Update on the Recognition and Management of Lactational Breast Inflammation

Differential Diagnosis of Breast Inflammation
Breast fullness Engorgement Plugged duct with or without a bleb Galactocele Noninfectious mastitis Infectious mastitis (unilateral, bilateral, recurrent, or abscessed) Ductal infection (also referred to in the literature as infections of the mammary ducts, ductal candidiasis, mammary candidosis, or candidiasis or deep pain syndrome) Nipple vasospasm or Raynaud's phenomenon of the nipple Group A streptococcal necrotizing fasciitis Overactive let-down Costochondritis Breast cancer Mastalgia (cyclic or noncyclic) Fat necrosis Subareolar abscess (duct ectasia) Mondor's disease (superficial phlebitis of the chest wall) Granulomatous disease Cat scratch disease, presenting as a breast mass Ruptured breast cyst

A Comparison of Breast Conditions
Condition	Definition	Erythema	Skin Temperature	Edema of Skin	Description	Systemic Symptoms	Fever	Pain	Unilateral vs Bilateral	Other
Breast fullness	The breast is full of milk but without obstruction of venous or lymphatic drainage, and the milk flows readily with suckling or pumping.	No	Occasionally increased	No	Firm, heavy	No	No	No	Usually bilateral	Occurs between postpartum days 3-5 when the "milk comes in"
Engorgement	The breast is "engorged" with milk and there is obstruction of venous and lymphatic drainage, which impedes the flow of milk with suckling or pumping.	Bilateral	Generalized warmth	Yes	Hard, enlarged, shiny	May have "milk fever"	<38.4°C	Yes, generalized	Usually bilateral	Often confused with breast fullness
Blocked ducts*	The breast has an area of localized milk stasis.	Often over a palpable lump	Little or no heat	No	Single lumpy area	Unlikely	Unlikely and if present <38.4°C	Tender or pain is localized	Usually unilateral	May occur with a painful white bleb on the nipple
Galactocele	A milk-retention cyst that is thought to result from a plugged duct.	No	No	No	Smooth rounded swelling	No	No	No	Usually unilateral	Compression of the cyst may cause milky fluid to exude from the nipple
Noninfectious mastitis	Secondary to ineffective and/or obstructed drainage of milk from the breast.	Yes	Warm to hot	Yes	Hard, usually wedged shaped	Yes in 50-66% of women	Mild, <37.5 °C; acute, >37.4°C- <38.5°C; hyperacute: >38°C	Yes, localized	Usually unilateral	See note^§
Infectious mastitis	Results from untreated milk stasis and/or colonization with pathogenic bacteria.	Yes, usually but not always	Warm to Hot	Yes	Hard, usually wedged shaped	No in 33%-50% of women	Mild, <37.5 °C; acute, >37.4°C- <38.5°C; hyperacute: >38°C	Usually	Usually unilateral but may be bilateral	See note^§
Breast abscess	A localized area of infection which has formed a barrier of granulation tissue.	Yes	Hot	Yes	Swollen lump, possibly fluctuant	May or may not be present		Severe	Often unilateral but may be bilateral	In neglected cases the skin may be discolored with necrosis

Sources: World Health Organization, 2000^[2]; The Academy of Breastfeeding Medicine, 2002^[3]; Riordan et al., 2005^[15]; Lawrence et al., 2005^[17]; Fetherston et al., 2006^[16]; Newman et al., 2003.^[2]
*May be referred to as "focal breast engorgement," "caked breast," or "plugged duct."
Also termed obstructive mastitis
The bleb may be opened up with a sterile needle to relieve discomfort.
^§The clinician cannot reliably differentiate noninfectious mastitis clinically from infectious mastitis. Treat with antibiotics if mother is toxic/acutely ill, there are severe or bilateral symptoms, there are nipple fissures, or symptom resolution does not occur within 12 to 24 hours of improved milk removal.

