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Pathway for the management of mastitis in the

Lactating woman

Document Number
Version
Ratified By and Date
Name of Approving Body(s) and
Dates

Job Title of Document Author

Name of Responsible Committee


Executive Director
Date Issued
Expiry Date (Maximum Two Years)
Target Audience

PP-024
1
Medicines Management Group 21 August
2014, SEOG 21January 2015
SACE South 11 September 2012
SACE North 8 October 2012
Medicines Management Group April 2014,
21 August 2014, SEOG 21 January 2015
UNICEF lead breastfeeding South
Health Visitor/BFI keyworker
Consultant Microbiologist
Medicines Management Group
Medical Director
January 2015
January 2017
Health Visitors and Breastfeeding
Specialists working within the Trust

This document may be made available in a different format


by contacting the Author of the Document

Pathway for the management of mastitis in the Lactating woman V1


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Version Control - Review and Amendment Log


Version
1.1
1.2

Type of
Change
Reformat
Changed from
a protocol to
pathway

Date
01/04/14
01/04/14

Description of Change
Reformatted into new Organisation
template
Previous protocol had PGDs for
Health Visitors. These have been
removed. This is now a pathway to
give guidance to manage mastitis.

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Document Title

Document Status
Date of
Publication
Key Points

DOCUMENT SUMMARY
Pathway for the management of mastitis in the
Lactating woman
New
Revision
Original: June 2012
Revision: April 2014 Jan 2015

YES

Mastitis is an inflammatory condition of the breast which may or may not be


accompanied by infection (Australian guideline 2009). The inefficient removal of milk
due to poor positioning and attachment of the infant at the breast is a significant
contributing factor of mastitis. However, it has been reported that health
professionals regard mastitis purely as an infection and are often not equipped to
help such women deal with the contributing factors, and may also advise Mothers to
stop breastfeeding.
It is consequently imperative for health professionals to understand the aetiology,
prevention and treatment of mastitis. This will then enable mothers to continue to
successfully breastfeed and thus facilitate achieving of the Department of Health
(DH) targets
Promoting and supporting sustainable breastfeeding is an essential part of an
integrated programme of child health promotion and parenting support as set out in
the Healthy Child Programme (DH, DCSF 2009) and Every Child Matters (2003).
The pathway is written in conjunction with the requirements necessary for the Trust
to achieve full UNICEF UK Baby Friendly Accreditation. UNICEF UK Baby Friendly
accreditation is a structured programme with an external verification process. Full
accreditation demonstrates compliance with set quality standards in relation to
breastfeeding support services and infant feeding.
A key recommendation of the NICE Guidance on Maternal and Child Nutrition
(NICE 2008a) is that childrens services should adopt a multifaceted approach
across different settings to increase breast feeding rates.
This should include:
Activities to raise awareness of the benefits of, and how to overcome the
barriers to, breastfeeding.
Training for health professionals.
Education and information for pregnant women on how to breastfeed,
followed by proactive support during the postnatal period.
If initial treatment of mastitis symptoms are prompt, symptoms may resolve in 12 -24
hours, if not, they may progress (below) and become more severe whereby Medical
treatment with antibiotics is recommended to help prevent further deterioration and
possible abscess formation.
Pathway for the management of mastitis in the Lactating woman V1
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It is important to encourage and support the mother to breastfeed from the affected
breast to aid recovery
If symptoms are not resolving or become more severe within approximately 12 -24
hours medical treatment with antibiotics is recommended to help prevent further
deterioration and possible abscess formation. However, it is very important that the
mother is advised to continue with the management of mastitis. Effective milk
removal is an essential part of treatment.

Available Support

Health visitors

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Contents
Page
1.

Introduction

2.

Purpose

3.

Explanation of Terms

4.

Duties & Responsibilities

5.

Scope

5.1 Causes
5.2 Symptoms
5.3 Predisposing factors
5.4 Management
5.5 Other information
5.6 Support

9
9
9
9
12
12

6.

Training & Resource Implications

13

7.

Consultation, Approval & Ratification Process

13

8.

Equality Analysis Summary

14

9.

Monitoring Compliance with the Document

15

10.

