Treatment of Lactational Mastitis
For lactational mastitis, begin with a 1-2 day trial of conservative management including NSAIDs, ice application, continued direct breastfeeding, and minimizing pumping; if symptoms do not improve within 24-48 hours, initiate narrow-spectrum antibiotics effective against Staphylococcus aureus such as dicloxacillin or cephalexin. 1
Initial Conservative Management (First 24-48 Hours)
Most cases of mastitis are inflammatory rather than infectious, making conservative measures the appropriate first-line approach 1:
- Administer NSAIDs for pain and inflammation control 1
- Apply ice to the affected breast 1
- Continue direct breastfeeding from the affected breast—this does not pose risk to the infant and helps with milk removal 2, 1
- Minimize or avoid pumping, as overstimulation worsens inflammation 1
- Avoid heat application and aggressive breast massage, as these increase tissue trauma and milk production, potentially worsening the condition 1
Critical Pitfall to Avoid
The traditional approach of "complete breast emptying" through frequent pumping and heat application is now contraindicated, as these practices overstimulate milk production and cause tissue trauma 1.
When to Initiate Antibiotic Therapy
Start antibiotics if symptoms fail to improve after 24-48 hours of conservative management 1. The diagnosis remains clinical—laboratory tests and imaging are not routinely needed unless the patient is immunocompromised or has worsening/recurrent symptoms 1.
Antibiotic Selection
First-line antibiotics should cover common skin flora (Staphylococcus and Streptococcus species) 1:
These agents are effective against Staphylococcus aureus, the most common causative organism 2, 4. Dicloxacillin transfers minimally into breast milk (relative infant dose only 0.03%), making it safe for continued breastfeeding 3.
Emerging Resistance Considerations
As methicillin-resistant S. aureus (MRSA) becomes more prevalent, antibiotics effective against MRSA may become preferred in areas with high community prevalence 2.
Obtaining Milk Cultures
Consider obtaining milk cultures to guide antibiotic therapy, particularly if initial treatment fails or in areas with high MRSA prevalence 1. However, cultures are not required for routine cases 1.
When to Escalate Care
Admit for intravenous antibiotics if 1:
- Symptoms worsen despite oral antibiotics
- Signs of sepsis develop
- Patient appears systemically ill
Obtain ultrasonography to evaluate for abscess formation in 1:
- Immunocompromised patients
- Those with worsening symptoms despite treatment
- Recurrent mastitis
Management of Breast Abscess
If an abscess develops (the most common complication of mastitis) 2:
- Perform surgical drainage or needle aspiration 2
- Continue breastfeeding from the affected breast even with a treated abscess 2
- Early treatment of mastitis and continued breastfeeding help prevent abscess formation 2
Breastfeeding Technique Optimization
The best prevention is proper lactation technique 1:
- Ensure proper infant latch—poor latch causes nipple trauma that precipitates mastitis 2
- Encourage physiologic breastfeeding rather than pumping when possible 1
- Address sore nipples promptly, as they can precipitate mastitis 2
- Consider lactation consultant involvement to optimize breastfeeding technique 2
What NOT to Do
Avoid these outdated practices that worsen outcomes 1:
- Frequent overfeeding to "empty the breast"
- Excessive pumping
- Heat application to the breast
- Aggressive breast massage
Do not use probiotics—evidence does not support their use for treatment or prevention 1.
Evidence Limitations
The evidence base for antibiotic therapy in mastitis is limited, with insufficient high-quality data to definitively confirm effectiveness 4. However, clinical experience and one older study suggest faster symptom clearance with antibiotics when conservative measures fail 4. Given the low risk of appropriate antibiotic therapy and the potential for progression to abscess, the conservative-then-antibiotic approach represents prudent clinical practice 1.