In the past, mastitis has been regarded as a reasonably common breastfeeding complication and many of the ways to treat symptoms have included applying heat, increased breastfeeding, massage and early introduction of antibiotics.

However, the Academy of Breastfeeding Medicine (ABM) have recently released peer-reviewed evidence that suggests a diagnosis of mastitis should reflect a much wider spectrum of conditions, as well as new recommendations for treatment of mastitis.  

Cause of mastitis

The biggest takeaway from this lengthy new protocol is that mastitis should not only be attributed to ‘milk stasis’ anymore (milk build up in the breast), but instead related to inflammation of the breast tissue.

This inflammation in the breast tissue can cause narrowing of the milk ducts – inhibiting effective milk removal, and if this inflammation is not resolved it can then lead to infection.

To put it simply - initial breast inflammation can be known as inflammatory mastitis, which can worsen to bacterial mastitis (infection) or progress to a breast abscess and so on.

The exact cause is not always known but some of the major contributors are:

• Hyperlactation (also known as oversupply)
• Sub-optimal infant attachment/milk removal
• Diversity of the milk microbiome (bacteria)

Can you still breastfeed and/or pump with mastitis?

• You can still breastfeed with mastitis. Breastfeed your baby on their demand and ensure they are attaching well to the breast.
• If your baby is able to breastfeed well and often, try avoid the use of breast pumps and nipple shields as your baby is most effective at maintaining breast health and milk supply.
• Mastitis and pumping: If you are not directly breastfeeding and instead using an electric breast pump, just express to meet the volume your baby needs per feed. This helps prevent stimulating an oversupply of milk.
• If you are unable to express or feed from the affected breast due to engorgement then consider the use of lymphatic drainage and reverse pressure softening to help alleviate fluid buildup in the areola (check out our post about lymphatic drainage massage too!)
• To soothe the inflamed breast caused by your mastitis, use ice compresses to provide comfort.

Treatments for mastitis to avoid:

• Avoid firm massage to treat your mastitis as this can actually cause more trauma to the inflamed breast tissue. Massaging the ‘lump’ towards the nipple while feeding is now recognised as ineffective. This is because the milk duct is not ‘blocked’ by a physical lump, but rather, the tissue inflammation around it. Instead, very gentle massage and free movement of the breast when feeding can help relieve pain.
• Avoid saline or Epsom salt soaking to ease your mastitis symptoms. Epsom salts can cause skin maceration and further contribute to engorgement. If nipple damage present it should be treated by correction of breastfeeding attachment, regulation of milk supply, applying breastmilk to the skin or 100% purified lanolin.

Medical management of persistent mastitis:

• Aim to decrease inflammation and pain in your breast by using anti-inflammatory medications (ibuprofen and equivalent)
• Ice can be applied to your breast every hour if needed and will help soothe inflammation and pain caused by your mastitis.
• Studies have shown warm showers/the use of heat may worsen mastitis symptoms. There is also no evidence currently to suggest heat improves mastitis, although it may provide comfort.
• Treatment of persistent hyperlactation/oversupply either through feeding techniques such as block feeding or through medication as needed.
• Therapeutic ultrasound by an experienced technician. Ultrasound can use thermal energy to reduce breast inflammation and relieve breast swelling.This should be performed on a daily basis until mastitis symptoms resolve.
• Consider the use of antibiotics only for cases of bacterial mastitis. Antibiotics prescribed during inflammatory mastitis can disrupt the breast microbiome, only increasing the risk of developing bacterial mastitis.
• If you do need antibiotics for mastitis, they are likely to prescribe Dicloxacillin or Flucloxacillin 500 mg QID for 10–14 days or Clindamycin 300 mg four times daily for 10–14 days.
• Consider the use of probiotics for mastitis. Several studies suggest that probiotics may be of benefit in preventing and treating mastitis however there are limitations to these studies so no strong recommendations can be made at this time.
• Consider supplementing with soy or sunflower lecithin to help reduce inflammation caused by mastitis (ABM recommends 5-10gms a day)

Important points for you to know about mastitis:

• Feelings of fullness and/or a ‘lumpy’ breast does not necessarily indicate a ‘blockage’ or inflammation.
• Sweating and hot flushes can be normal due to hormonal changes (particularly if your oestrogen levels are low).
• If you have breast pain and redness of the skin after a long sleep or if you have an oversupply of milk this is likely caused by inflammation of the breast tissue, not an infection.
• Inflammatory mastitis does not progress to a bacterial infection in a short time frame (i.e in the space of several hours).
• Bacterial mastitis is not a contradiction to breastfeeding - meaning, you should not be discarding your milk, but instead you should continue to breastfeed directly or offer your baby this expressed milk as they demand.
• Decreased milk supply in the affected breast following mastitis is not uncommon, but can usually be stimulated to return as needed.
• The ABM recommends direct breastfeeding on demand while experiencing mastitis, without aiming to constantly ‘empty’ the affected breast. This is because the ‘more you take, the more you make’. By feeding more frequently on the affected breast, you are increasing your milk supply in that breast - and high milk volume/oversupply is recognised as one of the major contributors to initial and persistent breast inflammation.
• Rest well and rehydrate!
• If your mastitis symptoms don’t resolve within 24 hours, you should seek medical advice for a possible bacterial mastitis diagnosis.

Written by Keryn Thompson, RM & IBCLC (L-301766)

References

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