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CME/CE

Recommendations Issued for Managing Mastitis in Mothers Breast-Feeding Their Infants

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Penny Murata, MD
  • CME/CE Released: 9/25/2008
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 9/25/2009, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, obstetricians, and other specialists who provide care to lactating women with mastitis.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Report risk factors for mastitis in lactating women.
  2. Describe the management of mastitis in lactating women.


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Author(s)

  • Laurie Barclay, MD

    is a freelance reviewer and writer for Medscape.

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor(s)

  • Brande Nicole Martin

    is the News CME editor for Medscape Medical News.

    Disclosures

    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Reviewer(s)

  • Laurie E Scudder, MS, NP-C

    Nurse Planner, Medscape; Adjunct Assistant Professor, School of Health Sciences, George Washington University, Washington, DC; Curriculum Coordinator, Nurse Practitioner Alternatives, Inc., Ellicott City; Nurse Practitioner, Baltimore City School-Based Health Centers, Baltimore, Maryland

    Disclosures

    Disclosure: Laurie Scudder, MS, NP-C, has disclosed no relevant financial information.

CME Author(s)

  • Penny Murata, MD

    Penny Murata, MD is a freelancer for Medscape.

    Disclosures

    Disclosure: Penny Murata, MD, has disclosed no relevant financial relationships.


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CME/CE

Recommendations Issued for Managing Mastitis in Mothers Breast-Feeding Their Infants

Authors: News Author: Laurie Barclay, MD CME Author: Penny Murata, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME/CE Released: 9/25/2008

Valid for credit through: 9/25/2009, 11:59 PM EST

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September 25, 2008 — Recommendations for diagnosing and treating mastitis in mothers who are breast-feeding their infants are reviewed in the September 15 issue of American Family Physician.

"Although [mastitis] can occur spontaneously or during lactation, this discussion is limited to mastitis in breastfeeding women, with mastitis defined clinically as localized, painful inflammation of the breast occurring in conjunction with flu-like symptoms (e.g., fever, malaise)," writes Jeanne P. Spencer, MD, from Conemaugh Memorial Medical Center in Johnstown, Pennsylvania. "Mastitis is especially problematic because it may lead to the discontinuation of breastfeeding, which provides optimal infant nutrition....To extend breastfeeding duration, family physicians must become more adept at helping mothers overcome breastfeeding difficulties such as mastitis."

The Healthy People 2010 goals for breast-feeding are that 75% of mothers start breast-feeding their infants, that 50% continue to 6 months, and that 25% continue to 12 months. However, most states failed to achieve these targets as of 2005. Mastitis, which occurs in approximately 10% of breast-feeding mothers in the United States, can cause mothers to stop breast-feeding.

Mastitis is usually diagnosed clinically from the characteristic presentation of focal tenderness in 1 breast, associated with fever and malaise.

To decrease the risk for mastitis, breast-feeding technique should be optimized, and the breast should be emptied frequently and completely. Mastitis may be triggered by sore nipples, which in turn may result from mechanical irritation from a poor latch, infant mouth anomalies including cleft palate, or bacterial or yeast infection.

Other risk factors for mastitis may include cracked nipples, local milk stasis, missed feeding, nipple piercing, use of plastic-backed breast pads, poor maternal nutrition, history of previous mastitis, primiparity, restriction from a tight bra, short frenulum in the infant, and/or use of a manual breast pump.

Blocked milk ducts, presenting as localized tenderness in the breast from inadequate milk removal from 1 duct, can also cause mastitis. A firm, red, tender area is typically present on the affected breast, often with a painful, white, 1-mm bleb on the nipple. It may be helpful to remove the bleb with a sterile needle or by rubbing with a cloth. Frequent breast-feeding, warm compresses or showers, massaging the affected area toward the nipple, and avoiding constrictive clothing may also help relieve blocked milk ducts.

A lactation consultant may assist in the treatment of mastitis by recommending changes in breast-feeding technique. When antibiotics are needed, dicloxacillin, cephalexin, or others effective against Staphylococcus aureus are preferred at present. With the increasing prevalence of methicillin-resistant S aureus, it is likely to be increasingly implicated as the underlying pathogen in mastitis, and antibiotics that are effective against methicillin-resistant S aureus may become preferred.

Oral antibiotics typically used for mastitis may include amoxicillin/clavulanate, 875 mg twice daily; cephalexin, 500 mg 4 times daily; ciprofloxacin, 500 mg twice daily; clindamycin, 300 mg 4 times daily; dicloxacillin, 500 mg 4 times daily; and trimethoprim/sulfamethoxazole, 160 mg/800 mg twice daily.

Ciprofloxacin, clindamycin, and trimethoprim/sulfamethoxazole are often effective against methicillin-resistant S aureus. However, trimethoprim/sulfamethoxazole should be avoided in women breast-feeding healthy infants aged 2 months or younger and compromised infants.

To prevent breast abscess, which is the most frequent complication of mastitis, clinicians should treat mastitis early and recommend continued breast-feeding, which typically presents no risk to the infant. The clinical presentation of a breast abscess is similar to that of mastitis except for the presence of a firm area in the breast, often with fluctuance. Ultrasonography can confirm the diagnosis of breast abscess.

