Author:
Sean N.Fling
KathrynWest
Description
- Inflammation, often accompanied by infection, of the breast tissue resulting in pain, erythema, and edema
- Lactational, most common—due to prolonged engorgement or poor drainage of milk
- Nonlactational, less common—due to inflammation of subareolar ducts (periductal mastitis) or idiopathic granulomatous lobar mastitis
- Often with systemic symptoms including:
- Incidence may be as high as 20% in lactating women
- Onset typically 1-6 wk postpartum
- Complications:
- Cessation of breastfeeding (most common)
- Recurrence
- Abscess (up to 3% of cases)
- Sepsis
- Necrotizing fasciitis
- Cutaneous fistula
- Long lasting decrease in milk production
Pediatric Considerations |
| Can occur in infants, typically those <2 mo of age |
Etiology
- Staphylococcus aureus most common
- Less common causes:
- Risk factors:
- Lactational
- Nipple trauma
- Poor infant latch
- Local milk stasis
- Poor maternal nutrition
- Previous mastitis
- Primiparity
- Use of a breast pump
- Advanced maternal age
- Maternal diabetes
- Maternal use of antibiotics
- Nonlactational
- Breaks in the skin barrier
- IV drug use
- Cigarette smoking
- Trauma
- Eczema or other dermatologic conditions
- Systemic diseases
Signs and Symptoms
History
- Flu-like symptoms; fever, headache, malaise, chills, and myalgias
- Fever is usually >38.3°C (101.3°F)
- Breast redness, pain, and swelling
- Decreased milk production
Physical Exam
- Breast is:
- Warm
- Tender
- Indurated
- Wedge-shaped area of erythema
- Usually unilateral
- Axillary lymphadenopathy
- Can be signs of nipple trauma
- Patient is typically febrile and tachycardic
Essential Workup
Physical exam with special attention to detecting abscess or signs of severe sepsis
Pediatric Considerations |
- In neonates:
- Usually unilateral
- 50-63% develop abscess
- Sepsis workup in neonates who are febrile or ill appearing
- Broad-spectrum IV antibiotics if <2 mo of age
|
Diagnostic Tests & Interpretation
Lab
Consider breast milk culture in recurrent or refractory cases
Imaging
Ultrasound if exam concerning for abscess or no improvement after 48 hr
Differential Diagnosis
- Breast engorgement:
- Transient fever <39°C of 4-16 hr duration
- Appearing 48-72 hr postpartum
- Bilateral nonerythematous engorgement
- Breast cancer
- Breast abscess
- Galactocele
- Plugged duct
Prehospital
Generally, no prehospital treatment needed
Initial Stabilization/Therapy
No specific stabilization
ED Treatment/Procedures
- Continue breast-emptying either by direct breastfeeding or breast pumping
- Massage
- Hot/cold compresses
- Improve breast-feeding technique:
- May need a lactation consultant
- Maintain maternal hydration
- Antibiotics are indicated if symptoms present >24 hr, severe symptoms, or associated with fever
- Surgical consultation if evidence of abscess
- Symptom control with antipyretics and nonsteroidal anti-inflammatory drugs
ALERT |
| Vertical transmission of HIV (mother to infant) may be increased in mothers with mastitis |
Medication
- Cephalexin: 500 mg PO q6h for 10 d
- Clindamycin: 300 mg PO q6h for 10 d
- Dicloxacillin: 500 mg PO q6h for 10 d (1st-line treatment)
- TMP/SMX: 160/800 mg PO q12h:
- Avoid in infants <2 mo old or if patient is breastfeeding an infant <2 mo
- If severe requiring IV antibiotics: Vancomycin 1 g IV q12h
- Oral lactobacillus effective in preventing recurrent episodes
Second Line
- Cephalexin
- Clindamycin (severe penicillin allergy)
- TMP/SMX (beyond neonatal period)
Disposition
Admission Criteria
- Abscess requiring incision and drainage under general anesthesia
- Immunocompromised or evidence of severe sepsis
- Mastitis in the neonate or ill-appearing infant
Discharge Criteria
- Most patients can be managed in outpatient setting
- Most symptoms resolve within 48 hr of therapy
- Home care includes frequent breast emptying, massage/vibratory therapy, breast support, warm compresses, and NSAIDs
- Ensure mother has appropriate social support
Follow-up Recommendations
- Patients should follow up with primary care physician or obstetrician within 48 hr
- Ultrasound should be obtained to assess for other causes of breast inflammation if no improvement in 48-72 hr
- Lactation consultant may be able to help improve latch
- AmirL, Academy of Breastfeeding Medicine Protocol Committee. ABM Clinical Protocol #4: Mastitis, Revised March 2014 . Breastfeed Med. 2014;9(5):239-243.
- CusackL, BrennanM. Lactational mastitis and breast abscess: Diagnosis and management in general practice . Aust Fam Physician. 2011;40(12):976-979.
- JahanfarS, NgCJ, TengCL. Antibiotics for mastitis in breastfeeding women . Cochrane Database Syst Rev. 2013;(2):CD005458.
- KatariaK, SrivastavaA, DharA. Management of lactational mastitis and breast abscesses: Review of current knowledge and practice . Indian J Surgery. 2013;75(6):430-435.
- MasoodiT, MuftiG. Neonatal mastitis: A clinico-microbiological study . J Neonatal Surg. 2014;3(1):2.
- NairCG, HiranPJ, MenonRR. Inflammatory diseases of the non-lactating female breasts . Int J Surg. 2015;13:8-11.
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