ABM Clinical Protocol #4: Mastitis, Revised March 2014

Abstract

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Introduction

Mastitis is a common condition in lactating women; estimates from prospective studies range from 3% to 20%, depending on the definition and length of postpartum follow-up. The majority of cases occur in the first 6 weeks, but mastitis can occur at any time during lactation. There have been few research trials in this area.

Quality of evidence (levels of evidence I, II-1, II-2, II-3, and III) for each recommendation as defined in the U.S. Preventive Services Task Force Appendix A Task Force Ratings is noted in parentheses in this document.

Definition and Diagnosis

The usual clinical definition of mastitis is a tender, hot, swollen, wedge-shaped area of breast associated with temperature of 38.5°C (101.3°F) or greater, chills, flu-like aching, and systemic illness. However, mastitis literally means, and is defined herein, as an inflammation of the breast; this inflammation may or may not involve a bacterial infection. Redness, pain, and heat may all be present when an area of the breast is engorged or “blocked”/“plugged,” but an infection is not necessarily present. There appears to be a continuum from engorgement to noninfective mastitis to infective mastitis to breast abscess. (II-2)

Predisposing Factors

The following factors may predispose a lactating woman to the development of mastitis. Other than the fact that these are factors that result in milk stasis, the evidence for these associations is generally inconclusive (II-2):

Damaged nipple, especially if colonized with Staphylococcus aureus
Infrequent feedings or scheduled frequency or duration of feedings
Missed feedings
Poor attachment or weak or uncoordinated suckling leading to inefficient removal of milk
Illness in mother or baby
Oversupply of milk
Rapid weaning
Pressure on the breast (e.g., tight bra, car seatbelt)
White spot on the nipple or a blocked nipple pore or duct: milk blister or “bleb” (a localized inflammatory response)
Maternal stress and fatigue

Investigations

Laboratory investigations and other diagnostic procedures are not routinely needed or performed for mastitis. The World Health Organization publication on mastitis suggests that breastmilk culture and sensitivity testing “should be undertaken if

there is no response to antibiotics within 2 days
the mastitis recurs
it is hospital-acquired mastitis
the patient is allergic to usual therapeutic antibiotics or
in severe or unusual cases.” (II-2)

Breastmilk culture may be obtained by collecting a hand-expressed midstream clean-catch sample into a sterile urine container (i.e., a small quantity of the initially expressed milk is discarded to avoid contamination of the sample with skin flora, and subsequent milk is expressed into the sterile container, taking care not to touch the inside of the container). Cleansing the nipple prior to collection may further reduce skin contamination and minimize false-positive culture results. Greater symptomatology has been associated with higher bacterial counts and/or pathogenic bacteria. (III)

Management

Effective milk removal

Because milk stasis is often the initiating factor in mastitis, the most important management step is frequent and effective milk removal:

Mothers should be encouraged to breastfeed more frequently, starting on the affected breast.
If pain interferes with the let-down, feeding may begin on the unaffected breast, switching to the affected breast as soon as let-down is achieved.
Positioning the infant at the breast with the chin or nose pointing to the blockage will help drain the affected area.
Massaging the breast during the feed with an edible oil or nontoxic lubricant on the fingers may also be helpful to facilitate milk removal. Massage, by the mother or a helper, should be directed from the blocked area moving toward the nipple.
After the feeding, expressing milk by hand or pump may augment milk drainage and hasten resolution of the problem. (III)

An alternate approach for a swollen breast is fluid mobilization, which aims to promote fluid drainage toward the axillary lymph nodes. The mother reclines, and gentle hand motions start stroking the skin surface from the areola to the axilla. (III)

There is no evidence of risk to the healthy, term infant of continuing breastfeeding from a mother with mastitis. Women who are unable to continue breastfeeding should express the milk from breast by hand or pump, as sudden cessation of breastfeeding leads to a greater risk of abscess development than continuing to feed. (III)

Supportive measures

Rest, adequate fluids, and nutrition are important measures. Practical help at home may be necessary for the mother to obtain adequate rest. Application of heat—for example, a shower or a hot pack—to the breast just prior to feeding may help with the let-down and milk flow. After a feeding or after milk is expressed from the breasts, cold packs can be applied to the breast in order to reduce pain and edema.

Although most women with mastitis can be managed as outpatients, hospital admission should be considered for women who are ill, require intravenous antibiotics, and/or do not have supportive care at home. Rooming-in of the infant with the mother is mandatory so that breastfeeding can continue. In some hospitals, rooming-in may require hospital admission of the infant.

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