References & Supporting Documents

15

11.

Policy Review

16

12.

Appendices
Appendix 1 Health Visitor Role
Appendix 2 Monitoring Compliance
Appendix 3 Appendix 3 Equality Analysis

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Pathway for the management of


mastitis in the Lactating woman
1.

Introduction
Mastitis is an inflammatory condition of the breast which may or may
not be accompanied by infection. The inefficient removal of milk due to
poor positioning and attachment of the infant at the breast is a
significant contributing factor of mastitis. However, it has been reported
that health professionals regard mastitis purely as an infection and are
often not equipped to help such women deal with the contributing
factors, and may also advise Mothers to stop breastfeeding. It is
consequently imperative for health professionals to understand the
aetiology, prevention and treatment of mastitis. This will then enable
mothers to continue to successfully breastfeed and thus facilitate
achieving of the Department of Health (DH) targets.

2.

Purpose
The main aim of this pathway is to standardise practice
The pathway is a statement of intent and it:
Supports the values of the Staffordshire and Stoke on Trent
Partnership NHS Trust in relation to breastfeeding and infant
feeding.
Outlines staff actions necessary to help mothers recognise the
causes, prevention and early treatment of mastitis.
The pathway outlines the responsibility of the Trust to provide training
in mastitis management, by way of the 3 day breastfeeding
management course, to enable health visitors that have contact with
lactating mums to provide full and competent support.
The Objectives of this pathway is:
To ensure standards are clearly identified
To ensure that trained practitioners provide appropriate treatment
for women with mastitis
Promoting and supporting sustainable breastfeeding is an essential
part of an integrated programme of child health promotion and
parenting support as set out in the Healthy Child Programme (DH,
DCSF 2009) and Every Child Matters (2003).
The pathway is written in conjunction with the requirements necessary
for the Trust to achieve full UNICEF UK Baby Friendly Accreditation.
UNICEF UK Baby Friendly accreditation is a structured programme

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with an external verification process. Full accreditation demonstrates


compliance with set quality standards in relation to breastfeeding
support services and infant feeding.
A key recommendation of the NICE Guidance on Maternal and Child
Nutrition (NICE 2008a) is that childrens services should adopt a
multifaceted approach across different settings to increase breast
feeding rates.
This should include:
Activities to raise awareness of the benefits of, and how to
overcome the barriers to, breastfeeding.
Training for health professionals.
Education and information for pregnant women on how to
breastfeed, followed by proactive support during the postnatal
period.
This pathway applies to Health Visitors and Breastfeeding Specialists
who are registered with the NMC and who have undertaken the
breastfeeding management training and have had their knowledge and
skills assessed as competent
Health Visitors (along with midwives and GPs) have the primary
responsibility for supporting breastfeeding women and helping them
to overcome related problems.
This pathway should be read in conjunction with the Infant feeding
policy.
This pathway should only be used if the woman is breastfeeding or
expressing breast milk. If woman using formula milk develops mastitis
symptoms she must be referred to her GP

3.

Explanation of Terms
For the purpose of this document, the following terms apply:
Term
Mastitis

4.

Explanation
an inflammatory condition of the breast which may or may not
be accompanied by infection

Duties & Responsibilities


Chief Executive
The Chief Executive has overall responsibility for the strategic and
operational management of the Trust, including ensuring that the
Trusts procedural documents comply with all legal, statutory and good

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practice requirements. The Chief Executive is responsible for ensuring


that there are safe and effective systems in place to deliver high quality
care to the persons who use our services.

Director of Nursing & Quality


The Director of Nursing & Quality has overall responsibility for the
implementation of this pathway and delivery of care including
standards for the management of mastitis in the breastfeeding woman.
Support and advice will be provided by infant feeding leads.
This pathway applies to all Staffordshire and Stoke on Trent
Partnership NHS Trust Health Visitor employees, including bank staff,
who have contact with breastfeeding mothers.
Health Visitor Professional Leads, UNICEF Leads and
Breastfeeding Specialists are responsible for promoting evidence
based practice in the promotion and management of breastfeeding
including overcoming barriers such as mastitis. The Partnership Trusts
UNICEF leads will work with Health Visitor professional leads / key
workers/ breastfeeding specialists in developing and reviewing this
pathway as necessary and participating in and reviewing training and
audit in relation to it.
Team Leaders are responsible for ensuring that staff are orientated to
this pathway and attend appropriate training
Individual employees are responsible for implementation of this
pathway in relation to the information and support they provide for
clients in relation to mastitis management

5.1

Scope

5.1.

