para>TMP/SMX given to breastfeeding mothers with mastitis can potentiate jaundice for neonates.
Second Line
- If mastitis is odoriferous and localized under areola, add metronidazole 500 mg TID IV or PO.
- If yeast is suspected in recurrent mastitis, add topical and oral nystatin.
ISSUES FOR REFERRAL
- Abscess formation
- Need for breast biopsy
ADDITIONAL THERAPIES
- Warm packs to improve blood flow and milk let down and/or ice packs to reduce inflammation to affected breast for comfort
- The use of a breast pump may aid in breast emptying, especially if the infant is unable to assist in doing this.
- Wear supporting bra that is not too tight.
SURGERY/OTHER PROCEDURES
In cases of biopsy-proven idiopathic granulomatous mastitis, surgical removal can result in a 5 " 50% chance of recurrence, fistula formation, and poor wound healing.
INPATIENT CONSIDERATIONS
If a new mother is admitted to the hospital for treatment of her mastitis, rooming-in of the infant with the mother is mandatory so that breastfeeding can continue (4)[C]. In some hospitals, rooming-in may require hospital admission of the infant.
Admission Criteria/Initial Stabilization
- Failure of outpatient/oral therapy
- Patient unable to tolerate oral therapy
- Patient noncompliant with oral therapy
- Severe illness without adequate supportive care at home
- Neonatal mastitis
- Antibiotics
- Frequent emptying of breasts, if breastfeeding
- Analgesics for pain
Nursing
- Breastfeeding/pumping of breasts encouraged
- Start infant with feedings on affected side.
- Abscess drainage is not a contraindication for breastfeeding.
- Massage in direction from blocked area toward nipple.
- Positioning infant at breast with chin or nose pointing to blockage will help drain affected area.
Discharge Criteria
- Afebrile
- Tolerating oral antibiotics well
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Rest for lactating mothers, up to bathroom
DIET
- Encourage oral fluids.
- Multivitamin, including vitamin A
PATIENT EDUCATION
- Encourage oral fluids.
- Rest is essential
- Regular emptying of both breasts with breastfeeding
- Nipple care to prevent fissures
PROGNOSIS
- Puerperal
- Good with prompt (within 24 hours of symptom onset) antibiotic treatment and breast emptying; 96% success rate
- 11% risk of abscess if left untreated with antibiotics
- Antibodies develop in breast glands within first few days of infection, which may provide protection against infection or reinfection.
- Rare risk of abscess formation beyond 6 weeks postpartum if no recurrent mastitis
COMPLICATIONS
- Breast abscess 3% of women with puerperal mastitis
- Recurrent mastitis with resumption of breastfeeding or with breastfeeding after next pregnancy
- Bacteremia
- Sepsis
REFERENCES
11 Crepinsek MA, Crowe L, Michener K, et al. Interventions for preventing mastitis after childbirth. Cochrane Database Syst Rev. 2012;(10):CD007239.22 Buck ML, Amir LH, Cullinane M, et al. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeeding Med. 2014;9(2):56 " 62.33 Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women. Cochrane Database Syst Rev. 2013;(2):CD005458.44 Amir LH. ABM clinical protocol #4: mastitis, revised March 2014. Breastfeed Med. 2014;9(5):239 " 243.55 Sheybani F, Sarvghad MR, Naderi HR, et al. Treatment for and clinical characteristics of granulomatous mastitis. Obstet Gynecol. 2015;125(4):801 " 807.
ADDITIONAL READING
Spencer JP. Management of mastitis in breastfeeding women. Am Fam Physician. 2008;78(6):727 " 731.
SEE ALSO
Algorithms: Breast Discharge; Breast Pain
CODES
ICD10
- N61 Inflammatory disorders of breast
- O91.22 Nonpurulent mastitis associated with the puerperium
- O91.23 Nonpurulent mastitis associated with lactation
- N60.19 Diffuse cystic mastopathy of unspecified breast
- N60.12 Diffuse cystic mastopathy of left breast
- O91.219 Nonpurulent mastitis associated w pregnancy, unsp trimester
- N60.11 Diffuse cystic mastopathy of right breast
- P39.0 Neonatal infective mastitis
- P83.4 Breast engorgement of newborn
ICD9
- 611.0 Inflammatory disease of breast
- 675.24 Nonpurulent mastitis associated with childbirth, postpartum condition or complication
- 675.20 Nonpurulent mastitis associated with childbirth, unspecified as to episode of care or not applicable
- 610.1 Diffuse cystic mastopathy
- 675.23 Nonpurulent mastitis associated with childbirth, antepartum condition or complication
- 675.21 Nonpurulent mastitis associated with childbirth, delivered, with or without mention of antepartum condition
- 675.22 Nonpurulent mastitis associated with childbirth, delivered, with mention of postpartum complication
- 771.5 Neonatal infective mastitis
- 778.7 Breast engorgement in newborn
SNOMED
- 45198002 Mastitis (disorder)
- 78697003 Nonpurulent mastitis associated with childbirth
- 82789004 Acute mastitis
- 83620003 Nonpuerperal mastitis
- 3468005 Neonatal infective mastitis
- 700038005 Mastitis associated with lactation (disorder)
- 47134002 Noninfective mastitis of newborn
- 21648003 Chronic mastitis
CLINICAL PEARLS
- Complete emptying of the breasts on a regular schedule, avoiding constrictive clothing or bras that might obstruct breast ducts, meticulous attention to nipple care, "adequate rest, " and a liberal intake of oral fluids for the mother can all reduce the risk of a breastfeeding mother 's developing mastitis.
- First-line treatment for puerperal mastitis is dicloxacillin 500 mg PO QID for 10 to 14 days. Most mastitis can be treated with oral therapy.
- Among breastfeeding mothers, if the symptoms of mastitis fail to resolve within several days of appropriate management, including antibiotics, further investigations may be required to confirm resistant bacteria, abscess formation, an underlying mass, or inflammatory or ductal carcinoma.
- More than two recurrences of mastitis in the same location or with associated axillary lymphadenopathy warrant evaluation with ultrasound or mammography to rule out an underlying mass.