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Witch's milk

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Witch's milk or neonatal milk is milk secreted from the breasts of some newborn human infants of either sex.[1] Production of neonatal milk by infants usually resolves itself and does not require treatment unless it is caused by an underlying condition or medications.[2] It is thought to be caused by a combination of the effects of maternal hormones before birth, prolactin, and growth hormone passed through breastfeeding and the postnatal pituitary and thyroid hormone surge in the infant.[citation needed] Its production also may be caused by certain medications.[3][4]

Neonatal milk production occurs in about 6% of newborns with age from 0 to 12 weeks. Within the age range, infants age 0 to 2 weeks were found to have the highest occurrence. Compared to those who did not have neonatal milk production, infants who did had larger breast nodules.[5] Pre-term infants under the gestational age of 34 weeks did not secrete milk as observed in one study.[6] The composition of neonatal milk is similar to maternal milk for most of their components except for fats and one type of antibody.[7][8] In extremely rare cases neonatal mastitis may develop but it is unclear if it is related to neonatal milk secretion.[citation needed] Blood from the nipples is nearly always benign and frequently associated with duct ectasia; it should only be investigated when it is unilateral.[9]

Cultural Interpretations

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The term "witch's milk" comes from ancient folklore that stems from the 17th century belief that the fluid leaking from a newborn's nipple was a source of nourishment for witches' familiar spirits.[10] Across Europe, neonatal lactation was called "witch's milk", "hexenmilch" and "lait de sorciere", and was accused of being a potential source for witchcraft.[11] Some would even go to the extent of "milking" infants with this condition of Galactorrhea in order to prevent a witch coming to collect it.[11] It was thought to be stolen from unwatched, sleeping infants.

There is also a religious interpretation behind the significance of witch's milk. In the 1500s in England, milk was symbolically linked with nurture and purity, and was particularly associated with the Virgin Mary.[11] However, when the milk came out of so-called "unnatural" places, it was either seen as divine or satanic.

The cultural interpretations of witch's milk, however, vary across different cultures. For instance, in India, there is an age-old practice in place where mothers would squeeze the swollen breasts of infants that contained witch's milk in an attempt to avoid large breasts, which are considered inappropriate before the age of marriage.[12]

Contributing Factors

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Hyperprolactinemia

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Witch's milk, or neonatal galactorrhea, in newborns is primarily caused by hyperprolactinemia,[13] which results from the decline of maternally transferred estrogen in the neonate, stimulating milk production. Maternal estrogens are essential for developing a newborn's mammary glands during pregnancy. These hormones cross the placenta and stimulate the growth of breast tissue in the fetus. After birth, the levels of maternal estrogens fall quickly since the placenta is no longer supplying these hormones. This rapid decrease can disturb the newborn's hormonal balance.[12] Consequently, the baby's pituitary gland may increase the production of prolactin, a hormone that triggers milk production. This condition, called hyperprolactinemia, can cause the newborn’s breasts to produce milk, a phenomenon known as "witch's milk." Usually, this milk production is temporary and resolves as the baby’s hormone levels adjust. However, in some cultures, the tradition of manually expressing this milk based on cultural beliefs can worsen the condition, resulting in prolonged breast enlargement and milk secretion.[14]

Prolactin

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In breastfeeding, pituitary hormone prolactin vary throughout pregnancy and in different lactation conditions.[15] Prolactin, produced by the pituitary gland, is essential for initiating and maintaining milk production. Its levels increase during pregnancy to prepare the breasts for milk production and remain high after childbirth to continue supporting breastfeeding. Issues related to abnormal lactation, such as inadequate milk supply or galactorrhea, an excessive milk flow not linked to childbirth, are also explored. Fluctuations in prolactin levels can significantly influence these problems. By analyzing prolactin levels in various lactation situations, insights are provided into how changes in prolactin affect milk production and overall lactation health. This emphasizes the importance of understanding prolactin's role for better diagnosis and management of lactation issues, offering valuable information for treating both normal and problematic lactation cases.[15]

Antidepressants

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A rare case of infant galactorrhea associated with maternal use of antidepressants is has been reported.[16] A 3-month-old infant developed nipple lesions and milk production. Initially, the condition was thought to be an infection due to excessive handling. However, repeated episodes prompted further investigation by a mastologist, who suggested that the galactorrhea could be linked to the mother’s antidepressant medication, specifically sertraline and quetiapine. Although these medications are generally considered safe during breastfeeding, they can still affect the infant. This case highlights the importance of considering this rare but possible side effect when diagnosing persistent galactorrhea in infants. It underscores the need for thorough monitoring and assessment of potential drug impacts on infants, particularly when common explanations for symptoms do not apply.[16]