Causes:
Non-infective mastitis is due to immunological responses to milk .
substances forced into the capillaries and connective tissue from the
alveoli by high pressure. This causes inflammation and pain.
Infective mastitis is less common and is caused by either infection on
the outer skin of the breast or within the glandular tissue. Usually
mastitis occurs unilaterally. If non-infective mastitis is not treated
appropriately then this may develop into infective mastitis and then a
breast abscess may form

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5.2

Symptoms:
Local or generalised swelling
Lump or tender area which may feel hot to touch
Breast pain tender lump
Inflammation often wedge shaped
The whole breast(s) ache and may become red.
Slight pyrexia
Flu like symptoms -aching, increased temperature, shivering, feeling
tearful and tired (this feeling can sometimes start very suddenly and
get worse very quickly)
Headache
If initial treatment is prompt, symptoms may resolve in 12 hours or so, if
not, they may progress (below) and become more severe whereby
Medical treatment with antibiotics is recommended to help prevent
further deterioration and possible abscess formation
Feels very ill
Severe pyrexia
Rigours
Mums may not have all the signs (Morbacher and Stock, 2003)

5.3

Predisposing Factors
1.

Ineffective breast drainage resulting from:Incorrect attachment at the breast


Missed feeds
Longer gap between feeds
Pressures on breast e.g. poorly fitting bra, from mums hands at
feeds, babys hand/arm at feeds, handbag, baby sling, lying on
breast
Mother giving formula instead of expressed breast milk
White Spot/Bleb

2.
3.
4.
5.
6.
7.
8.
9.

Sore cracked nipples


Stress
Poor physical health
Anaemia
Insulin Dependent Diabetic mother
Mouth/nose infection in infant
Breast trauma e.g. previous surgery, previous abscess, bruising
Lowered resistance to infection which may be attributed to
smoking
Nipple piercing

10.

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5.4

Management
It is important to encourage and support the mother to breastfeed from
the affected breast to aid recovery
The Role of the Health Visitor/ Breastfeeding Specialist
If signs and symptoms present-review without delay
Undertake breastfeeding assessment and observe position
and attachment help the mother make improvements.
Advise to feed 2-3 hourly, as often and for as long as the infant
is willing including during the night for as long as pain persists.
Discuss pain relief
Identify predisposing factor(s) and give information and provide
support.
Express at end of each feed until lump reduces /redness
subsides
The Health Visitor/ Breastfeeding Specialist should support and
encourage the mother to overcome mastitis by discussing self-help
measures such as: Feeding from the sore side first for good drainage. Leaning over
baby in an upright position may also encourage effective
drainage.
Establish milk flow before putting baby to the breast - run warm
water over the breast prior to feeds
Try different feeding positions - gravity feed or under arm hold
may help
Use massage and heat to soften the breast.
Use a wide toothed comb with rounded teeth to stroke gently
over the red area and towards the nipple to help milk flow.
Checking clothing to prevent continued pressure [a well-fitting
bra is essential].
Relieving symptoms with cooling treatments such as cold
flannels and gel-filled cool packs.
Rest, plenty of fluid and a good diet.
Homely remedies
Avoid sudden changes in feeding practice, for example, longer than
normal gaps between feeds which leave the breasts full for longer.
NOTE: Patient should be advised to attend the GP if either the
following two scenarios present. 1, If bilateral mastitis is present, as it is
advised that a culture of milk from both breasts is taken to establish the
responsible organism. 2, If mastitis is reoccurring it would be
appropriate to test the milk for culture and sensitivity and also to obtain
swabs from the infants nasopharynx and oropharynx to identify the
offending organism.

