Lactational Mastitis

Lactational mastitis is inflammation of the breast in a breastfeeding woman, caused by milk stasis, with or without bacterial infection.

• It affects 10 to 20 percent of breastfeeding women, most commonly in weeks 2 to 6 postpartum, and can appear at any stage of lactation.
• Organisms: Staphylococcus aureus (commonest; including methicillin resistant), Streptococcus species, coagulase-negative staphylococci, Corynebacterium, and Candida in nipple disease.
• Risk factors: cracked or damaged nipples, poor attachment, missed or infrequent feeds, oversupply, blocked ducts, tight clothing, previous mastitis, stress and fatigue, HIV, diabetes, and maternal anaemia.

Unilateral painful, red, hot, wedge-shaped area of breast, hardness, swelling, fever above 38.5 C, chills, myalgia and "flu-like" illness, malaise.

• Cracked nipples, blocked duct (palpable tender lump), milk blister, scanty milk output, tender axillary nodes.
• Differential diagnosis: breast engorgement, blocked duct, breast abscess, inflammatory breast cancer, galactocele, Candida infection of the nipple and ducts, eczema, herpes zoster, Mondor disease, periductal mastitis, mammary tuberculosis.
• Complications: breast abscess (3 to 11 percent), recurrent mastitis, early cessation of breastfeeding, sepsis, chronic pain, infant feeding difficulty.

Clinical diagnosis from symptoms and examination.

• Milk culture (clean catch after nipple cleaning) in hospital-acquired cases, recurrent or severe cases, no response to antibiotics in 48 hours, or suspicion of methicillin resistant Staphylococcus aureus.
• Ultrasound if a persistent mass, fluctuance or no improvement (abscess).
• Full blood count and blood cultures if septic; biopsy of any mass persisting beyond 6 weeks or an atypical course.

Supportive: continue breastfeeding or expressing from the affected breast (safe for the baby), starting feeds on the affected side if tolerated. Ensure effective drainage by correct attachment and frequent feeds (every 2 to 3 hours). Avoid vigorous deep massage (may worsen inflammation). Gentle lymphatic drainage massage, cold compresses after feeds, rest, fluids, supportive bra.

Pharmacological

• Analgesia and anti-inflammatory: ibuprofen 400 mg every 6 to 8 hours (compatible with breastfeeding), paracetamol 1 g every 6 hours.
• Antibiotics if no improvement within 12 to 24 hours of effective milk removal, or if symptoms are severe, there are cracked nipples, or the woman is systemically unwell:
  • Flucloxacillin 500 mg four times daily for 7 to 10 days, or cefalexin 500 mg four times daily.
  • Penicillin allergy: erythromycin 500 mg four times daily or clindamycin 300 mg four times daily.
  • Methicillin resistant Staphylococcus aureus: clindamycin 300 to 450 mg four times daily, cotrimoxazole 960 mg twice daily (avoid in the first weeks if infant jaundiced or premature), or doxycycline for short duration, or vancomycin IV for severe disease.
• Severe sepsis: IV flucloxacillin 1 to 2 g every 6 hours or vancomycin 15 mg/kg every 12 hours, with drainage of abscess.
• Candida nipple infection: topical miconazole 2 percent cream to the nipples after feeds for 7 to 14 days, fluconazole 200 mg once then 100 mg daily for 10 to 14 days; treat the infant (nystatin oral suspension 100,000 units four times daily).
• Recurrent mastitis: lecithin 1.2 g up to four times daily, probiotics (Lactobacillus strains) are used with unproven benefit.

Procedures: ultrasound guided needle aspiration of an abscess (repeated every 2 to 3 days under antibiotic cover, with local anaesthesia). Incision and drainage for large, multiloculated abscesses or skin necrosis. Breastfeeding may continue except from a drainage site that interferes with latch.

Special groups: HIV positive mothers (continue antiretroviral therapy, assess infant feeding plan; stop breastfeeding from the infected breast only in some programmes while expressing and discarding), diabetic mothers, premature infants (expressing support).

Red flags: fever above 39 C, rigors, spreading erythema, fluctuance, breast pain with systemic toxicity, no response in 48 hours, sepsis, bloody discharge.

Follow-up: review at 48 to 72 hours; ultrasound at 1 to 2 weeks if mass persists; lactation consultation for attachment; prevent recurrence with frequent feeding, avoiding gaps, treating nipple damage.