Mastitis in newborns

Mastitis in newborns is an inflammation of the mammary gland in a child of the first month after birth. This process occurs in older children, but more often in newborns because of the structure and functioning of the breast. Any inflammatory process in such a baby threatens with serious complications and generalized inflammation, so the problem of mastitis is so important for timely diagnosis.

Epidemiology

Epidemiology of mastitis in newborns is such that about 65% of all children of 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 methods of treatment. About 92% of cases of mastitis is primary, caused by exogenous ingestion of the pathogen through cracks or scratches of the nipple. Such data allows you to prevent the disease with simple conversations with parents about the rules of caring for a child, which will reduce the amount of mastitis.

[1],

Causes of the mastitis in newborns

Mom is the first person who notices any changes in the state of health of his baby. Mastitis develops very quickly in such a child, so sometimes it is difficult to pinpoint its cause. But you must know about all the possible factors that affect the development of mastitis, so that it is the mother who could prevent their development.

Breasts in a newborn child have their anatomical and physiological characteristics. The mammary gland consists of glandular tissue, loose connective tissue and milk ducts. In newborns, it lies on a large "fat cushion", which consists of a connective tissue that has a loose structure. The milk ducts themselves are not developed very much, but they have a slight branching in the radial direction. Under the action of the hormones of the mother, activation of the synthesis of myocytes and cells of the connective tissue before the very birth can occur, which after a while after birth gives the clinical manifestations of physiological engorgement of the mammary glands. This process is considered normal and not accompanied by inflammation. From the nipple can even stand out a small amount of secretion - colostrum, which is also not a pathology. But often parents are inexperienced or simply inadvertently injuring the gland or trying to somehow cure nagging, squeezing out the secret. This is often the main cause of mastitis, as a primary complication of physiological mastitis.

The pathogenesis of the inflammatory process is that, at the slightest crack on the nipple or on the halo, the bacteria that are on the surface of the skin enter the gland tissue. This leads to the activation of immune defense and the leukocytes are activated in the given place of penetration of the bacteria. After this, an active immune reaction begins and the inflammatory process causes the appearance of symptoms. But the peculiarity 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 spread instantaneously with a rapid injury of other tissues. Such features of the pathogenesis of the development of mastitis lead to the early occurrence of complications, which should be taken into account in the timely diagnosis.

Another common cause of mastitis in newborns can be considered incorrect skin care for the baby. This group of reasons includes not only insufficient hygiene measures, but also excessive care. By this term it is meant that often moms do massage to the child incorrectly, or try to wash it thoroughly, wiping the skin with a washcloth. These are all additional factors of traumatization, and as a consequence - entering gates for infection. Therefore, a healthy newborn child does not need such activities, a fairly easy bathing in the water without grinding.

The cause of mastitis can be not only a local inflammatory reaction, but also a systemic one. For example, a child with a sore throat or otitis, which is not diagnosed on time, can be spreading the infection lymphogenically or hematogenously. In this case, against the background of weakened immunity or in preterm infants, generalization of the infection with the development of secondary to angina mastitis can occur.

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

The causes of mastitis in the newborn are pathogenic bacteria that cause the inflammatory process. To date, aetiological importance in the development of mastitis have streptococci of group B (which are a common cause of mastitis in newborns), group C (cause sepsis in newborns). Since the 1980s, the number of diseases, pyogenic infections caused by coagulase-negative Staphylococcus strains of St.epidermidis, St.saprophiticus, St. Hemoliticus, St.xylosus, that is, the species composition of staphylococci changes. Therefore, the division of staphylococci into "pathogenic" and "non-pathogenic" to date is conditional. The disease-causing effect of staphylococci is due to their ability to release toxins (lethal toxin, enterotoxin, necrotoxin, gemotoxin, leukocidin) and enzymes of aggression (coagulase, fibrinolysin, hyaluronidase), which greatly facilitate the spread of the pathogen in the tissues of the baby. In addition, most pathogenic strains secrete penicillinase, cephalosporinase, which destroy penicillins, cephalosporins in usual therapeutic doses.

