Lactational mastitis and breast abscess - diagnosis and management in general practice

Lactational mastitis
Leila Cusack
Meagan Brennan

and breast abscess
Diagnosis and management in general practice Epidemiology
Lactational mastitis affects approximately 20% Lactational mastitis is common, affecting one in 5 breastfeeding women. As well as of breastfeeding Australian women in the first 6 causing significant discomfort, it is a frequent reason for women to stop breastfeeding. months postpartum.7 It is most common in the first 6 Objective
weeks of breastfeeding1,5 with the highest incidence This article outlines an evidence based approach to the diagnosis and management of occurring during the second and third weeks.6,9 It is lactational breast infections in general practice.
initial y localised to one segment of the breast, but Discussion
untreated can spread to affect the whole breast.5 Lactational mastitis is usually bacterial in aetiology and can generally be effectively Around 3% of lactating women with mastitis will managed with oral antibiotics. Infections that do not improve rapidly require further develop a breast abscess,1,10 although an incidence investigation for breast abscess and nonlactational causes of inflammation, including the rare cause of inflammatory breast cancer. In addition to antibiotics, management of lactational breast infections include symptomatic treatment, assessment of the infant’s Risk factors and prevention
attachment to the breast, and reassurance, emotional support, education and support The main risk factor for mastitis is breastfeeding during the early postpartum period.6 Milk stasis Keywords: mastitis; breast abscess; lactation; general practice
and cracked nipples may contribute to the development of mastitis,1,3–6 although the evidence for this is inconclusive.1 Other implicated factors include previous mastitis,6 maternal fatigue1,3 and primiparity.9 Reported risk factors for breast abscess process affecting the lactating breast.1–4 include a past history of mastitis, maternal age over It is usually bacterial in aetiology. It 30 years and gestational age greater than 41 weeks.5 There are no interventions that have been localised pain, tenderness, erythema and consistently proven to prevent mastitis. Encouraging engorgement,3–6 and may be accompanied emptying of milk from the breast is often recommended, however, evidence for its efficacy malaise, rigors, nausea and vomiting.4–8 is inconclusive.6 The most commonly practised intervention is the prevention and management of A breast abscess, a localised collection in the damaged nipples; in some settings this may reduce breast tissue that results in a painful breast lump, the risk of developing mastitis.3 A Cochrane review is potentially secondary to bacterial mastitis found that anti-secretory factor cereal, mupirocin that is rapidly progressive or is not managed ointment, fusidic acid ointment and breastfeeding expeditiously. Effective management is essential advice had no significant impact on the initiation to control the discomfort and reduce the likelihood or duration of breastfeeding or the incidence of of discontinuation of breastfeeding, which may occur as a consequence of mastitis.6,7 Mastitis Microbiology
and breast abscess may develop in women who are not breastfeeding; this article will focus on The most common causative organism for mastitis is Staphylococcus aureus.8,10 Strains of methicil in 976 Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011 Lactational mastitis and breast abscess – diagnosis and management in general practice CLINICAL
resistant S. aureus (MRSA) have been identified, may distinguish inflammation (mastitis) from a lump remains, no fluid is obtained or fluid is particularly in hospital acquired infections. Other collection of pus in the breast (abscess) (Figure bloodstained rather than purulent, then core organisms include streptococci and S. epidermidis. 2). Ultrasound also al ows guided aspiration of biopsy is recommended to exclude breast cancer.13 Patients who suffer with recurrent breast abscesses any abscess providing drainage and fluid for Mammography is not a first line investigation have a higher incidence of mixed flora, including microscopy and culture. A malignant lesion may in lactating women but is indicated if there are anaerobic organisms.5 On rare occasions Candida mimic an inflammatory col ection on ultrasound. clinical, sonographic or biopsy features suspicious albicans, not an uncommon cause of nipple pain in Hence, fol owing aspiration, if a significant lactating women,9 can cause parenchymal infection.12 Clinical assessment
History and physical examination

Breast pain is the primary symptom of mastitis.7 High fever is common, along with other generalised flu-like symptoms including malaise, lethargy, myalgia, sweating, headache, sometimes nausea and vomiting and occasionally rigors.1,5–7 Clinical examination of the breast should focus on looking for signs of inflammation (erythema, Figure 1. Mastitis is characterised by a Figure 2. Ultrasound of a breast abscess. localised tenderness, heat, engorgement and swelling) (Figure 1) and signs of nipple damage. Photo Science Photo Library, 2011. All General observations including temperature, pulse and blood pressure are important to exclude sepsis, which requires hospital admission.
