What are the guidelines for managing mastitis?

Mastitis Management Guidelines

For lactational mastitis, continue breastfeeding with conservative measures (NSAIDs, ice) for 1-2 days first, then initiate narrow-spectrum antibiotics targeting Staphylococcus aureus (dicloxacillin or cephalexin) only if symptoms fail to improve. 1

Initial Assessment and Diagnosis

Clinical diagnosis is sufficient without routine laboratory testing or imaging. Look specifically for: 1

• Focal breast tenderness in one breast
• Overlying skin erythema or hyperpigmentation
• Fever and malaise
• Timing: typically occurs within first 3 months postpartum 1

Obtain milk cultures to guide antibiotic selection, particularly if symptoms worsen or recur 1. Perform ultrasonography only in immunocompromised patients or those with worsening/recurrent symptoms to identify abscess formation 1.

First-Line Conservative Management (Days 1-2)

Most mastitis cases are inflammatory, not infectious, so begin with a 1-2 day trial of conservative measures: 1

• NSAIDs (ibuprofen, naproxen, or paracetamol) for pain and inflammation 2, 3
• Ice application to affected breast 1
• Continue direct breastfeeding from the affected breast—this is essential for treatment 3, 4
• Minimize pumping—excessive pumping worsens the condition 1

Critical pitfall: Avoid heat application, aggressive breast massage, and excessive pumping to "empty" the breast, as these overstimulate milk production and worsen inflammation 1.

Antibiotic Therapy (If No Improvement After 1-2 Days)

Initiate narrow-spectrum antibiotics if conservative measures fail: 1

First-Line Antibiotics:

• Dicloxacillin (preferred—minimal transfer to breast milk) 5
• Cephalexin (alternative) 4

These target Staphylococcus aureus, the most common causative organism 4, 5. The evidence base for antibiotics is limited—one Cochrane review found insufficient evidence to confirm effectiveness, though older studies suggest faster symptom clearance 6.

Antibiotic Selection Considerations:

• Culture-guided therapy is ideal when available 5
• Consider MRSA coverage if methicillin-resistant S. aureus is prevalent in your area 4
• Most patients respond to oral outpatient therapy 1

When to Escalate Care

Hospital admission with IV antibiotics is required for: 1

• Worsening symptoms despite oral antibiotics
• Signs of sepsis
• Immunocompromised patients

Abscess management: Occurs in approximately 10% of mastitis cases 3, 4

• Requires surgical drainage or needle aspiration 4
• Continue breastfeeding on affected side as long as infant's mouth does not contact purulent drainage 3

Breastfeeding Continuation

Never discontinue breastfeeding—this worsens the condition and increases abscess risk 3, 4. Regular milk removal through direct feeding is the most essential treatment component 3, 5. Breastfeeding poses no risk to the infant even during active mastitis or antibiotic treatment 4, 5.

Prevention Strategies

Optimize breastfeeding technique with proper infant latch 1, 7

• Address sore nipples immediately (poor latch, infant mouth anomalies, infection) 4
• Encourage physiologic breastfeeding over pumping when possible 1
• Avoid overstimulation of milk production 1

Pain Management During Lactation

Safe analgesics during breastfeeding: 2

• Ibuprofen (first choice—safe and effective)
• Naproxen (widely used postpartum)
• Paracetamol/acetaminophen (minimal infant exposure)
• Diclofenac (small amounts in breast milk but considered safe)

Avoid: 2

• Aspirin in analgesic doses
• Codeine (use with caution due to genetic variability)
• Oxycodone (higher risk of infant sedation)

Key Clinical Pitfalls

1. Do not delay treatment—untreated mastitis progresses to abscess formation 3
2. Do not stop breastfeeding—discontinuation worsens the condition 3
3. Do not overpump or apply heat—these worsen inflammation 1
4. Do not withhold analgesics—pain management is essential supportive care 3