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Mastitis causes a woman’s breast to become painful, inflamed and often red. It usually occurs within the first three months after giving birth.

About

• Mastitis is a painful inflammatory condition of the breast which may or may not be accompanied by infection.
• A breast abscess is a localised collection of pus within the breast that may be a complication of mastitis.

Aetiology

• Usually associated with lactation where milk stasis causes an inflammatory response in the breast tissue. Sometimes infection with bacteria (most commonly staph aureus) may occur.
• In non-lactating women, mastitis is usually accompanied by infection. Often no underlying cause found but can be associated with damage to subareolar ducts, diabetes mellitus, rheumatoid arthritis, corticosteroid treatment, and granulomatous mastitis.
• In non-lactating women, common pathogens are S. aureus, enterococci, and anaerobic bacteria (such as Bacteroides and anaerobic streptococci).
• Consider MRSA if Recent hospitalization, Recent surgery, Haemodialysis, HIV infection, Injection drug use and/or sharing needles, Prior antibiotic use, History of MRSA infection or colonization

Clinical

• Mastitis: painful breast, fever >38.5° C (101.3° F) /general malaise, a tender, red, swollen, and hard area of the breast, often in a wedge-shaped distribution.
• Breast abscess: recent mastitis, a painful, swollen lump in the breast, with localised redness, heat, swelling, fever and/or general malaise.
• Inflammatory breast cancer is uncommon but has symptoms that are a lot like mastitis and can be mistaken for an infection. Check for lymph nodes and nipple discharge and skin changes. It is important to follow up and ensure full resolution. If not then referral to the breast clinic.

Diagram

Investigations

• Pregnancy test may be needed
• Send breast milk for culture in case of first line antibiotic failure.
• Breast ultrasound to identify collection of pus
• Mammogram if malignancy concerns

Management

• Improved breastfeeding practices, including early skin-to-skin contact between mother and infant, rooming-in, skilled help to ensure that an infant is well attached at the breast, and unrestricted and exclusive breastfeeding, are an efficient way to prevent both milk stasis and spread of infection.
• Most cases of mastitis can be treated as outpatients, if haemodynamically stable. Offer reassurance that the breast should return to normal following appropriate treatment.
• Offer relief for pain and discomfort, such as the use of simple analgesics and advise applying a warm compress to the breast.
• In the past, suppression of lactation was often included in the management of engorgement and mastitis. Now, maintenance of lactation is preferred. Encourage breastfeeding women to continue feeding if possible, including from the affected breast, to prevent ongoing milk stasis.
• Identify and manage predisposing factors for mastitis, including poor infant attachment, nipple damage, smoking, and/or an underlying breast abnormality.
• Prescribe oral antibiotics if indicated. Usually, flucloxacillin first-line or erythromycin if penicillin-allergic. Consult local guidelines.
• Offer appropriate advice on measures to prevent a recurrence, such as encouraging good breastfeeding techniques and maintaining good hygiene.
• If breast abscess is suspected, refer to general surgery for management. This may involve Surgical drainage or needle aspiration needed with culture and antibiotics. Drainage may be by ultrasound-guided needle aspiration.
• Inflammatory breast cancer has symptoms that are a lot like mastitis and can be mistaken for an infection. If the mastitis does not resolve then refer to the breast clinic.
• HIV positive and Breastfeeding: Mastitis causes the amount of virus in breast milk to increase. If you develop mastitis, do not breastfeed your baby. The safest thing you can do if you develop mastitis is to stop breastfeeding and change to formula milk. Express and throw away milk regularly from both breasts

References

• NICE guidance
• Legal case where mastitis diagnosed and breast cancer diagnosis delayed but no medical liability
• Mastitis Causes and Management
• Patient information leaflet on Mastitis and Breastfeeding
• HIV and breastfeeding your baby