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Lactational mastitis
Leila Cusack
Meagan Brennan and breast abscess
Diagnosis and management in general practice

Lactational mastitis affects approximately 20%
Lactational mastitis is common, affecting one in 5 breastfeeding women. As well as
of breastfeeding Australian women in the first 6
causing significant discomfort, it is a frequent reason for women to stop breastfeeding.
months postpartum.7 It is most common in the first 6
Objective weeks of breastfeeding1,5 with the highest incidence
This article outlines an evidence based approach to the diagnosis and management of occurring during the second and third weeks.6,9 It is
lactational breast infections in general practice.
initially localised to one segment of the breast, but
Discussion untreated can spread to affect the whole breast.5
Lactational mastitis is usually bacterial in aetiology and can generally be effectively Around 3% of lactating women with mastitis will
managed with oral antibiotics. Infections that do not improve rapidly require further develop a breast abscess,1,10 although an incidence
investigation for breast abscess and nonlactational causes of inflammation, including of up to 11% has been reported.10
the rare cause of inflammatory breast cancer. In addition to antibiotics, management of
lactational breast infections include symptomatic treatment, assessment of the infant’s Risk factors and prevention
attachment to the breast, and reassurance, emotional support, education and support
The main risk factor for mastitis is breastfeeding
for ongoing breastfeeding.
during the early postpartum period.6 Milk stasis
Keywords: mastitis; breast abscess; lactation; general practice and cracked nipples may contribute to the
development of mastitis,1,3–6 although the evidence
for this is inconclusive.1 Other implicated factors
include previous mastitis,6 maternal fatigue1,3 and
Lactational mastitis is an inflammatory primiparity.9 Reported risk factors for breast abscess
process affecting the lactating breast.1–4 include a past history of mastitis, maternal age over
It is usually bacterial in aetiology. It 30 years and gestational age greater than 41 weeks.5
affects the breast parenchyma, causing There are no interventions that have been
localised pain, tenderness, erythema and consistently proven to prevent mastitis. Encouraging
engorgement,3–6 and may be accompanied emptying of milk from the breast is often
by systemic features such as fever, recommended, however, evidence for its efficacy
malaise, rigors, nausea and vomiting.4–8 is inconclusive.6 The most commonly practised
intervention is the prevention and management of
A breast abscess, a localised collection in the damaged nipples; in some settings this may reduce
breast tissue that results in a painful breast lump, the risk of developing mastitis.3 A Cochrane review
is potentially secondary to bacterial mastitis found that anti-secretory factor cereal, mupirocin
that is rapidly progressive or is not managed ointment, fusidic acid ointment and breastfeeding
expeditiously. Effective management is essential advice had no significant impact on the initiation
to control the discomfort and reduce the likelihood or duration of breastfeeding or the incidence of
of discontinuation of breastfeeding, which may symptoms of mastitis.11
occur as a consequence of mastitis.6,7 Mastitis
and breast abscess may develop in women who
are not breastfeeding; this article will focus on The most common causative organism for mastitis
lactational breast infections. is Staphylococcus aureus.8,10 Strains of methicillin

976 Reprinted from Australian Family Physician Vol. 40, No. 12, December 2011

Photo © Science Photo Library. breast abscess presents as a non- – viral (herpes. pulse rights reserved abscess and blood pressure are important to exclude sepsis. areus (abscess is sitting close to the surface of the skin). may distinguish inflammation (mastitis) from a lump remains. no fluid is obtained or fluid is particularly in hospital acquired infections. benign phyllodes may interfere with attachment. cleft palate growth and hydration.13 lactating women.1. fibrocystic change. if a significant for malignancy. Common breast problems in the puerperium Breast abscess is characterised by symptoms Benign conditions similar to mastitis. following aspiration. localised tenderness.5–7 Clinical examination of the breast should focus on looking for signs of inflammation (erythema. No. lethargy. sweating. then core organisms include streptococci and S.5 On rare occasions Candida mimic an inflammatory collection on ultrasound. albicans. sometimes nausea and vomiting and occasionally rigors. – sleeping or breastfeeding in an uncomfortable position • Raynaud disease of the nipple Investigation Malignant causes Mastitis is a clinical diagnosis and investigations • Breast cancer are not indicated in the initial assessment. A lactation – tender costochondral junctions (Tietze syndrome) consultant may be helpful.6. sonographic or biopsy features suspicious albicans. December 2011 977 . clinical. 