Clinical practice

Lactational mastitis: recognition

and breastfeeding support
M
astitis is an inf lammatory condition
of the breast which may be infective
or non-infective. It is usually associ-
ated with lactation and the terms lactational
mastitis or puerperal mastitis are also used
(World Health Organization (WHO), 2000).
The incidence of lactational mastitis may reach
33% but is usually less than 10% (WHO, 2000).
Scott et al (2008) undertook a longitudinal study
of 420 breastfeeding women and found that 18%
experienced at least one episode of mastitis. Of
women who develop mastitis 20–25% will expe-
rience recurrent episodes (Vogel et al, 1999;
Scott et al, 2008). Mastitis usually occurs in the
second and third week postpartum with 74–95%
of cases occurring in the first 12  weeks post-
partum (WHO, 2000). However mastitis can
occur at any stage of lactation. The case study
in Box 1 illustrates how a woman may present
with mastitis.
Causes of mastitis
The WHO (2000) provides a comprehensive expla-
nation of the causes of mastitis in its publication
Mastitis – Causes and Management. A summary is
shown in Box 2.
Predisposing factors
The following have been identified as predis-
posing risk factors for the development of mastitis
(WHO, 2000):
Abstract
Mastitis is an inflammatory condition of the breast which may be
infective or non-infective. The incidence of lactational mastitis may reach
33% but is usually less than 10% (World Health Organization, 2000). A
number of predisposing causes have been identified. A case study has
been included and the discussion may assist the midwife in recognizing
and supporting the woman with lactational mastitis.
ll Age (21–35 years of age)
ll Parity (primiparity found to be a risk factor in
some studies but not in others (Fulton, 1945;
Evans and Head, 1995)
ll Previous history of mastitis
ll Birth complications
ll Poor micro-nutrient status
ll Lowered maternal defences (e.g. as a result of
stress and fatigue)
ll Employment outside the home.
ll Trauma.
Some studies have found that the risk of mastitis
is higher among women who have breastfed previ-
ously, especially if they had a previous history of
mastitis (Foxman et al, 2002; Wambach, 2003).
Riordan and Wambach (2009) suggest that this
finding contradicts the notion that mastitis results
from inexperience with breastfeeding and it is an
important point to discuss with mothers.
Plugged or blocked ducts are more common
in women with an abundant milk supply; they

Box 1 Case study

Teresa presented to the breastfeeding clinic 14 days postpartum. She was exclusively
breastfeeding her baby who had regained and surpassed her birth weight. A cracked
nipple on her left side was healing well and she had previously experienced pain-free
breastfeeding. On examination, the baby was positioned and attached well. Tereasa reported
that she had six wet nappies and four stools in the pervious 24 hours. The baby settled and
slept well between most feeds and was alert and active when awake. Teresa had generally
felt unwell 24 hours before presenting to the clinic with general aches and pains and feeling
hot and cold. Teresa looked pale and tired. The morning of her visit she had noticed the left
upper outer quadrant of her breast was red, hot, painful and swollen. Her temperature was
taken and found to be 38.5ºC. A diagnosis of mastitis was made and Tereasa was referred Maria Noonan
to her GP for assessment and antibiotics. She was given a follow-up appointment for the Midwifery Lecturer,
breastfeeding clinic. University of Limerick

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 Clinical practice
Box 2 Causes of mastitis
Milk stasis
Milk stasis occurs when milk is not removed from the breast efficiently and
provides a medium for bacterial growth. Causes of milk stasis include:
ll Inadequate attachment of the infant to the breast
ll Ineffective suckling
ll Restriction of the frequency or duration of breastfeeds
ll Blockage of milk ducts.
ll Milk oversupply.
Infection
Bacteria are often found in milk from breasts and its presence does not
necessarily cause or indicate infection. The most common organism
isolated in mastitis is Staphylococcus aureus. Other organisms found
include:
ll Staphylococcus Albus
ll Escherichia coli
ll Streptococcus.
A possible route of entry for infection is through the lactiferous ducts into a
lobe, through haematogenous spread and through a nipple fissure into the
periductal lymphatic system.
