II. Epidemiology

  1. Incidence: 9-33% of lactating women
  2. Most common in first few weeks and nearly all cases within first 3 months

III. Pathophysiology

  1. Generally occurs in Lactation several weeks postpartum
  2. Bacteria enter through a cracked nipple

V. Symptoms

  1. Fatigue
  2. Malaise
  3. Myalgias
  4. Headache

VI. Signs

  1. Fever
  2. Unilateral Breast inflammation
    1. Warmth
    2. Tenderness
    3. Erythema
  3. Observe for signs of Breast Abscess
    1. Requires needle aspiration

VII. Labs: Milk Culture

  1. Indications (not routine)
    1. Severe Mastitis
    2. Refractory despite optimal antibiotics for at least 48 hours
    3. Hospital acquired infection
  2. Technique
    1. Cleanse nipple
    2. Hand express small quantity of Breast Milk and discard
    3. Hand express a sample into a sterile container

VIII. Differential Diagnosis

  1. Inflammatory Breast Cancer

IX. Management: General Measures

  1. Tylenol or Ibuprofen
  2. Ensure adequate hydration
  3. Apply warm packs and local massage
  4. Alternate feeding positions
  5. Antifungals (Monilial Infection)
    1. Topical Antifungals on Breast
    2. Oral Nystatin for infant
  6. Continue with frequent Breastfeeding (except if Breast Abscess present)
    1. Risk of Breast Abscess if Breast engorgement occurs
    2. Ensure proper technique (see prevention below)
    3. Safe for infant to continue to feed despite infection with following exceptions
      1. Mother HIV positive
      2. Breast Abscess
        1. Discard Breast Milk for the first 24 hours on antibiotics
        2. Resume Breast Feeding after the first 24 hours on antibiotics

X. Management: Antibiotics

  1. Course: 10 to 14 days
  2. Coverage: Staphylococcus aureus (or as directed by culture)
  3. May observe localized Breast redness, tenderness without systemic symptoms or abscess for 24 hours
    1. For first 24 hours may use general measures above and hold antibiotics
    2. Start antibiotics by 24 hours if not improving, systemic symptoms, other risks
  4. Antibiotics: Nursing Mothers
    1. Amoxacillin-Clavulanate (Augmentin) 875 mg orally twice daily
    2. Cephalexin (Keflex) 500 mg orally four times daily
    3. Dicloxacillin 500 mg orally four times daily
    4. Clindamycin 300 mg orally four times daily (for MRSA)
  5. Antibiotics: Non-Breast Feeding women
    1. Trimethoprim-sulfamethoxazole (Septra) 160mg/800 mg orally twice daily (for MRSA)
      1. May be used in Lactation after first 2 months of life

XI. Management: Breast Abscess

  1. Obtain Bacterial culture
  2. Needle aspiration under Ultrasound guidance (preferred, 60% effective)
    1. Attempt to irrigate the abscess via the same needle used for aspiration
    2. May repeat up to 3 times if fails to resolve (then incise in drain if still refractory)
  3. Incision and Drainage
    1. Indicated in refractory cases (after 3 attempted needle aspirations)
    2. Also first-line measure in very superficial lesions, with skin thinning over the abscess
  4. References
    1. Sacchetti in Herbert (2016) EM:Rap 16(5): 1

XII. Follow-up

  1. Early antibiotics prevent abscess formation
  2. If not better in 48 hours examine Breast for abscess
    1. Consider Incision and Drainage

XIII. Prevention

  1. Optimal Breast Feeding Technique with good latch-on by infant
  2. Address predisposing factors early
    1. Sore nipples suggest problems
      1. Correct latch-on problems
      2. Address dry nipples with lanolin
      3. Avoid plastic-backed Breast pads
      4. Evaluate infant for anatomic problems (e.g. short frenulum, Cleft Palate)
    2. Cracked nipples colonized with Staphylococcus aureus should be treated
      1. Oral antibiotics (e.g. Dicloxacillin) are preferred
      2. Livingstone (1999) J Hum Lact 15:241-6 [PubMed]
    3. Blocked milk ducts should be unblocked
      1. Blocked ducts will appear with a bleb overlying a tender, red area adjacent to nipple
      2. Remove bleb with moist cloth
    4. Yeast infection should be treated (both infant and mother)
      1. Infant: See Thrush for management options
      2. Mother
        1. Topical agents: Nystatin or Ketoconazole
        2. Oral agents: Fluconazole 400 mg on day #1, then 200 mg orally daily for 10 days
        3. Chetwynd (2002) J Hum Lact 18:168-71 [PubMed]

