Mastitis and sore nipples while breastfeeding

Mastitis is inflammation of the breast, occurring primarily in lactating women. It presents as warmth, redness and swelling in one area of the breast. When infection is involved, the inflammation is often accompanied by systemic flu-like symptoms (see box). If not quickly and properly treated, in extreme cases, a breast abscess can result.

One in five breastfeeding mothers will experience mastitis

It has been reported that up to 20% of breastfeeding mothers will experience mastitis at some point.¹ Some risk factors for its development include: cracked or sore nipples, infant attachment difficulties, missed feeds or changed routines, milk stasis including from restrictive clothing or straps, candida infection, maternal fatigue, previous mastitis or use of a manual breast pump.²

Management: maintaining breastfeeding is important

Should mastitis occur, maintaining breastfeeding is important. If breastfeeding is stopped, milk stasis will increase and make it more likely that a breast abscess will occur. Breastfeeding also provides the best removal of milk from the breast and allows for continued feeding after mastitis has resolved. In the first 24 hours, in the absence of systemic signs of infection, continued breastfeeding along with gentle breast massage, hot compresses and rest is recommended.¹

In practice, often a mother may have already been experiencing pain for 24 hours when they present to their GP, so antibiotics will be given straight away.

Feeding from an infected breast can continue without the concern of passing the infection to the infant because the infant is usually infected with the same organisms at the time mastitis develops. The milk from the infected breast may contain anti-inflammatory components that are beneficial to the infant. If the baby is not feeding well, breast milk will need to be expressed regularly.²

Medication: if required

Paracetamol or an NSAID such as ibuprofen may be used for pain and inflammation and are safe to use while breastfeeding.³

Antibiotics are required for women whose symptoms have not improved in 24 hours or who have systemic symptoms. One of the most common infecting organisms is Staphylococcus aureus and for that reason, flucloxacillin 500 mg four times daily for seven days is recommended.^1-3 Penicillins are considered safe for use during breastfeeding, however they may cause loose bowel motions in the infant.³

For more information on the treatment of mastitis with antibiotics, see the latest edition of our handbook, "Antibiotics: Choices for common infections", bpac^nz.

Complications � breast abscess

Breast abscess has similar symptoms to mastitis except that there is a firm area of the breast. It can be identified by breast ultrasound. Breast abscess is treated by surgical drainage or needle aspiration.² Breastfeeding can usually continue except where the mother is severely unwell or the drainage incision inhibits breastfeeding.

There are many causes of sore nipples including; normal tenderness in the initial days to weeks of breastfeeding, poor positioning and attachment of baby, or infection in the nipple.¹ Breastfeeding should not hurt. Pain is a sign that there is a problem.

The treatment of sore nipples depends on the cause

• Normal tenderness � reassure mother and make sure positioning and attachment are correct.
• Treat any nipple infection � Use flucloxacillin for bacterial infections such as Staphylococcus aureus. For candida infection, oral antifungal liquid such as nystatin for the baby and topical antifungals (e.g. clotrimazole or nystatin) for the mother are often effective. If topical treatments are applied, excess cream should be removed from the nipple before breastfeeding. Oral fluconazole may be required in more severe and painful cases. Use is unlicensed � suggested dose is a 400 mg loading dose followed by 200 mg/day for at least 10 days.²
• Paracetamol or ibuprofen can be used to relieve pain.

The Ministry of Health breastfeeding website is a good resource for mothers, partners, whānau/families and health practitioners and is available at: www.moh.govt.nz/breastfeeding