Treatment Options for Various Causes of Breast Inflammation
Disease	Antibiotics	Antifungal*	Other Therapy
Blocked duct/nipple blebs	Mupirocin 2% ointment (not cream) if blocked pore (bleb) opened.	Only if recurrent or persistent culture nipple, areola, milk, and bleb if present. Rx with fluconazole (Diflucan) 200-400 mg STAT followed by 100-200 mg qd x 2-3 weeks or until blocked duct has resolved for one week.	If no improvement in 24-48 hours, order therapeutic ultrasound 2 watts/cm², continuous, for 5 minutes daily up to 2 days to affected region. Lecithin 1 Tb qd or 1200 mg tid to qid can be used to prevent or treat recurrences. Lecithin can be rubbed into a bleb to soften. If recurrent, suggest limited intake of saturated fats and ↑ rest.
Noninfectious mastitis	Rx as infectious if symptoms don't resolve in 12-24 hrs.	No	Hot compresses, massage affected area, frequent milk removal on affected side.
Infectious mastitis	1. Dicloxacillin (Dynapen) 500 mg qid x 10-14 days or cephalexin (Keflex) 500 mg qid x 10-14 days. If PCN allergic use clindamycin 300 mg qid or erythromycin 250 mg or 500 mg qid x 10-14 days.	If indicated based on cultures or the development of burning breast pain.	Rx as above for noninfectious. Cultures of milk and nipple indicated for acute illness, failure to respond to treatment, high suspicion of MRSA, bilateral mastitis. Infant may need to be treated concurrently particularly if Group A or B streptococcus suspected.
Recurrent mastitis	Culture and treat as appropriate for 14-30 days	Culture and treat as appropriate for 14 -30 days.	Low dose erythromycin or clindamycin may be given on a daily or weekly basis. Consider cultures and treatment with nasal mupirocin (Bactroban) if S aureus carrier state suspected.
Ductal infections	Culture and treat as appropriate for at least 14 days. May be prudent to treat until symptoms resolved for at least 1 week. Can start empirical Rx with clindamycin 300 mg qid or sulfamethoxazole-trimethoprim (Bactrim DS) bid.	Rx with antifungals if any signs of yeast on infant. Fluconazole (Diflucan) 200-400mg STAT followed by 100-200 mg qd x 2-3 weeks or until symptoms resolved x 1 week. Ketoconazole (Nizoral) may also be used.	Sterilize any object that comes in contact with maternal breast, breast milk or infant mouth (i.e., pumping parts, bottles, pacifiers, toys). Consider other family members as carriers if yeast recurrent.
Nipple infections	Mupirocin 2% ointment (not cream): 15 g. If no improvement culture and treat based on sensitivity results or treat empirically for yeast or consider other etiologies. Apply mupirocin or polymyxin (Bacitracin) after each nursing or pumping.	Neonate: Nystatin (Nilstat) 100,000 units/mL. Swab inside of infant's mouth with 1 mL qid. 2 mL qid for older infants. Have infant drink what is left. Maternal: Nystatin (Nilstat) suspension or cream, apply topically s/p each nursing. Gentian violet 1% in 10% alcohol can be applied to the infant's mouth with a Q-tip before feeding so the mother's nipple will be coated during the feeding. Use qd x 4 days. Extend to 7 days if improvement, but no resolution. Clotrimazole cream, apply after each feeding/pumping and rub in well.	The following topical Rx, Dr. Newman's All purpose nipple ointment (APNO), will Rx bacterial and yeast infections. APNO is compounded and contains: 1) Mupirocin 2% oint: 15 g; 2) Betamethasone 0.1% ointment (not cream): 15 g; 3) Add miconazole powder to formulate a final concentration of 2% miconazole. If unavailable substitute clotrimazole powder added to a final concentration of 2%. Sparingly apply APNO after each feeding and use until nipple soreness has dissipated.
Abscess (Puerperal)	Outpatient: Dicloxacillin (Dynapen) 500 mg po qid x 10-14 days or clindamycin (Cleocin) 300 mg po qid. Inpatient: Nafcillin or 2.0.g q 4 hours IV or cefazolin 1.0 g q 6 hours IV or vancomycin 1.0 g q 12 hour IV.	If indicated based on cultures or the development of burning breast pain.	I & D or use ultrasound guided needle for aspiration. Send aspirate or discharge for culture. Infants may continue nursing on affected side unless the area of incision involves the areola. May treat infant concurrently if S aureus and should treat if Streptococcal disease present.

