Case studies
MMA Faridi
Pooja Dewan
Prerna Batra
Rusty pipe syndrome: counselling a key intervention
ABSTRACT
Presence of blood in the breastmilk renders a rusty or brownish colour to it; this entity is known as 'rusty pipe syndrome'.
Although this is a self-limiting condition, it can be particularly intimidating for mothers and may act as a psychological
barrier to successful breastfeeding. We describe this entity in two mothers who had spontaneous blood-stained
breastmilk from both breasts in the early post-partum period and were worried about feeding their infants. Subsequent
to proper counselling with the use of skills like active listening, accepting their concerns, building confidence by providing
relevant information in simple language and by giving suggestions and avoiding commands, both mothers were able to
successfully breastfeed their offspring.
Keywords: breastfeeding, blood, breastmilk, counselling, rusty pipe syndrome
Breastfeeding Review 20^3•, 21(3): 27-30
INTRODUCTION
'Rusty pipe syndrome' is a condition wherein the
breastmilk produced during early lactation appears dark
brown in colour due to the presence of blood (Virdi,
Goraya & Khadwal 2001). It is usually a benign condition
and usually resolves in 2-5 days (Merlob 1990). We
describe two mothers who presented with rusty pipe
syndrome between March 2012 and May 2012, along
with a review of literature and management of this
condition by proper counselling, enabling mothers to
successfully breastfeed.
Case 1
A 28-year-old, second grávida woman delivered a
full-term (38 weeks' gestation) healthy female baby
weighing 2800 g in Guru Tegh Bahadur Hospital, a
tertiary care hospital in Delhi. Within an hour of birth,
the baby was handed over to the mother who was
advised by the staff nurse to initiate breastfeeding. But
the mother expressed her breastmilk before putting the
baby to the breast and found that it was brownish-red
in colour (Figures la and b). She did not breastfeed her
baby and informed the staff nurse. A trained lactation
consultant evaluated her. Detailed history revealed that
her firstborn infant was admitted in the NICU soon after
birth and when she was asked to express breastmilk for
Breastfeeding Review • VOLUME 21 • NUMBER 3 • NOVEMBER 2013
her baby it was brown-red coloured which persisted for
about 10 days. She consulted a surgeon and underwent
mammography and other relevant investigations
for breast malignancy but the results were normal.
However, she opted not to breastfeed her first offspring
who was formula fed. The previous history of rusty
coloured breastmilk prompted her to express the milk
before breastfeeding her second baby.
On examination, breasts were soft, the local temperature
was not raised and the nipples were protractile and
healthy with no cracks or ulcers. She denied any history
of breast pain, breast lumps, any other abnormal
nipple discharge, trauma to her breast, or a history of
breast cancer in her family. She also did not have any
constitutional symptoms such as loss of appetite or
weight, or any fever. A manual expression revealed
reddish brown milk discharge from both breasts. The
mother and other family members were counselled by a
lactation consultant. Mother was comforted and an icebreaking session was conducted by observing nonverbal
communication strategies such as maintaining head
level, keeping eye contact, maintaining appropriate
distance without barriers, appropriate touching
and patting, and showing interest in the discussion.
Listening and learning skills like asking non-judging
27
questions studded with empathy, reflecting back and
acknowledging the mother's apprehensions were used
to build her confidence. The use of open-ended questions
during counselling allowed the mother to vent her
concerns and emotions. We showed the mother breast
models to simplify her understanding of physiology of
lactation and provided her with copies of published
literature on rusty pipe syndrome to emphasise its
innocuous nature.
Figure 1. (A) Mother expressing the blood-stained
colostrum from her breast on post-partum day 1,
(B) Rusty appearing breastmilk expressed on postpartum day 1, (C) Mother expressing her breast on
post-partum day 5, (D) Clearer breastmilk expressed
on post-partum day 5.
To facilitate continued communication between the
lactation consultant and the mother, we shifted the
mother-infant pair to the lying-in ward of the neonatal
intensive care unit (step down unit of the neonatal
intensive care area where mother-infant dyads are
kept together on the same bed]. She was advised to
express her breastmilk every 2-3 hours and discard
it as she was not confident to feed it to her baby. The
expressed breastmilk was subjected to biochemical
and cytopathological analysis. Breastmilk analysis
revealed: pH 8; haematocrit 14%; cytopathology: foamy
macrophages seen against a haemorrhagic background
but no malignant cells were seen. At the mother's
insistence, the neonate was fed formula milk by cup
while she continued to discard her expressed breastmilk.
By day 5, colour ofthe breastmilk had started clearing
(Figure lc] and by day 7, it was almost clear (Figure
Id]. On day 7, the mother was willing to breastfeed
her baby which was tolerated well by the infant. The
mother-infant pair was subsequently followed up in
the lactation clinic; at 4 months follow-up the baby was
gaining weight well and was exclusively breastfed.