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If symptoms are not resolving or become more severe within


approximately 12 - 24 hours then medical treatment with
antibiotics is recommended to help prevent further deterioration
and possible abscess formation, these may be prescribed by a
non medical prescriber or referral to a Medical Practitioner is
required at this point. However, it is very important that the
mother is advised to continue with the management of mastitis.
Effective milk removal is an essential part of treatment.
Medical Management
If the woman's symptoms do not improve after 1224 hours despite
effective milk removal, treatment with an antibiotic is indicated (Kvist et
al, 2008).
If empirically treating infection:
Prescribe flucloxacillin 500 mg, four times a day, for 14 days. If patient
is >80kg prescribe flucloxacillin 1g, four times a day, for 14 days.
An alternative (for patients with penicillin allergy) is erythromyc
500 mg, four times a day, for 14 days.
(Note this is inferior to 1st line treatment. Penicillin allergy should only
be accepted as genuine hypersensitivity if convincing history of either
rash within 72 hr of dose or anaphylactic reaction.)
Inform the woman that these antibiotics are only excreted in milk in
very small amounts. Usually the infant is not affected, but occasionally
stools may be looser or more frequent than usual or the infant may be
more irritable.
If symptoms fail to settle after 48 hours of antibiotic treatment:
Check that the woman has taken the antibiotic correctly.
Advise the woman to attend the GP as a sample of the milk should be
sent for culture.
Discuss with the GP.
If culture results are available, Gp will treat with an antibiotic the
organism is sensitive to.

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Consider an alternative diagnosis.


If there is an underlying mass or ductal cancer or inflammatory
breast cancer is suspected, the GP should arrange urgent
investigation or referral.
If a localized area of the breast remains hard, red, and tender
suspect an abscess. Malaise and fever may have subsided if
antibiotics have been taken. GP should refer the woman to a general
surgeon for management urgently.
If the woman has recurrent mastitis, the GP can liaise with the
microbiologist or refer patient to a surgeon to look for an underlying
cause.
Pain relief
Ibuprofen* 400mg one tablet 3 times daily
This considered the most effective as it reduces inflammation
and pain (WHO 2000)
Adults -Paracetamol 2 x 500mg x four times daily,
This is an appropriate alternative for the relief of pain (WHO)
12-16yrs Paracetamol 480-750mg 4-6 hrly, 16-18yrs
Paracetamol
500mg -1g every 4-6 hrs max 4 doses in 24 hrs.
* Check interactions and cautions with British National Formulary
5.5

Other information:
During mastitis the increased sodium levels in the milk resulting from
the inflammatory process, can affect the taste of the milk resulting in
the infant potentially refusing to feed from the affected breast. Also,
there may be a drop in lactose in the milk due to the damaged alveoli
tissue effecting milk synthesis, in the short term (Featherstone 2001)

5.6

Support
Provide the mother with information about breastfeeding support
session details, local and national breastfeeding telephone contact
details.
Provide follow up care and support as the cause needs to be
ascertained and remedied to prevent reoccurrence

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6.

Training & Resource Implications


All Health Visitors, Breastfeeding Specialists, Nursery nurses
and support staff who have contact with breastfeeding women
and their families should be aware of this guidance.
All Health Visitors and Breastfeeding Specialists who are
registered with the NMC will have undertaken the
breastfeeding management training and have had their
knowledge and skills assessed as competent
This pathway will be disseminated to Health Visitors initially
through professional meetings.
It should be provided to new staff as part of their local induction
and associated need for breastfeeding management training
assessed (and this should be evidenced within local induction
documentation later filed on staff personnel files).

7.

Consultation, Approval and Ratification Process


Consultation

7.1

The pathway has been developed based on current best practice.


