Mastitis Prevention and Treatment
Mastitis Prevention and Treatment
Mastitis Prevention and Treatment
Contents
1. Purpose of guideline
2. Guideline management principles and goals
3. Definitions
4. Incidence
5. Infectious and non-infectious mastitis
6. Pathology
7. Microbiology
8. Predisposing factors
9. Prevention
10. Positioning for breastfeeding
11. Diagnosis
12. Management - conservative
13. Management - antibiotic therapy
14. Follow up and recurrent mastitis
15. Complications
a) Breast engorgement
b) Cracked nipples
c) Candida infection
d) Chronic breast pain
e) Pus in breastmilk
f) Blood in breastmilk
g) Breast abscess
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1. Purpose of guideline
The purpose of this guideline is to assist clinicians with the prevention and
management of mastitis within Auckland District Health Board (ADHB).
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2. Guideline management principles and goals
The Guidelines and Audit Implementation Network (GAIN) in Northern Ireland identified
the need for regional guidelines on the prevention, management and treatment of
mastitis. Subsequently they convened a regional multi-disciplinary group and these
new guidelines have been developed, from which are intended to aid appropriate
mastitis diagnosis, treatment and care. The guidelines have been developed using the
most up-to-date evidence at time of publication.
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3. Definitions
Mastitis is an inflammatory condition of the breast that may or may not be accompanied
by infection. Lactational mastitis occurs when pressure builds within the milk cells
(alveoli) from stagnant or excess milk, leading to cellulitis of the interlobular connective
tissue within the mammary gland.
4. Incidence
Estimates of the global incidence of lactational mastitis vary considerably, with some
studies suggesting a figure as low as 2% and others reporting incidences up to 50%. A
recent study from Glasgow suggests an incidence of 18%. The results from this study
are similar to studies from Australia, and it is therefore feasible that around one in five
breastfeeding women may experience mastitis.
Recent studies have shown that approximately half of all cases occur in the first four
weeks of starting breastfeeding. However mastitis can also occur at any stage during
lactation and particularly when the number of breastfeeds or milk expressions is
suddenly reduced.
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6. Pathology
Lactational mastitis happens when pressure from stagnant or excess milk builds within
the alveoli. Over-distension of the alveolar cells can cause milk to leak into the
surrounding connective tissues. The presence of milk outside the ductal system of the
breast can cause a localised immune reaction with subsequent inflammation and
swelling. If milk escapes from the alveolar cells and enters the blood stream via the
mammary capillary system, the patient will experience an immune response with a
pyrexia and malaise even in the absence of infection.
During mastitis there are various changes to the biochemical and cellular composition
of breastmilk. These changes result in increased breast permeability, reduced milk
synthesis and raised concentrations of immune components. Despite these changes it
is safe to continue breastfeeding during an episode of mastitis.
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7. Microbiology
The organism found in almost all cases of lactational mastitis and breast abscess (a
complication of mastitis) is Staphylococcus aureus. Escherichia coli (or other Gram-
negative bacteria), Bacteroides species and Streptococcus species (alpha, beta and
non-haemolytic) are sometimes found, and these latter have, in a few cases, been
linked to neonatal streptococcal infection (see evidence table). However, there is no
significant correlation between bacterial counts and severity of symptoms. Infants are
often colonised with S.aureus and an Australian case control study found 82% nasal
carriage rate in infants of mothers with mastitis versus 56% in controls (see Amir et al
2006). The direction of transmission is not clear since there was no difference in nasal
carriage rates of the mothers. Pathogens such as S. aureus may be found in breastmilk
where there is no clinical manifestation of mastitis, as evidenced by a study from
Finland which took samples of breastmilk from healthy women and found 5 out of 40
samples with S.aureus (see Heikkila et al 2003).
Transmission of these organisms between mother and baby has been reported in
healthy lactating mothers (see Kawada) and is a potential source of infection for sick
preterm infants (see Gastelum et al 2005 and Behari et al 2004).
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8. Predisposing factors
Milk stasis
Nipple trauma
Other factors
The main underlying features of mastitis are milk stasis and nipple trauma.
