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Management of Lactational Mastitis

Author: Katherine (Katie) Au, MD, IBCLC

Mentor: Nicole Marshall, MD
Editor: Sireesha Reddy, MD

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Mastitis spectrum conditions are common disorders of lactation that can contribute to early cessation of lactation. Prompt recognition and consistent treatment recommendations can prevent worsening complications and assist patients with feeding goals. Risk factors for mastitis spectrum conditions include hyperlactation, oversupply, poor latch, nipple trauma, dysbiosis, and use of pumps. Previously, mastitis was thought to result from a single inflammatory or bacterial pathological entity. Emerging evidence supports that mastitis encompasses a spectrum of conditions, including ductal narrowing or “plugging,” inflammatory mastitis, bacterial mastitis, and abscess.

Mastitis spectrum conditions result from inflammation of the mammary gland with segmental distribution across lactational ducts, alveoli, and the surrounding stroma. Hyperlactation with or without disruption of the milk microbiome (dysbiosis) contributes to the additional narrowing of lactational ducts. Ductal narrowing or “plugging” due to inflammation can result in decreased milk flow, obstruction, worsening edema, and pain.

Inflammatory mastitis occurs when ductal narrowing persists and surrounding inflammation worsens. The clinical presentation consists of localized pain with erythema, edema, and systemic symptoms of fever, chills, and malaise. Bacterial infection is not necessarily present despite systemic symptoms. Supportive and treatment measures include scheduled use of nonsteroidal anti-inflammatory agents, application of ice, and continued physiologic feeding or expression of milk. Tissue massage, increased milk expression (“pump to empty”), or heat application should be discouraged, as these actions may worsen underlying inflammation and exacerbate issues with oversupply. If there is no improvement with conservative measures after 24 to 48 hours, this may reflect the progression from inflammatory mastitis to bacterial mastitis. The next step is antibiotic therapy.

Common organisms causing bacterial mastitis include Staphylococcus and Streptococcus species. Treatment of bacterial mastitis consists of empiric antibiotic therapy with dicloxacillin, 500 mg 4 times daily, or cephalexin, 500 mg 4 times daily, for 10 to 14 days. Second-line agents are clindamycin or trimethoprim-sulfamethoxazole if there are concerns for a methicillin-resistant infection or in patients with a β-lactam allergy. Patients need reassurance that their milk is safe to feed to their infant, the condition is not contagious or related to poor hygiene, and that sterilization of equipment in contact with their milk is not required. If the clinical condition shows no improvement with antibiotics, ultrasonography should be performed to evaluate for an underlying abscess and fluid should be aspirated for culture and sensitivities with suspicion of a methicillin-resistant Staphylococcus aureus infection.

Further Reading:

Mitchell KB, Johnson HM, Rodríguez JM, et al; Academy of Breastfeeding Medicine. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med. 2022 May;17(5):360-376. doi: 10.1089/bfm.2022.29207.kbm. Erratum in: Breastfeed Med. 2022 Nov;17(11):977-978. PMID: 35576513.

Initial publication August 2023

Final editing of initial publication performed by The Medical Pen, LLC.


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