Surgical drainage or needle aspiration, which may need to be repeated, is needed once an abscess develops. Fluid from the abscess should be cultured, and antibiotics should be prescribed. Breast-feeding can usually be continued in the presence of a treated abscess, unless the mother is severely ill or if the infant's mouth must occlude the open incision during breast-feeding.

In the presence of mastitis, vertical transmission of HIV from mother to infant is more likely. The World Health Organization recommends that women with HIV infection who are breast-feeding be educated on techniques to prevent mastitis and that those in whom mastitis does develop avoid breast-feeding from the affected breast until the mastitis resolves.

Key clinical recommendations for practice, all rated level of evidence C, are as follows:

  • In breast-feeding women with mastitis, optimizing lactation support is essential.
  • Although culturing breast milk is seldom required to diagnose mastitis, it should be considered in refractory and hospital-acquired cases.
  • For treatment of mastitis, antibiotics effective against S aureus are preferred.
  • In the presence of mastitis, breast-feeding usually does not pose a risk to the infant, and it should be continued to maintain milk supply.



"One of the most common complications of mastitis is the cessation of breastfeeding," Dr. Spencer concludes. "Mothers should be reminded of the many benefits of breastfeeding and encouraged to persevere....Because inflammatory breast cancer can resemble mastitis, this condition should be considered when the presentation is atypical or when the response to treatment is not as expected."

Dr. Spencer has disclosed no relevant financial relationships.

Am Fam Physician. 2008;78:727-731.

Clinical Context

Mastitis is localized erythema and tenderness of the breast in conjunction with fever, malaise, body aches, and headache. In the January 2002 issue of the American Journal of Epidemiology, Foxman and colleagues reported that the incidence of mastitis in the United States was 9.5%. A 2000 World Health Organization report noted that 75% to 95% of mastitis occurs before 3 months postpartum, most commonly during the second and third weeks.

This article describes the prevention, risk factors, diagnosis, treatment, and complications of mastitis in lactating women.

Study Highlights

  • Prevention of mastitis (based on limited data)
    • A study found that 1 breast-feeding counseling session did not significantly affect the incidence of mastitis.
    • Bedside hand disinfection by mothers in the postpartum unit reduces the incidence of mastitis.
  • Risk factors for mastitis
    • Infant mouth anomalies, including short frenulum, cleft lip, or cleft palate
    • Infant attachment difficulties
    • Missed feeding
    • Poor maternal nutrition
    • Previous mastitis
    • Manual breast pump
    • Possibly nipple piercing and primiparity
    • Sore nipples
    • Nipple fissures
    • Blocked milk ducts
    • Yeast infection
  • Sore nipples can be treated by lactation consultant counseling, discontinuation of plastic-backed breast pads, and application of expressed breast milk or lanolin to nipples.
  • Nipple fissures resolve more if treated with oral antibiotics vs breast-feeding education, topical mupirocin, or fusidic acid.
  • Blocked milk ducts often present as red, firm, tender areas with a painful, white, 1-mm bleb on the nipple and can be treated with removal by sterile needle, rubbing with a cloth, frequent breast-feeding, warm compresses or showers, massage, and avoidance of constrictive clothes.
  • Yeast infection, which might cause shooting pain from the nipple to the chest wall and oral thrush or diaper rash, must be treated in both mother and infant: topical nystatin or 1% gentian violet for infant and mother, topical miconazole or ketoconazole for mother, and oral fluconazole for severe cases in mother and infant.
  • Diagnosis of mastitis is based on clinical findings of localized breast tenderness and erythema with fever, malaise, fatigue, body aches, and headache.
  • Culture is recommended if mastitis is severe, unusual, hospital acquired, or unresponsive to antibiotics after 2 days, or if a high level of community bacterial resistance exists.
  • Treatment of mastitis
    • Improvement of breast-feeding technique, with the aid of lactation consultant
    • Adequate fluid intake
    • Adequate rest
    • Continuation of breast-feeding, unless infant dislikes milk from infected breast
    • Avoidance of breast-feeding in developing countries if mothers are HIV positive
    • Oral antibiotic treatment of S aureus (possibly methicillin-resistant) with amoxicillin/clavulanate, cephalexin, ciprofloxacin, clindamycin, dicloxacillin, or trimethoprim/sulfamethoxazole for 10 to 14 days
    • Consideration of treatment for rare causes including fungi, group A beta-hemolytic Streptococcus, Streptococcus pneumoniae, Escherichia coli, and Mycobacterium tuberculosis
  • Complications of mastitis include breast abscess or discontinuation of breast-feeding.
  • Management of breast abscess includes ultrasonographic confirmation, surgical drainage or needle aspiration, culture, antibiotics, and continuation of breast-feeding, unless the mother is severely ill or infant latches on at incision site.
  • Diagnosis of inflammatory breast cancer should be considered if atypical presentation or poor response to treatment.

Pearls for Practice

  • The risk factors for mastitis in lactating women include sore nipples, nipple fissures, blocked milk ducts, yeast infection, and infant mouth anomalies.
  • The management of mastitis in lactating women includes improvement of breast-feeding techniques, lactation consultant assistance, adequate fluid intake, adequate rest, antibiotic treatment of S aureus, and continued breast-feeding.

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