Table 1. Common breast problems in the puerperium
Breast abscess is characterised by symptoms Benign conditions
similar to mastitis, with the additional sign of Conditions related to lactation
a discrete tender lump, which may be tense or fluctuant. The mass may have overlying skin s¬ "REAST¬INFECTION¬MASTITIS¬OR¬ABSCESS necrosis suggesting that the abscess is ‘pointing’ – bacterial infection – usually S. areus (abscess is sitting close to the surface of the skin). ¬ n¬FUNGAL¬INFECTION¬C. albicans¬UNCOMMON Less frequently, breast abscess presents as a non- tender lump without erythema (‘cold abscess’).
attachment to the breast
¬ n¬CRACKEDDAMAGED¬NIPPLES¬ – incorrect attachment: misalignment of mother’s nipple and baby’s mouth The infant should be examined to ensure adequate ¬ n¬INFANT¬CAUSES¬POOR¬SUCKING ¬TONGUETIE ¬CLEFT¬PALATE growth and hydration. Examination of the baby’s mouth can exclude candida infection (white film adherent to the buccal mucosa),2 or anatomical Other conditions
conditions such as cleft palate or tongue-tie which s¬ ¬"ENIGN¬BREAST¬DISEASE¬FIBROADENOMA ¬FIBROCYSTIC¬CHANGE ¬CYST ¬BENIGN¬PHYLLODES¬ may interfere with attachment.6,9 Observation of breastfeeding can determine if there are difficulties with attachment to the breast. A lactation ¬ n¬TENDER¬COSTOCHONDRAL¬JUNCTIONS¬4IETZE¬SYNDROME – sleeping or breastfeeding in an uncomfortable position Investigation
Malignant causes
Mastitis is a clinical diagnosis and investigations are not indicated in the initial assessment.1 with a course of appropriate antibiotics should ¬ n¬¬INFLAMMATORY¬BREAST¬CANCER¬MAY¬MIMIC¬BACTERIAL¬MASTITIS ¬ be investigated with breast ultrasound.5 This Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011 977 CLINICAL Lactational mastitis and breast abscess – diagnosis and management in general practice
Differential diagnosis
Table 2. Management approach to breast infections
Other less common breast problems may present in the puerperium (Table 1). These differentials should Clinical assessment
presentation but should be considered if mastitis is not responding to treatment1,2 (Figure 3). Nonbreast causes of fever (such as urinary tract infection or endometritis, ie. fol owing complications of Antibiotic therapy
Caesarean delivery) should be considered where the s¬ Flucloxacillin or dicloxacillin 500 mg qid for at least 5 days presentation is with fever rather than breast pain s¬ For abscess – guided by microbiological culture and sensitivity Support continued breastfeeding
s¬ %DUCATION¬AND¬REASSURANCE¬s¬ 2EGULAR¬AND¬COMPLETE¬DRAINAGE¬OF¬BREAST¬USE¬BREAST¬PUMP¬IF¬NEEDED ¬ The key components of management are symptom control, oral antibiotics and encouraging continued milk flow from the affected breast (Table 2). The s¬ 2EFERRAL¬TO¬!USTRALIAN¬"REASTFEEDING¬!SSOCIATION patient should be reassured that antibiotics and Early and frequent review
simple analgesics wil not harm her baby. Women s¬ 2EVIEW¬IN¬n¬HOURS¬INVESTIGATE¬IF¬NOT¬SETTLING should be encouraged to continue breastfeeding, to s¬ ¬)F¬NOT¬SETTLING ¬ULTRASOUND¬TO¬LOOK¬FOR¬BREAST¬ABSCESS¬AND¬RARE¬CAUSES¬OF¬ rest whenever possible and to drink plenty of fluids. inflammation such as inflammatory breast cancer Close monitoring is required to ensure that the s¬ "IOPSY¬LESIONS¬SUSPICIOUS¬FOR¬MALIGNANCY
Management of breast abscess if present
Management of symptoms
breast clinics or ultrasound guidance are available s¬ Incision and drainage if not settling or aspiration is unavailable Regular oral paracetamol is first line treatment. s¬ /THER¬MANAGEMENT¬AS¬PER¬MASTITIS ¬ Nonsteroidal anti-inflammatory drugs can be added. Psychological support
Hot and cold packs to breast
s¬ %VALUATION¬FOR¬DEPRESSION¬s¬ 2EFERRAL¬TO¬!USTRALIAN¬"REASTFEEDING¬!SSOCIATION Evidence is inconsistent, however, breastfeeding authorities recommend: sæ APPLICATIONæOFæCOLDæPACKSæAFTERæFEEDINGæMAYæHELPæ options include cephalexin or clindamycin.15 sæ GENTLEæMASSAGEæANDæWARMæCOMPRESSæPRIORæTOæ Alternatives used overseas include amoxycillin/ Cabbage leaves have demonstrated inconsistent clavulanic acid and macrolides (erythromycin, effects; producing postfeeding symptom relief clarithromycin).5 Avoid tetracycline, ciprofloxacin similar to-ice packs in some studies,5 while and chloramphenicol as they are unsafe for use in lactating women.5 Hospitalisation for intravenous antibiotics is rarely required but is indicated if Antibiotic therapy
