Initial Treatment for Mastitis
The initial treatment for lactational mastitis is continued breastfeeding or milk expression combined with NSAIDs for pain and inflammation, followed by antibiotics targeting Staphylococcus aureus only if symptoms do not improve within 1-2 days of conservative management. 1, 2
First-Line Conservative Management (Days 1-2)
Continue breastfeeding directly from the affected breast as regular feeding or milk expression is essential for treatment and should never be discontinued unless purulent drainage contacts the infant's mouth. 1, 3
Supportive Measures:
- NSAIDs (ibuprofen, diclofenac, or naproxen) for pain and inflammation control 3
- Ice application to reduce inflammation 2
- Minimize pumping as overstimulation of milk production worsens the condition 2
- Avoid heat application and aggressive breast massage as tissue trauma from these practices increases mastitis risk 2
This conservative approach is sufficient for most cases since mastitis represents primarily an inflammatory condition rather than a true infection. 2
Antibiotic Therapy (If No Improvement After 1-2 Days)
Initiate narrow-spectrum antibiotics effective against Staphylococcus aureus (e.g., dicloxacillin or cephalexin) if symptoms persist beyond the initial conservative trial. 1, 4, 2
Antibiotic Selection Considerations:
- Consider obtaining milk cultures to guide antibiotic therapy, particularly in recurrent or severe cases 2
- As methicillin-resistant S. aureus becomes more prevalent, antibiotics effective against MRSA may become preferred 4
- Most patients can be treated as outpatients with oral antibiotics 2
When to Escalate Care
Hospitalize if fever, chills, and systemic symptoms suggest sepsis or if symptoms worsen despite outpatient management. 1, 2
Inpatient Management Includes:
- Intravenous antibiotics for systemic involvement 2
- Continued breastfeeding or provision of breast pump if prolonged separation occurs 1
- Pain management with appropriate analgesics 1
Critical Red Flags
If mastitis fails to respond to at least 1 week of antibiotics, inflammatory breast cancer must be excluded through bilateral diagnostic mammogram with ultrasound, core needle biopsy, and punch biopsy of skin. 3
Abscess Formation:
- Approximately 10% of mastitis cases progress to breast abscess, requiring drainage via needle aspiration or surgical incision 1, 3, 4
- Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage from the breast 1, 3
- Early treatment of mastitis and continued breastfeeding prevent abscess formation 4
Common Pitfalls to Avoid
- Do not discontinue breastfeeding, as this worsens the condition and delays resolution 1
- Do not encourage excessive pumping or "emptying the breast", as overstimulation exacerbates inflammation 2
- Do not delay evaluation beyond 1 week if antibiotics are ineffective, as inflammatory breast cancer must be ruled out 3
- Do not assume all breast erythema is simple mastitis—always consider inflammatory breast cancer in atypical or non-responsive presentations 3