Mastitis - An evidence-based insight
Mastitis
“An inflammatory condition of the breast, which may or may not be accompanied by infection”.WHO 2000
At least two breast symptoms: Breast Pain, Lump, Redness
At least one systematic symptom: Fever, Flu like symptoms ( myalgia, headache etc.)
Pace et al. Nutrients 2022: clinical and subclinical mastitis - A clinical appraisal - “Participants were classified as having clinical mastitis based on the presence of one or more of the following signs/symptoms:
Diffuse redness/red streak on the breast
Clogged duct
Engorgement
Breast lump or tissue swelling
Breast and/or nipple pain
Breast soreness/tenderness
Chills/fevers accompanied by other sign/symptom(s)
Nipple pain without systemic symptoms is not mastitis
“Itis” = inflammation of an organ
Misdiagnosis of Herpes Simplex - which is localized to the nipple, and not the entire breast.
How many women experience mastitis? Most experiences occur in the first 4 weeks postpartum, and then decline from there. In a recent study, 17% of women (206/1193) experienced at least one episode the first 6 mo postpartum. (Amir et al. BMC public health 2007 - Amir PHD cohort study.)
Determinants of Mastitis in a study of 346 women found that 20% of women developed Mastitis in the first 8 weeks postpartum. Mastitis in the first 8 weeks was associated with:
Nipple damage
Oversupply of breast milk
Nipple shield use
Expressing several times a day
(Cullinane, Amir et al BMC Family Practice 2015)
Nipple trauma relating directly to Mastitis is underestimated, nipple pain will impact breastfeeding, and the frequency of feedings, perhaps even length of feedings. Barriers, pumps, manipulations of the breast seem to be associated with Mastitis.
A few other causes:
Oversupply
Missed feed/expression
Ineffective milk removal (baby unwell; ineffective pump/flange)
Pressure on the breast (tight bra, car seat belt, vigorous massage)
‘Autoimmune’ conditions such as fibromyalgia (sen et al. Can mastalgia be another somatic symptom in fibromyalgia syndrome? Clinics (Sao Paulo) 2015)
Mastitis is not a common cause of early breastfeeding cessation.
Common organism in infectious mastitis is Staphylococcus aureus, sometimes Streptococcus, E.coli, coagulase negative.
When cellulitis or bilateral mastitis is suspected (redness of tissue surrounding the nipple moving to the chest) it may be a Streptococci infection and should be seen by a practitioner. Rest is key, deep massage not recommended.
IF mastitis was the diagnosis, but has not resolved with antibiotics, the non - infective differential diagnosis should be explored. In rare cases this could be inflammatory breast cancer, inflammatory lymphoma or autoimmune conditions such as lupus mastitis.
The best evidence that can be obtained is from Randomized Controlled Trials and Systematic Reviews.
Pharmacologic management of mastitis:
Ibuprofen (preferred anti inflammatory) or Acetaminophen
Antibiotics may be required if systemic symptoms don't resolve within 24 hrs.
Continue feeding, rest, take the antibiotic only if symptoms don't resolve in 24 hrs.
Antibiotic Management:
“ If symptoms of mastitis are mild and have been present for less than 24 hrs., conservative management (effective milk removal, and supportive measures) may be sufficient. If symptoms are not improving within 12-24 hrs. or if the woman is acutely ill, antibiotics should be started.” (Amir, ABM Mastitis protocol, 2014)
“If the symptoms are mild, with recent onset or minimal or no fever, it is appropriate to consider conservative therapy for up to 24 hrs before initiating antibiotics”. (Radke Clin Obs Gynecol 2022)
“Many authorities recommend a 10-14 day course of antibiotics; however, this has not been subject to controlled trials. ABM clinical protocol (Amir, ABM Mastitis Protocol 2014)
IF symptoms of mastitis have improved within 5 days or so, a woman may choose to stop taking the antibiotic.
Non pharmacological measures for management/treatment of mastitis:
Continued milk removal - breastfeeding is best, and gentle expression after feeding, until breast has softened.
Supportive measures - Rest, adequate hydration, adequate nutrition, free breast (no bra, no shirt, no shield).
Gentle massage - whether culturally based (Japan, Russia) or physiological treatments. A gentle massage whilst breastfeeding of the tissue from armpit to breast. Similar to a lymphatic drainage massage.
Hot or cold therapy. Cold is great for inflammation, whereas warm is great for let down. Warm compress under the armpit is often helpful. A warm shower, with a light towel across the chest can sometimes be found soothing. Heat is not ongoing but before feedings, apply cold compresses afterward.
In the study, Arroyo et al (2010) Clin Infect Dis the aim was to compare the efficacy of using Lactobacilli ( a probiotic) to treat mastitis instead of antibiotic therapy. Women in the probiotic groups experienced less pain at day 21 and had less recurrence of mastitis than the antibiotic group. Total n = 352 (124,127 and 101) Women who stopped BF (n=9) were all in the antibiotic group. Women were assessed day 7, 14, 28.
A group of physiotherapists are hoping to begin trials for the treatment of engorgement by therapeutic ultrasound.
Continue to breastfeed during mastitis. This is very important.
Milk production drops during breast inflammation, but milk production will recover once the inflammation gets under control. Use cold compresses for reducing inflammation.
If one breast continues to be an issue, consider ‘retiring’ this breast and breastfeed on the good side.
A diagnostic ultrasound is recommended when a fluctuant breast mass is present, or if mastitis is not resolving within 2 days of antibiotics, and an abscess is suspected.
If a woman is hospitalized for mastitis, or breast abscess the investigation should include:
Breast milk culture and sensitivity
Full blood count
C-reactive protein
Diagnostic ultrasound
Abscess can be identified with a diagnostic ultrasound, drained by needle aspiration, or if that's unsuccessful open drainage. Breastfeeding can continue.