Promoting and supporting sustainable breastfeeding is an essential
part of an integrated programme of child health promotion and
parenting support as set out in the Healthy Child Programme (DH,
DCSF 2009) and Every Child Matters (2003).
The pathway is written in conjunction with the requirements necessary
for the Trust to achieve full UNICEF UK Baby Friendly Accreditation.
UNICEF UK Baby Friendly accreditation is a structured programme
with an external verification process. Full accreditation demonstrates
compliance with set quality standards in relation to breastfeeding
support services and infant feeding.
A key recommendation of the NICE Guidance on Maternal and Child
Nutrition (NICE 2008a) is that childrens services should adopt a
multifaceted approach across different settings to increase breast
feeding rates.
This should include:
Activities to raise awareness of the benefits of, and how to
overcome the barriers to, breastfeeding.
Training for health professionals.
Education and information for pregnant women on how to
breastfeed, followed by proactive support during the postnatal
period

7.2

This document was previously circulated as a draft to All SSOTP


Health Visitors, Medicines management group, Infant feeding leads,

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Some GPS, South Division management team, locality managers, HV


Implementation group, CPTS, APG and the SACE North and South
groups in 2012. This revision was re-circulated to all Health Visitor
team leaders, Medicines management group, Childrens services
management team, CPTs, BFI keyworkers, Microbiologist, Medical
director and infection Control lead April 2014.

8.

Equality Analysis Summary

8.1

An equality Impact assessment was completed to ensure its


consideration to the impact on local vulnerable people and those from
the protected equality groups.

8.2

Staffordshire & Stoke on Trent Partnership NHS Trust considers how


the decision it makes affects people who share different protected
characteristics (race, disability, sex, gender re-assignment,
religion/belief, sexual orientation, age, marriage and civil partnership,
pregnancy and maternity). The Trust also recognises that there are
groups/communities that are recognised at a local level within society
as excluded or disadvantaged in addition to those listed as protected
groups above and this document is inclusive to these groups also for
example, young teenage parents, homeless people etc.
This pathway has been developed with due regard to relevant
legislation, MCA (2005), Equality Act (2010) and best practice
guidance. The pathway clearly sets out the framework in which all staff
employed or working on behalf of the organisation must work in relation
to managing mastitis. The pathway promotes a positive approach
towards and includes all equality groups as identified by the legislation
(Equality Act 2010). An equality analysis of this pathway has been
undertaken to ensure it is fair and accessible, compliant with legal and
best practice guidelines.
The Pathway for the management of mastitis in the Lactating
woman sets out the best practice regarding delivering a
minimum standard of quality care, equally accessible to lactating
women with signs/symptoms of mastitis. This fits well with
ensuring fair and quality care for all. The equality analysis
indicates that the pathway will meet equality inclusion criteria ;
cost implications in terms of resources and
training to meet the requisite standards will be negligible
because mastitis is already covered in the UNICEF accredited
training curriculum and this pathway will act as a supporting
practice document.
A completed equality analysis is presented at (Appendix 2 ) of
this document.

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9.

Monitoring Compliance with the Document


The pathway will be monitored via the UNICEF auditing process
which entails Internal / External audits by SSOTP and UNICEF
Anecdotal feedback from mums who say they may have given
up breastfeeding due to mastitis but carried on due to timely
treatment and support.
Data reports around primary and 6-8 week breastfeeding rates.
Achievement of full UNICEF accreditation which will
demonstrate that at least 80% of clients are receiving the care
and support they need to breastfeed their baby.

10.

References and Supporting Documents

10.1

References
Clinical Practice Guideline. Breastfeeding Challenges Mastitis and
breast abscess. Australian guideline 2009.
Cusack L, Brennan M. Lactational mastitis and breast abscess
diagnosis and management in general practice. Aust Fam Physician.
2011 Dec; 40(12):976-9.
Featherstone, C [2001] Mastitis in Breastfeeding Women: Physiology
or Pathology? Midirs: 12: 2: 235-240.
Foxman, B [2002] New Insights with Regard to risk Factors for
Lactation Mastitis: American Journal Epidemiology: 155: 103-114.
Hale, T [2010] Medications and Mothers Milk 14th Edition: Hale
Publishing: Texas.
Healthy Child Programme (DH, DCSF 2009).
HM Government (2003) Every Child Matters: change for children.
London; HMSO. Available at www.everychildmatters.gov.uk/
Inch, S [2006] Breastfeeding Problems: Prevention and Management:
Community Practitioner: 79: 5: 164-166.
Jones, W., Sachs, M [2009] Mastitis and Breastfeeding: The
Breastfeeding Network: BFN: Scotland.
http://www.breastfeedingnetwork.org.uk/pdfs/BFN_Mastitis.pdf
Kvist, l., Wilde Larsson, B., Hall-Lord, M [2008] The Role of Bacteria in
Lactational Mastitis and Some Considerations of the Use of antibiotic
Treatment: International Breastfeeding Journal: 3: 6.