Next to the staphylococcal infection, which occurs in newborns in 45-50% of mastitis and other skin infections, the specific gravity of gram-negative flora increases. Flashes caused by E. Coli, Klebsiella, Serration, Proteus, Pseudomonas aeruginosa (in 30-68%), their association begin to appear. Gram-negative conditional pathogenic flora has a pronounced biological plasticity, which allows them to adapt to different ecological niches. Some of them: E. Coli, Klebsiela, Proteus, Enterobacter are representatives of normal human microflora, other serrations, pseudomonas are mainly in the environment. They can cause in newborns different pathological processes besides mastitis omphalitis, enteritis, pneumonia, conjunctivitis, meningitis, sepsis. Particular danger is made by hospital strains that are formed in hospitals as a result of widespread, often irrational use of broad-spectrum antibiotics. As a result, strains with high resistance to antibiotics, to disinfectants are formed.

Another feature of the etiologic flora of mastitis is the presence of pathogenicity factors (enterotoxigenicity, adhesiveness), enzymes of aggression (protease, DNA as well), hemolytic activity, which enhance their pathogenic potential. Feature is the resistance in the external environment (their ability to long stay and reproduction in the external environment at low temperature). Especially favorable for them are wet places: toilets, sinks, soap, handwashing brushes, resuscitation equipment. All this contributes to their wide distribution in a hospital environment and is a risk factor for the development of mastitis in a child when it is infected in the hospital.

Thus, the cause of development of mastitis in newborns are bacteria that can represent the normal flora of a child or can be infected with them from the external environment. But in this case, an obligatory condition for the development of inflammation in the mammary gland of the child is the presence of an incoming gate for infection. This can be a scratch or damage to the skin of the breast, a crack on the nipple with physiological engorgement, which allows the pathogen to get under the skin and promotes 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 the development of mastitis:

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

Thus, mastitis can develop in an absolutely healthy baby with no signs of pathology after birth, and the main factor in this case is infection with a bacterial flora.

[3], [4], [5], [6]

Pathogenesis

The pathogenesis of the formation of inflammation of the breast in a newborn child is based on the features of the development of the gland in children after birth. Every child after birth has all the organs and systems adapted to the conditions of the external environment. One of such states of adaptation of the child is the sexual crisis. The appearance of hormonal crisis is caused by the action of estrogen hormones of the mother, which from the 7th month of gestation passes in utero from the mother to the fetus.

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

Susceptibility to infections in newborns is high, which is predetermined by the anatomical and physiological features of the skin of the newborn and their reduced immunological reactivity, imperfection of the system of nonspecific protection:

1. Low phagocytic activity of leukocytes, complement activity, low level of lysozyme violates the permeability of epithelio-endothelial barrier protection
2. Specific protection is provided by the humoral and cellular link of immunity, which also has its own characteristics that contribute to the development of mastitis in newborns:
   1. low synthesis of intrinsic IgG, secretory IgA;
   2. prevalence of synthesis of macroglobulin Ig M, which by its structure does not have sufficient protective properties;
   3. low cytotoxic activity of T-lymphocytes, insufficiency of the cell link.

[7], [8], [9], [10]

Symptoms of the mastitis in newborns

The first signs of mastitis in a newborn can appear against the background of physiological mastopathy. Then there is a violation of the general condition of the child, capriciousness or even severe anxiety. After a few hours, you can already see the objective symptoms of mastitis. The gland itself considerably increases in size, the skin above it becomes red or even with a shade of blue. If you try the breast of a child, it will react immediately, because it is accompanied by severe pain. If an abscess formed, you can feel how the pus moves under the fingers during palpation - a symptom of fluctuations. This process, as a rule, is one-sided. The discharge can also be from the nipple on the side of the lesion in the form of green or yellow pus. These are the main symptoms that indicate a local inflammatory process. They develop very quickly, sometimes for several hours. But it is not always possible to detect such changes. Sometimes the first symptom can be a significant increase in body temperature. Then the child screams, sometimes can be against this cramp.