Other medications

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Medications are a significant cause of hyperprolactinemia and galactorrhea. They can disrupt the normal regulation of prolactin by either inhibiting dopamine, which naturally suppresses prolactin secretion, or by directly stimulating the release of prolactin. Opiates are among these medications. They can elevate prolactin levels by inhibiting dopamine release, reducing the dopamine-mediated suppression of prolactin, thus leading to increased prolactin levels and possibly causing galactorrhea. The use of opiates by mothers during pregnancy or breastfeeding can transfer these drugs to the infant, potentially leading to neonatal galactorrhea, also known as "witch's milk."[17]

Pathophysiology of Causes

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Hyperprolactinemia

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The hormone prolactin has a key role in lactation and breast development in the human body and it is also a functional component of homeostasis.[18] It has varying originations including the central nervous system (CNS), the immune system, mammary glands, and uterus. Development and introduction of any of the following contributes to its production as well: thyrotropin releasing hormone (TRH), estrogen, and dopamine antagonists.[18]

However, the pituitary gland is a primary source for the synthesis and secretion of prolactin. Prolactin's primary functions are breast milk production and mammary gland development. Prolactin has a stimulating effect on alveoli within the mammary glands causing the production of milk that consists of lactose, casein, and lipids.[18] The anterior region of the pituitary gland, more specifically, houses an increasingly abundant number of lactotrophs (stimulated within the physiology of pregnancy) that synthesize prolactin for secretion. The rise of lactotroph proliferation is attributed to growing estrogen levels within a pregnant individual. [19] Connecting to the pituitary gland via the infundibular stalk, is the hypothalamus of which is the primary regulator of prolactin production.[18] The dopamine the hypothalamus releases has an inhibitory effect on lactotrophs, controlling its prolactin secretion.[20] The serum levels of prolactin are typically low in males and non-lactating females, inhibiting possibility for breastmilk production. In the cases that the serum levels of prolactin do become high in these individuals, the phenomenon galactorrhea is to occur.

Prolactinoma

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A tumor originating in the pituitary gland is one cause of galactorrhea.[21] This pituitary tumor, prolactinoma, results in an overproduction of prolactin, or hyperprolactinemia.[21] This type of cause is classified under organic hyperprolactinemia.[19] In pregnancy, the lactrotroph production increases through means of cellular proliferation of which gives rise to potential for neoplastic development.[22] This is especially true in cases where this proliferation becomes uncontrollable. In patients of varying ages who present with hyperprolactinemia, 12-70% of them have been diagnosed with prolactinoma.[22]

Thyrotoxicosis

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Changes in estrogen levels attributed to alterations in metabolism, for example, result in thyrotoxicosis which also leads to galactorrhea.[21] This type of cause is classified under functional hyperprolactinemia.[19] When estrogen levels rise in the placental-fetal circulation, breast enlargemenent in breastfed infants occurs temporarily but also has the potential to last longer in some cases.[2]

Comparison to Adolescent Galactorrhea

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"Witch's milk" and adolescent galactorrhea are both forms of abnormal milk production, but they differ significantly in terms of age group, causes, and management. Witch's milk occurs in newborns and is typically due to maternal hormones that cross the placenta during pregnancy. These hormones can stimulate the infant's mammary glands to produce milk, a condition that is relatively common, affecting about 5% of newborns.[13] Witch's milk is usually self-limiting and resolves within a few weeks as the maternal hormones dissipate from the infant's system. Parents are advised not to express the milk, as this can stimulate further production, and no specific treatment is generally required.

In contrast, adolescent galactorrhea occurs in teenagers and involves the production of milk in individuals who are not pregnant or breastfeeding. The causes of adolescent galactorrhea are varied and can include multiple factors. A common cause is hormonal imbalances, particularly high levels of prolactin, a hormone produced by the pituitary gland that regulates milk production. Excessive prolactin can lead to milk production even when it’s not warranted. Certain medications can also play a role; for example, antipsychotics might disrupt dopamine regulation, resulting in elevated prolactin levels. Similarly, antidepressants and some antihypertensives can have comparable effects.

Complications

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Witch's milk can last about 6 months then usually resolve on its own.[23] However, the breast area may become red, tender, or swollen, which is an indication that an infectious complication may have risen. The act of removal of the witch's milk by exploiting the neonatal's breast and breast tissue can allow bacteria to grow and cause the complications. These complications include mastitis and breast abscesses that progress from contamination of the witch's milk. It was reported that the most common bacteria that causes these complications is Staphylococcus aureus. [24] This was shown in one study that out of 32 of the 36 participants was shown to have an infection in their breast due to Staph. aureus.[25] On the other hand, breast enlargement can occur due to hormone imbalances that occur before birth, such as mastauxe. This can lead to neonatal galactorrhea or witch's milk.

Mastitis

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One problem that can arise from the infection of Staphylococcus aureus in the breast is mastitis. Additionally, Staphylococcus aureus causes about 85% of cases encounter.[26] However, other bacteria such as gram-negative enteric bacteria, anaerobes, and Group B Streptococcus can be the cause of the neonatal mastitis.[27] The clinical presentation of mastitis can manifest has painful, swelling, and an abscess can form after 4 weeks. Mastitis can occur in one of the breast but in some cases it can occur in both breasts of the neonate. Treatment can be done by using an aggressive course of antibiotics if treated right away and upon diagnosis, which was shown to be 50% effective.[26] Surgical interventions for drainage and abscess removal may be required if infection progresses. Untreated mastitis can lead to further consequences such as cellulitis, fasciitis, and sepsis.

