Mammary candidiasis: A medical condition without scientific evidence?

Metabolomics Approach to Identify Biomarkers of Acute and Subacute Mastitis in Milk Samples: A Pilot Case-Control Study

Background and aims: Mastitis is one of the main complications during breastfeeding and contributes to the cessation of breastfeeding. However, the etiopathogenesis and diagnosis of mastitis are complex and not yet well defined. We aimed to identify metabolic and lipidic changes in human milk during acute and subacute mastitis in order to detect potential biomarkers of mastitis. Methods: We conducted a pilot case-control study including 14 breastfeeding women with acute mastitis, 32 with subacute mastitis symptoms, and 19 without any mastitis symptoms (control). Milk samples were collected and analyzed by proton nuclear magnetic resonance (H-NMR) for metabolomics analysis. To assess the association between the significant metabolites and lipids and the development of acute and subacute mastitis, multi-adjusted logistic regression models were developed. Results: The NMR-based metabolomics approach was able to identify and quantify a total of 40 metabolites in breast milk samples. After adjusting for confounding variables, acute mastitis was significantly associated with acetate (OR 3.9 IC 1.4-10.8), total cholesterol (OR 14 CI 3.2-62), esterified cholesterol (OR 3.3 CI 1.9-5.8), and sphingomyelin (OR 2.6 CI 1.2-5.8). The other metabolites presented weak association (OR < 2.5). Subacute mastitis was significantly associated with glutamine, lysophosphatidylcholine, phosphatidylcholine, plasmalogen, and total polyunsaturated fatty acids, but only cholesterol showed a strong association (OR > 2.5) with an OR of 2.6 (IC 1.1-6.6). Conclusions: Metabolic alteration in breast milk occurs during a process of both acute and subacute mastitis. Acetate, esterified cholesterol, lysophostidylcholine, and polyunsaturated fatty acids increased in both acute and subacute mastitis. However, according to the multi-adjusted regression logistic models, the candidate biomarkers for acute and subacute mastitis are cholesterol, lysophosphatidylcoholine, phosphatidylcholine, plasmalogen, and polyunsaturated fatty acids.

Influence of donor characteristics on the milk donation volume and microbiological quality of donated human milk in first 3 years of work of the Croatian human milk bank-retrospective observational study

OBJECTIVES

Donated human milk is the best possible alternative when mother's own milk is not available. The aim of this study is to investigate whether there are differences in the milk donation volumes and microbiological quality of donated milk depending on human milk donors (HMDs) characteristics.

METHODS

We analyzed data on the HMDs who donated milk in the first three years of work of human milk bank (HMB) - November 2019 to January 2023. The data on the volume of donated milk in L and suitable microbiological quality assessed by the number and isolated species of bacteria were collected from questionnaires filled out by HMDs and documentation administered by HMB employees and are presented using descriptive and comparative statistics.

RESULTS

Two hundred HMDs were included in this study. The majority of them are between 26 and 35 years of age, reside in capital city or the surrounding county, have given birth to a full-term child vaginally, and express surplus milk through a breast pump. Donor mothers of preterm born infants (14.5 %) donated greater quantities, there is statistically significant difference in the median of volume of milk donated (9.6 vs. 6.4, p=0.026). Milk expressed manually shows better results in microbiological quality (median percentage 100 vs. 82 vs. 100, p=0.040), while by comparing other characteristics of the donors, no difference was found between the groups.

CONCLUSIONS

It is important to be aware of the characteristics of previous HMDs in order to direct the HMB future promotional and educational activities.

Differences in Diagnosis and Treatment of Nipple Conditions of Reproductive-Age Women at a Tertiary Health System

Background: Nipple-areolar complex (NAC) conditions affect reproductive-age women, yet it is not known how care of NAC complaints is distributed among medical specialties. There is a need to characterize all NAC conditions, including their treatment and the care team involved in their clinical management, of nonlactating and lactating patients to determine care gaps. Materials and Methods: This was a retrospective cohort study of reproductive-age females who presented to a large tertiary health system with an NAC complaint between 2015 and 2020. Data about the symptoms, diagnosis, specialty providing care, diagnostic considerations, and treatments were collected. Results: Nipple pain, dermatitis, and thrush were the most common diagnoses among 407 encounters (215 patients). Lactating patients represented half (204, 50%) of the study sample. Benign breast conditions like obstructed ductal openings, accessory nipples, nipple growth, inverted nipples, and chronic and bacterial infections represented a third of all encounters. Primary care physicians (167, 41%) and obstetricians (105, 26%) provided most of the care and referred a third and quarter of patients, respectively, to another provider. Conclusion: The care of patients with NAC complaints is not limited to obstetricians. Internal medicine, family medicine, emergency medicine, and obstetrician-gynecology, dermatology, and surgery resident physicians should receive training in benign breast conditions and clinical lactation.

Breastmilk microbiome changes associated with lactational mastitis and treatment with dandelion extract

Introduction

Dandelion (Pugongying) is one of the most frequently used Chinese herbs for treating lactational mastitis (LM). Pugongying granules, a patented medication primarily comprised of dandelion extract, have been approved by CFDA for LM treatment in China. The aims of this study were to investigate the etiology of LM and the mechanism by which Pugongying granules decrease LM symptoms, with a particular focus on the microbial communities found in breastmilk.

Methods

Participants were recruited from a previously performed randomized controlled trial (Identifier: NCT03756324, ClinicalTrials.gov). Between 2019 and 2020, women diagnosed with unilateral LM at the Beijing University of Chinese Medicine Third Affiliated Hospital were enrolled. In total, 42 paired breastmilk samples from the healthy and affected breasts of the participants were collected. Additionally, 37 paired pre- and post-treatment breastmilk samples from the affected breast were collected from women who received a 3-day course of either Pugongying granules (20 women) or cefdinir (17 women). Clinical outcomes [e.g., body temperature, visual analogue scale (VAS) score for breast pain, the percentage of neutrophils (NE%)] were analyzed pre- and post-treatment, and the breastmilk samples were subjected to 16S rRNA gene sequencing to analyze the alpha and beta diversities and identify significant bacteria. Finally, the relationship between microorganisms and clinical outcomes was analyzed.

