What is the management for a 33-month postpartum breastfeeding woman with breast pain and swelling for 24 hours?

Management of Lactational Mastitis in a Breastfeeding Woman

This is lactational mastitis requiring conservative management first, with antibiotics only if symptoms fail to improve after 1-2 days, while continuing breastfeeding throughout treatment.

Initial Clinical Approach

The presentation of unilateral breast pain and swelling at 33 months postpartum in a breastfeeding woman is consistent with lactational mastitis, which occurs in approximately 10% of breastfeeding mothers 1, 2. While most common in the first 3 months postpartum, mastitis can occur at any point during breastfeeding, as WHO recommends continued breastfeeding up to 2 years or beyond 3.

Diagnostic Confirmation

• Diagnosis is clinical, based on focal breast tenderness, fever, malaise, and overlying skin erythema or hyperpigmentation 2
• Laboratory tests and imaging are not routinely needed for initial diagnosis 2
• Consider ultrasonography only if symptoms worsen, recur, or if immunocompromised, to rule out abscess formation 2
• Milk cultures should be considered to guide antibiotic therapy if antibiotics become necessary 2

First-Line Conservative Management (1-2 Days)

Most cases of mastitis are inflammatory rather than infectious, making conservative measures the appropriate initial treatment 2.

• Administer NSAIDs (ibuprofen, diclofenac, naproxen) for pain and inflammation, which are compatible with breastfeeding 3, 2
• Apply ice to the affected breast 2
• Continue direct breastfeeding from the affected breast - this is crucial and does not pose risk to the infant 1, 2, 4
• Minimize pumping, as overstimulation can worsen the condition 2
• Avoid heat application and aggressive breast massage, as these may exacerbate inflammation 2

Critical Pitfall to Avoid

Do not advise expressing and discarding breast milk or interrupting breastfeeding - this outdated practice can lead to breast engorgement, blocked ducts, worsening mastitis, and premature cessation of breastfeeding 3. The infant can continue feeding normally from both breasts 1, 4.

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

If symptoms persist or worsen after conservative management:

• Prescribe narrow-spectrum antibiotics effective against Staphylococcus aureus and Streptococcus species 2
• First-line options: dicloxacillin or cephalexin (e.g., cephalexin) 1
• Consider methicillin-resistant S. aureus coverage if risk factors present or if initial antibiotics fail 1
• Most patients can be treated as outpatients with oral antibiotics 2

Breastfeeding should continue during antibiotic treatment - standard antibiotics for mastitis are compatible with breastfeeding 1, 4.

When to Escalate Care

• Hospital admission with intravenous antibiotics if signs of sepsis develop or condition significantly worsens 2
• Surgical drainage or needle aspiration if breast abscess develops (the most common complication of inadequately treated mastitis) 1, 2
• Even with a treated abscess, breastfeeding can usually continue 1

Prevention of Recurrence

• Optimize breastfeeding technique with proper infant latch 1, 2
• Encourage physiologic breastfeeding rather than excessive pumping 2
• Ensure frequent, complete emptying of the breast through normal feeding patterns 1
• Address any sore nipples promptly, as they can precipitate mastitis 1

Note: Probiotics are not supported by good evidence for treatment or prevention 2.