Treatment of Mastitis
The primary treatment for mastitis includes continued breastfeeding, supportive measures, and antibiotics effective against Staphylococcus aureus such as dicloxacillin or cephalexin when symptoms persist beyond 24-48 hours of conservative management. 1
Definition and Diagnosis
Mastitis is an inflammation of the breast tissue 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
- Systemic symptoms (fever, malaise)
No laboratory tests or imaging are routinely required for diagnosis in straightforward cases 1.
Treatment Algorithm
Step 1: Conservative Management (1-2 days)
- Continue breastfeeding from the affected breast
- Use non-steroidal anti-inflammatory drugs for pain and inflammation
- Apply ice to reduce inflammation
- Minimize pumping (contrary to previous recommendations)
- Ensure proper latch and breastfeeding technique
Step 2: If No Improvement After 24-48 Hours
- Initiate antibiotic therapy targeting common skin flora:
- First-line: Dicloxacillin or cephalexin (effective against S. aureus)
- For penicillin allergy: Clindamycin
- For suspected MRSA: Consider trimethoprim-sulfamethoxazole or clindamycin
Step 3: For Severe Cases or Complications
- Consider hospitalization for IV antibiotics if:
- Signs of sepsis
- Symptoms rapidly worsening
- Immunocompromised patient
- Ultrasound evaluation if:
- Symptoms not improving with antibiotics
- Suspicion of abscess formation
- Recurrent mastitis
Important Clinical Considerations
Safety of Continued Breastfeeding
- Continued breastfeeding is strongly encouraged during mastitis treatment 2, 3
- Breastfeeding helps with breast drainage and does not pose a risk to healthy infants
- Dicloxacillin has minimal transfer into breast milk (relative infant dose of only 0.03%) 4
Antibiotic Selection
- Limited evidence exists regarding antibiotic efficacy for mastitis 5
- When antibiotics are needed, those effective against S. aureus are preferred 3
- Treatment duration is typically 10-14 days
Prevention of Recurrence
- Optimize breastfeeding technique with proper latch
- Avoid practices that may worsen mastitis:
- Excessive pumping
- Aggressive breast massage
- Overfeeding
- Heat application 1
Complications to Monitor
- Breast abscess (most common complication)
- Requires surgical drainage or needle aspiration if it develops
- Candida infection may develop as a secondary complication of antibiotic therapy 6
Common Pitfalls to Avoid
- Stopping breastfeeding: This can worsen milk stasis and delay recovery
- Excessive breast emptying: Current evidence suggests this may worsen inflammation 1
- Delaying antibiotics: When symptoms persist beyond 1-2 days of conservative measures, antibiotics should be initiated
- Missing an abscess: Consider ultrasound for worsening or non-responsive cases
Remember that most cases of mastitis represent inflammation rather than true infection, which is why a brief trial of conservative measures is appropriate before starting antibiotics 1.