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9. Prevention
Ensure skin to skin contact at birth and unrestricted during hospital stay
Ensure effective positioning and attachment
Encourage frequent, baby led feeding
Prevent nipple trauma through good position and attachment
Keep the mother and the baby together 24/7 so the mother is able to respond to
feeding cues – rooming in
Avoid missing feeds and leaving long gaps between feeds
Avoid unnecessary breast milk supplements (BMS)
Avoid the use of teats and dummies
Avoid and treat breast engorgement
Teach gentle massage and hand expression of breastmilk as a self help measure
Avoid pressure on the breast (tight bra or holding the breast firmly during feeding)
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The baby’s head and body should be in alignment and the neck not twisted
Baby’s tummy turned towards mummy’s tummy
The baby’s head should not be held; rather, the baby’s neck and shoulders should
be supported so that the baby’s head is free to tilt backwards
The woman shapes her breast to maximise a deeper latch
The baby starts a breastfeed with the nose opposite the nipple
When the mouth is wide open the baby should be brought swiftly to the breast
with the chin leading
The nipple should be pointing towards the roof of the baby’s mouth
The baby’s body should be held close to the mothers’ body
The mother’s position should be made sustainable after the baby is attached
To attach well, the baby is held, nose to nipple to be able to tilt the head back and
reach for the breast with the chin leading. The baby’s lower lip touches the breast first
and a wide open mouth forms a teat from both breast tissue and nipple. Then
negative pressure within the mouth, produces a seal which prevents the nipple and
breast from moving in and out during suckling.
The nipple is situated far back in the mouth at the junction of the hard and soft palate
where it will not be damaged. If the baby has not attached well, feeding will be painful
and prolonged, and the nipple will be rubbed against the hard palate during feeding,
resulting in trauma. If a blister has formed at the tip of the nipple or the nipple is
flattened, or has a white line on the tip, this is an indicator that the attachment
technique requires improvement.
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11. Diagnosis
Women who suspect they have mastitis will usually refer to their GP, midwife, child
health nurse or LMC for diagnosis and treatment. Voluntary breastfeeding
counsellors, breastfeeding support groups and peer support programmes are an
additional point of contact for women seeking guidance on managing mastitis.
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Mastitis can be a distressing and debilitating experience and its emotional and
physical effects are strongly associated with premature weaning. It is therefore
important that patients are provided with information to enable them to find out the
cause of their mastitis. Access to skilled, knowledgeable support, while still
breastfeeding during mastitis, enables patients to cope with and appropriately
manage their symptoms.
Support and encouragement within the home should help enable patients to sustain
a decision to breastfeed despite the challenge of mastitis. Families should be
encouraged to help patients rest and focus on effective feeding and breast drainage
so that they can recover quickly.
All patients with mastitis should be provided with written information and contact
details of professional and voluntary breastfeeding support organisations within their
community.
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Self management
Frequent effective milk removal is required to treat mastitis and prevent further
complications, such as breast abscess or recurrent mastitis. The most reliable
method of milk removal is usually effective feeding by the baby. If feeding is not
possible, or is not sufficient to ensure good breast emptying, the patient should
express milk from the affected breast by hand, by pump* or both. Patients should not
routinely be advised to stop breastfeeding or expressing during an episode of
mastitis: if they wish to wean this can be supported once they have recovered.
Those supporting a patient with mastitis should ensure that she is able to express
breastmilk effectively. When expressing breastmilk by hand or by pump* it is
important to use an effective technique, one that avoids trauma to the breast. Gentle
massage before expressing should encourage the “let down” reflex and aid milk flow.
All breastfeeding mothers should be taught how to hand express in the early days
after birth so that they can use this technique as needed to manage breast over-
fullness and early signs of mastitis or during an episode of mastitis.
To remove milk from the inflamed breast as effectively as possible, mothers should
be encouraged to offer feeds on the affected side first for the next two or three feeds.
To prevent further engorgement, care must be taken to ensure that there is also good
milk removal on the unaffected breast while managing mastitis.