BID = twice daily; IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus; po = orally; qid = four times daily; q = every; qd = every day; TID = three times daily.
Sources: World Health Organization, et al., 2000^[2]; The Academy of Breastfeeding Medicine, et al., 2002^[3]; Betzold, 2004^[12]; Riordan, et al., 2005^[15]; Fetherston, et al., 2006^[16]; Lawrence, et al., 2005^[17]; Newman et al., 2003.^[27]
*If Candida is suspected or diagnosed, mother and infant must be treated concurrently even if one is asymptomatic.
Consider undiagnosed maternal IgA deficiency.

Treatment Options for Various Causes of Breast Inflammation
Disease	Antibiotics	Antifungal*	Other Therapy
Blocked duct/nipple blebs	Mupirocin 2% ointment (not cream) if blocked pore (bleb) opened.	Only if recurrent or persistent culture nipple, areola, milk, and bleb if present. Rx with fluconazole (Diflucan) 200-400 mg STAT followed by 100-200 mg qd x 2-3 weeks or until blocked duct has resolved for one week.	If no improvement in 24-48 hours, order therapeutic ultrasound 2 watts/cm², continuous, for 5 minutes daily up to 2 days to affected region. Lecithin 1 Tb qd or 1200 mg tid to qid can be used to prevent or treat recurrences. Lecithin can be rubbed into a bleb to soften. If recurrent, suggest limited intake of saturated fats and ↑ rest.
Noninfectious mastitis	Rx as infectious if symptoms don't resolve in 12-24 hrs.	No	Hot compresses, massage affected area, frequent milk removal on affected side.
Infectious mastitis	1. Dicloxacillin (Dynapen) 500 mg qid x 10-14 days or cephalexin (Keflex) 500 mg qid x 10-14 days. If PCN allergic use clindamycin 300 mg qid or erythromycin 250 mg or 500 mg qid x 10-14 days.	If indicated based on cultures or the development of burning breast pain.	Rx as above for noninfectious. Cultures of milk and nipple indicated for acute illness, failure to respond to treatment, high suspicion of MRSA, bilateral mastitis. Infant may need to be treated concurrently particularly if Group A or B streptococcus suspected.
Recurrent mastitis	Culture and treat as appropriate for 14-30 days	Culture and treat as appropriate for 14 -30 days.	Low dose erythromycin or clindamycin may be given on a daily or weekly basis. Consider cultures and treatment with nasal mupirocin (Bactroban) if S aureus carrier state suspected.
Ductal infections	Culture and treat as appropriate for at least 14 days. May be prudent to treat until symptoms resolved for at least 1 week. Can start empirical Rx with clindamycin 300 mg qid or sulfamethoxazole-trimethoprim (Bactrim DS) bid.	Rx with antifungals if any signs of yeast on infant. Fluconazole (Diflucan) 200-400mg STAT followed by 100-200 mg qd x 2-3 weeks or until symptoms resolved x 1 week. Ketoconazole (Nizoral) may also be used.	Sterilize any object that comes in contact with maternal breast, breast milk or infant mouth (i.e., pumping parts, bottles, pacifiers, toys). Consider other family members as carriers if yeast recurrent.
Nipple infections	Mupirocin 2% ointment (not cream): 15 g. If no improvement culture and treat based on sensitivity results or treat empirically for yeast or consider other etiologies. Apply mupirocin or polymyxin (Bacitracin) after each nursing or pumping.	Neonate: Nystatin (Nilstat) 100,000 units/mL. Swab inside of infant's mouth with 1 mL qid. 2 mL qid for older infants. Have infant drink what is left. Maternal: Nystatin (Nilstat) suspension or cream, apply topically s/p each nursing. Gentian violet 1% in 10% alcohol can be applied to the infant's mouth with a Q-tip before feeding so the mother's nipple will be coated during the feeding. Use qd x 4 days. Extend to 7 days if improvement, but no resolution. Clotrimazole cream, apply after each feeding/pumping and rub in well.	The following topical Rx, Dr. Newman's All purpose nipple ointment (APNO), will Rx bacterial and yeast infections. APNO is compounded and contains: 1) Mupirocin 2% oint: 15 g; 2) Betamethasone 0.1% ointment (not cream): 15 g; 3) Add miconazole powder to formulate a final concentration of 2% miconazole. If unavailable substitute clotrimazole powder added to a final concentration of 2%. Sparingly apply APNO after each feeding and use until nipple soreness has dissipated.
Abscess (Puerperal)	Outpatient: Dicloxacillin (Dynapen) 500 mg po qid x 10-14 days or clindamycin (Cleocin) 300 mg po qid. Inpatient: Nafcillin or 2.0.g q 4 hours IV or cefazolin 1.0 g q 6 hours IV or vancomycin 1.0 g q 12 hour IV.	If indicated based on cultures or the development of burning breast pain.	I & D or use ultrasound guided needle for aspiration. Send aspirate or discharge for culture. Infants may continue nursing on affected side unless the area of incision involves the areola. May treat infant concurrently if S aureus and should treat if Streptococcal disease present.