Source: WHO (2000)
signify inadequate milk removal and may
progress to mastitis (Riordan and Wambach,
2009). Abrupt weaning or sudden changes in
breastfeeding pattern, such as the baby sleeping
through the night, may cause engorgement and
plugging which can lead to mastitis (Mohrbacher
and Stock, 2003). Anecdotally, it has been
reported that ducts can become constricted or
obstructed from wearing a tight bra, sleeping in
a prone position, using a manual breast pump
and vigorous upper arm exercise (Riordan and
Wambach, 2009).
Poor attachment at the breast has been found
to lead to fissured or painful nipples which are
commonly associated with mastitis as a cracked
nipple provides an entry site for infection
(WHO, 2000). Poor attachment can also lead
to inadequate milk removal because the mother
may avoid completely emptying the breast on
the painful side (Lawerence and Lawerence,
2005). The nipple may become colonized with
Staphyloccus aureus from the mother’s own
nasal or skin f lora or from a hospital source
(Betzold, 2007).
Mastitis from sore, cracked nipples usually
presents in the first weeks postpartum (Riordan and
Wambach, 2009). In the case study, Teresa reported
a history of a cracked nipple, which may have
predisposed her to the development of mastitis.
It is important for midwives to observe a woman
504
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breastfeeding when she presents with mastitis to
check for correct positioning and attachment.
Signs and symptoms of mastitis
Flu-like symptoms are often the first symptoms
experienced by the mother. Cadwell et al (2006)
use the maxim ‘flu in a nursing mother is mastitis
until proven otherwise’ because they have found
that new mothers suddenly feel ill but do not
necessarily have symptoms that would guide them
to examine their breasts for signs of mastitis (such
as redness or lumps). In the case study, Teresa had
felt generally unwell with flu-like symptoms before
she identified breast symptoms. The following
symptoms are common in mastitis (Lawerence and
Lawerence, 2005; Smith and Heads, 2007):
ll Breasts are red, tender and hot
ll A swollen wedge-shaped area of breast may be
felt
ll An elevated temperature of ≥38ºC
ll Body aches
ll Headaches
ll Chills
ll Nausea and vomiting.
The upper, outer quadrant of the breast is the
most common site for mastitis to occur because
most of the breast tissue is located there with both
the right and left breasts being equally affected
(Riordan and Wambach, 2009). Blood and pus
may be present in the mother’s milk and an infant
may refuse the affected breast if the mother has
mastitis because the breastmilk may taste salty
owing to elevated sodium and chloride levels.
Elevated levels of sodium and chloride are caused
by the temporary opening of the normally tight
junctions between secretory cells in the paracel-
lular pathways (Riordan and Wambach, 2009).
One of the difficulties in diagnosing mastitis
is differentiating infectious mastitis from non-
infectious mastitis and common lactational breast
complaints (such as engorgement, plugged or
blocked ducts (Betzold, 2007)). Although an
absence of fever generally indicates a blocked duct
mastitis may occur without fever (Newman and
Pitman, 2006). Inflammation around the blocked
duct may result in fever. With mastitis the mother
will have more flu-like symptoms associated with
the fever >38.4ºC and the redness of the breast
is often redder, hotter and more painful with a
sudden onset of symptoms (Newman and Pitman,
2006). Infectious mastitis is more likely to persist
for greater than 24 hours (Betzold, 2007).
Treatment of mastitis
The treatment of mastitis involves supportive
counselling, effective milk removal, antibiotic
British Journal of Midwifery • August 2010 • Vol 18, No 8

therapy and symptomatic treatment (WHO,
2000). Antibiotics treat the infection but they
do not treat the underlying cause of mastitis.
Failure to identify an underlying cause can lead
to recurrent mastitis (Smith and Heads, 2007).
Because milk stasis is the primary contributor
to both infective and non-infective mastitis, a
lactation history is crucial in determining the
underlying cause. In Teresa’s case, the finding of a
history of cracked nipples may have predisposed
her to the development of mastitis. The primary
cause of cracked, sore nipples is poor positioning
and attachment which leads to inadequate milk
transfer and nipple trauma.
A feeding assessment should be under-
taken to ensure optimal attachment and milk
transfer. A breastfeed should be observed to
look for signs of correct positioning and attach-
ment. This can be overlooked if the assessment
concentrates on the mastitis. Teresa’s baby had
good output and weight gain which indicates
sufficient milk intake.