40. with the additional sign of Conditions related to lactation a discrete tender lump. heat. along with other generalised flu-like symptoms including malaise. 2011. Mastitis is characterised by a Figure 2. Other collection of pus in the breast (abscess) (Figure bloodstained rather than purulent. engorgement and tender area of localised erythema Image shows a heterogeneous area which swelling) (Figure 1) and signs of nipple damage. aureus (MRSA) have been identified. which may be tense or • Engorgement fluctuant. which requires hospital admission. cyst. tongue-tie. Ultrasound of a breast abscess.9 can cause parenchymal infection. including microscopy and culture. 12. • Galactocoele (noninfected milk-filled cyst) Examination of the infant and • Nipple pain attachment to the breast – cracked/damaged nipples – incorrect attachment: misalignment of mother’s nipple and baby’s mouth The infant should be examined to ensure adequate – infant causes: poor sucking. headache. epidermidis.13 Patients who suffer with recurrent breast abscesses any abscess providing drainage and fluid for Mammography is not a first line investigation have a higher incidence of mixed flora. not an uncommon cause of nipple pain in Hence. myalgia. very rare) tender lump without erythema (‘cold abscess’). Figure 1.1 – lobular and ductal carcinoma Breast infection that does not improve – inflammatory breast cancer (may mimic bacterial mastitis) with a course of appropriate antibiotics should – malignant phyllodes tumour be investigated with breast ultrasound. – fungal infection (C.2 or anatomical Other conditions conditions such as cleft palate or tongue-tie which • Benign breast disease: fibroadenoma. All has the typical appearance of a breast General observations including temperature. Table 1. The mass may have overlying skin • Breast infection (mastitis or abscess) necrosis suggesting that the abscess is ‘pointing’ – bacterial infection – usually S.5 This Reprinted from Australian Family Physician Vol. Examination of the baby’s – incorrect use of breast pump mouth can exclude candida infection (white film – C. Ultrasound also allows guided aspiration of biopsy is recommended to exclude breast cancer. A malignant lesion may in lactating women but is indicated if there are anaerobic organisms. Lactational mastitis and breast abscess – diagnosis and management in general practice clinical resistant S.7 High fever is common. uncommon) Less frequently. 2).12 Clinical assessment History and physical examination Breast pain is the primary symptom of mastitis.9 Observation of tumour breastfeeding can determine if there are difficulties • Musculoskeletal conditions with attachment to the breast. albicans nipple infection adherent to the buccal mucosa).

ciprofloxacin similar to-ice packs in some studies. • Biopsy lesions suspicious for malignancy Management of breast abscess if present Management of symptoms • Aspiration with antibiotic cover is a safe first line approach where specialist breast clinics or ultrasound guidance are available Simple analgesia • Incision and drainage if not settling or aspiration is unavailable Regular oral paracetamol is first line treatment. All rights reserved of antibiotics. This relieves symptoms and reduces 978 Reprinted from Australian Family Physician Vol. and the absence of breast aspirated from an abscess). Inflammatory breast cancer may of choice at least 5 days of flucloxacillin or Support for continued mimic mastitis. Where rare cause of mastitis and is characterised by the possible this should be guided by microbiological presence of intense pain. • Other management (as per mastitis) Nonsteroidal anti-inflammatory drugs can be added. particularly if the clinical features • Systemic features (fever.4.15 • gentle massage and warm compress prior to alleviate pain).14 As S.15 Candida is a Adequate antibiotic therapy is essential. 40. 12. dicloxacillin in a dose of 500 mg four times per skin thickening and peau d’orange (‘orange day. Nonbreast • Hot packs before feeding causes of fever (such as urinary tract infection • Cold packs after feeding or endometritis. antibiotic therapy Figure 3. 