II. Epidemiology
- Incidence: 9-33% of lactating women
- Most common in first few weeks and nearly all cases within first 3 months
III. Pathophysiology
IV. Causes
VI. Signs
VII. Labs: Milk Culture
- Indications (not routine)
- Severe Mastitis
- Refractory despite optimal antibiotics for at least 48 hours
- Hospital acquired infection
- Technique
- Cleanse nipple
- Hand express small quantity of Breast Milk and discard
- Hand express a sample into a sterile container
VIII. Differential Diagnosis
- Inflammatory Breast Cancer
IX. Management: General Measures
- Tylenol or Ibuprofen
- Ensure adequate hydration
- Apply warm packs and local massage
- Alternate feeding positions
-
Antifungals (Monilial Infection)
- Topical Antifungals on Breast
- Oral Nystatin for infant
- Continue with frequent Breastfeeding (except if Breast Abscess present)
- Risk of Breast Abscess if Breast engorgement occurs
- Ensure proper technique (see prevention below)
- Safe for infant to continue to feed despite infection with following exceptions
- Mother HIV positive
- Breast Abscess
- Discard Breast Milk for the first 24 hours on antibiotics
- Resume Breast Feeding after the first 24 hours on antibiotics
X. Management: Antibiotics
- Course: 10 to 14 days
- Coverage: Staphylococcus aureus (or as directed by culture)
- May observe localized Breast redness, tenderness without systemic symptoms or abscess for 24 hours
- For first 24 hours may use general measures above and hold antibiotics
- Start antibiotics by 24 hours if not improving, systemic symptoms, other risks
- Antibiotics: Nursing Mothers
- Amoxacillin-Clavulanate (Augmentin) 875 mg orally twice daily
- Cephalexin (Keflex) 500 mg orally four times daily
- Dicloxacillin 500 mg orally four times daily
- Clindamycin 300 mg orally four times daily (for MRSA)
- Antibiotics: Non-Breast Feeding women
XI. Management: Breast Abscess
- Obtain Bacterial culture
- Needle aspiration under Ultrasound guidance (preferred, 60% effective)
- Attempt to irrigate the abscess via the same needle used for aspiration
- May repeat up to 3 times if fails to resolve (then incise in drain if still refractory)
-
Incision and Drainage
- Indicated in refractory cases (after 3 attempted needle aspirations)
- Also first-line measure in very superficial lesions, with skin thinning over the abscess
- References
- Sacchetti in Herbert (2016) EM:Rap 16(5): 1
XII. Follow-up
- Early antibiotics prevent abscess formation
- If not better in 48 hours examine Breast for abscess
- Consider Incision and Drainage
XIII. Prevention
- Optimal Breast Feeding Technique with good latch-on by infant
- Address predisposing factors early
- Sore nipples suggest problems
- Correct latch-on problems
- Address dry nipples with lanolin
- Avoid plastic-backed Breast pads
- Evaluate infant for anatomic problems (e.g. short frenulum, Cleft Palate)
- Cracked nipples colonized with Staphylococcus aureus should be treated
- Oral antibiotics (e.g. Dicloxacillin) are preferred
- Livingstone (1999) J Hum Lact 15:241-6 [PubMed]
- Blocked milk ducts should be unblocked
- Blocked ducts will appear with a bleb overlying a tender, red area adjacent to nipple
- Remove bleb with moist cloth
- Yeast infection should be treated (both infant and mother)
- Infant: See Thrush for management options
- Mother
- Topical agents: Nystatin or Ketoconazole
- Oral agents: Fluconazole 400 mg on day #1, then 200 mg orally daily for 10 days
- Chetwynd (2002) J Hum Lact 18:168-71 [PubMed]
- Sore nipples suggest problems