Effective milk removal is the most essential part
of treatment (WHO, 2000) so a midwife should
support the woman to improve her baby’s attach-
ment at the breast if necessary and encourage
frequent breastfeeding on both sides at least 8–12
times in a 24-hour period. The breastfeed should
begin on the affected side unless the breast is so
painful that latch is impossible. Babies often suck
more vigorously and effectively on the first side,
which would help to empty the breast.
If pain prohibits the let down reflex then it
could be suggestedto the mother that she begins
feeding on the unaffected breast, switching to the
affected breast once let down occurs. Massaging
the breast, from the blocked area moving outward
toward the nipple, during the feed may augment
milk drainage. The midwife can show the mother
alternative positions to help relieve a plugged
duct, for example, the football (clutch hold) or
the hands and knees (leaning over) position. This
involves the mother positioned on her hands and
knees in a leaning over position with the baby
lying on his or her back beneath her (Both and
Frischknecht 2008). The midwife must ensure that
the baby is attached correctly on all the positions
the mother uses (Mohrbacher and Stock, 2003).
It is important that the baby is positioned at the
breast so that his nose or chin points toward the plug
(Riordan and Wambach, 2009). Hand expression
or pumping may be necessary after the breastfeed
if the infant has not adequately drained the breast
(Betzold, 2007). If breastfeeding is too painful the
woman may have to express breast-milk by hand or
pump until breastfeeding can be resumed.
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Clinical practice
SCIENCEPHOTOLIBRARY
Breasts affected by mastitis are often red, tender and hot
A concern expressed by some health profes-
sionals relates to the possible risk of infection to
the baby, especially if the milk appears to contain
pus. Scott et al (2008) found that a clinically
significant number of women in their study were
advised to stop breastfeeding from the affected
breast or to stop breastfeeding altogether. This
inappropriate advice deprives the woman and her
baby of the nutritional and immunological bene-
fits of breast milk and may result in prolongation
of the episode of mastitis and to a greater risk of
abscess development (Scott et al, 2008).
The midwife needs to inform the woman that it
is safe to continue to breastfeed from the affected
side and to explain why it is so important to empty
the affected breast to prevent milk stasis and
progression of the inflammation and infection
and relapse. Effective removal of milk will reduce
pain for the mother and promote faster resolution
of the episode of mastitis. Breastfeeding is consid-
ered generally safe in the healthy term infant even
in the presence of Staphyloccus aureus (WHO,
2000). Higher levels of some selected components
are present in breastmilk during a breast infec-
tion and may protect the baby from any ill effects
of consuming mastitic milk (Buescher and Hair,
2001)but the baby should be observed for signs of
infection (Betzold, 2007).
Symptomatic treatment
An appropriate analgesic should be recommended
to treat the pain associated with mastitis. A non-
steroidal anti-inflammatory such as Ibuprofen
reduces inflammation and pain, which may help
with the milk ejection reflex and is considered the
505
 ‘
Clinical practice
Women may
request an alternative
treatment to antibiotics
because they are
perceived as likely
to cause harmful
’
and undesirable side
effects.
most effective choice (Academy of Breastfeeding
Medicine (ABM), 2008). Paracetamol may also be
recommended.
The woman is advised to rest as much as is
possible (WHO, 2000). External supports such
as family and friends are involved. They can help
by providing fluids for the woman, ensuring she
has nutritious meals to eat, preparing her hot
compresses and taking care of the baby. Rest
promotes recovery of the woman and resting
near the baby is a useful way of increasing the
frequency of breastfeeds and, thus, milk removal
(WHO, 2000).
The application of warm packs to the affected
breast relieves pain, fights off infection and
promotes milk flow (WHO, 2000). Local heat
should not be too hot or applied for too long so as
to cause damage to the skin. Warm, moist packs
or cold/cabbage compresses, depending on the
woman’s preference, may be used between feeds
(Smith and Heads, 2007). Cold packs applied to
the breast reduce pain and oedema. Other meas-
ures suggested include immersing the affected
breast in warm water before breastfeeding, using
gravity by lying in a bath of hot water with the
affected breast hanging, feeding in a hands-and-
knees position (Smith and Heads, 2007). The
mother can massage the affected side while it is
warm and hand express some milk immediately
after to promote milk flow and help unplug the
affected duct. Midwives can suggest the mother
loosens constrictive clothing, especially her bra.
