First Line Treatment for 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 do not improve after 1-2 days of conservative management. 1
Diagnosis and Clinical Presentation
Mastitis is diagnosed clinically based on:
- Focal breast tenderness
- Fever and malaise
- Overlying skin erythema or hyperpigmentation
- Symptoms typically occurring within first 3 months postpartum
Laboratory tests or imaging are generally not required for initial diagnosis, though milk cultures may be considered to guide antibiotic therapy in cases that don't respond to initial treatment 1.
Treatment Algorithm
Step 1: Conservative Management (1-2 days)
- Continue breastfeeding on the affected breast (crucial for recovery)
- Use of nonsteroidal anti-inflammatory drugs for pain and inflammation
- Application of ice to reduce inflammation
- Feed infant directly from breast
- Minimize pumping (excessive emptying can worsen condition)
Step 2: If No Improvement After 1-2 Days, Add Antibiotics
- First-line antibiotics: Those effective against Staphylococcus aureus 2
- Dicloxacillin
- Cephalexin
Step 3: For Severe Cases or No Response to Oral Antibiotics
- Consider intravenous antibiotics
- Hospitalization may be required if there are signs of sepsis
- Ultrasound to rule out abscess formation in immunocompromised patients or those with worsening/recurrent symptoms
Important Considerations
- Continue breastfeeding: This is essential and generally does not pose a risk to the infant 2
- Avoid practices that may worsen mastitis: Excessive pumping, aggressive breast massage, and heat application are no longer recommended as they may worsen the condition 1
- Monitor for complications: Breast abscess is the most common complication and can be prevented by early treatment and continued breastfeeding 2
- If abscess develops: Surgical drainage or needle aspiration is needed, but breastfeeding can usually continue 2
Evidence Quality and Controversies
The evidence for antibiotic use in mastitis is somewhat limited. A Cochrane review found insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for lactational mastitis 3. However, more recent clinical practice guidelines recommend antibiotics if symptoms don't improve after 1-2 days of conservative measures 1.
The current understanding is that many cases of mastitis are primarily inflammatory rather than infectious, which explains why conservative measures are recommended as the initial approach before antibiotics 1.
Prevention
The best prevention is proper lactation technique:
- Ensuring good infant latch
- Encouraging physiologic breastfeeding rather than pumping when possible
- Avoiding overstimulation of milk production and tissue trauma from aggressive breast massage 1
By following this treatment algorithm and preventive measures, most cases of mastitis can be effectively managed while supporting continued breastfeeding.