BID = twice daily; IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus; po = orally; qid = four times daily; q = every; qd = every day; TID = three times daily.
Sources: World Health Organization, et al., 2000^[2]; The Academy of Breastfeeding Medicine, et al., 2002^[3]; Betzold, 2004^[12]; Riordan, et al., 2005^[15]; Fetherston, et al., 2006^[16]; Lawrence, et al., 2005^[17]; Newman et al., 2003.^[27]
*If Candida is suspected or diagnosed, mother and infant must be treated concurrently even if one is asymptomatic.
Consider undiagnosed maternal IgA deficiency.

Treatment Options for Various Causes of Breast Inflammation
Disease	Antibiotics	Antifungal*	Other Therapy
Blocked duct/nipple blebs	Mupirocin 2% ointment (not cream) if blocked pore (bleb) opened.	Only if recurrent or persistent culture nipple, areola, milk, and bleb if present. Rx with fluconazole (Diflucan) 200-400 mg STAT followed by 100-200 mg qd x 2-3 weeks or until blocked duct has resolved for one week.	If no improvement in 24-48 hours, order therapeutic ultrasound 2 watts/cm², continuous, for 5 minutes daily up to 2 days to affected region. Lecithin 1 Tb qd or 1200 mg tid to qid can be used to prevent or treat recurrences. Lecithin can be rubbed into a bleb to soften. If recurrent, suggest limited intake of saturated fats and ↑ rest.
Noninfectious mastitis	Rx as infectious if symptoms don't resolve in 12-24 hrs.	No	Hot compresses, massage affected area, frequent milk removal on affected side.
Infectious mastitis	1. Dicloxacillin (Dynapen) 500 mg qid x 10-14 days or cephalexin (Keflex) 500 mg qid x 10-14 days. If PCN allergic use clindamycin 300 mg qid or erythromycin 250 mg or 500 mg qid x 10-14 days.	If indicated based on cultures or the development of burning breast pain.	Rx as above for noninfectious. Cultures of milk and nipple indicated for acute illness, failure to respond to treatment, high suspicion of MRSA, bilateral mastitis. Infant may need to be treated concurrently particularly if Group A or B streptococcus suspected.
Recurrent mastitis	Culture and treat as appropriate for 14-30 days	Culture and treat as appropriate for 14 -30 days.	Low dose erythromycin or clindamycin may be given on a daily or weekly basis. Consider cultures and treatment with nasal mupirocin (Bactroban) if S aureus carrier state suspected.
Ductal infections	Culture and treat as appropriate for at least 14 days. May be prudent to treat until symptoms resolved for at least 1 week. Can start empirical Rx with clindamycin 300 mg qid or sulfamethoxazole-trimethoprim (Bactrim DS) bid.	Rx with antifungals if any signs of yeast on infant. Fluconazole (Diflucan) 200-400mg STAT followed by 100-200 mg qd x 2-3 weeks or until symptoms resolved x 1 week. Ketoconazole (Nizoral) may also be used.	Sterilize any object that comes in contact with maternal breast, breast milk or infant mouth (i.e., pumping parts, bottles, pacifiers, toys). Consider other family members as carriers if yeast recurrent.