Mastitis in newborn girls and boys is equally common and the symptoms also do not differ. But the stages of the inflammatory process that differ in manifestations are distinguished. Not always the dynamics of stages can be traced in newborns, as the process quickly passes from one to another.

Serous mastitis is an inflammation that is characterized by initial changes in the breast tissue and the accumulation of serous secretions. This stage is characterized by initial manifestations of the disease in the form of a general condition disorder and swelling of the gland. Changes in skin color may not yet be, but 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. It already manifests with reddening of the skin, pain, high body temperature. Further, the infiltration foci merge and the number of leukocytes deceased forms pus, which leads to the next stage.

Purulent mastitis of a newborn is characterized by an extreme degree of symptomatology on the background of a massive infectious process that can easily spread to tissues located deeper.

Forms

Types of mastitis are classified according to stages, which is sometimes difficult to distinguish because of the rapid dynamics in such children. Therefore, the main task of the mother is timely prompt treatment to 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 breast.

1. According to the clinical course.
   1. Acute:
      1. stage of serous inflammation;
      2. infiltrative (phlegmonous) form;
      3. the stage of abscessing;
      4. gangrenous.
   2. Chronic:
      1. nonspecific;
      2. specific.
2.  By localization:
   1. Subareolar
   2. Antemarine (premarishing).
   3. Intramarine:
      1. parenchymal
      2. interstitial.
   4. Retromamarny.
   5. Panmastitis.

In newborns, one breast is most often involved in the process, and all at once, so it's 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 breast, rapidly growing pain. The pain is intense, it can be of a pulsating nature, it does not radiate, it increases with palpation of the gland. Such an inflammatory process causes an early rise in body temperature to high digits (39-40). As a result of the inflammatory process, weakness develops, a child's anxiety, a shrill scream. Further there is a pronounced hyperemia and fluctuation of the skin over the site of inflammation. The general condition is disturbed, an intoxication syndrome is expressed, appetite is reduced, sluggish sucking. Passing through the successive stages of the disease, at the stage of formation of the gangrenous or phlegmonous process, the condition of the child can be significantly aggravated. The body temperature rises quickly, which can not be reduced. The child begins to refuse to eat, he can always sleep or on the contrary shouting. On the skin can be seen a dark gray or blue color of the inflammatory process, which can shine through the thin skin of the child. The inflammatory process spreads very quickly and the child's condition can worsen in a few hours. Therefore purulent mastitis in a newborn occurs most often when the process quickly passes from the serous stage to the stage of purulent inflammation. 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

The complications of mastitis can be the generalization of infection with the development of sepsis in just a few hours, so it's just necessary to begin treatment immediately after the diagnosis is established. The consequence of the operation can be a violation of lactation in the future, if it is a girl, but such consequences are not comparable to the health of the baby. The prognosis can be very serious, therefore it is necessary to prevent such pathology.

[12], [13], [14]

Diagnostics of the mastitis in newborns

Diagnosis of mastitis is not difficult, even by external characteristics. First, you need to listen to all the complaints of my mother and find out how the symptoms developed. The benefit of mastitis is evidenced by high body temperature, acute onset of the disease, impaired state of the child.

When examined, the diagnostic signs of the pathology are very simple - the enlarged hyperemia mammary gland is visible, sometimes the local temperature can be increased. When palpation, it can be noted that the child begins to cry and you can feel the fluctuation or uneven consistency due to the accumulation of pus.

As a rule, the diagnosis is not in doubt in the presence of such objective symptoms. Additional research methods for a newborn baby can be complex. Therefore, if the child was healthy before, then limited to general clinical analysis. Changes may be characteristic of a pronounced bacterial infection with high leukocytosis and an increase in ESR. But the absence of changes in the analysis of blood does not exclude acute bacterial inflammation, because due to the immaturity of the immune system, a pronounced reaction may not be.

Instrumental diagnosis of mastitis is not often used, as there is no need for a pronounced clinic. Therefore, only for the purpose of differential diagnosis can be carried out ultrasound.