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Mohrbacher, N., [2010] Breastfeeding Answers Made Simple: La Leche


League: Illinois.
NICE Guidance on Maternal and Child Nutrition (NICE 2008a).
NICE Clinical Knowledge Summaries. Mastitis and Breast abscess.
May 2010
UK Baby Friendly Initiative (1994) Introducing Baby Friendly Initiative
into the UK. London; UNICEF UK. www.babyfriendly.org.
World Health Organisation [2000] Mastitis: Causes and Management:
World Health Organisation: Geneva.
Other associated documents
This pathway must be read in conjunction with the Trusts Infant feeding
policy, postnatal guidelines and any other relevant corporate
documents.

11.

Policy Review
This pathway will be reviewed in two years following ratification or
sooner if the necessity arises.

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Appendix 1
The Role of the Health Visitor / Breastfeeding Specialist
Practice

Rationale/Research

Mothers presenting with the signs


and symptoms of mastitis should be
reviewed by the Health Visitor
without delay.

If mastitis is not treated promptly a


bacterial infection and breast abscess
may develop [Inch, 2006; World Health
Organisation, 2000, Cusack L,
Brennan M, 2011]
Removing milk from the breast is
essential to relieve the pressure and
help clear any blockages. Stopping
breastfeeding at this point may actually
make mastitis worse [Featherstone,
2001, Australian guideline 2009].
Expressing gently after feeds or when
the breast[s] are uncomfortably full
using either her hand or a breast
pump, will help ensure the breasts are
kept as well drained as possible
[Jones and Sachs, 2009 Australian
guideline 2009].
To reduce pain, inflammation and
temperature [Hale, 2010; WHO, 2000
Australian guideline 2009, Cusack L,
Brennan M, 2011, ]

The Health Visitor/ Breastfeeding


Specialist should encourage the
mother to continue breastfeeding as
often and for as long as the infant is
willing aiming for at least 8-12
times in 24 hours.

To achieve effect milk removal the


mother may also need guidance on
expressing breast milk
[Featherstone, 2001].
Pain should be treated with a
suitable analgesic. Medical
treatment may also be
recommended.
Effective pain relief includes
paracetamol and/or ibuprofen.
The Health Visitor/ Breastfeeding
Specialist should assess positioning
and attachment of the baby at the
breast and if necessary help the
mother make improvements.
Unrestricted baby led feeding should
be recommended.
The Health Visitor/ Breastfeeding
Specialist should support and
encourage the mother to overcome
mastitis by discussing self-help
measures such as: Feeding from the sore side
first for good drainage.
Leaning over baby in a
upright position may also

As mastitis starts with poor milk


drainage, good positioning, attachment
and effective milk transfer at the breast
is essential [Jones and Sachs, 2009;
Mohrbacher, 2010]. Unrestricted baby
led feeding is recommended to reduce
the risk of mastitis reoccurring [Inch,
2006].
Women often feel unwell and find
mastitis painful and frustrating. They
may even wish to discontinue
breastfeeding [Mohrbacher , 2010]. It
is really important that the mother
continues breastfeeding. Removing
milk from the breast is essential to
relieve the pressure, help clear
blocked ducts and engorgement

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encourage effective drainage.


