the pathogen and, if necessary, prescribe those antibacterial drugs to which the pathogen is definitely sensitive.

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Differential diagnosis

Differential diagnostics of mastitis in newborns should be carried out primarily with physiological mastopathy. Physiological "mastitis" is characterized by a symmetrical enlargement of the gland to a small size. There is no change in skin color and it does not cause concern in the child. At the same time, the baby's appetite is preserved, sleep is not disturbed, he gains enough weight, the stool is normal, and there are no signs of intoxication. And with purulent mastopathy, the symptoms are the opposite.

Mastitis should also be differentiated from erysipelas caused by hemolytic streptococcus. Erysipelas is an inflammation of the skin with clear boundaries of the process and a gradual onset of the disease. It causes a gradual and moderate increase in body temperature without other general symptoms. The child's appetite and sleep are usually preserved, unlike mastitis.

Treatment neonatal mastitis

Treatment of mastitis is complex – in such small children, surgical intervention and massive antibacterial therapy are required.

Treatment tactics depend on the stage of the disease and the spread of the inflammatory process. At the initial stages of the disease, serous and infiltrative, complex conservative therapy is carried out; when an abscess and purulent focus are formed, surgical intervention is performed.

Conservative treatment.

1. Regime: bed rest; for the child's mammary gland, it is necessary to provide it with minimal conditions for traumatization using a suspensory, which should hold the gland, and not squeeze it.
2. Locally apply cold with an ice pack through gauze to the affected areas of the gland for 20 minutes every 1-1.5 hours.
3. Retromammary novocaine block: 70-80 ml of 0.25-0.5% novocaine solution + antibiotic is rarely performed in newborns due to the complexity of the technique.
4. Antibiotic therapy according to modern principles of its implementation and after conducting a bacterial analysis and flora sensitivity test.
5. Stimulation of the body's defenses: administration of antistaphylococcal J-globulin, immunomodulators, autohemotherapy.
6. Massage of the gland.

Treatment of mastitis in a newborn using medications involves the use of two broad-spectrum antibiotics. The following preparations can be used for this purpose:

1. Ampicillin is an antibiotic from the aminopenicillin group, which acts on most microorganisms that can cause skin inflammation and mastitis in newborns. The drug destroys the bacterial wall and neutralizes the cell membrane, disrupting its reproduction. The dosage of the drug for infants is at least 45 milligrams per kilogram of the child's body weight. The course of treatment is at least one week. Method of administration - in the form of a suspension, dividing the daily dose into three doses. Side effects may be in the form of allergic reactions, and due to the effect on the intestines in newborns, diarrhea may occur. Precautions - do not use if you have a history of allergies to this group of drugs.
2. Amikacin is an antibiotic from the aminoglycoside group, which is widely used in combination with ampicillin to treat mastitis. The mechanism of action of the drug is associated with the disruption of ribosomes and disruption of the inclusion of amino acids in the RNA chain. This leads to the death of the bacterial cell. For newborns with mastitis, it is advisable to use one antibacterial drug orally and the other parenterally. Therefore, the recommended method of using this drug is intramuscular or intravenous. The dosage is 15 milligrams per kilogram in two doses. Side effects can be in the form of systemic or skin allergic reactions.
3. Cefodox is an oral cephalosporin of the third generation, which does not die in the presence of bacteria that contain lactamases. The drug is well absorbed when taken orally and is immediately divided into fractions, circulating in the blood throughout the day. This allows you to maintain the required concentration of the drug in the inflammation site, given that other antibiotics may poorly accumulate in the breast tissue during mastitis. The mechanism of action of the drug is the activation of enzymes that promote the destruction of the bacterial wall and the release of bacterial endotoxin (impaired synthesis of polysaccharides in the cell wall of the microorganism). This ensures the death of the pathogen during mastitis and prevents the development of further infection. Dosage of 10 mg / kg per day, divided into one or two doses. Cefodox can be combined with a parenteral antibiotic from the macrolide or aminoglycoside group, and in severe cases - with fluoroquinolones.
4. Paracetamol is a drug used to treat mastitis to reduce high body temperature in newborns. The main mechanism of action of paracetamol is the inhibition of prostaglandin synthesis. These substances potentiate the inflammatory response by synthesizing inflammatory substances. The drug blocks the release of these substances and reduces temperature and other symptoms of inflammation. In addition to reducing body temperature, paracetamol has an analgesic effect. For newborns, this is the only drug that can be used from the first days. The best way to use it is in the form of syrup. The dosage is 10-15 milligrams per kilogram of body weight per dose. The dose can be repeated no less than 4 hours after the last time. The syrup is available in a dose of 120 milligrams in five milliliters, which is then calculated based on body weight. Side effects from the gastrointestinal tract in the form of dyspeptic disorders, erosions and ulcers of the stomach and duodenum, bleeding and perforation may occur.

