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Letters to the Editor

Indian Pediatrics 2001; 38: 931-932  

Rusty-Pipe Syndrome

Blood stained or frankly bloody discharge during lactation can be a frightening event, but may represent a totally harmless and self-limited condition. We report one such case with emphasis on the differential diagnoses.

A twenty-six-year-old primigravida vaginally delivered a healthy female baby weighing 3100g. Breast feeding was started within two hours of birth. Since the baby was not sucking well at breast, expressed breast milk was advised. At about twenty hours after delivery, mother noticed frank blood coming out along with milk from both the breasts while she was trying to express the milk. There was no history of pain, trauma to breast, fever or bleeding from any other site. On examination, the mother was in good health. Examination of the breasts revealed no tenderness, area of redness or any lump. There was no evidence of breast engorgement. Nipples were protractile and healthy with no cracks or ulcers. Smears from the discharge did not show any malignant cells. The mother was reassured and breast-feeding continued. The blood discharge stopped within 48 hours and did not recur.

Blood or serosanguineous discharge in milk during lactation can occur due to varied factors related to lactation such as cracked nipples, mastitis, trauma or vascular engorgement(1). These conditions are painful and can be unilateral or bilateral. The diagnosis in such cases is usually self-evident on clinical examination. Blood in breast milk during pregnancy and lactation can also be because of some diseases as serious as ductal papilloma and fibrocystic disease. Ductal papilloma is the most common cause of bloody nipple discharge among all women(1,2). Discharge is usually spontaneous, unilateral and from a single duct in ductal papilloma(1,2). The bleeding is painless and usually not associated with a palpable lesion. Fibrocystic disease shows areas of lumpiness and there is associated mastalgia(2). The disease is prominent in the childbearing years and is a benign disorder.

Frank bloody milk can also be due, to a condition termed as ‘rusty-pipe syndrome’(1,3). It is a painless condition and may go unnoticed unless the mother is expressing the milk or the infant vomits out blood, which tests positive for adult hemoglobin (Apt test)(1). The bloody discharge from the breasts is usually bilateral but may be unilateral to begin with. Most cases begin at birth or in early lactation but it may start in pregnancy also. The cause is an increased vascularization of rapidly developing alveolae with delicate network of capillaries, which get traumatized easily and result in blood escaping into breast secretion(1,4). It is commonly seen in first time mothers and is usually associated with nipple exercises like Hoffman’s procedure, which is often recommended for flat or inverted nipples(3).

Rusty-pipe syndrome is a self-limited condition and most cases clear within 3 to 7 days of onset of lactation. Nipple manipulation should be discontinued. If the infant tolerates milk, breast feeding can continue during this period. The discharge should be evaluated if the bleeding persists for more than one week(1,3). Since this benign condition is not described in standard neonatology and pediatric texts, we thought it appropriate to bring it to the attention of readers.

Verinderjit S. Virdi,
Jatinder S. Goraya
Alka Khadwal
Department of Pediatrics,
Government Medical College and 
Hospital, Sector-32,
Chandigarh 160 047, India


1. Lawrence RA. Breastfeeding: A Guide for the Medical Profession, 4th edn. St. Louis, Mosby, 1994; pp 473-540.

2. Saunders CM, Baun M. The breast. In: Bailey and Love’s Short Practice of Surgery, 23rd edn. Eds. Russell RCG, Williams NS, Bulstrode CJK. London, Arnold, 2000; pp 749-772.

3. Donovan D. Breastfeeding: Rustypipe syn-drome. www.parentsplace.com/expert/lactation /basics/qa/0,3459,6304,00.html.

4. Kline TS, Lash SR. The bleeding nipple of pregnancy and postpartum period–a cytologic and histologic study. Acta Cytol 1964; 8: 336-339.


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