5.6 Mastitis – treatment and complications

Key Points - Case Study E
Anna is seven days postpartum. She is unsure whether she can continue to breastfeed her baby, Joshua, because of sore and cracked nipples. The cracks have increased in size since they first developed and it is excruciating to feed Joshua. What is the most likely cause of Anna's sore nipple?
- Topic 5.1: Sore nipples
- Nipple tenderness is common in the first seven to ten days postpartum. Nipple cracks, grazes or significant pain indicates nipple trauma, usually associated with sub-optimal positioning and attachment.
What other conditions may contribute to nipple damage occurring in the first week postpartum?
- Topic 5.2: Factors causing nipple damage
- Other factors that cause nipple pain and damage in the first week postpartum are: engorgement; inverted nipples and other nipple variations; tongue-tie and palatial variations and abnormalities in the infant; infant neurological problems; inappropriate use of lactation aids; and high intra-oral pressure.
After careful assessment, it appears that sub-optimal positioning and attachment issues are the cause of Anna's sore and cracked nipples. What is the most appropriate treatment to offer Anna at this stage?
- Topic 5.3: General treatment for sore nipples
- The most important factor in the treatment of sore or cracked nipples is to ensure optimal attachment at all breastfeeds. There is no evidence that any particular topical treatment is effective in preventing or relieving nipple cracks or pain. Occasionally, breastfeeding needs to be suspended until the nipples begin to heal, with the mother expressing her milk and feeding it to her baby with a cup, spoon or bottle.
Anna returns in a week. While there has been some improvement, she is still troubled by nipple pain. What causes should you now consider?
- Topic 5.4: Further causes of nipple pain
- Nipple infection (Staph, thrush and herpes), vasospasm and other nipple conditions such as eczema and Paget's disease of the nipple can also cause nipple pain and nipple changes. These usually begin after the first week postpartum.
Anna's cracked nipples have some yellow exudate and appear inflamed. She is given a prescription for mupirocin; however, the next day she notices a firm, tender area in the upper inner aspect of her left breast that is gradually becoming more painful. She is beginning to feel unwell and has developed a fever. What is your diagnosis?
- Topic 5.5: Mastitis – diagnosis
- Mastitis is an inflammation in the breast, and in lactating women may cause breast pain, erythema, tenderness, heat and a lump as well as fever, rigors, myalgia and malaise. Predisposing factors include sore or cracked nipples, poor breast drainage, a past history of mastitis and maternal factors such as illness, stress or a depressed immune system.
What would be the appropriate treatment to give her now?
- Topic 5.6: Mastitis – treatment and complications
- Good breast drainage is an essential component of the treatment of mastitis. Antibiotics may be required, especially if the mother has moderate to severe local or systemic symptoms, that she has cracked nipples, or the symptoms have been present for more than 12 hours without improving. Recurrent infection, Candida and a breast abscess are complications of mastitis.
What would be the appropriate treatment to give her now?
Effective milk removal/breast drainage
As milk stasis is an important precursor for mastitis, good breast drainage is an essential component of treatment.