2011. For patients allergic to penicillin. heat.2 (Figure 3). No. oral antibiotics and encouraging continued • Referral to lactation consultant milk flow from the affected breast (Table 2).2. inflammation such as inflammatory breast cancer Close monitoring is required to ensure that the • Aspiration of abscess collection infection resolves. erythema.12 common causative organism. ie. however.5 while and chloramphenicol as they are unsafe for use in demonstrating no effect in others.9. producing postfeeding symptom relief clarithromycin). Psychological support Both are safe in breastfeeding. swelling) be kept in mind. each feed.1.2 Support continued breastfeeding • Education and reassurance Management • Regular and complete drainage of breast (use breast pump if needed) The key components of management are symptom • Observe feeding and attachment control. malaise. to • If not settling. December 2011 . particularly noted after culture and sensitivity (such as when fluid is the breast empties.9 lactating women. Women • Review in 24–48 hours. effects.clinical Lactational mastitis and breast abscess – diagnosis and management in general practice Differential diagnosis Table 2.9 Alternatives used overseas include amoxycillin/ feeding (may encourage milk flow)1. The • Referral to Australian Breastfeeding Association patient should be reassured that antibiotics and Early and frequent review simple analgesics will not harm her baby. Classically it presents with a breastfeeding poorly defined clinical mass with erythema. ultrasound to look for breast abscess and rare causes of rest whenever possible and to drink plenty of fluids.6 Cabbage leaves have demonstrated inconsistent clavulanic acid and macrolides (erythromycin. These differentials should • Localised inflammatory features (pain. Management approach to breast infections Other less common breast problems may present in Clinical assessment the puerperium (Table 1).2 • Reassurance and support Hot and cold packs to breast • Evaluation for depression • Referral to Australian Breastfeeding Association Evidence is inconsistent. myalgia) are not of a classic nature.5 Hospitalisation for intravenous antibiotics is rarely required but is indicated if Antibiotic therapy there are systemic signs of sepsis.5.4. aureus is the erythema. following complications of Antibiotic therapy Caesarean delivery) should be considered where the • Flucloxacillin or dicloxacillin 500 mg qid for at least 5 days presentation is with fever rather than breast pain • For abscess – guided by microbiological culture and sensitivity and erythema.15 Due to antibiotic packaging in Australia The aim of therapy is to continue breastfeeding peel’ appearance to the skin) this may require two consecutive 6 day courses and to empty the breast as fully as possible with Photo © Slaven.1. • Assessment of infant hydration and weight Inflammatory breast cancer is a rare Symptom management presentation but should be considered if mastitis is • Simple analgesia not responding to treatment1. investigate if not settling should be encouraged to continue breastfeeding. breastfeeding authorities recommend: • application of cold packs after feeding (may help options include cephalexin or clindamycin.5 Avoid tetracycline.

hormonal 4. Emptying of the breast can Guidelines Ltd.4. breast and lifestyle change. This has been largely Leila Cusack BSc. Amir LH. Investigation of a minimise associated morbidity. The Australian under local anaesthetic where specialist breast gmail. Amir LH. so surgical 1.52:595–605.20:288. Am Fam Physician 2008. Lumley J. Clin Obstet Gynecol 2004. mastitis descriptive study of mastitis in Australian breast- feeding women: incidence and determinants. University of Sydney.4 incision and drainage may be the treatment of Committee. Figure 4. should be first-line therapy for breast abscess. J Hum Lact 1991. 2. May 2008. FRACGP. Smart NA. Francis-Morrill J. It Public Health 2007.47:676–82.5 The traditional management of • Lactation Resource Centre www. McLachlan H. Dixon JM.5. J their child. the infection has resolved. Crepinsek MA. Breastfeed Med 2008.asn. Summary Interventions for preventing mastitis after childbirth. 10. Cochrane Database Syst Rev 2010. Ultrasound anxiety. a breast pump can be used present late when the abscess is established and • www.7 Depression. Antibiotic Expert World J Surg 2010. Lactational breast infections are common and 12.111:1378–81. Continued breastfeeding is trigger investigation and identify breast abscess to 15. breast. antibiotic. Melbourne: Therapeutic breast abscess.14 Access to Conflict of interest: none declared.3:177–80. 􀁓􀁔􀁒 enough to allow the baby to feed from the breast breast abscess was surgical incision and drainage Authors (Figure 4). 