What is the treatment for mastitis?

Treatment of Mastitis

The first-line treatment for mastitis includes continued breastfeeding, supportive measures, and antibiotics effective against Staphylococcus aureus such as dicloxacillin or cephalexin if symptoms persist beyond 24-48 hours of conservative management. 1

Diagnosis and Clinical Presentation

Mastitis is diagnosed clinically based on:

• Focal breast tenderness
• Overlying skin erythema or hyperpigmentation
• Systemic symptoms (fever, malaise)

Laboratory tests and imaging are not routinely needed for initial diagnosis, though milk cultures may guide antibiotic therapy in refractory cases 1.

Treatment Algorithm

Step 1: Conservative Management (1-2 days)

• Continue breastfeeding from the affected breast (does not pose risk to infant)
• Use nonsteroidal anti-inflammatory drugs for pain and inflammation
• Apply ice to reduce inflammation
• Ensure proper breastfeeding technique (often with lactation consultant assistance)
• Avoid excessive pumping, aggressive breast massage, and heat application as these may worsen inflammation 1

Step 2: If No Improvement After 24-48 Hours

• Initiate antibiotics effective against Staphylococcus aureus:
  • Dicloxacillin (500 mg orally four times daily)
  • Cephalexin (500 mg orally four times daily)
  • Continue for 10-14 days

Step 3: For Severe Cases or Complications

• Consider ultrasound to evaluate for abscess in:
  • Immunocompromised patients
  • Cases with worsening symptoms
  • Recurrent mastitis 1
• If abscess is present, surgical drainage or needle aspiration is required
• For severe systemic symptoms, consider intravenous antibiotics and hospitalization

Special Considerations

Medication Safety During Breastfeeding

• Dicloxacillin has minimal transfer into breast milk (relative infant dose of only 0.03%) 2
• Continued breastfeeding is recommended during antibiotic treatment

Prevention Strategies

• Optimize breastfeeding technique with proper infant latch
• Frequent, complete emptying of the breast
• Encourage physiologic breastfeeding rather than pumping when possible
• Address sore nipples promptly as they can precipitate mastitis 3

Common Pitfalls to Avoid

1. Discontinuing breastfeeding - This can worsen milk stasis and is unnecessary
2. Excessive breast massage - Can cause tissue trauma and worsen inflammation
3. Overuse of pumping - May overstimulate milk production
4. Delayed antibiotic therapy - Can lead to abscess formation
5. Heat application - No longer recommended as it may worsen inflammation 1

While the Cochrane review notes insufficient evidence regarding antibiotic effectiveness 4, the most recent clinical evidence supports their use when symptoms persist beyond conservative management. Early and appropriate treatment helps prevent complications such as breast abscess, which occurs in approximately 10% of untreated cases 3.