*Note: if using a breast pump, it is vital to ensure that the funnel of the pump
attachment is large enough. The nipple should not touch the sides or extend the
length of the attachment funnel during expression. If a pump attachment larger than
the 24 - 25 mm standard is required this can be obtained from ward stock.
It may be helpful to support the mother to change her feeding position for a few feeds
so that the area of affected breast is drained as efficiently as possible. The area of
the breast corresponding to the baby’s chin will be the area most effectively drained.
For example, the underarm position will be helpful if the lower outer quadrant of the
breast is affected.
Medication may be started to treat pain, inflammation and pyrexia. If there are no
contra-indications, use Paracetamol 500 mg – 1g every 6 hours to treat pain and
pyrexia, or Ibuprofen 400mg three to four times a day after food to treat pain, pyrexia
and inflammation. .
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If the breast is inflamed a cold breast compress (3 -5 minutes maximum - protect skin
of breast with a dry wash cloth to prevent thermal shock and ductal damage) can be
useful to reduce inflammation and relieve discomfort. This in turn should aid milk flow
when used with reverse pressure massage (RPM).
If a breast abscess is suspected do not used RPM until the USS has excluded a
collection. Never do RPM for a breast abscess. Warm compresses could be used to
assist milk flow before feeding or expressing.
Gentle massage (RPM) of the affected breast and lying flat prior to a feed should
help to drain fluid within the tissues aiding milk flow prior to and during feeding or
expression of milk. The fingers (not tips) can be used in firm stroking movements
towards the sternum and axilla. Care must be taken to avoid massage that is too firm
as this can cause trauma and undue pressure and increase inflammation. A soft
stretchy support such as tubigrip has been found to be a useful support rather than a
bra at this time. Please ensure the correct size is used – not folded over and does not
gather or roll at the top as this will cause extra pressure on ductal and breast tissue.
In the community the patient can use a stretchy “boob tube” It is important to always
obtain consent prior to any massage.
Family support is important to allow the mother time to rest and recover from mastitis
and to continue breastfeeding. Extra help will be needed for at least 48 hours. It is
important that family members understand that it will not help the mother’s recovery if
they formula feed the baby and miss out breastfeeds.
The mother should be supported and encouraged to eat nutritious food to aid
recovery and healing. Extra fluids should help alleviate symptoms and reduce any
pyrexia.
The patient should be advised to seek urgent LMC or medical advice if after 12 - 24
hours from the onset of symptoms there is no improvement or the symptoms are
severe or worsening despite following the recommended self management. For
example, if her temperature increases to 38.4oC or above, or the affected breast
becomes more painful, swollen or inflamed.
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However, if symptoms are not improving within 12 - 24 hours from onset or the
symptoms are severe or worsening despite the patient implementing the
recommended self-management practices, the patient should seek urgent LMC or
medical advice and antibiotics should be started. An individual judgement on when to
start antibiotics should be made on the basis of a full case history and examination of
the patient. In severe cases it may not be desirable to wait. It is also important to
continue to empty the breast as previously described. A pain score should be
obtained. If necessary the patient should be admitted to hospital and commenced on
IV antibiotics.
Oral antibiotics for the patient with early infective mastitis (symptomatic)
*** NB: Longer treatment duration is seldom warranted. Resolution of all symptoms
will not occur until some time after effective antibiotic treatment. According to
Therapeutic Guidelines - Antibiotic version 14 2010 page 2 “keep duration of therapy
as short as possible. Do not exceed 7 days without a proven indication for longer
duration (e.g. endocarditis)”.
Please follow the admission flowchart to follow the admission procedure. Should the
patient’s condition indicate that IV antibiotics are required see table below:
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*For patients with a history of penicillin causing a severe rash, clindamycin may be a
more appropriate choice. Please discuss with the ID service for pre-approval..
All patients known to be colonised with MRSA should be discussed with the ID
service so the most appropriate antibiotic can be chosen.
** Switch patients to oral antibiotic when the following criteria are met; clinically
improving, tolerating oral fluid; temperature ≤38°C over preceding 24 hours and BP
≥90mmHg.