Of the antibacterial agents, at least two, and sometimes three antibiotics are used, one of which must be administered intravenously.

1. Netilmicin is an aminoglycoside antibiotic that is effective against many aerobic and anaerobic pathogens. In the treatment of mastitis in children, a dosage of 3-4 mg / kg / day in 2-3 doses is used. The course of therapy is at least 7-10 days. Side effects are possible when affecting the stomach - colitis or dysbacteriosis develops, which is manifested by bloating, stool disorders, so when treating children, it is imperative to use probiotics. Precautions - do not use in case of kidney damage.
2. Clarithromycin is an antibacterial agent from the macrolide group. Among the known drugs, it has the maximum activity against intracellular parasites, is able to accumulate in the cell, in the foci of inflammation, does not lose qualities under the influence of lysosomes, that is, it acts on possible causative agents of mastitis, thus interrupting the persistence of the pathogen. Clarithromycin has a long half-life. The method of administration depends on age and can be in the form of a suspension or tablets, but in the initial stages it is better to start taking intramuscularly in parallel with another antibiotic. It is prescribed to children over 3 years old and the dosage is 10 mg / kg / day on the first day, from the 2nd to the 7-10th day - 5 mg / kg / day 1 time per day. A mandatory condition is to use two hours after a meal or an hour before it. The course of treatment is 5-7-10 days. Side effects of azithromycin include paresthesia, impaired skin sensitivity, numbness of the arms and legs, tremor, impaired bile flow, and dyspeptic symptoms. Precautions: do not use in case of cholestasis or gallstone disease.
3. Panadol is an antipyretic drug in the form of a suspension to reduce the temperature of children. This is a mandatory element of treatment, since with mastitis the temperature can rise to significant numbers and cause a condition that threatens the health of the child. The main active ingredient is paracetamol. Five milliliters of suspension contains one hundred and twenty milligrams of the substance. Method of administration of the drug - a single dose inside, the dose can be repeated no earlier than four hours later. The dosage is 10-15 milligrams per kilogram of body weight per dose. For newborns, the dose is from one to two milliliters depending on the weight of the child. Side effects - the effect on the liver can lead to cytolysis, there may be inhibition of the formation of blood elements, laryngeal edema, decreased sugar levels. Precautions - do not use more than six times a day.

Local treatment of mastitis is carried out depending on the phase of the inflammatory process against the background of general conservative therapy. In phase I, the phase of inflammation, preference should be given to multicomponent water-soluble ointments on a polyethylene oxide basis: levosin, levomekol, oflokain. They simultaneously have antibacterial, dehydrating and analgesic effects, and due to the presence of such a component as methyluracil in their composition, they contribute to the activation of the reparative process. In the presence of necrotic areas that were not removed during surgery, proteolytic enzymes are used. In the regeneration phase, it is advisable to use aqueous solutions of antiseptics: dioxidine, chlorhexidine, furacilin.

A mandatory element of mastitis treatment in newborns is surgical treatment, since the accumulation of pus in such a baby quickly spreads and without surgery the disease will not resolve. Immediately after the diagnosis is made, the child is immediately hospitalized in the pediatric surgical department. Under general anesthesia, an emergency operation is performed. The scope of the operation consists of making incisions on the skin of the affected area of the mammary gland in a checkerboard pattern. There can be a large number of them, which depends on the volume of the affected gland. The incisions are made in such a way that they are located on the border of healthy and affected skin. Then drains are installed, through which active washing of such an area is carried out. Then the drains are left for better outflow of pus. Dressings should be done several times a day after the operation and the mother should monitor this. Feeding such a child continues as usual with breast milk, which provides better protection for the child. In addition, symptomatic therapy is used.

For drainage, preference should be given to active methods of flow-washing, vacuum aspiration. Methods of improved surgical treatment of purulent wounds, which are used to reduce the number of microorganisms in it, should use physiotherapeutic treatment:

• wound treatment with a pulsating stream of liquid;
• vacuum wound treatment;
• laser beam treatment;
• ultrasonic treatment.

Vitamins and physiotherapy treatment can be carried out at the stage of convalescence, when it is necessary to support the baby’s defenses.

Traditional medicine, herbal medicine and homeopathic remedies are not used for mastitis, since such a disease in the neonatal period has fatal consequences that develop quickly. Traditional methods do not have such a property of rapid elimination of pus, therefore they are not recommended for use by doctors.

Prevention

The main methods of prevention are proper care of the newborn, following the doctor's recommendations, and if the child shows symptoms of "anxiety", you should immediately seek advice.

Mastitis in newborns is unfortunately a common occurrence, but given timely diagnosis and treatment, mortality from such pathology has significantly decreased. But despite this, serious complications can develop, which requires caution on the part of the mother first of all and disease prevention.

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