Nipple infections	Mupirocin 2% ointment (not cream): 15 g. If no improvement culture and treat based on sensitivity results or treat empirically for yeast or consider other etiologies. Apply mupirocin or polymyxin (Bacitracin) after each nursing or pumping.	Neonate: Nystatin (Nilstat) 100,000 units/mL. Swab inside of infant's mouth with 1 mL qid. 2 mL qid for older infants. Have infant drink what is left. Maternal: Nystatin (Nilstat) suspension or cream, apply topically s/p each nursing. Gentian violet 1% in 10% alcohol can be applied to the infant's mouth with a Q-tip before feeding so the mother's nipple will be coated during the feeding. Use qd x 4 days. Extend to 7 days if improvement, but no resolution. Clotrimazole cream, apply after each feeding/pumping and rub in well.	The following topical Rx, Dr. Newman's All purpose nipple ointment (APNO), will Rx bacterial and yeast infections. APNO is compounded and contains: 1) Mupirocin 2% oint: 15 g; 2) Betamethasone 0.1% ointment (not cream): 15 g; 3) Add miconazole powder to formulate a final concentration of 2% miconazole. If unavailable substitute clotrimazole powder added to a final concentration of 2%. Sparingly apply APNO after each feeding and use until nipple soreness has dissipated.
Abscess (Puerperal)	Outpatient: Dicloxacillin (Dynapen) 500 mg po qid x 10-14 days or clindamycin (Cleocin) 300 mg po qid. Inpatient: Nafcillin or 2.0.g q 4 hours IV or cefazolin 1.0 g q 6 hours IV or vancomycin 1.0 g q 12 hour IV.	If indicated based on cultures or the development of burning breast pain.	I & D or use ultrasound guided needle for aspiration. Send aspirate or discharge for culture. Infants may continue nursing on affected side unless the area of incision involves the areola. May treat infant concurrently if S aureus and should treat if Streptococcal disease present.

BID = twice daily; IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus; po = orally; qid = four times daily; q = every; qd = every day; TID = three times daily.
Sources: World Health Organization, et al., 2000^[2]; The Academy of Breastfeeding Medicine, et al., 2002^[3]; Betzold, 2004^[12]; Riordan, et al., 2005^[15]; Fetherston, et al., 2006^[16]; Lawrence, et al., 2005^[17]; Newman et al., 2003.^[27]
*If Candida is suspected or diagnosed, mother and infant must be treated concurrently even if one is asymptomatic.
Consider undiagnosed maternal IgA deficiency.