*** NB: Longer treatment duration is seldom warranted. Resolution of all symptoms
will not occur until some time after effective antibiotic treatment. According to
Therapeutic Guidelines - Antibiotic version 14 2010 page 2 “keep duration of therapy
as short as possible. Do not exceed 7 days without a proven indication for longer
duration (e.g. endocarditis)”
Patients should be reminded that they need to complete the full course of antibiotic
therapy to ensure their mastitis does not recur. Specific instructions regarding
antibiotic administration should be given to the patient.
Patients should also be reassured that the above recommended antibiotics may be
used during breastfeeding. Only small amounts pass through to the milk and any
effects on the baby are usually temporary. The importance to the baby of continued
breastfeeding far outweighs the temporary effects of the antibiotics. Effects can
include restlessness, diarrhoea, and a sore bottom for the baby. If the patient
develops diarrhoea (> 3 loose stools in a 24 hour period) this may be due to
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Alternative treatments
As these are merely complementary, the first line of treatment for mastitis should
always be based on the best available evidence as contained within these guidelines.
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Breastmilk cultures
The lactation consultant should be involved in the decision making along with a
clinician.
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15. Complications
a) Breast engorgement
Breast fullness commonly occurs between the second and fifth day following
delivery and the onset of lactogenesis II. Then there is a significant increase in the
volume of milk being produced. At this time, the breasts feel firm, heavy and
warm, and the milk flows readily: this is a normal physiological response. It is not
unusual for the breast to feel hot and look flushed.
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b) Cracked nipples
Trauma to the nipples during breastfeeding is most often caused by poor
attachment of the baby to the breast. All patients with cracked nipples require
further support from a midwife or lactation consultant, who should ensure that the
mother positions her baby correctly and achieves good attachment to prevent
further trauma. Positioning for breastfeeding describes how to achieve and
recognise effective positioning and attachment.
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c) Candida infection
It is important to remember that thrush is commonly misdiagnosed, under and
over treated. It is therefore advisable to take a detailed history to ascertain if
thrush is present. Generally nipple and areola thrush is seen after the patient is
discharged into the community.
Nipple and areola thrush presents with a red shiny appearance that is often itchy
with sharp stabbing pain on feeding. The nipples should be carefully observed
with a magnifying glass to assess for any white spots.
If thrush is suspected the baby’s mouth should be assessed for white spots on the
cheeks, tongue or pharynx and the baby’s anal area observed for red spots. Oral
thrush in the baby should be treated with nystatin oral suspension 0.5 – 1ml 4
times a day. For areola, nipple thrush it is recommended that clotrimazole cream
1% be applied three times a day after feeds. This treatment should continue for a
further 10 - 14 days after the symptoms have subsided.
Ductal thrush
Ductal thrush presents with specific symptoms that help in confirming the
diagnosis. For this reason a lactation consultant should be contacted.
Fluconazole 100mg once daily for a minimum of 7 days (see Heinig et al and
prescribing notes below). It is important that the prescriber follows up the patient
closely and adjusts the dosage accordingly in line with her symptoms. Refer to
the BNF for precautions when prescribing fluconazole. At ADHB the use of
fluconazole requires approval from the ID Team.
It is unlikely that the infant will need to be prescribed oral nystatin suspension if
the mother is taking fluconazole.
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e) Pus in breastmilk
It is recommended that women continue to breastfeed.
Note: Thickened milk or string like milk solids may indicate previous blocked duct,
the water content has been reabsorbed and the milk solids only obtained until the
blockage cleared. The milk obtained is safe for the baby and the mother should
continue breastfeeding.
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f) Blood in breastmilk
Recommend that the mother continue breastfeeding.
i. Stop expressing if possible, or ensure only light hand or minimum setting for
electric breast pump if expressing is required;
ii. Make sure pumping equipment fits correctly and not the cause of further
trauma;
iii. Expected outcome – bleeding should resolve spontaneously within 24 - 48
hours;
iv. Refer to lactation consultant if mother requires reassurance;
v. Refer for medical opinion if prolonged bleeding;
vi. Document the assessment, management plan, and outcome.
Note: If the patient is Hepatitis C positive she should be provided with information
on the possible risks associated with Hepatitis C. Nipple trauma should be
prevented, it is recommended she express and discard milk until signs of blood in
the milk have ceased.
