Treatment for Mastitis While Breastfeeding
First-line antibiotic therapy for mastitis in breastfeeding women should be cephalexin or dicloxacillin, which are safe during breastfeeding and effective against Staphylococcus aureus, the most common causative organism. 1, 2
Initial Conservative Management (First 24-48 Hours)
Before initiating antibiotics, a 1-2 day trial of conservative measures is appropriate since most mastitis cases are inflammatory rather than infectious 3:
- Continue breastfeeding from the affected breast - this does not pose risk to the infant and helps resolve the condition 1, 2
- NSAIDs for pain and inflammation (compatible with breastfeeding for short-term use) 4, 3
- Ice application to reduce inflammation 3
- Feed infant directly from breast rather than pumping when possible, as pumping may worsen tissue trauma 3
Antibiotic Therapy
When to Start Antibiotics
Initiate antibiotics if symptoms do not improve within 24-48 hours of conservative management, or if the patient presents with severe symptoms initially 3.
First-Line Antibiotic Options
Cephalexin (cephalosporin) is the preferred first-line agent 1:
- Safe during breastfeeding with minimal transfer to breast milk 1
- Effective against common skin flora including Staphylococcus and Streptococcus 3
Dicloxacillin is equally effective 2, 5:
- Relative infant dose of only 0.03% of maternal dose 5
- High plasma protein binding results in poor penetration into breast milk 5
- Effective against Staphylococcus aureus 2
Alternative Options
For penicillin-allergic patients 1:
- Erythromycin or azithromycin are acceptable alternatives
- Important caveat: Very low risk of infantile hypertrophic pyloric stenosis if infant exposed during first 13 days of breastfeeding 1
Amoxicillin/clavulanic acid is a broad-spectrum alternative that is safe during breastfeeding 1, 4
MRSA Coverage
Consider antibiotics effective against methicillin-resistant S. aureus if 1:
- High local MRSA prevalence
- Previous MRSA infection
- No response to first-line therapy within 48-72 hours
Monitoring and Follow-Up
Reevaluate within 48-72 hours if 1:
- Symptoms worsen
- No improvement with antibiotic therapy
- Concern for abscess formation (occurs in approximately 10% of mastitis cases) 1, 2
Obtain milk cultures to guide antibiotic therapy, particularly in treatment failures 3
Perform ultrasonography in immunocompromised patients or those with worsening/recurrent symptoms to identify abscess 3
Critical Management Points
Continue breastfeeding throughout treatment - this is essential and does not harm the infant 1, 2, 6. All recommended antibiotics (dicloxacillin, cephalexin, clindamycin) are compatible with breastfeeding with minimal transfer to breast milk 1.
Avoid practices that worsen mastitis 3:
- Excessive pumping to "empty" the breast
- Aggressive breast massage
- Heat application
- Overfeeding or overstimulation of milk production
Optimize breastfeeding technique with lactation consultant assistance to prevent recurrence 2, 3
Common Pitfalls
The evidence for antibiotic effectiveness is limited, with one Cochrane review noting insufficient high-quality data 7. However, in clinical practice, antibiotics are widely used and recommended when conservative measures fail 1, 2, 3.
Do not discontinue breastfeeding - this is the most important intervention for resolution and does not require interruption even with antibiotic therapy 1, 2, 6.
If abscess develops (10% of cases), surgical drainage or needle aspiration is required, but breastfeeding can usually continue even with a treated abscess 2.