Results

There was no significant difference in fever and pain between the Pugongying group and cefdinir group. The most prevalent bacterial genera in breastmilk were Streptococcus and Staphylococcus. Compared to healthy breastmilk, microbial diversity was reduced in affected breastmilk, and there was a higher relative abundance of Streptococcus. After Pugongying treatment, there was an increase in microbial diversity with significantly higher abundance of Corynebacterium. A negative correlation was found between Corynebacterium, VAS score, and NE%. Treatment with cefdinir did not affect microbial diversity. Taken together, our results show a correlation between LM and reduced microbial diversity, as well as an increased abundance of Streptococcus in affected breastmilk.

Conclusion

Pugongying granules enhanced microbial diversity in breastmilk samples. Given the substantial variation in individual microbiomes, identifying specific species of Streptococcus and Corynebacterium associated with LM may provide additional insight into LM pathogenesis and treatment.

Initiating and Supporting Breastfeeding: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Exclusive breastfeeding is recommended for children for the first 4 to 6 months of life, with complementary foods added thereafter. It is the most ecological way of protecting the child's and mother's health. Training of health professionals is required to avoid transmitting inconsistent information in 3 areas: 1) implementing these 3 predictors: safe skin-to-skin, first breastfeed, and rooming-in 24/7; 2) teaching and monitoring: i) early signs of waking and feeding rhythms, ii) positioning and latching, and iii) signs of effective transfer; and 3) referring women to specialized support services if difficulties arise (eg, inadequate milk production, pain, cracked nipples, engorgement). Breastfeeding should continue during mastitis or an abscess. Ultrasound-guided needle aspiration is beneficial in treating an abscess. Précis: Information is provided to enable health professionals to better support breastfeeding and help women with the most common difficulties, thus promoting breastfeeding initiation and duration.

Methodological approaches for studying the human milk microbiome

Human milk contains a low-biomass, low-diversity microbiome, consisting largely of bacteria. This community is of great research interest in the context of infant health and maternal and mammary health. However, this sample type presents many unique methodological challenges. In particular, there are numerous technical considerations relating to sample collection and storage, DNA extraction and sequencing, viability, and contamination. Failure to properly address these challenges may lead to distortion of bacterial DNA profiles generated from human milk samples, ultimately leading to spurious conclusions. Here, these technical challenges are discussed, and various methodological approaches used to address them are analyzed. Data were collected from studies in which a breadth of methodological approaches were used, and recommendations for robust and reproducible analysis of the human milk microbiome are proposed. Such methods will ensure high-quality data are produced in this field, ultimately supporting better research outcomes for mothers and infants.

Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Recent concepts in fungal involvement in skin and soft tissue infections

As the at-risk population expands and new antifungal resistance patterns develop, it is critical to understand and recognize cutaneous manifestations of old and emerging fungal diseases.

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the most frequent and emerging deep cutaneous fungal infections following either primary inoculation or secondary spread after haematogenous seeding in disseminated infections in different geographical areas.

RECENT FINDINGS

Fungal skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions based on the site of the infection, route of acquisition of the pathogen, epidemiological setting and the virulence of the fungus in relation to the host. The approach to a patient suspected of having a fungal SSTI is complex and usually poses a major diagnostic challenge. The treatment approach should include attempts at immune reconstitution, targeted antifungal therapy and/or aggressive surgical debridement.

SUMMARY

Fungal SSTIs can be an important cause of morbidity and mortality in both immunocompromised and immunocompetent patients and are being reported with increasing frequency worldwide.

Microbiological Quality of Milk Donated to the Regional Human Milk Bank in Warsaw in the First Four Years of Activity

As the survival rate for preterm infants increases, more emphasis is placed on improving health-related quality of life through optimal nutritional management. Human Milk Banks (HMBs) provide bioactive nutrients and probiotic microorganisms to premature newborns, especially in the first year of life. Donated milk screening and selection of potential donors ensures the quality and microbiological safety of the donated milk. Therefore we reviewed the basic characteristics of donors and the amounts and contamination of breast milk donated to the Regional Human Milk Bank (RHMB) in Warsaw. In four years, the RHMB collected 1445.59 L of milk, of which 96.60% was distributed among hospitalised infants. Additionally, breastmilk from donor candidates (139 samples from 96 women) was tested at least once in the first year of lactation. First analyses showed that 18 women’s milk samples were microbiologically pure, and 78 samples had one or more species of commensal and/or potentially pathogenic bacteria. In human milk samples from 31 women, the bacteria level was above the standard required by the RHMB; therefore, donors were re-educated, and further samples were tested. Most women followed the recommendations on hygienic expression and storage of milk before transfer to the RHMB. Our analysis will help to increase the accessibility and quality of raw donor milk and to meet the needs of more newborns.

Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management

Despite the known benefits of breastfeeding for both infant and mother, clinical support for problems such as benign inflammation of the lactating breast remain a research frontier. Breast pain associated with inflammation is a common reason for premature weaning. Multiple diagnoses are used for benign inflammatory conditions of the lactating breast which lack agreed or evidence-based aetiology, definitions, and treatment. This article is the second in a three-part series. This second review analyses the heterogeneous research literature concerning benign lactation-related breast inflammation from the perspectives of the mechanobiological model and complexity science, to re-think classification, prevention, and management of lactation-related breast inflammation. Benign lactation-related breast inflammation is a spectrum condition, either localized or generalized. Acute benign lactation-related breast inflammation includes engorgement and the commonly used but poorly defined diagnoses of blocked ducts, phlegmon, mammary candidiasis, subacute mastitis, and mastitis. End-stage (non-malignant) lactation-related breast inflammation presents as the active inflammations of abscess, fistula, and septicaemia, and the inactive condition of a galactocoele. The first preventive or management principle of breast inflammation is avoidance of excessively high intra-alveolar and intra-ductal pressures, which prevents strain and rupture of a critical mass of lactocyte tight junctions. This is achieved by frequent and flexible milk removal. The second preventive or management principle is elimination of the mechanical forces which result in high intra-alveolar pressures. This requires elimination of conflicting vectors of force upon the nipple and breast tissue during milk removal; avoidance of focussed external pressure applied to the breast, including avoidance of lump massage or vibration; and avoidance of other prolonged external pressures upon the breast. Three other key preventive or management principles are discussed. Conservative management is expected to be effective for most, once recommendations to massage or vibrate out lumps, which worsen micro-vascular trauma and inflammation, are ceased.

