What is the recommended treatment for mastitis in breastfeeding mothers?

Treatment of Mastitis in Breastfeeding Mothers

The first-line treatment for mastitis in breastfeeding mothers is amoxicillin-clavulanate for 7-10 days, combined with continued breastfeeding and supportive measures. 1

Diagnosis and Clinical Presentation

Mastitis is diagnosed clinically based on:

• Focal breast tenderness
• Fever and malaise
• Overlying skin erythema or hyperpigmentation
• Occurs in approximately 10% of breastfeeding mothers, usually within first 3 months postpartum 2

Treatment Algorithm

Step 1: Conservative Management (1-2 days)

• Continue breastfeeding from the affected breast to ensure complete emptying 1, 2
• Apply cold compresses (not heat) to reduce inflammation 2
• Use NSAIDs for pain and inflammation 2
• Ensure proper latch and breastfeeding technique, potentially with lactation consultant assistance 3

Step 2: Antibiotic Therapy (if no improvement after 1-2 days)

• First-line antibiotic: Amoxicillin-clavulanate for 7-10 days 1
• Alternative options (for penicillin allergy):
  • Cephalexin (if non-anaphylactic allergy) 3
  • Clindamycin 1

Step 3: Management of Complications

• If symptoms worsen or no improvement after 48 hours of antibiotics, evaluate for:
  • Breast abscess (requires surgical drainage or needle aspiration) 3
  • Resistant organisms (consider MRSA coverage) 3
• For severe cases with signs of sepsis, hospitalization and IV antibiotics may be required 2

Important Considerations

Breastfeeding During Treatment

• Continue breastfeeding during antibiotic treatment 1
• Frequent and complete emptying of the affected breast is essential for recovery 1
• Breastfeeding does not pose a risk to the infant even during active mastitis 3

Antibiotic Safety During Breastfeeding

• Amoxicillin-clavulanate is safe during breastfeeding 1
• Dicloxacillin has very low transfer into breast milk (RID of 0.03%) 4
• Monitor infants for potential side effects such as diarrhea, rash, or thrush 1

Prevention of Recurrence

• Optimize breastfeeding technique 3
• Avoid practices that may worsen mastitis:
  • Excessive pumping
  • Aggressive breast massage
  • Heat application 2
• Ensure a proper latch and encourage physiologic breastfeeding rather than pumping when possible 2

Cautions and Pitfalls

• Untreated mastitis can lead to breast abscess formation and premature cessation of breastfeeding 5
• Avoid restricting breastfeeding from the affected breast as this can worsen symptoms 1
• Do not rely on heat application or aggressive breast massage as these may worsen inflammation 2
• Be aware that as MRSA becomes more common, antibiotic choices may need to be adjusted 3

The evidence for antibiotic therapy in mastitis is limited, with a Cochrane review noting insufficient evidence to confirm or refute effectiveness 6. However, clinical practice guidelines still recommend antibiotics when there are clear signs of infection, with amoxicillin-clavulanate providing adequate coverage against common pathogens 1.