Thermography: zones are formed with increasing temperature locally.

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

[15], [16], [17]

Differential diagnosis

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

Mastitis also needs to be differentiated with 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 common symptoms. Appetite and sleep of a child, as a rule, is preserved, in contrast to mastitis.

Treatment of the mastitis in newborns

Treatment of mastitis is complex - it is compulsory for such small children to use surgery and massive antibacterial therapy.

The tactics of treatment 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 performed, with the formation of an abscess and purulent focus, surgical intervention is performed.

Conservative treatment.

1. Mode: bed; for the baby's mammary gland, it is necessary to give her the minimum conditions for traumatization with the help of a suspension that must hold the gland, rather than squeeze it.
2. Locally cold the bladder with ice through the gauze to the affected areas of the gland for 20 minutes every 1-1.5 hours.
3. Retromamarnaya novocainic blockade: 70-80ml 0.25-0.5% solution of novocaine + antibiotic in infants is rarely carried out because of the complexity of the technique.
4. Antibiotic therapy according to the modern principles of its conduct and after bacterial analysis and flora studies on sensitivity.
5. Stimulation of the body's defenses: the introduction of antistaphylococcal J-globulin, immunomodulators, and autohemotherapy.
6. Massage of the gland.

Treatment of mastitis in a newborn with the use of drugs provides for the use of two broad-spectrum antibiotics. For this purpose, you can use the following preperates:

1. Ampicillin is an antibiotic from the group of aminopennicillins, which acts on most microorganisms, which in newborns can cause skin inflammation and the development of mastitis. The drug destroys the bacterial wall and neutralizes the cell membrane, disrupting its multiplication. 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 not less than one week. Method of application - in the form of a suspension, dividing the daily dose into three doses. Side effects can be in the form of allergic reactions, and also due to the effect in newborns on the intestines can be diarrhea. Precautions - do not use with an allergy in the history of this group of drugs.
2. Amikacin is an antibiotic from the aminoglycoside group, which is widely used in combination with ampicillin for the treatment of mastitis. The mechanism of action of the drug is associated with disruption of the ribosome and the violation 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 in the oral form, and the other in the parenteral. Therefore, the method of application of this drug is recommended intramuscular or intravenous. Dosage is 15 milligrams per kilogram in two doses. Side effects can be in the form of systemic or skin allergic reactions.
3. Cefodox oral cephalosporin III generation, which does not die in the presence of bacteria that contain lactamases. The drug is well absorbed when taken internally and is immediately divided into fractions, circulating in blood throughout the day. This allows you to maintain the necessary concentration of the drug in the inflammation focus, given that other antibiotics may not accumulate well in the mammary tissue of mastitis. The mechanism of action of the drug consists in the activation of enzymes that contribute to the destruction of the bacterial wall and the exit of the endotoxin of the bacterium (a violation of the synthesis of polysaccharides in the wall of the cell of the microorganism). This ensures the death of the pathogen in mastitis and prevents the development of further infection. Dosage of 10 mg / kg per day, divided into one or two doses. Combine the use of cefodox with a parenteral antibiotic from the group of macrolides or aminoglycosides, and in severe cases with fluoroquinolones.
4. Paracetamol is a drug that is used to treat mastitis to reduce high body temperature in a newborn. The main mechanism of action of paracetamol is oppression of the synthesis of prostaglandins. These substances potentiate the inflammatory reaction due to the synthesis of inflammatory substances. The drug blocks the release of these substances and reduces the temperature and other symptoms of inflammation. In addition to lowering 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 as a syrup. Dosage of 10-15 milligrams per kilogram of body weight at one time. You can repeat the reception at least 4 hours after the last time. The syrup is released in a dose of 120 milligrams in five milliliters, which is already calculated on the body weight. Side effects from the gastrointestinal tract in the form of dyspeptic disorders, erosions and ulcers of the stomach and duodenum, can be bleeding and perforation.

From antibacterial agents use at least two, and sometimes three antibiotics, one of which is necessarily administered intravenously.