Treatment Options for Various Causes of Breast Inflammation
Disease	Antibiotics	Antifungal*	Other Therapy
Blocked duct/nipple blebs	Mupirocin 2% ointment (not cream) if blocked pore (bleb) opened.	Only if recurrent or persistent culture nipple, areola, milk, and bleb if present. Rx with fluconazole (Diflucan) 200-400 mg STAT followed by 100-200 mg qd x 2-3 weeks or until blocked duct has resolved for one week.	If no improvement in 24-48 hours, order therapeutic ultrasound 2 watts/cm², continuous, for 5 minutes daily up to 2 days to affected region. Lecithin 1 Tb qd or 1200 mg tid to qid can be used to prevent or treat recurrences. Lecithin can be rubbed into a bleb to soften. If recurrent, suggest limited intake of saturated fats and ↑ rest.
Noninfectious mastitis	Rx as infectious if symptoms don't resolve in 12-24 hrs.	No	Hot compresses, massage affected area, frequent milk removal on affected side.
Infectious mastitis	1. Dicloxacillin (Dynapen) 500 mg qid x 10-14 days or cephalexin (Keflex) 500 mg qid x 10-14 days. If PCN allergic use clindamycin 300 mg qid or erythromycin 250 mg or 500 mg qid x 10-14 days.	If indicated based on cultures or the development of burning breast pain.	Rx as above for noninfectious. Cultures of milk and nipple indicated for acute illness, failure to respond to treatment, high suspicion of MRSA, bilateral mastitis. Infant may need to be treated concurrently particularly if Group A or B streptococcus suspected.
Recurrent mastitis	Culture and treat as appropriate for 14-30 days	Culture and treat as appropriate for 14 -30 days.	Low dose erythromycin or clindamycin may be given on a daily or weekly basis. Consider cultures and treatment with nasal mupirocin (Bactroban) if S aureus carrier state suspected.
Ductal infections	Culture and treat as appropriate for at least 14 days. May be prudent to treat until symptoms resolved for at least 1 week. Can start empirical Rx with clindamycin 300 mg qid or sulfamethoxazole-trimethoprim (Bactrim DS) bid.	Rx with antifungals if any signs of yeast on infant. Fluconazole (Diflucan) 200-400mg STAT followed by 100-200 mg qd x 2-3 weeks or until symptoms resolved x 1 week. Ketoconazole (Nizoral) may also be used.	Sterilize any object that comes in contact with maternal breast, breast milk or infant mouth (i.e., pumping parts, bottles, pacifiers, toys). Consider other family members as carriers if yeast recurrent.
Nipple infections	Mupirocin 2% ointment (not cream): 15 g. If no improvement culture and treat based on sensitivity results or treat empirically for yeast or consider other etiologies. Apply mupirocin or polymyxin (Bacitracin) after each nursing or pumping.	Neonate: Nystatin (Nilstat) 100,000 units/mL. Swab inside of infant's mouth with 1 mL qid. 2 mL qid for older infants. Have infant drink what is left. Maternal: Nystatin (Nilstat) suspension or cream, apply topically s/p each nursing. Gentian violet 1% in 10% alcohol can be applied to the infant's mouth with a Q-tip before feeding so the mother's nipple will be coated during the feeding. Use qd x 4 days. Extend to 7 days if improvement, but no resolution. Clotrimazole cream, apply after each feeding/pumping and rub in well.	The following topical Rx, Dr. Newman's All purpose nipple ointment (APNO), will Rx bacterial and yeast infections. APNO is compounded and contains: 1) Mupirocin 2% oint: 15 g; 2) Betamethasone 0.1% ointment (not cream): 15 g; 3) Add miconazole powder to formulate a final concentration of 2% miconazole. If unavailable substitute clotrimazole powder added to a final concentration of 2%. Sparingly apply APNO after each feeding and use until nipple soreness has dissipated.
Abscess (Puerperal)	Outpatient: Dicloxacillin (Dynapen) 500 mg po qid x 10-14 days or clindamycin (Cleocin) 300 mg po qid. Inpatient: Nafcillin or 2.0.g q 4 hours IV or cefazolin 1.0 g q 6 hours IV or vancomycin 1.0 g q 12 hour IV.	If indicated based on cultures or the development of burning breast pain.	I & D or use ultrasound guided needle for aspiration. Send aspirate or discharge for culture. Infants may continue nursing on affected side unless the area of incision involves the areola. May treat infant concurrently if S aureus and should treat if Streptococcal disease present.