Dietary Habits and Relationship with the Presence of Main and Trace Elements, Bisphenol A, Tetrabromobisphenol A, and the Lipid, Microbiological and Immunological Profiles of Breast Milk

Breastfeeding is the best way to feed an infant, although it can also be a source of abiotic contaminants such as heavy metals or bisphenol A (BPA). The early life exposure to these compounds can lead to serious toxic effects in both the short and long-term. These substances can reach breast milk through the mother’s habits, diet being one of the main routes of exposure. The aim of the present work was to analyse possible associations between the dietary habits of women and the content of major trace elements, BPA, fatty acids and lipids, and the microbiological and immunological profiles of human milk. Possible associations between major trace elements and BPA and the lipid, microbiological and immunological profiles were also analysed. The results of this study support that the microbiological composition of human milk is associated with the dietary habits of the women, and that the consumption of canned drinks is related to the presence of BPA in human milk. Furthermore, some relationships were found between the amount of major trace elements and the microbiological and immunological profile of the milk samples. Finally, the presence of BPA was associated with changes in the immunological profile of human milk.

Inoculation of mother's own milk could personalize pasteurized donor human milk used for feeding preterm infants

BACKGROUND

Human milk is a vehicle for bioactive compounds and beneficial bacteria which promote the establishment of a healthy gut microbiome of newborns, especially of preterm infants. Pasteurized donor human milk (PDHM) is the second-best option when preterm mother's own milk is unavailable. Since pasteurization affect the microbiological quality of donor milk, PDHM was inoculated with different preterm milk samples and then incubated, in order to evaluate the effect in terms of bacterial growth, human milk microbiome and proteolytic phenomena.

METHODS

In an in-vitro study PDHM was inoculated at 10% v/v using ten preterm milk samples. Microbiological, metataxonomic and peptidomic analyses, on preterm milk samples at the baseline (T0), on PDHM and on inoculated milk (IM) samples at T0, after 2 h (T1) and 4 h (T2) of incubation at 37 °C, were conducted.

RESULTS

IM samples at T2 showed a Total Bacterial Count not significantly different (p > 0.01) compared to preterm milk samples. At T2 lactic acid bacteria level was restored in all IM. After inoculation, metataxonomic analysis in IM samples showed that Proteobacteria remained the predominant phylum while Firmicutes moved from 3% at T1 to 9.4% at T2. Peptidomic profile of IM resembled that of PDHM, incubated for the same time, in terms of number and type of peptides.

CONCLUSION

The study demonstrated that inoculation of PDHM with mother's own milk could restore bacterial growth and personalize human milk microbiome in PDHM. This effect could be beneficial because of the presence of maternal probiotic bacteria which make PDHM more similar to mother's own milk.

It's Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain

Introduction: Health care providers treating lactating women for nipple and breast pain often attribute symptoms to Candida albicans infection. However, multiple other conditions may present with pain, erythema, and pruritis. We explored the experience of a breastfeeding medicine practice that received referrals for patients failing antifungal therapy and who desired further evaluation for alternative diagnoses. Materials and Methods: We conducted a retrospective chart review of breastfeeding women referred for evaluation of "yeast" to a breast surgery/breastfeeding medicine practice from July 2016 to August 2019. Results: Twenty-five women met inclusion criteria. Median age was 33 (range 24-43) and median months postpartum was 4 (range 0.5-18). All 25 women reported minimal to no improvement on oral and/or topical antifungal therapy. In addition to history and examination, milk culture was obtained in four women, punch biopsy in one, and core needle biopsy in one. No woman was confirmed to have a diagnosis of Candida. Diagnoses were changed to the following: subacute mastitis/mammary dysbiosis (n = 8), nipple bleb (n = 6), dermatitis (n = 6), vasospasm (n = 2), milk crust (n = 1), hyperlactation (n = 1), and postpartum depression (n = 1). Treatment included discontinuation of antifungal medication, as well as the following per individual diagnoses: antibiotics and probiotics; 0.1% triamcinolone cream; heat therapy; discontinuation of exclusive pumping; and antidepressant medication and counseling referral. All women experienced resolution of symptoms following revision of diagnosis and change in management (range 2-42 days). Conclusion: While persistent nipple and breast pain in breastfeeding is often attributed to Candida, this cohort demonstrates that providers should consider multiple other conditions in their differential diagnosis. Accurate, timely diagnosis is crucial, as pain is a risk factor for premature cessation of breastfeeding. Symptomatic resolution occurs on appropriate therapy.

Management of idiopathic granulomatous mastitis in lactation: case report and review of the literature

Background

Idiopathic Granulomatous Mastitis (IGM) is a benign chronic inflammatory breast condition that mimics two common breast disorders: breast carcinoma and breast abscess. It can form breast masses, fistulae, and fluid collections, resulting in breast disfigurement with retraction and nipple areolar complex (NAC) inversion. IGM most often presents in women of childbearing age within a few years of pregnancy, and can significantly impact lactation. Despite the prevalence of this disease, no current literature describes an approach to managing IGM during breastfeeding.