Case 2
A 27-year-old primigrávida delivered a term (37
weeks' gestation] male infant weighing 2500 g, by
vaginal route. The neonate was started on breastfeeds
at 1 hour of life, which he accepted well. Fourteen
hours after the delivery, the mother informed the
attending paediatrician that she noticed discharge
of blood-stained breastmilk from both breasts while
the infant was being taken off the breast. A trained
lactation management counsellor evaluated her.
The mother did not complain of any régurgitation of
breastfeed or vomiting by the neonate. The local breast
examination was normal, except for bilateral bloodstained breastmilk. Detailed history revealed she also
noticed blood-stained breastmilk from both the breasts
at 7 months of gestation, which subsided on its own
within 2 to 3 days, and no investigations were done.
The expressed breastmilk analysis revealed pH of 7.0,
haematocrit of 5% and no abnormal cells. A surgical
consultation was obtained and surgeon ruled out
intraductal papilloma as the blood-stained breastmilk
was bilateral and seen to emanate from the multiple
ducts. We counselled this mother to breastfeed her
newborn on similar lines as described previously. She
was quite comfortable and confident and continued
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Breastfeeding Review • VOLUME 21 • NUMBER 3 • NOVEMBER 2013
to breastfeed. The colour of the breastmilk started
improving on third post-partum day. The infant
breastfed well without any vomiting or régurgitation.
DISCUSSION
Breastfeeding is important preventive, promotive and
curative health behaviour with health implications
for the infant, her mother and family. The World
Health Organization [2003) recommends exclusive
breastfeeding for the flrst 6 months of life, with
continued breastfeeding until 2 years and beyond
with appropriate complementary foods. Although the
importance of breastfeeding is undeniable, assisting
new mothers as they breastfeed can be a challenging
task. Since breastfeeding is a bebaviour which is not
performed only by instinct, there could be several
socio-cultural factors and medical reasons which
could hamper breastfeeding in the mothers [Shaheen
Premani, Kurji & Mithani 2011). One such condition can
be blood-stained breastmilk.
The presence of blood-stained breastmilk during lactation
can impart various shades of red-brown colour to the
breastmilk, and is described as 'rusty pipe syndrome'.
Occurring more commonly in primiparous women, bloodmixed milk is seen more often from both breasts [Merlob
et al 1990; Virdi, Goraya & Khadwal 2001). It is generally
noticed at birth or in early lactation, but it may be seen as
early as the fourth month of gestation [Guèye et al 2013).
The blood-stained breastmilk production is a consequence
of accelerated growth of alveoli and their vascularisation
during pregnancy and lactation [Sabate et al 2007).
The blood in the breastmilk may arise from capillaries
broken due to trauma to the breast, which can be due to
faulty techniques of breastfeeding, manual breastmilk
expression, or the use of a breast pump. Intraductal
papilloma is another cause of presence of blood-strained
breastmilk. However, it should be looked for in mothers
with prolonged blood-stained breastmilk [Levèque et
al 1990) and unlike rusty pipe syndrome, intraductal
papilloma is mostly unilateral and associated with bloodstained breastmilk from a wart-like growth on the lining of
a duct that bleeds as it erodes [Sainsbury 2008).
As was seen in both our cases, rusty-pipe syndrome is
a self-limited condition and most cases clears within
2 to 7 days of onset of lactation [Cizmeci et al 2013;
Virdi, Goraya & Khadwal 2001). The fact that the second
mother managed to breastfeed her baby despite the
colostrum being blood-tinged supports that blood in
the milk is not a gut irritant. Despite the condition being
benign, it might be intimidating for some mothers. The
presence of blood in breastmilk can cause significant
psychological, aesthetic and functional concerns in
the mother. In a survey, conducted amongst health
professionals in neonatal intensive care units regarding
the practice of feeding blood-tinged colostrum, 75% of
Breastfeeding Review • VOLUME 21 • NUMBER 3 • NOVEMBER 2013
respondents reported that their practice was not to feed
the blood-stained breastmilk [Phelps et al 2009). About
57% ofthe neonatologists and the lactation consultants
and only 22% ofthe neonatal nurse practitioners, nurses
and dietitians recommended feeding moderately bloody
milk [p<0.001). The most common reason for not feeding
blood-stained breastmilk was that it was believed to
cause gastrointestinal upset and feeding intolerance.
However, in the light of the obvious importance of
breastmilk, scientiflc evidence is needed to prove that
feeding blood-stained breastmilk will actually result in
the perceived problems [Bua et al 2012). As was seen in
our second case, wben mothers exclusively breastfeed,
without expressing, they are unaware of their 'rusty
pipes' unless a baby happens to regurgitate some ofthe
blood-stained breastmilk [Guèye et al 2013). Also any
blood in the breastmilk undergoes considerable dilution
with milk and as such is not much of a problem.
