Treatment of Mastitis
The treatment of mastitis should begin with continued breastfeeding or milk expression, supportive measures, and antibiotics effective against Staphylococcus aureus if symptoms persist beyond 24-48 hours or are severe. 1, 2, 3
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 3
Laboratory tests and imaging are not routinely needed for diagnosis 3
- Consider milk cultures for recurrent or severe cases
- Ultrasound if abscess is suspected (especially in immunocompromised patients)
First-Line Treatment Approach
Conservative Management (1-2 days)
- Continue breastfeeding or milk expression from the affected breast 1, 2, 3
- Regular feeding or expression of milk is an essential part of treatment
- Breastfeeding can continue on the affected side as long as drainage is not purulent
- Pain management with NSAIDs 3
- Ice application to reduce inflammation 3
- Minimize excessive pumping (can worsen inflammation) 3
When to Add Antibiotics
- If no improvement after 24-48 hours of conservative measures
- If symptoms are severe from the outset
- If signs of infection are present
Antibiotic Selection
- First-line antibiotics should target Staphylococcus aureus: 2, 3
- Dicloxacillin 500 mg orally four times daily for 7-10 days
- Cephalexin 500 mg orally four times daily for 7-10 days
- Consider coverage for methicillin-resistant S. aureus (MRSA) if:
- Previous MRSA infection
- High local prevalence of MRSA
- No response to first-line antibiotics 2
Important Considerations
Breastfeeding Continuation
- Mothers with mastitis should be strongly encouraged to continue breastfeeding 1, 2, 4
- Continued breastfeeding does not pose a risk to the infant
- Helps prevent breast engorgement which can worsen symptoms
- Supports milk supply maintenance
Prevention of Complications
- Most common complication is breast abscess (occurs in approximately 10% of mastitis cases) 1, 2
- Prevention strategies:
- Early treatment of mastitis
- Continued breastfeeding
- Proper latch technique
- Avoiding excessive pumping and breast massage 3
Management of Breast Abscess
- Requires drainage (surgical or needle aspiration) 2
- Continue antibiotics
- Breastfeeding can usually continue with a treated abscess 2
Prevention of Recurrence
Optimize breastfeeding technique 2, 3
- Ensure proper infant latch
- Encourage physiologic breastfeeding rather than excessive pumping
- Avoid overstimulation of milk production
- Avoid aggressive breast massage (can cause tissue trauma)
Address predisposing factors:
- Treat sore nipples promptly (can precipitate mastitis) 2
- Manage engorgement appropriately
- Avoid sudden changes in feeding patterns
Evidence Limitations
- There is insufficient high-quality evidence to definitively confirm the effectiveness of antibiotic therapy for lactational mastitis 5
- Current recommendations are based on clinical experience and observational studies
- The most recent evidence suggests that many cases of mastitis are inflammatory rather than infectious, explaining why conservative measures are often effective 3
Special Considerations
- For recurrent mastitis, consider:
- Milk culture to guide antibiotic therapy
- Evaluation of breastfeeding technique
- Assessment for anatomical issues that may predispose to recurrence