Treatment of Mastitis
For lactational mastitis, begin with a 1-2 day trial of conservative management including NSAIDs, ice application, continued breastfeeding from the affected breast, and minimizing pumping; if symptoms do not improve, initiate narrow-spectrum oral antibiotics effective against Staphylococcus aureus such as dicloxacillin or cephalexin. 1
Initial Conservative Management (First 1-2 Days)
Most cases of mastitis are inflammatory rather than infectious, making conservative measures the appropriate first-line approach 1:
- Continue breastfeeding directly from the affected breast rather than pumping, as physiologic breastfeeding is preferred 1
- Apply ice to the affected area (not heat, which can worsen inflammation) 1
- Use NSAIDs for pain and inflammation control 1
- Minimize pumping to avoid overstimulation of milk production 1
- Avoid aggressive breast massage and heat application, as these can worsen the condition through tissue trauma and overstimulation 1
When to Initiate Antibiotic Therapy
Start antibiotics if there is no improvement after 1-2 days of conservative management 1. The diagnosis is clinical, based on focal breast tenderness, fever, malaise, and overlying erythema or hyperpigmentation, without requiring laboratory confirmation 1.
Antibiotic Selection
- First-line: Dicloxacillin or cephalexin to cover common skin flora, particularly Staphylococcus aureus and Streptococcus species 2
- Consider milk cultures to guide antibiotic selection, especially if symptoms worsen or recur 1
- Be aware of methicillin-resistant S. aureus (MRSA) as an increasingly common cause; antibiotics effective against MRSA may be needed in areas with high prevalence 2
Route of Administration
- Oral antibiotics for outpatient management in most cases 1
- Intravenous antibiotics with hospital admission if the condition worsens or there is concern for sepsis 1
Imaging and Further Evaluation
- Ultrasonography should be performed in immunocompromised patients or those with worsening or recurrent symptoms to identify abscess formation 1
- Breast abscess is the most common complication and requires surgical drainage or needle aspiration once identified 2
- Breastfeeding can usually continue even in the presence of a treated abscess 2
Important Caveats
Do not discontinue breastfeeding during mastitis treatment, as continued breastfeeding does not pose risk to the infant and helps resolve the condition 2. The evidence for antibiotic effectiveness is limited—one Cochrane review found insufficient high-quality evidence to confirm or refute antibiotic therapy's effectiveness 3—but clinical practice supports their use when conservative measures fail 1.
Probiotics are not recommended for treatment or prevention, as they lack good supporting evidence 1.
Prevention Strategies
- Optimize breastfeeding technique with proper infant latch 1, 2
- Avoid frequent overfeeding and excessive pumping to prevent overstimulation of milk production 1
- Address sore nipples promptly, as they can precipitate mastitis through mechanical irritation from poor latch or infant mouth anomalies 2
- Ensure frequent, complete breast emptying through physiologic breastfeeding 2