Editors

TarjaVihtamäki

Lactational Mastitis

When a breast-feeding mother presents with fever, early intervention with antimicrobials is indicated in order to prevent complications (e.g. an abscess) Incidence and Risk Factors of Breast Abscess in Lactating Women.
The mother should be encouraged to continue breast-feeding in order to empty the breast and thus hasten recovery.

Staphylococcus is the causative agent in more than half of the cases. Other commonest causative agents include streptococci and E. coli. The infection is often also mixed.
However, not all cases of mastitis have bacterial aetiology: engorgement of milk in the mammary gland may cause duct obstruction, thus preventing effective emptying of the breast.
A non-febrile mastitis with symptoms (burning pain in the nipple or breast, possibly radiating to the back) may be a fungal infection, most often caused by Candida albicans.
Cracked nipples and a poorly emptying breast are risk factors of mastitis Risk Factors of Mastitis.

The decision to treat does not usually need laboratory investigations; clinical presentation suffices. Antimicrobials may also be prescribed after a telephone consultation, provided that the symptoms are of short duration and follow-up is arranged (i.e. the patient knows when and who to contact should the symptoms fail to alleviate).
Antimicrobials Antibiotics for Mastitis in Breastfeeding Women should be prescribed immediately if the patient is febrile.
If the patient remains afebrile with no obvious abscess formation, the treatment consists only of monitoring and effective breast emptying. The most likely cause is milk engorgement in the mammary glands. Application of heat (for example, a hairdryer, hot water bottle wrapped in a towel, warm shower) before breast-feeding will help to empty the breast. The mother should be advised to seek help without delay should she become febrile.
- Treatment of engorgement: the infant should always be fed first from the affected breast. It is also possible to first express some milk with a breast pump, leaving the residue for the infant. If possible, the feeding position should be such that the worst affected area is uppermost (to assist the drainage of exudate).
If the mastitis recurs, a sample for bacterial culture should be taken.
If the mastitis is not healed by antimicrobials, it may be caused by a fungus.

An antimicrobial drug effective against staphylococci should be chosen. The treatment duration is 10-14 days.
Flucloxacillin 750 mg 3 times daily
First-generation cephalosporin
- Cefalexin 500 mg 3 times daily
If the patient is allergic to the aforementioned antimicrobials, a macrolide may be used.
- Roxithromycin 150 mg twice daily
- Erythromycin 500 mg 4 times daily
Candidal mastitis: fluconazole 150 mg once daily

The mother is encouraged to continue using the inflamed breast for feeding as normal. Alternatively, the breast may be emptied regularly with a breast pump. This will alleviate pain, enhance exudate drainage and prevent the formation of an abscess.
Ibuprofen or paracetamol for pain if needed
A sign of a breast abscess is persistent fever despite antimicrobial treatment and regular emptying of the breast.
- An abscess must be drained under general anaesthesia.
No check-up is needed if the patient becomes symptom free.
The possibility of carcinoma must also be borne in mind, even in a lactating mother, particularly if the inflammation recurs or a residual lump is felt in the breast.
See also Nipple Discharge and Mastitis in a Non-Lactating Woman.