An Update on the Recognition and Management of Lactational Breast Inflammation

Christine M. Betzold, NP, CLC, MSN

Disclosures

J Midwifery Womens Health. 2007;52(6):595-605. 

In This Article

Treatment of Mastitis or Breast Inflammation

Regardless of whether the presumed etiology is infectious or noninfectious, the treatment of breast inflammation is consistent. The focus is on reversing milk stasis, maintaining milk supply, and continuing breastfeeding, along with providing maternal comfort and hopefully preventing recurrence. There are a several existing alternative therapies in use that may or may not be effective. Specific criteria for antibiotic usage and treatment strategies for mastitis (including recurrent mastitis) are outlined below.

One essential hallmark of the management and treatment of breast inflammation is frequent and regular drainage of the breast by either the infant, hand expression, and/or pumping. To guarantee maximal breast emptying from infant feeding, an assessment of infant latching and sucking is necessary. Moreover, in the exclusively breastfeeding mother, feedings should occur eight to 12 times per day to maintain adequate drainage. When necessary, pumping or hand expression can be done after feedings if the infant fails to adequately drain the breast. Ideally, the mother starts on the affected side, with the infant's chin pointing in the direction of the affected area.[3,17,27] To minimize nipple discomfort, the mother can start on the unaffected side and then switch to the affected breast once the let-down occurs. If direct breastfeeding is not possible, regular bilateral pumping should be done with a hospital-grade, double-electric pump eight to 12 times per day for 15 to 20 minutes. Failure to provide for the regular removal of milk during mastitis increases the risk of abscess, hinders prompt resolution of the illness, and delays recovery.[3,17] Close attention to regular drainage and maternal comfort is warranted, even if the mother is extremely unwell or the milk is contaminated. Infants should be observed for signs of infection, but breastfeeding is considered to be safe in normal healthy infants and should not be interrupted, even in the presence of infection presumed to be caused by S aureus.[2]

Mothers may need lots of support and encouragement to maintain breastfeeding, both for her and her infant's health.[2] This includes maternal mental health, because when a woman weans before she is emotionally ready, she may experience substantial psychological distress.[2] Many mothers also need extra reassurance that their milk is irreplaceable, valuable, and safe for their child (even while on antibiotics).[2,3] Women who choose to wean should do so slowly, partially, or fully dropping one or two pumpings or feedings every couple of days after the infection is resolved.

As an adjunct to milk removal, hot compress and gentle massage can be used. Hot compresses provide pain relief and promote drainage. Cold compresses can also be used to treat discomfort. Use whatever provides the mother the best relief. Bed rest, eating a proper diet, and increasing fluids may also be suggested.[15,17] Systemic symptoms and pain should be controlled with analgesics.

Herbal homeopathic options offered include: high potency belladonna, Hepar sulph, Bellis perennis, and Phytolacca.[5,18] In Sweden, midwives use acupuncture needles placed at heart 3, gallbladder 21, and spleen 6. They also routinely use oxytocin nasal spray to improve the milk ejection reflex which may have become over-distended from milk stasis.[5] Oxytocin nasal spray is only available in the US through compounding pharmacies.

A number of other alternative treatment approaches for breast inflammation have been offered and reviewed by the World Health Organization for effectiveness.[2] One is pus stripping, which is very painful and is unlikely to work any better than frequent milk removal. Another is application of cabbage leaves to the skin (over the affected area) to relieve engorgement. They are as effective as cold packs for pain relief, but there is no evidence that they hasten recovery. A traditional Chinese herb (extracts of Fructus gleditsiae) has been used successfully. But dietary measures, such as avoiding methylxanthines and lowering fat, have only been found to be helpful anecdotally.

Dietary studies in cows found that mastitis is linked to inadequate intake of selenium, vitamin E, vitamin A, and ß-carotene.[14] But follow-up studies, which supplemented mothers with retinol, vitamin A, or ß-carotene, did not find that using these supplements prevented subclinical mastitis.[14,28,29] Vitamin E may help.[29]

Mothers with acute pain, severe symptoms, systemic symptoms, and/or fever need prompt antibiotic treatment irrespective to the presumed infectious versus noninfectious etiology.

Antibiotic treatment should also be initiated when laboratory results (i.e., bacterial colony counts, white blood cell counts, and/or positive cultures) are consistent with infection. Antibiotics are recommended for women with nipple fissures.[2] Mothers without these signs or symptoms should be instructed to feed frequently, monitor their temperature, and maintain regular drainage of the breast as previously described. If symptoms have not resolved within 12 to 24 hours, or if symptoms worsen, antibiotic treatment should be commenced.[2] When antibiotic treatment is necessary, a culture and sensitivity of the milk from the affected breast should be considered.[2,3]

While infants should continue to breastfeed, simultaneous antibiotic treatment of the infant may be warranted if it is determined that the infectious agent is staphylococcal because a small number of infants have developed staphylococcal infection.[2] Infants should be treated concurrently if streptococcal infection is present or suspected as a few infants have developed beta streptococcal infection.[2,17] It is worth noting that case reports of illness in infants related to infectious mastitis do not warrant breastfeeding cessation, only consideration for concurrent treatment.

Although there is no standard recommendation for treatment length, most authorities advise a 10- to 14-day antibiotic course.[1,2,3] This is consistent with the treatment recommendations for bacterial infections in most other large organs. Treatment regimens are listed in Table 3 .

Recurrent mastitis, believed to be of an infectious etiology, should be treated with antibiotics for no less than 14 days.[17] Chronic bacterial disease can be treated with daily low-dose antibiotics for the duration of lactation.[15,17,30] If only one breast is recurrently infected, the mother can choose to wean from the affected side while continuing breastfeeding from the unaffected breast.[30] Moreover, women who have two to three reoccurrences in the same area warrant further evaluation for an underlying etiology, such as a breast mass. Ultrasonography would generally be used initially, followed by mammography if the results are ambiguous or if a breast mass persists and cancer is suspected. Next, culturing the infant and mother's oro-nasopharynx and breast milk[2,17] may be indicated. If S aureus or MRSA is suspected or discovered, cultures of other family members' nasal mucosa may be indicated (Figure 3). If staphylococcal carrier states are discovered, concurrent treatment of mother and child (and possibly other family members) is warranted as a possible means of preventing repeated infection.[19,20]

Management of recurrent mastitis.

Some breast abscesses are obvious, and others can only be discerned by ultrasound. If there is any question, ultrasound should be ordered, followed by a referral to a general surgeon if the ultrasound is positive. Mothers with obvious abscesses should be urgently referred to a general surgeon who may perform incision and drainage. Another option is referral for ultrasound-guided needle aspiration. Parental antibiotics may be required and treatment with aspiration may need to be repeated every other day until resolution.[1] Medically, breastfeeding need not be interrupted unless the incision site or drainage of pus interferes with feeding. If breastfeeding cannot occur comfortably, frequent gentle pumping should still continue on the affected breast. See Table 3 for recommendations for treatment of abscesses.

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