1. Nethylmicin is an antibiotic of the aminoglycoside group, which 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 not less than 7-10 days. Side effects are possible with the influence on the stomach - develops colitis or dysbiosis, which manifests by bloating, a violation of the stool, so when using therapy in children, it is necessary to use probiotics. Precautions - do not use with kidney damage.
2. Clarithromycin is an antibacterial agent from the macrolide group. Among the known drugs has the maximum activity with respect to intracellular parasites, is able to accumulate in the cell, in inflammatory foci, does not lose qualities under the influence of lysosomes, that is, it acts on possible pathogens of mastitis, thus interrupting the persistence of the pathogen. Clarithromycin has a long half-life. The method of application depends on the age and can be in the form of suspension or tablets, but the initial stages are better to start the reception intramuscularly in parallel with another antibiotic. It is prescribed for children older than 3 years and the dosage is 10 mg / kg / day on the first day, from 2 to 7-10 days - 5 mg / kg / day 1 time per day. A mandatory condition is eating two hours after a meal or an hour before it. The course of treatment is 5-7-10 days. Side effects of azithromycin - paresthesia, violations of skin sensitivity, numbness of the hands and feet, tremor, violation of the outflow of bile, as well as dyspepsia. Precautions - do not use for cholestasis or cholelithiasis.
3. Panadol is an antipyretic medicine in the form of a suspension to reduce the temperature in children. This is an indispensable element of treatment, because with mastitis, the temperature can rise to a significant number and cause a health threatening to the child's health. The main active ingredient is paracetamol. One hundred milliliters of the suspension contains one hundred and twenty milligrams of the substance. The way of using the drug - inside a single dose, you can repeat the reception no earlier than four hours later. 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, can be an inhibition of the formation of blood cells, swelling of the larynx, lowering of the sugar level. Precautions - can not be used 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 the phase I phase of inflammation, preference should be given to multicomponent water-soluble ointments on a polyethylene oxide basis, levosin, levomecol, and ofcocaine. They simultaneously have antibacterial, dehydrating and analgesic effect, and also due to the presence in their composition of such a component as methyluracil, contribute to the activation of the reparative process. In the presence of necrosis areas that are not removed during surgery, proteolytic enzymes are used. In the regeneration phase, it is advisable to use aqueous solutions of antiseptics dioxydin, chlorhexidine, furacilin.

An obligatory element of treatment of mastitis in newborns is surgical treatment, as the accumulation of pus in such a baby spreads quickly and without surgery the disease will not be resolved. Immediately after determining the diagnosis, the child immediately hospitalized in the children's surgical department. Under general anesthesia, in an urgent order, an operation is performed. The volume of the operation is to make incisions on the skin of the affected area of the breast in a checkerboard pattern. They can be a large number, depending on the volume of the affected gland. The incisions are made in such a way that they are located on the verge of healthy and affected skin. Next, drainages are installed, through which an active washing of such a site is carried out. Then drainage is left for a better outflow of pus. The dressings should be done after the operation several times a day and the mother should monitor this. Feeding such a child continues in normal mode with breast milk, which provides better protection for the child. In addition, symptomatic therapy is also used.

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

• wound healing pulsating fluid;
• vacuum wound treatment;
• laser treatment;
• sonication.

Vitamins and physiotherapy can be carried out at the stage of convalescence, when it is necessary to support the protective forces of the baby.

Alternative treatment, herbal treatment and homeopathic remedies for mastitis are not used, since such a disease in the neonatal period has lethal consequences that are rapidly developing. Alternative methods do not have such a property of rapid elimination of pus, therefore are not recommended for use by doctors.

Prevention

The main methods of prevention is proper care for the newborn, the implementation of the doctor's recommendations, and when symptoms of "anxiety" appear in the child, you need to urgently seek advice.

Mastitis in newborns, unfortunately a frequent phenomenon, but given the timely diagnosis and treatment, the mortality from this pathology has significantly decreased. But despite this, serious complications can develop, which requires caution from the mother in the first place and prevention of the disease.

[18], [19]