Case presentation

A 28-year-old G3P2 patient of Native American origin presented to her obstetrician at 7 months pregnant with worsening left breast swelling and redness. She underwent a mammogram, ultrasound and core needle biopsy that confirmed the diagnosis of Idiopathic Granulomatous Mastitis. During the postpartum period, she underwent intralesional triamcinolone injections of her left breast. Due to the contraindication of breastfeeding after local steroid injection, the patient stopped breastfeeding from the affected breast and continued breastfeeding unilaterally.

Conclusions

Idiopathic Granulomatous Mastitis is a challenging chronic inflammatory breast disease that affects women primarily in the reproductive years, with a higher incidence in patients of Hispanic, Native American, Middle Eastern, and African descent. Treatment of IGM during pregnancy and lactation has thus far not been addressed. We review the literature on the treatment of IGM in the non-lactating population, and propose considerations for treating breastfeeding women affected by this disease. Traditional treatment has included systemic immunosuppression and surgery, but newer literature demonstrates that intralesional injection of steroid can provide significant symptomatic relief to patients. A diagnosis of IGM does not preclude breastfeeding, though patients may experience challenges with milk production and latch on the affected breast. Individualized care should be provided, with considerations given to the following: side effects of systemic steroids, the need to wean a breast being treated with intralesional steroids, and augmentation of milk production on the unaffected breast to promote continued breastfeeding.

Impact of expression mode and timing of sample collection, relative to milk ejection, on human milk bacterial DNA profiles

AIM

To investigate the impact of expression mode: electric breast pump or hand expression, and timing of sample collection: pre- and post-milk ejection on human milk (HM) bacterial DNA profiles.

METHODS AND RESULTS

Three HM samples from the same breast were collected from 30 breastfeeding mothers: a pre-milk ejection pump-expressed sample (pre-pump), a post-milk ejection pump-expressed sample (post-pump) and a post-milk ejection hand-expressed sample (post-hand). Full-length 16S rRNA gene sequencing was used to assess milk bacterial DNA profiles. Bacterial profiles did not differ significantly based on mode of expression nor timing of sample collection. No significant differences were detected in the relative abundance of any OTUs based on expression condition (pre-pump/ post-pump and post-pump/post-hand) with univariate linear mixed-effects regression analyses (all P-values > 0·01; α = 0·01). Similarly, no difference in richness was observed between sample types (number of observed OTUs: post-pump/post-hand P = 0·13; pre-pump/post-pump P = 0. 45).

CONCLUSION

Bacterial DNA profiles of HM did not differ according to either expression method or timing of sample collection.

SIGNIFICANCE AND IMPACT OF THE STUDY

Hand or pump expression can be utilized to collect samples for microbiome studies. This has implications for the design of future HM microbiome studies.

New perspectives on the topical management of recurrent candidiasis

Candidiasis is a common opportunistic infection caused by fungi of the Candida genus that affects mainly mucocutaneous tissues (e.g., vaginal, oral, and mammary). This condition has been known for a long time; thus, innumerous topical and systemic treatments are already available on the market worldwide. Yet, recurrent superficial candidiasis (RSC) is an expected outcome, still lacking effective and convenient treatments. Although several individual conditions may contribute to disease recurrence, biofilms' presence seems to be the main etiological factor contributing to antifungal resistance. More than proposing novel antifungal agents, current research seems to be focusing on improving the pharmaceutical technology aspects of formulations to address such a challenge. These include extending and improving intimate contact of drug delivery systems with the mucocutaneous tissues, increasing drug loading dose, and enhancing topical drug permeation. This review discusses the current understanding of the RSC and the use of pharmaceutical technology tools in obtaining better results. Even though several drawbacks of conventional formulations have been circumvented with the help of nano- or microencapsulation techniques and with the use of mucoadhesive formulation excipients, many challenges remain. In particular, the need to mask the unpalatable taste of formulations for the treatment of oral candidiasis, and the necessity of formulations with a "dryer" sensorial feeling and improved performances in providing higher bioavailability for the treatment of mammary and vaginal candidiasis.

Capturing the diversity of the human milk microbiota through culture-enriched molecular profiling: a feasibility study

Previous human milk studies have confirmed the existence of a highly diverse bacterial community using culture-independent and targeted culture-dependent techniques. However, culture-enriched molecular profiling of milk microbiota has not been done. Additionally, the impact of storage conditions and milk fractionation on microbiota composition is not understood. In this feasibility study, we optimized and applied culture-enriched molecular profiling to study culturable milk microbiota in eight milk samples collected from mothers of infants admitted to a neonatal intensive care unit. Fresh samples were immediately plated or stored at -80°C for 2 weeks (short-term frozen). Long-term samples were stored at -20°C for >6 months. Samples were cultured using 10 different culture media and incubated both aerobically and anaerobically. We successfully isolated major milk bacteria, including Streptococcus, Staphylococcus and Bifidobacterium, from fresh milk samples, but were unable to culture any bacteria from the long-term frozen samples. Short-term freezing shifted the composition of viable milk bacteria from the original composition in fresh samples. Nevertheless, the inter-individual variability of milk microbiota composition was observed even after short-term storage. There was no major difference in the overall milk microbiota composition between milk fractions in this feasibility study. This is among the first studies on culture-enriched molecular profiling of the milk microbiota demonstrating the effect of storage and fractionation on milk microbiota composition.

Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women

BACKGROUND

Breastfeeding mothers commonly experience nipple pain accompanied by radiating, stabbing or constant breast pain between feeds, sometimes associated with pink shiny nipple epithelium and white flakes of skin. Current guidelines diagnose these signs and symptoms as mammary candidiasis and stipulate antifungal medications.

AIM

This study reviews existing research into the relationship between Candida albicans and nipple and breast pain in breastfeeding women who have been diagnosed with mammary candidiasis; whether fluconazole is an effective treatment; and the presence of C. albicans in the human milk microbiome.

METHOD

The author conducted three searches to investigate (a) breastfeeding-related pain and C. albicans; (b) the efficacy of fluconazole in breastfeeding-related pain; and (c) composition of the human milk mycobiome. These findings are critiqued and integrated in a narrative review.