BID = twice daily; IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus; po = orally; qid = four times daily; q = every; qd = every day; TID = three times daily.
Sources: World Health Organization, et al., 2000^[2]; The Academy of Breastfeeding Medicine, et al., 2002^[3]; Betzold, 2004^[12]; Riordan, et al., 2005^[15]; Fetherston, et al., 2006^[16]; Lawrence, et al., 2005^[17]; Newman et al., 2003.^[27]
*If Candida is suspected or diagnosed, mother and infant must be treated concurrently even if one is asymptomatic.
Consider undiagnosed maternal IgA deficiency.

Treatment Options for Various Causes of Breast Inflammation
Disease	Antibiotics	Antifungal*	Other Therapy
Blocked duct/nipple blebs	Mupirocin 2% ointment (not cream) if blocked pore (bleb) opened.	Only if recurrent or persistent culture nipple, areola, milk, and bleb if present. Rx with fluconazole (Diflucan) 200-400 mg STAT followed by 100-200 mg qd x 2-3 weeks or until blocked duct has resolved for one week.	If no improvement in 24-48 hours, order therapeutic ultrasound 2 watts/cm², continuous, for 5 minutes daily up to 2 days to affected region. Lecithin 1 Tb qd or 1200 mg tid to qid can be used to prevent or treat recurrences. Lecithin can be rubbed into a bleb to soften. If recurrent, suggest limited intake of saturated fats and ↑ rest.
Noninfectious mastitis	Rx as infectious if symptoms don't resolve in 12-24 hrs.	No	Hot compresses, massage affected area, frequent milk removal on affected side.
Infectious mastitis	1. Dicloxacillin (Dynapen) 500 mg qid x 10-14 days or cephalexin (Keflex) 500 mg qid x 10-14 days. If PCN allergic use clindamycin 300 mg qid or erythromycin 250 mg or 500 mg qid x 10-14 days.	If indicated based on cultures or the development of burning breast pain.	Rx as above for noninfectious. Cultures of milk and nipple indicated for acute illness, failure to respond to treatment, high suspicion of MRSA, bilateral mastitis. Infant may need to be treated concurrently particularly if Group A or B streptococcus suspected.
Recurrent mastitis	Culture and treat as appropriate for 14-30 days	Culture and treat as appropriate for 14 -30 days.	Low dose erythromycin or clindamycin may be given on a daily or weekly basis. Consider cultures and treatment with nasal mupirocin (Bactroban) if S aureus carrier state suspected.
Ductal infections	Culture and treat as appropriate for at least 14 days. May be prudent to treat until symptoms resolved for at least 1 week. Can start empirical Rx with clindamycin 300 mg qid or sulfamethoxazole-trimethoprim (Bactrim DS) bid.	Rx with antifungals if any signs of yeast on infant. Fluconazole (Diflucan) 200-400mg STAT followed by 100-200 mg qd x 2-3 weeks or until symptoms resolved x 1 week. Ketoconazole (Nizoral) may also be used.	Sterilize any object that comes in contact with maternal breast, breast milk or infant mouth (i.e., pumping parts, bottles, pacifiers, toys). Consider other family members as carriers if yeast recurrent.
Nipple infections	Mupirocin 2% ointment (not cream): 15 g. If no improvement culture and treat based on sensitivity results or treat empirically for yeast or consider other etiologies. Apply mupirocin or polymyxin (Bacitracin) after each nursing or pumping.	Neonate: Nystatin (Nilstat) 100,000 units/mL. Swab inside of infant's mouth with 1 mL qid. 2 mL qid for older infants. Have infant drink what is left. Maternal: Nystatin (Nilstat) suspension or cream, apply topically s/p each nursing. Gentian violet 1% in 10% alcohol can be applied to the infant's mouth with a Q-tip before feeding so the mother's nipple will be coated during the feeding. Use qd x 4 days. Extend to 7 days if improvement, but no resolution. Clotrimazole cream, apply after each feeding/pumping and rub in well.	The following topical Rx, Dr. Newman's All purpose nipple ointment (APNO), will Rx bacterial and yeast infections. APNO is compounded and contains: 1) Mupirocin 2% oint: 15 g; 2) Betamethasone 0.1% ointment (not cream): 15 g; 3) Add miconazole powder to formulate a final concentration of 2% miconazole. If unavailable substitute clotrimazole powder added to a final concentration of 2%. Sparingly apply APNO after each feeding and use until nipple soreness has dissipated.
Abscess (Puerperal)	Outpatient: Dicloxacillin (Dynapen) 500 mg po qid x 10-14 days or clindamycin (Cleocin) 300 mg po qid. Inpatient: Nafcillin or 2.0.g q 4 hours IV or cefazolin 1.0 g q 6 hours IV or vancomycin 1.0 g q 12 hour IV.	If indicated based on cultures or the development of burning breast pain.	I & D or use ultrasound guided needle for aspiration. Send aspirate or discharge for culture. Infants may continue nursing on affected side unless the area of incision involves the areola. May treat infant concurrently if S aureus and should treat if Streptococcal disease present.