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g) Breast abscess
Approximately 3% of mastitis cases result in a breast abscess. Most are caused
by inappropriate management of mastitis or sudden cessation of breastfeeding
during mastitis. All patients suspected of having a breast abscess should be
referred to the lactation consultant.
All confirmed or suspected breast abscesses should be clerked and admitted into
hospital for appropriate management. (See referrals to breast care team
flowchart.)
Clinical features
The abscess may present as a well defined area of breast which remains hard
sometimes flutuant, red, and tender despite treatment. The initial systemic
symptoms and fever may have resolved. Some early breast abscess collections
are difficult to detect clinically.
Should the patient present with a pyrexia > than 38.5 ºC blood cultures should be
done together with U&Es, FBC and CRP. The patient may require IV fluid therapy
if she is clinically dehydrated.
should be expressing milk from the affected breast until she is able to resume
breastfeeding, the milk can be safely given to her baby via a cup or supply line at
the unaffected breast. During this time breastfeeding can continue from the
unaffected side.
Patients should be reassured that continued breastfeeding is safe for their baby.
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* For patients with a history of penicillin causing a severe rash, clindamycin may
be a more appropriate choice. Please discuss with the ID service for pre-
approval..
All patients known to be colonised with MRSA should be discussed with the ID
service so the most appropriate antibiotic can be chosen.
** Switch patients to oral antibiotic when the following criteria are met; clinically
improving, tolerating oral fluid; temperature ≤38°C over preceding 24 hours and BP
≥90mmHg.
*** NB: Longer treatment duration is seldom warranted. Resolution of all symptoms
will not occur until some time after effective antibiotic treatment. According to
Therapeutic Guidelines - Antibiotic version 14 2010 page 2 “keep duration of therapy
as short as possible. Do not exceed 7 days without a proven indication for longer
duration (e.g. endocarditis)”
If facilities for breast ultrasound are not available and the patient presents with a
clinically fluctuant abscess, surgical drainage may be required urgently. This may
also be necessitated by necrotic skin and soft tissue involvement.
The surgical incision should follow skin crease lines. Consider the incision
placement that will best facilitate drainage, even if an inframammary incision is
required BMJ volume 297 JM DIXON 10/12/88 ROYAL INFIRMARY
EDINGBURGH
A surgical incision close to the areola may preclude breastfeeding during
recovery, so care should be taken in planning an incision that best facilitates
dependent drainage and continued breastfeeding
Adequate surgical drainage is crucial and digital interruption of loculi will be
required, and this is best performed under a general anaesthetic
If available, a diagnostic breast ultrasound will be valuable in documenting the
extent of the abscess, assisting with incision planning, and may help avoid a
repeat surgical drainage procedure
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Post operatively, loose packing with Seasorb will be required and then covered
with an Allevyn dressing, and there will be a need to change the packing to allow
healing by secondary intention. Breastfeeding is to continue, the lactation
consultant needs be involved in this patient’s care.
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AED
APU
WAU
After hours
Refer to LC for initial review
assessment
during working hours. If
significant delay in medical
Review by team on
assessment LC may gain verbal
call as above
approval for ultrasound scan
Be followed up by LC
Daily reassessment and review of
care input required by surgical
breast team and LC. LMC/team
to remain involved
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Please note:
Adequate analgesia must be given at all times pending assessment, and antibiotics started by
verbal order if needed
If there is significant delay in assessment, an ultrasound may be arranged prior to assessment by
the surgical team
These women should be handed over to the next O&G team coming on if their care involves a
change of shift
All referrals after hours for breast abscess will be handed over to the breast team the next
morning and noted on the computer list held by the breast team
Ongoing responsibility of these patients will be with the breast team if an abscess or mastitis is
confirmed until the problem is resolved
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19. Associated ADHB documents
20. Disclaimer
No guideline can cover all variations required for specific circumstances. It is the
responsibility of the health care practitioners using this ADHB guideline to adapt it for
safe use within their own institution, recognise the need for specialist help, and call
for it without delay, when an individual patient falls outside of the boundaries of this
guideline.
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