Giant Mastauxe

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Mastauxe is derived from two Greek words 'mastos' (breasts) and 'auxein' (increase in size). Mastauxe is breast enlargement that is characterized by the increase in diameter size of breast buds that is larger than 3cm. This phenomena is not fully understood today but it is said to be caused by the transfer of maternal estrogens or the decrease of estrogens in the late stages of pregnancy. The differentiation between mastitis or breast abscess should be established by certain labs or test, such as ultrasonography and laboratory findings. These laboratory findings include white blood cell count and C-reactive protein levels. This condition resolves on it's own through continuous observation and reassurance.[28]

See also

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References

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  1. ^ Devidayal MD (November 2005). "A male infant with gynecomastia-galactorrhea". The Journal of Pediatrics. 147 (5): 712. doi:10.1016/j.jpeds.2005.06.026. PMID 16291370. "full text" (PDF).
  2. ^ a b Leung AK, Pacaud D (August 2004). "Diagnosis and management of galactorrhea". American Family Physician. 70 (3): 543–550. PMID 15317441.
  3. ^ Paturi B, Ryan RM, Michienzi KA, Lakshminrusimha S (May 2009). "Galactorrhea with metoclopramide use in the neonatal unit". Journal of Perinatology. 29 (5): 391–392. doi:10.1038/jp.2008.246. PMID 19398999.
  4. ^ De S, Taylor CM (January 2007). "Domperidone toxicity in an infant on maintenance haemodialysis". Pediatric Nephrology. 22 (1): 161–162. doi:10.1007/s00467-006-0263-7. PMID 16960712.
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  16. ^ a b Gomes ÉB, Nogueira CT, da Silva Gomes AL, de Albuquerque Oliveira A, Guimarães MR, Belchior HO, et al. (2024). "Galactorrhea in infant induced by maternal antidepressants use: case report". Brazilian Journal of Case Reports. 4 (3): 30–34. doi:10.52600/2763-583X.bjcr.2024.4.3.30-34. ISSN 2763-583X.
  17. ^ Bruehlman RD, Winters S, McKittrick C (December 2022). "Galactorrhea: Rapid Evidence Review". American Family Physician. 106 (6): 695–700. PMID 36521467.
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  20. ^ Glezer A, Bronstein MD (2022), Bandeira F, Gharib H, Griz L, Faria M (eds.), "Hyperprolactinemia", Endocrinology and Diabetes: A Problem Oriented Approach, Cham: Springer International Publishing, pp. 47–54, doi:10.1007/978-3-030-90684-9_5, ISBN 978-3-030-90684-9, PMID 25905218, retrieved 2024-07-29
  21. ^ a b c Leung AK, Pacaud D (2004-08-01). "Diagnosis and Management of Galactorrhea". American Family Physician. 70 (3): 543–550. PMID 15317441.
  22. ^ a b Chanson P, Maiter D (2022-01-01), Melmed S (ed.), "Chapter 16 - Prolactinoma", The Pituitary (Fifth Edition), Academic Press, pp. 495–543, ISBN 978-0-323-99899-4, retrieved 2024-07-28
  23. ^ Jean Bertrand KA, Rose NK, Franck LG, Célestin BA, Ibrahim T, N'gouan Constance BU (2022). "Mastitis and breast abscess in newborns and infants". African Journal of Paediatric Surgery. 19 (4): 238–240. doi:10.4103/ajps.ajps_92_21. PMC 9615954. PMID 36018205.
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  25. ^ Rudoy RC, Nelson JD (1975-09-01). "Breast Abscess During the Neonatal Period: A Review". American Journal of Diseases of Children. 129 (9): 1031–1034. doi:10.1001/archpedi.1975.02120460019005. ISSN 0002-922X. PMID 1103616.
  26. ^ a b Efrat M, Mogilner JG, Iujtman M, Eldemberg D, Kunin J, Eldar S (September 1995). "Neonatal mastitis--diagnosis and treatment". Israel Journal of Medical Sciences. 31 (9): 558–560. ISSN 0021-2180. PMID 7558780.
  27. ^ Masoodi T, Mufti GN, Bhat JI, Lone R, Arshi S, Ahmad SK (2014-01-01). "Neonatal Mastitis: A Clinico-Microbiological Study". Journal of Neonatal Surgery. 3 (1): 2. doi:10.47338/jns.v3.66. ISSN 2226-0439. PMC 4420425. PMID 26023473.
  28. ^ Pant VP, Mishra D (2023-07-19). "Neonatal giant mastauxe: a case report". Annals of Medicine and Surgery. 85 (8): 4134–4136. doi:10.1097/MS9.0000000000001036. ISSN 2049-0801. PMID 37554865.
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