BID = twice daily; IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus; po = orally; qid = four times daily; q = every; qd = every day; TID = three times daily.
Sources: World Health Organization, et al., 2000^[2]; The Academy of Breastfeeding Medicine, et al., 2002^[3]; Betzold, 2004^[12]; Riordan, et al., 2005^[15]; Fetherston, et al., 2006^[16]; Lawrence, et al., 2005^[17]; Newman et al., 2003.^[27]
*If Candida is suspected or diagnosed, mother and infant must be treated concurrently even if one is asymptomatic.
Consider undiagnosed maternal IgA deficiency.

Management of Mastitis: Key Points
Routinely examine women who complain of breast pain Examine the infant when available (especially the oral cavity, skin, and diaper area) Identify women who are at high risk of being a carrier of Staphylococcus aureus and/or having recurrences Order breast milk and nipple cultures for mothers who are acutely ill, not responding to first-line therapy, and/or complaining of burning breast pain Maintain adequate breast drainage and thus milk supply Use antibiotics judiciously

Appendix: Resources for Clinicians Treating Mother with Infections of the Breast

Source	Description
Betzold CM. Infections of the mammary ducts in the breastfeeding mother. J Nurse Pract 2005;1:15-21.	Discusses three cases of women afflicted with mammary duct infections, their course and treatment. Outlines a protocol for cultures based on a review of the literature and provides recommendations for exam and treatment of mothers with breast pain, redness or mass. Available from: www.npjournal.org/article/PIIS1555415505000024/fulltext
Morrill JF, Pappagianis D, Heinig MJ, Lönnerdal B, Dewey KG. Detecting Candida albicans in human milk. J of Clinical Microbiology 2003; 41:475-478.	Outlines a culturing method which increases the ability to yield C albicans from human milk.
World Health Organization 2000. Mastitis: Causes and Management. Department of Child and Adolescent Health and Development. WHO/FCH/CAH/00.13, Geneva.	Available from: www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_FCH_CAH_00_13.PDF
The Academy of Breastfeeding Medicine. Clinical Protocol Number 4: Mastitis. ABM NEWS and VIEWS 2002; 8 (4): 30, 34.	Available from: www.bfmed.org/ace-files/protocol/mastitis.pdf

An Update on the Recognition and Management of Lactational Breast Inflammation

Recurrent Mastitis and Abscesses

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Appendix

Appendix: Resources for Clinicians Treating Mother with Infections of the Breast

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