Clinical Note
This is not a time to wean.
- The infant should be encouraged to feed frequently (at least eight times a day) from the affected breast. Occasionally expressing by hand or pump is also required to drain the breast well.
- Frequent breast expression by hand or pump is required if the infant refuses the breast (milk often has higher sodium and chloride levels and lower lactose levels) or the mother finds it too painful to breastfeed.
- Correcting any positioning and attachment problems is integral to good breast drainage.
- Commence feeds on the affected side first unless it is too painful and change feeding positions to drain the breast well.
Analgesia
Paracetamol or anti-inflammatory medications such as Ibuprofen reduce local and systemic symptoms.
Antibiotics
Non-infective mastitis will resolve with good breast drainage and supportive measures. It is not possible to distinguish between non-infective and infective mastitis by symptoms and signs alone, therefore prescribing antibiotics initially is appropriate when:
- local symptoms are moderate to severe;
- systemic symptoms are moderate to severe;
- the woman has cracked nipples;
- symptoms have been present for more than 24 hours and are not improving.
The most appropriate antibiotics are:
- Penicillinase-resistant penicillins such as dicloxacillin or flucloxicillin 500mg qid; or cephalexin 500mg qid;
- Cephalexin 500mg qid for women with penicillin hypersensitivity;
- Clindamycin 450mg tds can be used if there is concern about immediate or severe penicillin allergy or there are indications of an unusual or severe infection 1 .
- Methicillin-resistant Staphyloccus Aureus is becoming a more common cause of mastitis and should be considered if the symptoms are unusual or are not responding to treatment 2 3 . Appropriate treatment will depend on local antibiotic sensitivities.
Supportive measures
- Bed rest.
- Gentle breast massage.
- Correcting underlying problems such as anaemia or constricting clothing.
- Adequate fluid and nutrition.
- Warm packs prior to a feed and cold packs following a feed may give symptomatic relief5.
The infant
Very few infants are affected adversely if their mother develops mastitis. There is no need to stop the infant feeding on the affected side, or to discard any milk expressed from that side, although as mentioned previously some infants will refuse the breast. The infant does not need to be treated at the same time as the mother. The antibiotics and anti-inflammatory medications mentioned are compatible with breastfeeding, although some infants may develop self-limiting diarrhoea due to maternal treatment5.
What complications may arise from mastitis?
Recurrent mastitis
Approximately 17-27 percent of women with mastitis have recurrent episodes. It is often thought to be due to inadequate or inappropriate treatment for the original episode of mastitis, or the persistence of predisposing causes such as chronic over-supply or ongoing nipple problems. Mid-stream milk leukocyte counts, culture and sensitivity and nasal swabs of mother and infant may provide useful information for ongoing management. Further antibiotic treatment for at least 10 days is indicated. Long-term low-dose antibiotic therapy may be appropriate for some women.
Candida infection
Described previously may be secondary to antibiotic use.
Occasionally, a woman with mastitis develops a breast abscess. What would predispose Anna to a breast abscess?
- Poor breast drainage during an episode of mastitis. These may be ongoing problems that predisposed to the development of mastitis in the first place (e.g. difficulties with positioning and attachment) or as a consequence of mastitis (e.g. weaning, infant refusing to breastfeed on the affected side, but the breast not being drained by expression).
- Antibiotic treatment that is inappropriate or for a short duration.
- A delay in seeking treatment for mastitis.
- Occasionally, abscesses develop rapidly despite appropriate treatment. Approximately 3 percent of women who are treated for mastitis develop a breast abscess6.
What symptoms or signs would make you suspect a breast abscess?
- A localised red, tender, indurated area that has not responded to antibiotic therapy.
- Symptoms may range from palpable lump and few local or systemic symptoms to an extremely ill woman with a red, erythematous breast and a localised area of increased induration.
- Fluctuant mass in a breastfeeding woman, particularly if she had recently been treated for mastitis.
How would you investigate a suspected breast abscess, and what would be the most appropriate treatment?
Ultrasound
Ultrasound is the investigation of choice. It will distinguish between ongoing inflammation, development of a fluid collection7 or other causes of breast inflammation such as inflammatory carcinoma.
Abscess drainage
- Fine needle aspiration biopsy (preferably under ultrasound control)
- This provides material for culture and sensitivity and in many cases provides definitive treatment. Depending on the size and shape of the abscess, recurrent aspiration may be required (8,9).
- Incision and drainage
- This is the most appropriate treatment in some cases, particularly if the abscess is large and is multiloculated (8,9).
Antibiotics
Antibiotics should be commenced immediately but may need to be changed based on gram stain and culture results when available. They should be continued until the abscess has resolved. MRSA breast abscesses are becoming more frequent10.

Case Study Activity
Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.
Notes
- # Therapeutic Guidelines Ltd (2003) Therapeutic guidelines: Antibiotics
- # Berens P et al. (2010) Incidence of methicillin-resistant Staphylococcus aureus in postpartum breast abscesses.
- # Stafford I et al. (2008) Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization.
- # World Health Organization WHO (2000) Mastitis: Causes and management
- # Amir LH (2008) Clinical Protocol # 4: Mastitis
- # Amir LH et al. (2004) Incidence of breast abscess in lactating women: report from an Australian cohort
- # Kamal RM et al. (2009) Classification of inflammatory breast disorders and step by step diagnosis.
- # Dener C et al. (2003) Breast abscesses in lactating women
- # Eryilmaz R et al. (2005) Management of lactational breast abscesses
- # Branch-Elliman W et al. (2012) Risk factors for Staphylococcus aureus postpartum breast abscess.
- # Marchant DJ (2002) Inflammation of the breast