Therefore, we must emphasise that mothers must not
withhold breastfeeding even if the breastmilk is bloodstained. In such cases, it would be very rewarding to
provide mothers breastfeeding support and counselling
to enable them to continue breastfeeding. As seen in our
cases, one mother did not breastfeed her flrst offspring
at all but could do so with the second child after active
communication and counselling, albeit after few days
when the colour of the breastmilk started changing to
normal. Counselling encouraged the second mother to
continue breastfeeding in spite of rusty colour of the
breastmilk. It is to be reiterated that feeding bloodstained breastmilk is tolerated well without risk of
régurgitation and vomiting.
With proper counselling and help, it is possible to foster
breastfeeding even in cballenging situations. One mother
did not breastfeed ber flrst-born due to lack of proper
counselling. However, sbe managed to successfully
breastfeed her second offspring with appropriate help
and proper counselling. We recommend continued
breastfeeding in mothers producing blood-stained
breastmilk and advocate breastfeeding support and
reassurance to these mothers.
REFERENCES
Bua J, Travan L, Davanzo R, Demarini S 2012, More on
professionals' attitudes on blood-tinged milk: a survey from
Italy/Per/nato/32(3]: 243-244.
Cizmeci MN, Kanburoglu MK, Akelma AZ, Tatli MM 2013,
Rusty-pipe syndrome: a rare cause of change in the color
of breastmilk. Breastfeed Med 8(3]: 340-341. doi:10.1089/
bfm.2012.0143
Guèye M, Kane-Guèye SM, Mbaye M, Ndiaye-Guèye MD,
Faye-Diémé ME, Diouf AA, Moreau JC 2013, Rusty pipe
syndrome in a 22-year-old primigrávida at 26 weeks'
gestation. SAfrJ Obstet Gynaecol 19(1]: 17-18.
29
Levèque J, Priou G, Palaric JC, De Korvin B, Marcorelles
P, Poulain P 1990, Nipple discharge without palpable tumor.
Apropos of 46 cases. Rev Fr Cynecol Oèsiet 85(5]: 329-335.
Merlob P, Aloni R, Präger H, Mor N, Litwin A 1990, Bloodstained maternal milk: prevalence, characteristics and
counselling. Eur] Obs Gynecol Reprod Biot 35(2): 153-157.
Phelps MM, Bedard WS, Henry E, Christensen SS, Gardner
RW, Karp T, Wiedmeier SE, Christensen RD 2009, Attitudes
of NICU professionals regarding feeding blood-tinged
colostrum or milk./Pennato/29(2]: 119-123.
Sabate JM, Clotet M, Torrubia S, Gomez A, Guerrero R, de
las Heras P, Lerma E 2007, Radiologie evaluation of breast
disorders related to pregnancy and lactation. Radiographies
27:S101-124.
AUTHORS
Dr MMA Faridi MD DCH, MNAMS FIAP FNNF
Professor and Head
Dr Pooja Dewan MD MNAMS
Assistant Professor
Dr Prerna Batra MD
Associate Professor
Affiliation
Department of Paediatrics, University College of Medical
Sciences and Guru Tegh Bahadur Hospital, Delhi 110095 India
Sainsbury R 2013, The breast. In William NS, Bulstrode CJK,
O'Connell PR (eds) Bailey and Love's short practice of surgery.
26th edn. Hodder Arnold, London. pp798-822.
Shaheen Premani Z, Kurji Z, Mithani Y 2011, To explore
the experiences of women on reasons in initiating and
maintaining breastfeeding in urban area of Karachi, Pakistan:
an exploratory study /S/?A/Peci;atrdoi:10.5402/2011/514323
Virdi VS, Goraya JS, Khadwal A 2001, Rusty-pipe syndrome.
Indian Pediatr 38(8]: 931-932.
World Health Organization 2003, Global strategy for infant
and young child feeding. WHO, Geneva. URL: http://www.who.
int/nutrition/publications/gs_infant_feeding_ text_eng.pdf
Accessed 6/05/13.
Mary Paton
Research Aivard
2013
Presented by the Australian Breastfeeding
Association for the best original paper on
breastfeeding to
Australian
Breastfeeding
Association
O
college of lactation
consultants victoria inc.
Dr Karleen Gribble
Adjunct Fellow, School of Nursing a n d M i d w i f e r y
University of Western Sydney
For her original research
A better alternative: w h y w o m e n use peer-to-peer shared milk
The Mary Paton Research Award is presented by the Australian
Breastfeeding Association and is kindly sponsored by the College of
Lactation Consultants Victoria Inc.
Photograph of Mary Paton: courtesy Prue Carr 2004
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Breastfeeding Review • VOLUME 21 • NUMBER 3 • NOVEMBER 2013
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