Information
Lactation mastitis is an inflammatory condition of the breast, which may or may not be accompanied by infection. Breast abscess, a localised collection of pus within the breast, and sepsis are severe complications of mastitis. Mastitis is usually associated with lactation but can also occur in non-lactating women. The incidence of lactation mastitis is reported to be between 10% to 33% of breastfeeding women; it is most common within the first 2-3 weeks postpartum. Abscess is reported to occur in 3% to 11% of women with mastitis; it is most common during the first six weeks postpartum.
The primary cause of mastitis is milk stasis whereby the accumulated milk causes an inflammatory response which may progress to infection. The most common infective organism is Staphylococcus aureus (including MRSA). Other organisms involved may include Streptococcus groups A and B, Escherichia coli and anaerobes: Bacteroides species. Lactation mastitis and breast abscess are largely preventable if breastfeeding issues such as engorgement, blocked duct or sore nipples are managed appropriately and promptly from the beginning to prevent milk stasis. When treated appropriately women will make a rapid and complete recovery.
Referral hospitals in Lothian – management of lactation mastitis Postnatal women
• Up to 6 weeks postnatal – refer to St John’s or Royal Infirmary hospitals
• Beyond 6 weeks postnatal – refer to Breast Unit at Western General Hospital
Simpson Centre for Reproductive Health, Edinburgh (0131 536 1000)
• Phone switchboard and bleep on call Obstetric Registrar,
• Phone Triage & Assessment Dept (0131 242 2657)
Western General Hospital, Edinburgh (0131 537 1000)
• Phone switchboard and bleep on-call Registrar for Breast Unit (24 hr service)
• If no success, contact the Consultant Breast Surgeon on call:
• Mon-Fri, 8.30-4.30, phone the Breast Unit directly on 0131 537 1031 • Outside normal hours, ask switchboard to bleep him/her
St John’s Hospital, Livingston (01506 523 000)
• There is a Breast Surgeon in the hospital Monday pm and Wed – Fri all day
• Contact him/her via
• Breast Care Nurse (01506 524 047 or ext. 54047)
• Breast Secretary (01506 524 030 or ext. 54030)
• Out of hours, phone Western General Hospital & ask for Consultant Breast Surgeon on call.
Microbiologists – Royal Infirmary of Edinburgh / St. John’s hospital
• RIE on 0131 536 3373 during “office hours”
• via hospital switchboard 0131 536 1000
Specialist Breastfeeding support:
• Simpsons Centre for Reproductive health:
o 0131 2422490 / 07815702732/ 07872420986
• St John’s Hospital: o 01506 524010/ 07872420986
Signs and symptoms of mastitis:
· A localised area of tenderness, erythema, firmness and or swelling in the breast.
· Pyrexia and/or flu-like symptoms
Suspect a breast abscess if:
· There is a history of recurrent mastitis
· A palpable swollen, fluctuant lump within the breast which is warm and tender to touch with red discolouration of the skin
· Fever/general malaise
Consider referral in the following postnatal women:
• Mother is very unwell / has signs of sepsis
• The infection is progressing rapidly
• The woman is haemodynamically unstable
• An abscess is suspected
• An episode of mastitis does not settle with one course of antibiotics
• A second episode of mastitis occurs
• MRSA is suspected (seek advice from microbiologist at RIE on 0131 5363373 during “office hours” or via hospital switchboard 0131 536 1000).
Prevention of engorgement:
• Good positioning and attachment technique
• Unrestricted feeding
• Help with feeding & expressing if baby not yet feeding effectively
• If breasts become overfull at any time, mother should always express enough milk to soften the breasts until she is comfortable – it is not necessary to empty the breasts.
Management of engorgement:
Feed baby and/or express to empty both breasts every 3-4 hours until breasts are comfortable – then follow prevention of engorgement advice above. If not able to empty breasts, mother should seek help urgently from her
• Midwife
• Health Visitor/ Family Nurse Partnership (FNP)
• Local Breastfeeding Support Group
• Specialist Breastfeeding Service
Supportive care and measures which help milk to flow: (to promote effective milk removal)
• Warm shower or bath, warm compresses
• Breast massage/stroking to trigger milk let-down
• Hand expressing may cause less trauma to a tender breast than using a pump
• Non-steroidal anti-inflammatory medication may help reduce swelling and allow milk to flow more readily (e.g. ibuprofen 400 mg orally 6-8 hourly initially, then 8 hourly as required once pain and localised swelling improves)
• Between feeds, cool compresses may provide comfort.
Management of lactation mastitis in primary care:
In an early stage, when signs and symptoms of mastitis have been present for less than 12 to 24 hours, it may be possible to manage the condition without antibiotics as follows:
1 Feed (baby)
2 Rest (mother)
3 Empty the breast: by feeding and/or expressing at least 6 times in 24 hours if mother unable to empty breasts well, she should seek help urgently (see management of engorgement)
There should be a low threshold for using antibiotics where infection is suspected after 12-24hrs. Breastfeeding should continue frequently (e.g. breastfeeding 8 to 12 times per day) to promote effective milk removal. If these measures do not result in an improvement in symptoms within 24 hours, or if symptoms are severe or if there are any signs of systemic infection continue 1,2 & 3 (as per above) and start antibiotics as follows:
Antibiotic treatment in primary care
Appropriate antibiotics should be given early to reduce the risk of abscess formation. Antibiotic therapy is based initially on likely pathogens. In cases of failure of initial treatment or where complications arise, cultures may be indicated, and treatment may have to be altered depending on the specific pathogens isolated and corresponding antibiotic susceptibilities.
• First line – Flucloxacillin 500 mg orally 4 times a day
• Second line – Co-amoxiclav 625mg orally 3 times a day
Penicillin allergy:
• Mild allergy: Cephalexin 500mg orally 4 times a day
• Severe allergy: anaphylaxis • First line – Clindamycin 300-450mg orally 4 times a day.Caution is required due to the risk of developing Clostridioides difficile infection.
• Second line- Erythromycin 500mg orally 4 times per day. Treatment course: 10 to 14 days.
Infections should begin to respond within 48 hours. If the infection is worsening despite oral antibiotics then seek help from obstetricians, breast unit surgeons or microbiologist. If the patient is not improving, consider sending breast milk for culture and antibiotic sensitivity. Send a swab of the breast and a MRSA screen if there are risk factors for MRSA infection.
Safety of continuing to breastfeed:
• Mother – stopping breastfeeding during an attack of mastitis does not help the mother recover and on the contrary, there is a risk that it can make her condition worse. Regular emptying of the breast by feeding and/or expressing is essential to promote rapid recovery. Mothers who wish to stop lactating can be safely helped to do so once the mastitis is resolved.
• Baby – continuing to breastfeed is generally safe, even in the presence of S. aureus.
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National Institute for Health and Care Excellence. Mastitis and breast abscess. January 2021.
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BMJ Best practice (2020) Mastitis and breast abscess. London BMJ Publishing Group
