What is the treatment for lactational mastitis?

Treatment for Lactational Mastitis

The first-line treatment for lactational mastitis includes continued breastfeeding or milk expression, supportive measures such as NSAIDs for pain relief, and antibiotics effective against Staphylococcus aureus if symptoms persist beyond 24-48 hours of conservative management. 1, 2

Diagnosis and Clinical Presentation

• Lactational mastitis affects approximately 10% of breastfeeding women in the United States, typically occurring within the first 3 months postpartum 1
• Diagnosis is primarily clinical, based on symptoms including fever, malaise, focal breast tenderness, and overlying skin erythema or hyperpigmentation 1
• Laboratory tests or imaging are not routinely required for diagnosis, though milk cultures may be considered to guide antibiotic therapy in non-responsive cases 1, 2

Initial Management Approach

• Continue breastfeeding: Mothers should be encouraged to continue breastfeeding as regular milk removal is essential for treatment 3, 2
• Conservative measures (first 24-48 hours):
  • NSAIDs for pain relief and inflammation reduction (ibuprofen is considered safe during lactation) 4, 1
  • Ice application to reduce inflammation 1
  • Feed infant directly from the affected breast to ensure effective milk removal 1, 2
  • Minimize excessive pumping which may worsen the condition 1

Antibiotic Therapy

• If symptoms do not improve after 24-48 hours of conservative measures, antibiotics should be initiated 1, 2
• First-line antibiotics should target Staphylococcus aureus:
  • Dicloxacillin or cephalexin are preferred options 2
  • With increasing prevalence of methicillin-resistant S. aureus (MRSA), coverage may need to be adjusted accordingly 2
• Antibiotic duration is typically 10-14 days 2
• While evidence from randomized controlled trials is limited, clinical practice supports antibiotic use for non-responsive mastitis 5

Pain Management During Treatment

• Safe analgesic options during lactation include:
  • Ibuprofen - widely used for postpartum pain and considered safe during breastfeeding 4
  • Paracetamol (acetaminophen) - safe during lactation as infant exposure is significantly below therapeutic pediatric doses 4
  • Diclofenaco - detected in small amounts in breast milk but considered safe based on extensive use 4
  • Naproxen - commonly used after cesarean delivery; breastfeeding can continue normally 4
• Avoid aspirin at analgesic doses during lactation 4
• Use caution with opioids:
  • Codeine should be used cautiously due to genetic variability in metabolism affecting breast milk levels 4
  • Oxicodone may pose higher risk of infant sedation, with risk being dose-related 4

Management of Complications

• Approximately 10% of mastitis cases progress to breast abscesses 3, 6
• If an abscess develops, it requires drainage (surgical or needle aspiration) 3, 2
• Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage 3
• Ultrasonography should be performed to identify abscesses in immunocompromised patients or those with worsening/recurrent symptoms 1

Prevention Strategies

• Proper breastfeeding technique is the best prevention strategy, including:
  • Ensuring good infant latch 1, 2
  • Encouraging physiologic breastfeeding rather than excessive pumping 1
• Avoid practices that may increase risk:
  • Overstimulation of milk production 1
  • Tissue trauma from aggressive breast massage 1
  • Excessive pumping to completely empty the breast 1
  • Excessive heat application 1

Important Considerations

• Delaying treatment of non-responsive mastitis may lead to abscess formation 3, 6
• Discontinuing breastfeeding during mastitis treatment can worsen the condition 3, 7
• Candida infection may develop as a secondary complication following antibiotic therapy and should be treated appropriately if diagnosed 7