RESULTS

There is little evidence to support the hypothesis that Candida spp, including C. albicans, in maternal milk or on the nipple-areolar complex causes the signs and symptoms popularly diagnosed as mammary candidiasis. There is no evidence that antifungal treatments are any more effective than the passage of time in women with these symptoms. Candida spp including C. albicans are commonly identified in healthy human milk and nipple-areolar complex mycobiomes.

DISCUSSION

Clinical breastfeeding support remains a research frontier. The human milk microbiome, which includes a mycobiome, interacts with the microbiomes of the infant mouth and nipple-areolar complex, including their mycobiomes, to form protective ecosystems. Topical or oral antifungals may disrupt immunoprotective microbial homeostasis. Unnecessary use contributes to the serious global problem of antifungal resistance.

CONCLUSION

Antifungal treatment is rarely indicated and prolonged courses cannot be justified in breastfeeding women experiencing breast and nipple pain. Multiple strategies for stabilizing microbiome feedback loops when nipple and breast pain emerge are required, in order to avoid overtreatment of breastfeeding mothers and their infants with antifungal medications.

Candida and Breastfeeding: A Critical Commentary on the Dilemmas Around Diagnosis, Treatment, and Management

Objective

The etiology of nipple pain in breastfeeding women can be challenging for healthcare professionals. The most common cause of nipple pain or damage in breastfeeding women is poor latch and positioning of the baby at the breast (Duncan, 2015). However, when position and attachment is not identified as the cause, controversy exists as to the etiology of the pain with nipple or breast thrush identified as a probable suspect.

Review

The literature was reviewed to explore the diagnosis and management of thrush in breastfeeding women.

Findings

There is a lack of robust evidence in the literature to support an accurate diagnosis of candida as the cause of nipple and/or deep breast pain in breastfeeding women. Diagnosis and management strategies vary between the USA and Europe.

Conclusion

It is important that clinicians supporting and working with breastfeeding women are aware of the differential diagnosis for both breast and nipple pain, as well as utilize their clinical skills effectively to offer the correct treatment and management to women presenting with candida like symptoms (Amir et al., 2013, Wilson-Clay & Hoover, 2017). Culture and sensitivity of mothers expressed milk may be supportive of a diagnosis; however, analysis of mothers' milk is not without its challenges. Breastfeeding women should not be treated for potential candida infection with a traditional clinical examination alone.

Candida albicans Mastitis in Breastfeeding Woman: An Under Recognized Diagnosis

Breastfeeding has been demonstrated to have many benefits for both mother and child. The diagnosis and management of Candida in the breastfeeding dyad are difficult because diagnosis is most often based on subjective signs and symptoms. Few studies have attempted to confirm the diagnosis with biological tests. A 26-year-old breastfeeding mother presented with stabbing breast pain, accompanied by erythematous, hyperkeratotic areola, and nipples. Histopathological results and direct mycological examination, followed by culture and auxanogram, revealed Candida albicans as an etiological agent of mastitis; the case was managed successfully by antifungal medication. Candida mastitis in lactating women is an under-recognized and under-treated cause of breast pain, hyperkeratosis over areola, and discharge of nipple should be assessed by biological tests. The hope is that with an increased awareness of this infection, more mothers will be appropriately treated and will thus be more likely to continue breastfeeding.

The Microbiota of the Human Mammary Ecosystem

Human milk contains a dynamic and complex site-specific microbiome, which is not assembled in an aleatory way, formed by organized microbial consortia and networks. Presence of some genera, such as Staphylococcus, Streptococcus, Corynebacterium, Cutibacterium (formerly known as Propionibacterium), Lactobacillus, Lactococcus and Bifidobacterium, has been detected by both culture-dependent and culture-independent approaches. DNA from some gut-associated strict anaerobes has also been repeatedly found and some studies have revealed the presence of cells and/or nucleic acids from viruses, archaea, fungi and protozoa in human milk. Colostrum and milk microbes are transmitted to the infant and, therefore, they are among the first colonizers of the human gut. Still, the significance of human milk microbes in infant gut colonization remains an open question. Clinical studies trying to elucidate the question are confounded by the profound impact of non-microbial human milk components to intestinal microecology. Modifications in the microbiota of human milk may have biological consequences for infant colonization, metabolism, immune and neuroendocrine development, and for mammary health. However, the factors driving differences in the composition of the human milk microbiome remain poorly known. In addition to colostrum and milk, breast tissue in lactating and non-lactating women may also contain a microbiota, with implications in the pathogenesis of breast cancer and in some of the adverse outcomes associated with breast implants. This and other open issues, such as the origin of the human milk microbiome, and the current limitations and future prospects are addressed in this review.

Effect of Sample Collection (Manual Expression vs. Pumping) and Skimming on the Microbial Profile of Human Milk Using Culture Techniques and Metataxonomic Analysis

Human milk microbiota is a unique bacterial community playing a relevant role in infant health, but its composition depends on different factors (woman health, lactation stage, and geographical lactation). However, information is lacking regarding some other factors that may affect the bacterial community of human milk. In this study we aimed to study the impact of the sample collection method and the skimming procedure using culture-dependent and culture-independent techniques to study the human milk microbial profile. One set of milk samples was provided by women (n = 10) in two consecutive days; half of the samples were collected the first day by manual expression and the other half on the second day by pumping. The rest of the participants (n = 17) provided milk samples that were fractionated by centrifugation; the bacterial profiles of whole milk and skimmed milk were compared by culture techniques in 10 milk samples, while those of whole milk, fat and skimmed milk were subjected to metataxonomic analysis in seven samples. Globally, the results obtained revealed high interindividual variability but that neither the use of single-use sterile devices to collect the sample nor the skimming procedure have a significant impact of the microbial profile of human samples.