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Related Studies

Ontology: Mastitis (C0024894)

Definition (MSH) INFLAMMATION of the BREAST, or MAMMARY GLAND.
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MSH D008413
SnomedCT 155952005, 155955007, 266644004, 198099006, 266641007, 45198002
French MASTITE, Inflammation du sein, INFLAMMATION DU SEIN, Mammite, Mastite
English BREAST INFLAMMATION, MASTITIS, Breast inflammation, Breast inflammation NOS, mastitis (diagnosis), mastitis, Mastitis [Disease/Finding], Mastitis, breasts inflammation, Breast inflammation NOS (disorder), Mammitis, Mastitis (disorder), breast; inflammation, inflammation; breast, Mastitis, NOS, Mastitis NOS
Portuguese MASTITE, Inflamação da mama, INFLAMACAO DA MAMA, Mamite, Mastite
Spanish MASTITIS, Inflamación mamaria, MAMA, INFLAMACION, inflamación mamaria, SAI, Breast inflammation NOS, inflamación mamaria, SAI (trastorno), Mamitis, mastitis (trastorno), mastitis, Mastitis
German MASTITIS, Brustentzuendung, BRUSTENTZUENDUNG, Mammitis, Mastitis
Japanese 乳腺炎, ニュウセンエン, 乳房炎症, ニュウボウエンショウ
Swedish Bröstkörtelinflammation
Dutch mastitis, borstontsteking, mammitis, mamma; ontsteking, ontsteking; mamma, Mastitis
Italian Infiammazione mammaria, Mammite, Mastite
Czech mastitida, Zánět prsu, Mastitida
Finnish Mastiitti
Russian MASTIT, МАСТИТ
Croatian MASTITIS
Polish Zapalenie sutka
Hungarian Emlő gyulladás, mastitis, Mammitis
Norwegian Brystkjertelbetennelse, Brystbetennelse, Mastitt

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Concepts Disease or Syndrome (T047)
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English BREAST ABSCESS, Breast abscess, Abscess breast, abscess breast, abscesses breast, breast abscess, Breast abscess (disorder), Abscess of breast, Abscess of breast (disorder), breast; abscess, abscess; breast, Abscess of breast, NOS
Italian Ascesso mammario, Ascesso della mammella
Dutch abces borst, abces; mamma, mamma; abces, borstabces
French Abcès au sein, ABCES DU SEIN, Abcès du sein
German Abszess der Brust, BRUSTDRUESENABSZESS, Brustdruesenabszess
Portuguese Abcesso mamário, ABCESSO DA MAMA, Abcesso da mama
Spanish Absceso de mama, ABSCESO MAMARIO, absceso de la mama (trastorno), absceso de la mama, absceso mamario, Absceso mamario
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Dutch postnatale mastitis, puerperale mastitis, Mastitis puerperalis, lactatie; mastitis, mammitis; puerperium, mastitis; lactatie, mastitis; puerperium, mastitis postpartum
French Mastite postnatale, Mastite puerpérale, Mastite du post-partum
German postnatale Mastitis, Mastitis puerperalis, Mastitis postpartum
Portuguese Mastite puerperal, Mastite pós-parto
Spanish Mastitis postnatal, Mastitis puerperal, mastitis puerperal, mastitis postparto, mastitis asociada con el parto, mastitis asociada con la lactancia (trastorno), mastitis asociada con la lactancia, mastitis asociada con el parto (trastorno), mastitis posparto, Mastitis postpartum
Japanese 産褥乳腺炎, サンジョクニュウセンエン
English puerperal mastitis, puerperal mastitis (diagnosis), Postnatal mastitis, Mastitis postpartum, Mastitis NOS associated with lactation, Puerperal mastitis NOS, Mastitis;puerperalis, Postpartum mastitis, Mastitis associated with lactation, Puerperal mastitis, Mastitis associated with breastfeeding, Mastitis, associated with childbirth, Mastitis, associated with childbirth (disorder), Mastitis associated with lactation (disorder), lactation; mastitis, mammitis; puerperal, mastitis; lactation, mastitis; puerperal, Mastitis, NOS, associated with childbirth, Postpartum mastitis, NOS, Puerperal mastitis, NOS, mastitis puerperalis
Czech Puerperální mastitida, Poporodní mastitida
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