What is the treatment for mastitis (inflammation of breast tissue)?

Treatment of Mastitis

The first-line treatment for mastitis includes continued breastfeeding or breast milk expression, supportive measures such as NSAIDs, and antibiotics effective against Staphylococcus aureus (dicloxacillin or cephalexin) if symptoms do not improve within 24-48 hours of conservative management. 1

Diagnosis and Clinical Presentation

Mastitis is an inflammatory condition of the breast that occurs in approximately 10% of breastfeeding women in the United States, typically within the first 3 months postpartum 1. The diagnosis is primarily clinical, based on:

• Focal breast tenderness
• Overlying skin erythema or hyperpigmentation
• Fever and malaise
• May present with a palpable mass or area of induration

Treatment Algorithm

Step 1: Conservative Management (1-2 days)

• Continue breastfeeding or milk expression from the affected breast
• Use of non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation
• Application of ice to reduce inflammation
• Minimize excessive pumping (which can worsen inflammation)
• Ensure proper infant latch and breastfeeding technique

Step 2: If No Improvement After 1-2 Days

• Initiate antibiotic therapy effective against Staphylococcus aureus:
  • Dicloxacillin 500 mg orally every 6 hours 2
  • Alternative: Cephalexin 500 mg orally every 6 hours 3
  • Continue for 10-14 days

Step 3: For Worsening Symptoms or No Response

• Consider milk culture to guide antibiotic therapy 1
• Evaluate for breast abscess with ultrasound
• Consider methicillin-resistant S. aureus (MRSA) coverage if indicated by local resistance patterns 3
• For severe cases: intravenous antibiotics and hospital admission may be required

Important Clinical Considerations

1. Continued Breastfeeding: Breastfeeding should be encouraged during mastitis treatment as it helps with breast emptying and does not pose a risk to the infant 3.

2. Antibiotic Safety: Dicloxacillin has minimal transfer into breast milk (relative infant dose of only 0.03%) and is considered safe during breastfeeding 2.

3. Monitoring for Complications: The most common complication of mastitis is breast abscess, occurring in approximately 10% of cases. If suspected, ultrasound evaluation is needed, followed by surgical drainage or needle aspiration if confirmed 3.

4. Prevention Strategies:

   • Proper breastfeeding technique with good infant latch
   • Frequent, complete emptying of the breast
   • Avoid excessive pumping and aggressive breast massage
   • Physiologic breastfeeding rather than pumping when possible 1

Common Pitfalls to Avoid

1. Overtreatment: Not all mastitis cases require immediate antibiotics. Many cases are inflammatory rather than infectious and respond to conservative measures 1.

2. Counterproductive Interventions: Excessive pumping, aggressive breast massage, and heat application can worsen inflammation and are no longer recommended 1.

3. Premature Cessation of Breastfeeding: Discontinuing breastfeeding during mastitis can worsen milk stasis and potentially lead to abscess formation 3.

4. Inadequate Follow-up: Patients should be reassessed within 48-72 hours to ensure improvement. Worsening symptoms may indicate abscess formation or need for antibiotic adjustment.

By following this structured approach to mastitis management, most cases can be effectively treated while supporting continued breastfeeding and minimizing complications.