Establish milk flow before
putting baby to the breast.
Try different feeding
positions.
Use massage and heat to
soften the breast.
Use a wide toothed comb with
rounded teeth to stroke gently
over the red area and towards
the nipple to help milk flow.
Checking clothing to prevent
continued pressure [a well
fitting bra is essential].
Relieving symptoms with
cooling treatments such as,
cold flannels and gel-filled
cool packs.
Homely remedies
Rest, plenty of fluid and a
good diet.
Avoid sudden changes in
feeding practice, for example,
longer than normal gaps
between feeds which leave
the breasts full for longer.
It is important for the Health Visitor/
Breastfeeding Specialist to reassure
the mother that the breast milk will
not harm her baby even if an
infection is present [Foxman, 2002]

The Health Visitor/ Breastfeeding


specialist should advise referral to a
Medical Practitioner if symptoms are
not resolving or become more
severe within approximately 12-24
hours. Medical treatment is
recommended to help prevent
further deterioration and possible
abscess formation. However it is
very important the mother is advised
to continue with the self-help
management of mastitis as well.
Effective milk removal is an essential
part of treatment.

[Jones and Sachs, 2009].

To ensure the mother does not abstain


from breastfeeding. Fresh human milk
is normally not a good medium for
bacterial growth. Infective mastitis
results when milk stasis remains
unresolved and the protection by the
immune factors in the milk and by the
inflammatory response is overcome
[Kvist et al, 2008].
Mastitis can either be non-infective or
infective. Infective mastitis should be
treated with antibiotics in addition to
regular milk removal [Morbacher,
2010]. A prompt clinical diagnostic
test for infective mastitis has not yet
been developed, therefore, all cases of
mastitis which have not improved after
12-24 hours of improved milk removal
should be treated as infective [Inch,
2006; World Health Organisation
[WHO], 2000].

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Occasionally the baby may be


reluctant to feed from the affected
breast because the infection may
make the breast milk salty, in which
case the mother will need to express
milk manually or by using a breast
pump

Most antibiotics can be safely taken


whilst breastfeeding [Hale, 2010;
WHO, 2000].
It is important that the mother finishes
the whole course of antibiotics to
ensure a full recovery and also to help
prevent the mastitis coming back
[Jones and Sachs, 2009]

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Appendix 2
Name of Procedural
Document
Monitoring Officer
Reporting Arrangements

MONITORING COMPLIANCE
Pathway for the management of Mastitis in the Lactating woman.

UNICEF Implementation leads North /South


Baby Friendly keyworker group Bi-monthly
HV Team meetings Bi-monthly
Element to be Monitored - NSLA Criteria
Tool
Change in Practice
and Lessons to be
Ref
Standard Criteria
Shared
Staff education standard which meets
UNICEF audit tools
Update training
UNICEF BFI accreditation
Patient Feedback from breastfeeding
Evaluation tool
Update training
support group evaluation
Data for primary/6-8 week breastfeeding
status

SSOTP data reports

Timeframe

6-12 monthly
quarterly

ongoing

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Nominated
Lead
UNICEF
Leads
Breastfeeding
support group
leads
UNICEF
Leads

Appendix 3

EQUALITY ANALYSIS
Pathway for the management of mastitis in the Lactating woman
STEP 1: What is the background and starting point for this pathway?
1.1 This is a new pathway.
Currently there is no local guidance on how to manage mastitis in the lactating
woman. Mastitis, if left untreated at worst can cause a breast abscess and at
least may lead to a woman being wrongly advised to give up breastfeeding.
1.2 The pathway fits with the organisational objective/values of
Providing high quality and safe services which provide excellent
experience and best possible outcomes
Empowering and supporting the workforce to deliver care in a way
which is consistent with our values
Putting quality first
Be user focussed and responsive
Be respectful and caring of people
1.3 Health Visitors and FNP nurses who have undertaken breastfeeding
management training and who are SSOTP employees are responsible for the
implementation of this Pathway.
STEP 2: What do we want to achieve?
To ensure that all mothers are given timely information/ treatment to
treat and reduce the complications that mastitis may cause.
To ensure that staff who are involved with supporting women with
breast feeding receive essential training to enable them to support
women with mastitis symptoms/diagnosis
Supporting mothers to breastfeed which is key to reducing health
inequalities.
Who is the target audience?
Lactating women, health visiting staff, staff returning to work and who
are breastfeeding.
The aim of this pathway is to ensure a quality standard of care is given
to lactating women with symptoms/signs of mastitis. It will not
discriminate against any of the equality groups
Without the pathway, there is a potential for larger costs to the
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organisation if mastitis turns into a breast abscess and incurs costs in


