Thanks for your inquiry about idiopathic granulomatous mastitis (IGM). This is a rare, chronic inflammatory condition that is difficult to treat. I am going to try to answer your questions in order, but please be aware that I have never personally managed a client with this condition and am referring to what I’ve learned from other LCs (especially from Lisa Marasco, IBCLC) and from the literature on the subject (citations to follow at the end).
1.Did long term pumping increase her risk for this condition?
I doubt that long-term pumping increased her risk. The risk is simply persistent and chronic and is sometimes associated with underlying autoimmune disorders
2. The patient is concerned about stimulating milk production on her left (affected) breast and prefers to not stimulate it although wants to know if it is better to pump to relieve her engorgement.
I agree she should not stimulate the affected breast if she intends to wean unilaterally. My rule of thumb has always been to take just enough pressure off by hand expression or pumping for comfort relief, and to use cold compresses.
3. Currently when she pumps the affected left breast very little milk is flowing. She is concerned the mass is blocking the ductal openings. This is only day 3 postpartum and she is now engorged. I can manually express colostrum from both sides and when pumping she does have better milk flow from the right breast. I expect it is likely that milk flow will be affected by this mass.
If the ducts are blocked, she will experience engorgement until involution occurs. Again, just manage the way you would any emergency weaning. Hopefully she has some postpartum pain meds on board that are safe to use as prescribed to help her through the worst discomfort.
4. Would you recommend avoiding all stimulation of the left (affected) breast and allow this breast to involute. She plans to pump the unaffected, right breast. Or is it better to bilaterally pump and keep milk moving.
I would not bilaterally pump if she intends to wean the affected breast. Just take off small amounts for comfort.
5. Her surgeon plans to start steroid at two weeks – long term for 6-8 months and therefore there are concerns for this infant and her pediatrician is considering partial EBM feedings to minimize infant’s risk related to long term steroid use.
Perhaps she can discuss with the pediatrician how long a period of exclusive breast milk feeds she can safely provide. I would assume at least 2 weeks, but hopefully longer if the infant is monitored. At some point, they may need to be guided by research into how much steroid will be transferred vs weight of baby and all the drug related questions. They might want to check with the experts at the Infant Risk Center at Texas Tech which has pharmacy PhDs on hand to assist with such calculations.
The InfantRisk Center (IRC) is a world-wide call center presently in the Texas Tech University Health Sciences Center, School of Medicine, Department of Pediatrics, in Amarillo.
The InfantRisk Center is used by physicians, nurses, lactation consultants, and mothers in every part of the world. Virtually all calls are about multiple drugs, averaging 3-4 individual drugs. We do our best to help moms, lactation consultants, and doctors evaluate the risk to the infant from exposure to multiple drugs, and keep the mom breastfeeding.
Citations re: IGM These articles would be useful for your own understanding (although they all conclude that the condition is still poorly understood and that optimal treatment has not yet been identified).
Awomolo AM, Louis-Jacques A, Crowe S. Idiopathic granulomatous mastitis diagnosed during pregnancy associated with successful breastfeeding experience. BMJ Case Reports. 2021 Aug 19;14(8):e241232. doi: 10.1136/bcr-2020-241232.PMID: 34413030
Lei X, Chen K, Zhu L, Song E, Su F, Li S. Treatments for Idiopathic Granulomatous Mastitis: Systematic Review and Meta-Analysis. Breastfeed Medicine. 2017 Sep;12(7):415-421. doi: 10.1089/bfm.2017.0030. Epub 2017 Jul 21. PMID: 28731822.
Li SB, Xiong Y, Han XR, Liu ZY, Lv XL, Ning P. Pregnancy Associated Granulomatous Mastitis: Clinical Characteristics, Management, and Outcome. Breastfeeding Medicine. 2021 Sep;16(9):759-764. doi: 10.1089/bfm.2021.0023. Epub 2021 Apr 19.PMID: 33872053
Martinez-Ramos D, Simon-Monterde L, Suelves-Piqueres C, et al. Idiopathic granulomatous mastitis: A systematic review of 3060 patients. Breast J. 2019 Nov;25(6):1245-1250. doi: 10.1111/tbj.13446. Epub 2019 Jul 4. (free full text on PubMed).
Omranipour R, Vasigh M. Mastitis, Breast Abscess, and Granulomatous Mastitis. Adv Exp Med Biol. 2020;1252:53-61. doi: 10.1007/978-3-030-41596-9_7.PMID: 32816262 Review.
Wolfrum A, Kümmel S, Theuerkauf I, et al. Granulomatous Mastitis: A Therapeutic and Diagnostic Challenge. Breast Care (Basel). 2018 Dec;13(6):413-418. doi: 10.1159/000495146. Epub 2018 Nov 23. PMID: 30800035; PMCID: PMC6381909. (Free full text).