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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 (See handout #15, Breast
Compression).
- 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.
Questions? (416) 813-5757
(option 3) or drjacknewman@sympatico.ca
or my book Dr. Jack Newman’s Guide
to Breastfeeding (called The Ultimate Breastfeeding
Book of Answers in the USA)
See
the videos
showing how to latch a baby on, how to know
a baby is getting milk, how to use compression,
etc.
Handout #22 Blocked Ducts
and Mastitis. Revised January 2005
Written by Jack Newman, MD, FRCPC. ©
2005
This handout may be copied
and distributed without further permission,
on the condition that it is not used in
any context in which the WHO code on the
marketing of breastmilk substitutes is violated
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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