Mastitis is a bacterial infection of the breast that usually occurs in
breastfeeding mothers. However, it can occur in women who are not breastfeeding
or pregnant, and can occur even in small babies of either sex.
Nobody knows exactly why some women get mastitis and others do not. Bacteria
may gain access to the breast through a crack or sore in the nipple, but women
without sore nipples also get mastitis, and most women with cracks in the nipple
do not.
Mastitis needs to be differentiated from a plugged or blocked duct, because a
plugged or blocked duct does not need treatment with antibiotics, whereas
mastitis often, but not always, requires treatment with antibiotics. A blocked
duct presents as a painful, swollen, firm mass in the breast. The skin overlying
the blocked duct is often quite red, similar to what happens during mastitis,
but less intense. Mastitis is usually also associated with fever and more
intense pain as well. However, it is not always easy to distinguish between a
mild mastitis and a severe blocked duct. Both are associated with a painful lump
in the breast. Without a lump in the breast, one cannot make a diagnosis of
mastitis or a blocked duct. A blocked duct can, apparently, go on to become
mastitis.
In France, physicians also recognize something they call lymphangite that is
fever associated with skin which is hot and red, but there is no underlying
painful mass. They do not believe this requires treatment with antibiotics. I
have seen a few cases that fit this description in my practice, and indeed, the
problem resolves without antibiotics. But then, often a full blow mastitis also
resolves without antibiotics.
As with almost all breastfeeding problems, a poor latch, and thus, poor
draining of the breast sets up the situation where mastitis is more likely to
occur.
Blocked Ducts
Blocked ducts will almost always resolve spontaneously within 24 to 48 hours
after onset, even without any treatment at all. During the time the block is
present, the baby may be fussy when nursing on that side, as milk flow may be
slower than usual, probably due to pressure causing collapse of other ducts.
Blocked ducts can be made to resolve more quickly by:
Continuing breastfeeding on the affected side
Draining the affected area better. One way of doing this is to position the baby
so his chin “points” to the area of hardness. Thus if the blocked duct is in the
outside, lower area of your breast (about 4 o’clock), the football hold would be
best. Another way of achieving better draining of the breast is using breast
compression while the baby is feeding, getting your hand around the blocked duct
and using steady pressure as the baby sucks.
Applying heat to the affected area (with a heating pad or hot water bottle,
but be careful not to injure your skin by using too much heat for too long a
period of time).
Trying to rest. (Not always easy, but take the baby to bed with you.)
If the blocked duct is associated with a small blister on the end of the
nipple, you can open it with a sterile needle. Flame a sewing needle or a pin,
let it cool off, and puncture the blister. No need to dig around. Just pop the
top or side of the blister. Sometimes you can squeeze out a little toothpaste
like material from the duct and the duct will immediately unblock. Or, put the
baby to the breast and he may unblock it for you. Opening the blister has the
added benefit of decreasing nipple pain, even if the blocked duct does not
immediately resolve. Come to the clinic if you cannot do it yourself.
If a blocked duct has not settled within 48 hours (unusual), therapeutic
ultrasound often works. This can be arranged at a neighbourhood physiotherapy
office or sports medicine clinic. Many ultrasound therapists are not aware of
this use for ultrasound. The dose is:
2 watts/cm², continuous, for five minutes to the affected area, once daily
for up to two doses.
If two treatments on two consecutive days have not worked, there is no point
in continuing with ultrasound. Get the blocked duct re-evaluated at the clinic
or by your own physician. Usually, however, if ultrasound is going to work, one
treatment is all that is needed. Ultrasound also seems to prevent recurrent
blocked ducts that always occur in the same part of the breast. Lecithin, one
capsule (1200 mg) 3 or 4 times a day also seems to prevent recurrent blocked
ducts, at least in some mothers.
Mastitis
Here is my approach to dealing with mastitis.
If the mother has symptoms consistent with mastitis for more than 24 hours,
she should start antibiotics. If the mother has consistent symptoms for less
than 24 hours, I will prescribe an antibiotic, but suggest the mother wait
before starting to take it. If, over the next 8-12 hours, her symptoms are
worsening (more pain, more spreading of the redness, enlargement of the hardened
area), then the mother should start the antibiotics. If, over the next 24 hours,
the mother has not worsened, but not improved, she should start the antibiotics.
However, if symptoms are starting to decrease, there is no need to start the
antibiotics. The symptoms usually will continue to resolve and will have
disappeared over the next 2 to 5 days. Fever will usually be gone within 24
hours, the pain within 24 to 48 hours, and the breast hardness within the next
few days. The redness may remain for a week or longer. Once improvement begins,
with or without antibiotics, it should continue. If the course of your mastitis
does not follow this pattern, contact the clinic.
Note: Amoxicillin, plain penicillin, and some other antibiotics often
prescribed for mastitis are usually useless for mastitis. If you need an
antibiotic, it must be effective against Staphylococcus aureus. Effective for
this bacterium are: cephalexin, cloxacillin, flucloxacillin, amoxicillin-clavulinic
acid, clindamycin and ciprofloxacin. The last two are effective for mothers
allergic to penicillin. You can and should continue breastfeeding while taking
these medications.
Remember:
Continue breastfeeding, unless it is just too painful to do so. If you
cannot, at least express your milk as best you can in the meantime. Restart
breastfeeding as soon as you are up to it, the sooner the better. Continuing
breastfeeding helps mastitis to resolve more quickly. There is no danger for the
baby.
Heat (hot water bottle or heating pad) applied to the affected area helps
healing.
Rest helps fight off infection.
Fever helps fight off infection. Treat fever if it makes you feel terrible,
not just because it is there.
Medication (acetaminophen, ibuprofen, others) for pain can be very good. You
will feel better and the amount that gets to the baby is insignificant.
Acetaminophen is probably less useful as it does not have an anti-inflammatory
effect.
Abscess
An abscess occasionally complicates mastitis. You do not have to stop
breastfeeding, not even on the affected side. In the past, an abscess was almost
always drained surgically. Now, more and more, repeated needle aspiration or
drainage under radiographic control is done, and interferes less with
breastfeeding. If you need surgery, the incision should be kept as far away as
possible from the areola. Contact the clinic.
A Lump Which Isn’t Going Away
If you have a lump that is not going away or getting smaller over more than a
couple of weeks, you should be seen by a breastfeeding friendly physician or
surgeon. You don’t have to stop breastfeeding to get a breast lump investigated
(Ultrasound, mammogram, and even biopsy do not require you to stop breastfeeding
even on the affected side). A breastfeeding friendly surgeon will not tell you
that you must stop breastfeeding before s/he can do tests for a breast lump.
