Treatment of Lactational Mastitis
Continue breastfeeding or milk expression combined with conservative measures for 1-2 days, then add narrow-spectrum antibiotics targeting Staphylococcus aureus (dicloxacillin or cephalexin) if symptoms do not improve. 1, 2
Initial Conservative Management (First 1-2 Days)
Most mastitis cases are inflammatory rather than infectious, so begin with conservative therapy 2:
- Continue breastfeeding or regular milk expression from the affected breast - this is essential for treatment and should never be discontinued 1, 2
- Administer NSAIDs for pain and inflammation 2
- Apply ice to the affected area 2
- Feed the infant directly from the breast rather than pumping when possible 2
- Minimize pumping - excessive pumping can worsen the condition 2
Critical pitfall to avoid: Do NOT use heat application, aggressive breast massage, or excessive pumping to "empty the breast" - these practices overstimulate milk production and cause tissue trauma, worsening mastitis 2. This represents a significant shift from older recommendations.
Antibiotic Therapy (If No Improvement After 1-2 Days)
If conservative measures fail to improve symptoms within 1-2 days, initiate antibiotics 2:
- First-line antibiotics: Dicloxacillin or cephalexin (effective against Staphylococcus aureus) 3
- Consider obtaining milk cultures to guide antibiotic selection, especially in recurrent or severe cases 2
- Adjust coverage for MRSA if it becomes a concern based on local resistance patterns or culture results 3
The evidence for antibiotics is mixed - a Cochrane review found insufficient high-quality evidence, though one older study suggested faster symptom clearance with antibiotics 4. However, clinical practice and expert consensus support antibiotic use when conservative measures fail 1.
Inpatient Management Criteria
Hospitalization is warranted when 1:
- Fever and chills indicate systemic involvement requiring close monitoring 1
- Worsening symptoms or concern for sepsis develops 1, 2
- Intravenous antibiotics may be required for severe cases 2
During hospitalization 1:
- Provide breast pump access if mother-infant separation occurs 1
- Ensure trained breastfeeding support staff are available 1
- Schedule procedures to allow breastfeeding or milk expression 1
- Continue pain management with appropriate analgesics 1
Management of Breast Abscess
Approximately 10% of mastitis cases progress to abscess formation 1, 3:
- Perform ultrasonography in immunocompromised patients or those with worsening/recurrent symptoms to identify abscesses 2
- Drainage is required via surgical drainage or needle aspiration 3
- Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage 1, 3
- Early treatment of mastitis and continued breastfeeding prevent abscess formation 3