2nd edn. No. Nonsurgical management monitoring is important to detect poor responders. helplessness and concerns 5.7:62. FASBP. Lactational mastitis and breast abscess – diagnosis and management in general practice clinical the likelihood of progression to breast abscess. Brennan M. Infant attachment to the breast should under general anaesthetic. Amir LH.6 If Lactating women with a breast abscess often 686 286) attachment is painful. ultrasound guided biopsy if indicated by the support. Mass S.7:177. distress.lrc. Heinig MJ. are taking appropriate antibiotics. 12. be helped by the use of a breast pump Resources The Australian Breastfeeding Association provides Photo © iStockphoto. encouragement of milk flow from the affected February 2006.4. If minimal improvement occurs. Crowe L. December 2011 979 .32:141–5. ABM Clinical Protocol #4: Mastitis.7 By acknowledging the ing women. Dewey imaging findings. 40. Amir LH. Meagan Brennan BMed. Therapeutic Guidelines: encouraged for women with mastitis and/or allow urgent referral for specialist management. nipple pain and Breastfeeding Association is an excellent source mastitis. The Poche Centre. helps detect any abscess and can guide about milk supply have been associated with BMJ 2011. These than surgical management (including reduced Clinical School.78:727–31. Close 14. Lumley J. Revision. Khan LR.34:2257–8. Betzold CM. Michener K. Candida and the lactating breast: predis- posing factors.1. Breast pain in lactating women: mastitis or recommended in this situation. Forster D. Northern women choose to cease breastfeeding. An update on the recognition and management of lactational breast inflammation.1. The Australian􀁕 to drain the breast until the infection settles of large volume.1. McLachlan H. Elder EE. Incidence of free information and support and women of breast abscess in lactating women: report from an should be encouraged to use this resource. Sudden cessation specialist breast clinics may be limited in some References of breastfeeding may exacerbate the infection. some are better for outpatient clinic management Sydney and Clinical Senior Lecturer. preferably after of continued breastfeeding).342:d396. Surgery can usually be avoided and outcomes is a breast physician. Sydney Medical School. Forster DA. ideally with ongoing breastfeeding. New South Wales. areas. 24–48 hours to ensure that the inflammation is occurs at a time of great physical. their milk is extremely valuable to the health of KG. J settling. ultrasound is indicated (Figure 2). National Breast Cancer Centre. Midwifery Womens Health 2007. 2010. Version 14. 6. Management new breast symptom: a guide for general practition- of mastitis includes antibiotic therapy and ers. general advice for health professionals and support for Reprinted from Australian Family Physician Vol. Australian cohort. Referral to a lactation replaced by percutaneous (outpatient) aspiration officer. require prompt and effective management to 13. other causes of inflammatory breast signs such difficulties involved in breastfeeding. 11. leilacusack@ consultant may be helpful. and is safe for their baby when they Hum Lact 2004. Amir LH. Academy of Breastfeeding Medicine Protocol increasing the risk of abscess formation. Aust Fam Physician 2006. particularly in rural areas. currently living in Europe. something else? Aust Fam Physician 2003. Lumley J. MBBS(Hons) is a junior medical be checked and corrected. tearfulness. DFM. encouragement and reassurance that Breastfeeding Association is also useful for clinics or radiology services are available. Spencer JP. Management of mastitis in breastfeed- aspiration. BMC Women with mastitis should be reviewed within is often associated with complex emotions. BJOG 2004. North Despite support and encouragement.breastfeeding.(8):CD007239.35:745–7. Medication to suppress milk production is not choice in this setting. Women’s experience of lacta- as inflammatory breast cancer and can facilitate practitioners can help mothers while providing tional mastitis – ‘I have never felt worse’. Treatment of breast infection. mother-to-mother support (see Resource).5 Ultrasound can identify or exclude episodes of mastitis. women should be supported in their decision and pain and scarring and increased likelihood encouraged to wean gradually. A Early and frequent review As well as the severe physical pain. Pappagianis D. NBCC report: Evidence relevant to guidelines for the investigation of breast symptoms. Identification and drainage of breastfeeding women including telephone and breast abscess email counselling and helpful resources: There is no evidence of risk of harm to a healthy • Breastfeeding Helpline 1800 mum 2 mum (1800 infant feeding from an infected breast. Diagnostic value of signs and symptoms of mammary candidosis among lactating women. Psychological issues 3. Breast pain: engorgement.