Mastitis While Breastfeeding: Prevention, the Importance of Proper Treatment, and Potential Complications

Mastitis is an inflammation in the breast, which may involve a bacterial infection. Breast infection during breastfeeding is a common phenomenon that requires immediate and appropriate treatment. Without proper treatment, inflammation may lead to the cessation of breastfeeding. Another potential complication is the development of an abscess. Based on the nutritional and immunological value of breast milk, the recommendations of the American Academy of Pediatrics (AAP) and the World Health Organization (WHO) is exclusive breastfeeding up to 6 months of age, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infanRecent meta-analyses indicate breastfeeding protects against childhood infections, allows for a possible increase in intelligence, and for a reduction in overweight and diabetes. Breastfeeding is beneficial for nursing women as well. It is therefore important to help the mother overcome difficulties such as mastitis and to continue breastfeeding. The choice of a proper treatment and the provision of therapeutic instructions to the patient are crucial for a cure, for a successful duration of breastfeeding, and for preventing complications for mother and baby. In this article, we provide the latest clinical guidelines regarding drug treatment and supportive therapy in mastitis. We also discuss the latest guidelines of candida treatment, as candida infection may develop as a result of antibiotic therapy. Overall, improperly treated mastitis may cause the premature cessation of breastfeeding, and will cause suffering to both mother and baby; giving proper treatment and instructions to the mother are hence of the utmost importance.

Human milk fungi: environmental determinants and inter-kingdom associations with milk bacteria in the CHILD Cohort Study

Background

Fungi constitute an important yet frequently neglected component of the human microbiota with a possible role in health and disease. Fungi and bacteria colonise the infant gastrointestinal tract in parallel, yet most infant microbiome studies have ignored fungi. Milk is a source of diverse and viable bacteria, but few studies have assessed the diversity of fungi in human milk.

Results

Here we profiled mycobiota in milk from 271 mothers in the CHILD birth cohort and detected fungi in 58 (21.4%). Samples containing detectable fungi were dominated by Candida, Alternaria, and Rhodotorula, and had lower concentrations of two human milk oligosaccharides (disialyllacto-N-tetraose and lacto-N-hexaose). The presence of milk fungi was associated with multiple outdoor environmental features (city, population density, and season), maternal atopy, and early-life antibiotic exposure. In addition, despite a strong positive correlation between bacterial and fungal richness, there was a co-exclusion pattern between the most abundant fungus (Candida) and most of the core bacterial genera.

Conclusion

We profiled human milk mycobiota in a well-characterised cohort of mother-infant dyads and provide evidence of possible host-environment interactions in fungal inoculation. Further research is required to establish the role of breastfeeding in delivering fungi to the developing infant, and to assess the health impact of the milk microbiota in its entirety, including both bacterial and fungal components.

Breast Pathology That Contributes to Dysfunction of Human Lactation: a Spotlight on Nipple Blebs

Nipple blebs are blister-like fibrinous lesions that form on the surface of the nipple during lactation, and can result in orifice obstruction and mastitis. They likely result from superficial extension of underlying ductal plugging, and can present concurrently with hyperlactation and mammary dysbiosis. Despite their prevalence, few formal reports on nipple blebs exist. In this perspective, we review the experience of a breastfeeding medicine practice that receives referrals for patients with nipple blebs, and provide preliminary insight into etiology, management, and outcomes of these lesions.

Novel use of a continuous PECS II block for mastitis pain treatment

Nipple trauma and mastitis (an inflammatory condition of the breast) are common causes of intense pain during breast feeding. Although such pain normally results in early weaning, which has negative impacts on both maternal and child health, little is understood about the treatment of pain experienced during breast feeding. Here, we describe our experience with a woman who presented at 26 days post partum with a 15-day history of deep nipple wounds that caused bilateral mastitis and excruciating pain that radiated dorsally. Antibiotic, antifungal and non-pharmacological therapies were unsuccessful, and she wished to suspend breast feeding. We performed a bilateral pectoralis nerve block type II and inserted intrafascial catheters between the pectoralis minor and serratus muscles for continuous analgesia. Following block completion, the pain in her torso resolved immediately. The local anesthetic infusion continued for 40 hours and the patient had sustained analgesia with rapid healing of nipple lesions and her breast feeding commencing at 36 hours after block placement.

Mammary Dysbiosis and Nipple Blebs Treated With Intravenous Daptomycin and Dalbavancin

INTRODUCTION

Mammary dysbiosis, also known as subacute mastitis, may be associated with nipple blebs. These overlapping diagnoses represent a challenging clinical scenario during lactation. Little research has been published on etiology, management strategies, and outcomes of these concurrent diagnoses.

MAIN ISSUE

We document the treatment and outcome of a patient who presented with left-breast dysbiosis and nipple blebs and whose milk culture grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus. She was treated safely and effectively with intravenous daptomycin and dalbavancin. This has not been described previously in the lactation literature.

MANAGEMENT

The 35-year-old lactating gravida 3, para 3 patient presented at 6 months postpartum to a breast surgery clinic with a 1-week history of worsening deep left-breast pain, blebs, and recurrent plugging. She was afebrile and she had no erythema or induration on her breast exam. A culture of her milk grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus, and she was referred to infectious disease for assistance with intravenous antibiotic therapy. She continued to feed expressed milk throughout treatment and demonstrated complete resolution of symptoms 8 weeks later.

CONCLUSIONS

We report that in patients with a multi-drug-resistant, methicillin-resistant Staphylococcus aureus-positive human milk culture and a clinical presentation of mammary dysbiosis and nipple blebs, intravenous daptomycin and dalbavancin may be an effective treatment.

Maternal and Perinatal Factors Associated with the Human Milk Microbiome

Microbes are present in human milk regardless of the mother's health. The origins of the milk microbiota likely include the mother's skin, infant's mouth, and transfer from the maternal gastrointestinal (GI) tract. Prominent bacterial taxa in human milk are Staphylococcus and Streptococcus, but many other genera are also found including anaerobic Lactobacillus, Bifidobacterium, and Bacteroides. The milk microbiome is highly variable and potentially influenced by geographic location, delivery mode, time postpartum, feeding mode, social networks, environment, maternal diet, and milk composition. Mastitis alters the milk microbiome, and the intake of Lactobacilli has shown potential for mastitis treatment and prevention. Although milk and infant fecal microbiomes are different, their variations appear to be related - suggesting that milk is an important contributor of early GI colonization. Nonetheless, nothing is known regarding whether the milk microbiome influences infant health. Further research and clinical interventions are needed to determine if changes in the microbiomes of human milk and infant formula/food impact health.

