What is the recommended treatment for postpartum mastitis?

Treatment for Postpartum Mastitis

First-line treatment for postpartum mastitis should include continued breastfeeding with proper technique, pain management with NSAIDs, and antibiotics effective against Staphylococcus aureus such as dicloxacillin or cephalexin if symptoms persist beyond 24-48 hours of conservative measures. 1

Diagnosis and Initial Assessment

• Mastitis is diagnosed clinically based on:

  • Focal breast tenderness
  • Overlying skin erythema or hyperpigmentation
  • Systemic symptoms (fever, malaise)
  • Typically occurs within first 3 months postpartum (most commonly in first 6 weeks)
  • Affects approximately 10% of breastfeeding women in the US 1, 2

• Laboratory tests or imaging are not routinely needed for diagnosis

• Consider milk cultures to guide antibiotic therapy in:

  • Severe cases
  • Treatment failures
  • Recurrent mastitis

Treatment Algorithm

Step 1: Conservative Management (1-2 days)

• Continue breastfeeding from the affected breast (does not pose risk to infant) 2
• Apply cold compresses to reduce pain and swelling
• Take NSAIDs for pain and inflammation
• Ensure proper infant latch and breastfeeding technique
• Minimize excessive pumping (may worsen condition) 1

Step 2: If No Improvement After 24-48 Hours, Add Antibiotics

• First-line antibiotics (7-10 day course):

  • Dicloxacillin 500 mg orally every 6 hours (extremely low transfer to breast milk with RID of only 0.03%) 3
  • Cephalexin 500 mg orally every 6 hours

• For penicillin-allergic patients:

  • Clindamycin 300-450 mg orally every 6-8 hours

• For suspected MRSA:

  • Trimethoprim-sulfamethoxazole or clindamycin

Step 3: For Worsening Symptoms or Suspected Abscess

• Obtain breast ultrasound to evaluate for abscess
• If abscess present: surgical drainage or needle aspiration
• Consider hospitalization for IV antibiotics if:
  • Severe systemic symptoms
  • Signs of sepsis
  • Immunocompromised patient
  • Failed outpatient therapy

Special Considerations

• Breastfeeding should continue during mastitis treatment 2

  • Helps with breast drainage
  • Does not pose risk to healthy term infants
  • May need to express milk if too painful to breastfeed directly

• Avoid practices that may worsen mastitis:

  • Excessive pumping to empty breast
  • Aggressive breast massage
  • Heat application
  • Overfeeding 1

• Consult lactation specialist to:

  • Evaluate and correct breastfeeding technique
  • Address any nipple trauma or latch issues
  • Provide support for continued breastfeeding

Prevention Strategies

• Ensure proper infant latch and breastfeeding technique
• Avoid skipped feedings and sudden weaning
• Treat sore nipples promptly
• Avoid restrictive clothing or bras
• Encourage physiologic breastfeeding rather than pumping when possible 1

Evidence Quality

The evidence for antibiotic treatment in mastitis is limited, with a Cochrane review noting insufficient high-quality evidence to confirm or refute effectiveness 4. However, clinical practice guidelines and expert consensus support the use of antibiotics when symptoms persist beyond 24-48 hours of conservative measures or when symptoms are severe.

Despite limited evidence from randomized controlled trials, the clinical approach outlined above represents the current standard of care based on observational studies and expert opinion.