What is the recommended treatment for lactational mastitis?

Treatment of Lactational Mastitis

The first-line treatment for lactational mastitis is continued breastfeeding with proper milk removal, supportive measures including pain management with NSAIDs, and antibiotics effective against Staphylococcus aureus if symptoms persist beyond 24-48 hours of conservative management. 1, 2

Diagnosis and Initial Assessment

Lactational mastitis affects approximately 10% of breastfeeding women, typically occurring within the first three months postpartum 2. The diagnosis is primarily clinical, based on:

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

Treatment Algorithm

Step 1: Conservative Management (First 24-48 hours)

• Continue breastfeeding from the affected breast to prevent engorgement and worsening of symptoms 1
• Apply cold compresses to the affected area to reduce inflammation
• Take pain medications compatible with breastfeeding:
  • Ibuprofen (first choice) 1
  • Paracetamol/acetaminophen (alternative) 1
• Ensure proper infant latch and breastfeeding technique
• Avoid excessive pumping, aggressive breast massage, or overfeeding, as these may worsen the condition 2

Step 2: Antibiotic Therapy (If no improvement after 24-48 hours)

• Initiate antibiotics effective against Staphylococcus aureus:
  • Dicloxacillin 500 mg orally four times daily for 10-14 days 3
  • Cephalexin 500 mg orally four times daily for 10-14 days (alternative) 3
• Consider obtaining milk cultures to guide antibiotic therapy in cases of:
  • Severe symptoms
  • No response to initial antibiotics
  • Recurrent mastitis
  • Hospital-acquired infections

Step 3: Management of Complications

• If symptoms worsen despite antibiotics, evaluate for breast abscess using ultrasonography 2
• For confirmed abscess: surgical drainage or needle aspiration is required 3
• Continue breastfeeding even with a treated abscess 3

Special Considerations

Continuing Breastfeeding During Treatment

Continuing breastfeeding during mastitis treatment is strongly recommended because:

• It helps prevent engorgement and blocked ducts 1
• Stopping breastfeeding may lead to early cessation altogether 1
• It does not pose a risk to the infant 3

Antibiotic Selection

• With increasing prevalence of methicillin-resistant S. aureus (MRSA), consider alternative antibiotics if initial therapy fails 3
• All recommended antibiotics are compatible with breastfeeding 4

Prevention Strategies

• Optimize breastfeeding technique with proper infant latch 2
• Encourage physiologic breastfeeding rather than pumping when possible 2
• Avoid practices that overstimulate milk production 2

Common Pitfalls to Avoid

1. Stopping breastfeeding during mastitis treatment - This can worsen engorgement and prolong recovery
2. Excessive pumping or aggressive breast massage - These practices can cause tissue trauma and worsen inflammation 2
3. Delaying antibiotic therapy - If symptoms don't improve with conservative measures within 24-48 hours, antibiotics should be started promptly
4. Missing a breast abscess - Consider ultrasonography in immunocompromised patients or those with worsening/recurrent symptoms 2

By following this evidence-based approach to lactational mastitis management, most cases can be effectively treated in the outpatient setting while supporting continued breastfeeding.