Nonpharmacologic Approaches to Pain, Engorgement, and Plugging in Lactation: Applying Physical Therapy Techniques From Breast Cancer Care to Breastfeeding Patients

Introduction

Breast and nipple pain is one of the most common reasons why mothers stop breastfeeding earlier than recommended. Once conditions such as subacute mastitis, oversupply, and dermatitis have been treated or ruled out, functional breast pain may persist.

Review

We describe validated physical therapy techniques that may reduce chronic pain in breastfeeding. These techniques include lymphatic massage, reverse-pressure softening, kinesiology taping, neural mobilization, cupping, and therapeutic ultrasound.

Conclusion

While more commonly used in the breast cancer population after radiation and surgery, we propose these techniques may also prove efficacious in breastfeeding patients as well.

Human Milk Microbiome and Maternal Postnatal Psychosocial Distress

Human milk contains many bioactive components, including bacteria, which are transferred to the developing infant through breastfeeding. Milk bacteria appear to, amongst others, originate from the maternal gut. A mother’s postnatal psychosocial distress may alter maternal gut microbiota, which in turn may affect the bacteria present in milk. The aim of this study was to explore whether maternal postnatal psychosocial distress was related to alterations in the relative abundances of specific bacteria and to milk microbial diversity. Healthy mothers (N = 77; N = 51 with complete data) collected breast milk samples at 2, 6, and 12 weeks postpartum and filled in mood questionnaires on experienced stress, anxiety, and depressive symptoms at 6 weeks postpartum. A metataxonomic approach (16S rRNA gene sequencing (region V3 and V4) using Illumina MiSeq technology) was used to assess bacterial abundances and diversity. For the group as a whole, an increase in diversity of the milk bacterial community was observed during the first 3 months of breastfeeding (Shannon index). This general increase in diversity appears to be explained by an increase of Lactobacillus and other minor genera, together with a decrease in Staphylococcus. With respect to psychological distress and milk microbial composition, no significant differences in the relative abundance of major bacterial genera were detected between women with high (N = 13) and low (N = 13) psychosocial distress. However, progressive and distinct changes in the content of Firmicutes, Proteobacteria, and Bacteroidetes at the phylum level and Acinetobacter, Flavobacterium, and Lactobacillus at the genera level were observed in milk samples of women with low psychosocial distress. With respect to milk microbial diversity, high maternal psychosocial distress, compared to low maternal psychosocial distress, was related to significantly lower bacterial diversity in milk at 3 months post-delivery. Anxiety, stress, and depressive symptoms separately were unrelated to specific bacterial profiles. The current study suggests a potential relation between maternal psychosocial distress and milk microbiota, providing first evidence of a possible mechanism through which post-partum psychological symptoms may affect infant development and health.

Composition and Variation of the Human Milk Microbiota Are Influenced by Maternal and Early-Life Factors

Breastmilk contains a complex community of bacteria that may help seed the infant gut microbiota. The composition and determinants of milk microbiota are poorly understood. Among 393 mother-infant dyads from the CHILD cohort, we found that milk microbiota at 3-4 months postpartum was dominated by inversely correlated Proteobacteria and Firmicutes, and exhibited discrete compositional patterns. Milk microbiota composition and diversity were associated with maternal factors (BMI, parity, and mode of delivery), breastfeeding practices, and other milk components in a sex-specific manner. Causal modeling identified mode of breastfeeding as a key determinant of milk microbiota composition. Specifically, providing pumped breastmilk was consistently associated with multiple microbiota parameters including enrichment of potential pathogens and depletion of bifidobacteria. Further, these data support the retrograde inoculation hypothesis, whereby the infant oral cavity impacts the milk microbiota. Collectively, these results identify features and determinants of human milk microbiota composition, with potential implications for infant health and development.

Balancing the Use of Medications While Maintaining Breastfeeding

Breast milk is the most beneficial nutrition a mother can give her infant. Fortunately, the dose of most drugs transferred into milk is small and does not lead to clinically significant effects on the infant. In almost all instances, the mother should be advised to continue breastfeeding. Certain medications are absolutely contraindicated, including anticancer agents, radioactive drugs, and those that inhibit milk production. However, most medications can be used safely. An improved understanding of the relationship between maternal and infant exposure to medications would provide a more enlightened understanding of the risk and benefit analysis for individual drugs.

Strategies for the Preservation, Restoration and Modulation of the Human Milk Microbiota. Implications for Human Milk Banks and Neonatal Intensive Care Units

Studies carried in the last years have revealed that human milk contains a site-specific microbiota and constitutes a source of potentially beneficial bacteria to the infant gut. Once in the infant gut, these bacteria contribute to the assembly of a physiological gut microbiota and may play several functions, contributing to infant metabolism, protection against infections, immunomodulation or neuromodulation. Many preterm neonates are fed with pasteurized donor's human milk (DHM) or formula and, therefore, are devoid of contact with human milk microbes. As a consequence, new strategies are required to allow the exposition of a higher number of preterm infants to the human milk microbiota early in life. The first strategy would be to promote and to increase the use of own mother's milk (OMM) in Neonatal Intensive Care Units (NICUs). Even small quantities of OMM can be very valuable since they would be added to DHM in order to microbiologically "customize" it. When OMM is not available, a better screening of donor women, including routine cytomegalovirus (CMV) screening of milk, may help to avoid the pasteurization of the milk provided by, at least, a relevant proportion of donors. Finally, when pasteurized DHM or formula are the only feeding option, their supplementation with probiotic bacteria isolated from human milk, such as lactic acid bacteria or bifidobacteria, may be an alternative to try to restore a human milk-like microbiota before feeding the babies. In the future, the design of human milk bacterial consortia (minimal human milk microbiotas), including well characterized strains representative of a healthy human milk microbiota, may be an attractive strategy to provide a complex mix of strains specifically tailored to this target population.

