The management of two conditions that commonly, but unnecessarily, lead to discontinuation of breastfeeding are outlined.
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Key Reviewer: Dr Kath Ryan, Reader in Maternal and Perinatal Research, Bournemouth University, UK
In BPJ 15 (August 2008), we emphasised that breast
feeding was the best option for infant nutrition. Here we outline the management of two conditions that commonly,
but unnecessarily, lead to discontinuation of breast feeding.
Common symptoms of infective mastitis
- Localised, painful inflammation of the breast
- Temperature over 38.5 degrees celsius
- Systemic flu-like symptoms (e.g. fever, malaise)
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", bpacnz.
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:
- Ministry of Health. Mastitis and breast abscesses. Available from:
- Spencer J. Management of mastitis in breastfeeding women. Am Fam Physician 2008; 78 (6): 727-32
- Australian Medicines Handbook 2006.