The woman may benefit from not wearing a bra for
a few days or, alternatively, wear a bra that is a size
larger (Morhbacher and Stock, 2003).
Complementary therapy
Women may request an alternative treatment
to antibiotics because they are perceived as
likely to cause harmful and undesirable side
effects. Complementary therapies, such as
506
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herbal homeopathy treatments e.g. Phytolacca
have been used with various successes for the
treatment of lactational mastitis (Castro, 1999).
A woman should only be referred to a licensed
practitioner with experience in treating women
with mastitis.
Antibiotic therapy
Supportive treatment and the maternal immune
response may clear the infection. However, if
there is no improvement of the symptoms within
12–24  hours of improved breast drainage, then
referral of the woman to her GP for antibiotic
treatment is necessary (ABM, 2008). Referral is
also indicated if the woman’s symptoms are severe
from the beginning or worsen, if the woman
has multiple risk factors such as bilateral nipple
damage, previous history of mastitis, or if cell and
bacterial colony counts and culture are available
and indicate infection (WHO, 2000).
The bacteriological analysis of breastmilk is
not routinely practised. Women are prescribed
antibiotics based on the severity and duration of
symptoms (Scott et al, 2008). Bacteriological anal-
ysis of breastmilk is not a reliable laboratory test,
with low bacterial counts common even when
pathogens are cultured from breastmilk (Betzold,
2007; Kvist et al, 2008).
Penicillinase-resistant penicillin, e.g. flucloxa-
cillin and dicloxacillin, which are effective against
Staphyloccus aureus for 10–14 days are the anti-
biotics of choice in the treatment of mastitis
(ABM, 2008). Cepahalexin and Clindamycin are
prescribed for women allergic to penicillin. Scott
et al (2008) found that of the woman in their
study who could recall the antibiotic they were
prescribed (n=20), almost half were prescribed
an antibiotic that was not consistent with current
practice recommendations.
The midwife needs to ensure that the woman
is prescribed and receives an appropriate length
of antibiotic treatment to prevent recurrence and
abscess formation. Lawerence and Lawerence
(2005) suggest that the antibiotic should be given
for at least 10–14  days, which is consistent with
the treatment recommendations for bacterial
infections for most other large organs (Betzold,
2007). This has not been subjected to controlled
trials however.
Jahanfar et al (2009) undertook a review of
antibiotics for mastitis in breastfeeding women
and concluded that there was limited evidence
on the effectiveness of antibiotic therapy for the
treatment of lactational mastitis and suggested
the urgent need for further research. Symptoms
of mastitis decrease within 24  hours of starting
British Journal of Midwifery • August 2010 • Vol 18, No 8

antibiotics with complete resolution of symptoms
within 3–5 days (Newman and Pitman, 2006). If
the mastitis has not completely resolved within
5  days after starting antibiotics the woman is
advised to see her GP to out rule an abscess, to
send a sample of breastmilk for bacteriological
analysis and/or change antibiotics. Mastitis-
causing staphylococcal strains have become
resistant to methicillin and other antibiotics and
this is one of the reasons for recurrence and the
development of chronic mastitis (ABM, 2008).
The appropriate use of antibiotics is essential
to prevent the development of MRSA and other
multi-resistant pathogens (Kvist et al, 2008). It
is worth noting, however, that the use of anti-
biotics in a lactating woman may result in the
development of candida infection (Riordan and
Wambach, 2009).
Adequate support
Mastitis is a painful and debilitating experi-
ence and the woman may feel very ill, lethargic
and emotional. It is crucial that the midwife
supports the woman emotionally, in addition to
providing accurate and consistent information
on mastitis and its treatment. In their grounded
theory study of Swedish women’s experiences of
inflammatory symptoms of the breast during
breastfeeding, Kvist et al (2006) reported that
the availability of professional care and infor-
mation was of great importance to the women
in their study. The occurrence of mastitis can
be frustrating and disappointing for the woman
particularly when it occurs after earlier prob-
lems have been resolved and breastfeeding has
been going well. For the woman it may represent
a step backwards and be accompanied by feel-
ings of failure. It is important that the woman
receives follow-up support and guidance until
she has recovered fully. In the case study, Tereasa
was referred to her GP but also given an appoint-
ment to return to the breastfeeding clinic when
she had recovered.