The Antisecretory Factor in Plasma and Breast Milk in Breastfeeding Mothers-A Prospective Cohort Study in Sweden

Inflammation and infection postpartum threaten the mother and her infant. Human milk provides a defense for the infant, but inflammatory complications like mastitis may lead to the cessation of breastfeeding. Antisecretory factor (AF) has a role in the regulation of secretory processes and inflammation. The objective of the study was to describe AF-levels in plasma and breast milk, and in relation to breast complications. Breastfeeding mothers (n = 95) were consecutively recruited at a Well Baby Clinic in Umeå, Sweden. At inclusion four weeks postpartum, samples of venous blood (10 mL) and breast milk (10 mL) were collected. Active AF was analyzed with ELISA using a monoclonal antibody mAb43, and was detected in all samples of plasma and breast milk with a positive correlation (Spearman coefficient = 0.40, p < 0.001; Pearson correlation = 0.34, p < 0.01). High AF-levels in plasma correlated with high AF-levels in breast milk. The results suggest a co-regulation between active AF in plasma and breastmilk, and/or a local regulation of AF in the breast. Further studies are needed to determine the pathways for the activation of AF-levels in breast milk and plasma.

High-Risk Factors for Suppurative Mastitis in Lactating Women

Background

Acute mastitis is a common disease occurring in postpartum lactating women. This study aimed to identify the high-risk factors for suppurative mastitis (SM) in women who were breastfeeding.

Material/Methods

A total of 262 non-SM patients and 63 SM patients admitted to the Department of Breast and Thyroid Surgery of Liaocheng People’s Hospital were retrospectively enrolled in this study. The high-risk factors for SM during lactation were determined by assessing admission time after acute mastitis, galactostasis, primipara or pluripara, nipple injuries, antibiotic treatment course, and diabetes.

Results

The incidence of SM in patients with admission time greater than 72 h after occurrence of acute mastitis was significantly higher than that in patients whose admission time was less than 72 h (p<0.0001). Patients with galactostasis were more prone to develop SM compared to patients without galactostasis (p<0.0001), and the incidence of SM in primiparous patients was significantly higher than that in pluriparous patients (p=0.003). The incidence rate of SM was significantly higher in patients with diabetes than in patients without diabetes (p=0.002). Patients with nipple injuries were more prone to suffer from SM relative to the patients without nipple injuries (p<0.0001). However, there was no significant difference in the incidence of SM according to the antibiotic treatment course (p=0.134).

Conclusions

SM during lactation was closely associated with admission time after the occurrence of acute mastitis, galactostasis, primipara, diabetes, and nipple injuries.

Deep breast pain during lactation: a case-control study in Sweden investigating the role of Candida albicans

Background

Deep breast pain during lactation, with or without accompanying nipple pain and soreness continues to be anecdotally linked to infection by Candia albicans despite lack of robust evidence in the literature that Candida albicans is the cause of women’s breast symptoms.

Methods

A case-control study of breastfeeding women in Sweden with (n 35) and without (n 35) symptoms that may be attributable to Candida albicans was carried out. The symptoms were radiating, burning and penetrating or non-penetrating breast pain with or without associated nipple pain during or after breastfeeding. The primary aim of the study was to test the hypothesis that breastfeeding women with symptoms commonly associated with Candida albicans infection will have a growth of Candida albicans in their breast milk significantly more often than women without these symptoms. A secondary aim was comparison of breastfeeding self-efficacy, measured by the BSES-SF (Breastfeeding Self Efficacy Scale –Short Form), between cases and controls.

Results

None of the women in the control group and eight of the women in the case group showed a growth of Candida albicans in their breast milk (p <  0.01), which confirms the hypothesis. There were no statistically significant differences in severity or type of symptoms between those in the case group with and without growth of Candida albicans in their breast milk. Results of the BSES-SF measurement showed no statistically significant differences between cases and controls. However, when analyses were stratified for parity, multiparous controls showed statistically significant higher scores for breastfeeding self-efficacy than multiparous cases.

Conclusions

Neither clinical symptoms nor microbial cultivation appear to be reliable means for making a diagnosis of Candida albicans infection of the breast. Skilled breastfeeding consultants should offer support and help with positioning, attachment and identification of physical impediments to successful breastfeeding. Professionals should be aware that it is possible that uncertainty in the breastfeeding situation may to some extent account for mothers’ breast symptoms. The ISRCTN (International Standard Randomised Controlled Trial Number) identity for this case-control study is ISRCTN88839993. The study was retrospectively registered on 30 November 2016.

Physiological Translocation of Lactic Acid Bacteria during Pregnancy Contributes to the Composition of the Milk Microbiota in Mice

The human milk microbiota is a complex and diverse ecosystem that seems to play a relevant role in the mother-to-infant transmission of microorganisms during early life. Bacteria present in human milk may arise from different sources, and recent studies suggest that at least some of them may be originally present in the maternal digestive tract and may reach the mammary gland through an endogenous route during pregnancy and lactation. The objective of this work was to elucidate whether some lactic acid bacteria are able to translocate and colonize the mammary gland and milk. For this purpose, two lactic acid bacteria strains (Lactococcus lactis MG1614 and Lactobacillus salivarius PS2) were transformed with a plasmid containing the lux genes; subsequently, the transformed strains were orally administered to pregnant mice. The murine model allowed the visualization, isolation, and Polymerase Chain Reaction (PCR)-detection of the transformed bacteria in different body locations, including mammary tissue and milk, reinforcing the hypothesis that physiological translocation of maternal bacteria during pregnancy and lactation may contribute to the composition of the mammary and milk microbiota.