Breast milk should be obtained for culture and sensitivity.
A careful history should be taken to identify any obvious causes or predisposing factors for the mastitis. The breast feeding technique and the infant’s attachment to the mother’s breast should be observed and if needed advice on necessary improvements should be given (1).
Conservative management of lactational mastitis
- patients should be advised about self management techniques based on the basic principals of: emptying the breast, heat and rest.
- continuing breast feeding should be encouraged
- this helps to drain the affected segment of the breast and to prevent further progression leading to breast abscess or recurrent mastitis.
- it is important to empty the affected breast and if it is too tender for feeding to continue, the baby should be fed from the non-infected breast and milk should be expressed from the infected one by hand, by pump or both (2)
- women should be informed that the baby can be fed during an episode of mastitis since it is unlikely to cause any harm to the infant
- if pain affects letdown reflex, patients can always start feeding from the unaffected breast and later move to the affected one once letdown is achieved (3)
- massaging the breast – should be done from the direction of the blocked area moving towards the nipple, is helpful to stimulate the letdown reflex before or during feeding and during expression of the milk (3)
- after a feed, expressing the excess milk by hand or pump will speed up the resolution of the condition (3)
- for pain relief and pyrexia - paracetamol 1g four times a day can be used, Ibuprofen can be used as an alternate (2)
- hot and cold compresses using clean flannels or wash cloths - can be used to relieve pain and help in milk flow (2)
- women should be advised to rest and avoid wearing a bra especially in the night (4)
- correct positioning of the infant - in order to drain the affected area of the breast effectively. The area of the breast which is most effectively drained is related to the baby’s chin e.g.- if the lower outer quadrant is affected the underarm position will be helpful in successful draining (2)
- women should be supported to recover from mastitis and should be encouraged to take nutritious food and to increase fluid intake to help in recovery and healing (2)
Women should be advised to consult a health care professional immediately after 12-24 hours from the onset of the symptoms if the symptoms do not improve (or if the symptoms worsen) while following self management (2)
If the women is extremely ill and does not have any support at home, hospitalization should be considered (3)
Pharmacological management of lactational mastitis
- antibiotics should be offered to a patient if symptoms do not improve within 12-24 hours or in severe cases (3).
- the women should be educated about
- importance of completing the full course of antibiotics in order to prevent recurrence
- the effects of antibiotics on the baby is temporary and may include restlessness and diarrhoea (2).
- antibiotics used in empirical treatment of mastitis are:
- flucloxacillin - 500 mg, four times a day, for 14 days
- erythromycin - 500 mg, four times a day, for 10-14 days in patients who are allergic to penicillin
Other antibiotics which may adversely effect the baby should of course be avoided.
If the infection persists after an initial course of flucloxacillin (and results of culture and sensitivity are not available), then co-amoxiclav, which has a wider spectrum of action, may be tried.
Any abscess which develops should be recurrently aspirated or incised and drained.
If inflammation or an associated mass persists, the possibility of underlying breast carcinoma should be considered and investigated with further imaging or needle biopsy.