Outcomes and recurrence
When a woman receives timely, appropriate and
consistent clinical care and emotional support,
she should make a complete recovery and
continue with exclusive breastfeeding. However,
delayed, inappropriate or inadequate manage-
ment of mastitis may result in recurrence, more
extensive lesions, permanent tissue damage and
early discontinuation of breastfeeding (WHO,
2000). Recurrent episodes of mastitis may result
in chronic inflammation, and irreversible distor-
tion of the breast (WHO, 2000). The mother’s
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Clinical practice
supply of milk may also be diminished for
several weeks following mastitis (Riordan and
Wambach, 2009).
Recurrence of mastitis is common suggesting
that certain women are prone to the condition
(Riordan and Wambach, 2009). A full review of
the factors that preceded and may have predis-
posed the woman to the mastitis is essential. For
example, a mother may not appreciate the role
stress plays in reducing immunity and there-
fore increasing her susceptability to developing
mastitis. Identifying ways of reducing stressful
events may prevent reoccurrence (Mohrbacher
and Stock, 2003). When a lactating woman expe-
riences recurrent mastitis that does not respond
to antibiotic treatment, the woman must be
referred for further investigations so that inflam-
matory carcinoma can be ruled out (Riordan and
Wambach, 2009).
Prevention
Mastitis and its complications are largely
preventable with appropriate management of
breastfeeding to prevent situations such as
engorgement, blocked duct and nipple soreness
leading to milk stasis. Skin-to-skin contact after
birth promotes the normal process of bacterial
colonization of the infant and breast (Hanson,
2004; Smith 2010). A mother in skin-to-skin
contact with her infant immediately after birth
transfers to her infant her own strain of respi-
ratory and skin organisms, which then grow
and populate the infant’s gut, skin and respi-
ratory tract. The establishment of a f lora of
commensal organisms inhibits the growth of
pathogenic bacteria. (WHO, 2000).
Effective breastfeeding management is essential
for the prevention of mastitis and includes (Smith
and Heads, 2007):
ll Initiation of breastfeeding within the first hour
of birth
ll Correct positioning and attachment
ll Baby-led breastfeeding
ll Finishing the first breast before offering the
second
ll Rooming in to promote the prompt recognition
of infant feeding cues
ll Frequesnt draining of the breasts helps to
prevents the spread of organisms responsible
for mastitis (WHO, 2000)
ll Exclusive breastfeeding for the first 6 months.
The use of a pacifier, giving supplements of
formula or taking a baby off the first breast
prematurely may interfere with breastfeeding,
limit or reduce the amount that an infant suckles
and increase the risk of milk stasis (WHO, 2000).
507
 Clinical practice
The midwife has an important role in teaching
mothers to check for signs of milk stasis (such
as lumps, pain, redness) and, if present to rest,
increase the frequency of breastfeeding, apply
heat and massage any lumps present. Education
should also include early signs and symptoms of
mastitis and common predisposing factors as well
as when to contact health professionals (Smith
and Heads, 2007).
Conclusion
Mastitis is a common and preventable condition.
Inefficient milk removal and bacterial infec-
tion are the primary causes of mastitis. Mastitis
varies in severity, ranging from mild symptoms
of local inflammation, through to the more
serious symptoms of fever, abscess and septi-
caemia. Early, unnecessary weaning may also
result if the woman does not get adequate treat-
ment and support (WHO, 2000; Scott et al, 2008).
Midwives have a key role to play in the preven-
tion of mastitis and providing appropriate and
adequate support to the mother who develops
mastitis. A detailed history and observation of
breastfeeding are essential components of the
support provided to identify the underlying cause
and avoid premature weaning and inappropriate
antibiotic therapy. BJM
Academy of Breastfeeding Medicine (2008) ABM
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Buescher ES, Hair PS (2001) Human milk anti-inf lam-
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Key points
ll Frequent and effective milk removal is the most essential part of
treatment.
ll A breastfeeding assessment to identify and remedy the cause or
precipitating factors of the mastitis is an important management step.
ll Antibiotics are currently recommended for 10–14 days to treat infec-
tious mastitis and prevent recurrence and complications.
ll Optimal support and treatment will assist the woman to continue
breastfeeding.
ll Information on signs of milk stasis and steps to resolve same should
continue to form part of the postnatal advice provided to women who
are breastfeeding.
508
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