terms of physical, psychological and emotional scarring to a woman
who has to undergo an operative procedure to treat an abscess and
financial costs of surgery.
STEP 3: What do we know?
Department of Health (2004a) Good Practice and Innovation in
Breastfeeding
NICE.: www.nice.org.uk/Guidance/PH11/Guidance/pdf.English
UK Baby Friendly Initiative (1994) Introducing Baby Friendly Initiative
into the UK. London; UNICEF UK
Continuous programme of audits using UNICEF tools to establish staff
knowledge and skills, and information given to antenatal and postnatal
women in relation to infant feeding
Anecdotal evidence suggests that breastfeeding mums find accessing
GPs for early diagnosis and treatment of mastitis very difficult.
Health visitors undergo extensive breastfeeding management training
to support breastfeeding women. Mastitis is generally caused by poor
positioning and attachment of the baby at the breast. Therefore they
are best placed to carry out a positioning and attachment assessment
to determine reasons for mastitis symptoms and to possibly prevent
further deterioration to full blown mastitis.
If mastitis signs and symptoms are detected and support given to
resolve in a timely manner this is likely to prevent the need for
medication and further deterioration and support breastfeeding
continuance
If mastitis is treated with a medical prescription given by a GP or nurse
prescriber, Health visitors, FNP nurses and infant feeding team staff
are best placed to support the woman.
STEP 4: What consultation has been taken: engagement and
involvement
4.1 This pathway is a revised document. It was sent out in 2012 and again in
March/ April 2014. It has been shared with Health visitors, childrens
service managers, medicines management, microbiologist and medical
lead, a number of GPs and infant feeding leads and the SACE groups
North and South 2012.
In terms of involvement, the Continuous programme of audits using
UNICEF tools will establish staff knowledge and skills, and information
and support given to women who are breastfeeding.
Client satisfaction surveys at breastfeeding support groups will help
ascertain womens views on their care.
Feedback from staff members and mums with mastitis about the lack of
consistency in the diagnosis and treatment of mastitis in the community
4.3 Training and updates are planned according with findings/outcomes of the
UNICEF audits.
STEP 5:
The impact of the pathway is that it will standardise and improve care
given to the identified client groups. There is a positive impact on
woman across age, disability, faith etc since the pathway promotes

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universal support and education to mums wishing to b/f babies and the
inclusive approach enables education and support to be at the pace
and in the format most suitable to the mother.
Actions identified within the pathway will have minimal cost
implications. Mastitis treatment and diagnosis is already part of the
breastfeeding training curriculum. This pathway will support the existing
breastfeeding training which takes place over 3 days.
STEP 6: Have you identified any actions:
The pathway will support existing breastfeeding training and give further guidance
to manage mastitis in the our practice based community.
STEP 7: How will we know that the pathway has been successful?
7.1 The pathway will be reviewed annually or as new information comes to
light.
UNICEF Audits will show that staff can demonstrate the knowledge and
practice advice they give to breastfeeding women in relation to
managing mastitis and that breastfeeding women with mastitis were
given the correct information/support to prevent/manage mastitis.
Anecdotal feedback from mums who say they may have given up
breastfeeding due to mastitis but carried on due to timely treatment and
support.
Monitoring of breastfeeding rates.
Achievement of full UNICEF accreditation which will demonstrate that
at least 80% of clients are receiving the care and support they need to
breastfeed their baby.
7.2 as above and
Via health visitor team leaders, health visitor team meetings and
updates
SSOTP NHS Trust have set up a web page re breastfeeding
information
STEP 8: Executive Summary
The Pathway for the management of mastitis in the Lactating woman
sets out the best practice regarding delivering a minimum standard of
quality care, equally accessible to lactating women with
signs/symptoms of mastitis. This fits well with ensuring fair and quality
care for all.
The equality analysis indicates that the pathway will meet equality and
inclusion criteria; cost implications in terms of resources and training to
meet
the requisite standards will be negligible because mastitis is already
covered
in the UNICEF accredited training curriculum and this pathway will act
as a
supporting practice document

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