there are systemic signs of sepsis.5,15 Candida is a Adequate antibiotic therapy is essential. Where rare cause of mastitis and is characterised by the possible this should be guided by microbiological presence of intense pain, particularly noted after culture and sensitivity (such as when fluid is the breast empties, and the absence of breast aspirated from an abscess).14 As S. aureus is the common causative organism, antibiotic therapy Figure 3. Inflammatory breast cancer may Support for continued
of choice at least 5 days of flucloxacillin or mimic mastitis. Classically it presents with a breastfeeding
poorly defined clinical mass with erythema, dicloxacillin in a dose of 500 mg four times per skin thickening and peau d’orange (‘orange day.15 Due to antibiotic packaging in Australia The aim of therapy is to continue breastfeeding this may require two consecutive 6 day courses and to empty the breast as fully as possible with Photo Slaven, 2011. All rights reserved of antibiotics. For patients allergic to penicillin, each feed. This relieves symptoms and reduces 978 Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011 Lactational mastitis and breast abscess – diagnosis and management in general practice CLINICAL
the likelihood of progression to breast abscess.
Identification and drainage of
breastfeeding women including telephone and email counselling and helpful resources: There is no evidence of risk of harm to a healthy breast abscess
sæ æ"REASTFEEDINGæ(ELPLINEææMUMææMUMææ infant feeding from an infected breast.1,4,6 If Lactating women with a breast abscess often attachment is painful, a breast pump can be used present late when the abscess is established and to drain the breast until the infection settles of large volume.5 The traditional management of sæ ,ACTATIONæ2ESOURCEæ#ENTREæWWWLRCASNAUæ enough to allow the baby to feed from the breast breast abscess was surgical incision and drainage (Figure 4). Infant attachment to the breast should under general anaesthetic. This has been largely Leila Cusack BSc, MBBS(Hons) is a junior medical be checked and corrected. Referral to a lactation replaced by percutaneous (outpatient) aspiration officer, currently living in Europe. leilacusack@ consultant may be helpful. The Australian under local anaesthetic where specialist breast Breastfeeding Association is also useful for clinics or radiology services are available. Meagan Brennan BMed, FRACGP, DFM, FASBP, mother-to-mother support (see Resource). Surgery can usual y be avoided and outcomes is a breast physician, The Poche Centre, North are better for outpatient clinic management Sydney and Clinical Senior Lecturer, Northern women choose to cease breastfeeding. These than surgical management (including reduced Clinical School, Sydney Medical School, University of Sydney, New South Wales.
women should be supported in their decision and pain and scarring and increased likelihood encouraged to wean gradually, preferably after of continued breastfeeding).5,10,14 Access to Conflict of interest: none declared.
the infection has resolved. Sudden cessation specialist breast clinics may be limited in some References
of breastfeeding may exacerbate the infection, areas, particularly in rural areas, so surgical 1. Academy of Breastfeeding Medicine Protocol increasing the risk of abscess formation.1,4 incision and drainage may be the treatment of Committee. ABM Clinical Protocol #4: Mastitis. Medication to suppress milk production is not Revision, May 2008. Breastfeed Med 2008;3:177–80.
2. Amir LH. Breast pain in lactating women: mastitis or Psychological issues
something else? Aust Fam Physician 2003;32:141–5.
3. Amir LH, Forster DA, Lumley J, McLachlan H. A Early and frequent review
As well as the severe physical pain, mastitis descriptive study of mastitis in Australian breast- feeding women: incidence and determinants. BMC Women with mastitis should be reviewed within is often associated with complex emotions. It 24–48 hours to ensure that the inflammation is occurs at a time of great physical, hormonal 4. Betzold CM. An update on the recognition and settling. If minimal improvement occurs, breast and lifestyle change.7 Depression, distress, management of lactational breast inflammation. J Midwifery Womens Health 2007;52:595–605.
ultrasound is indicated (Figure 2). Ultrasound anxiety, tearfulness, helplessness and concerns 5. Dixon JM, Khan LR. Treatment of breast infection. about milk supply have been associated with 6. Spencer JP. Management of mastitis in breastfeed- aspiration.1,4,5 Ultrasound can identify or exclude episodes of mastitis.7 By acknowledging the ing women. Am Fam Physician 2008;78:727–31.
other causes of inflammatory breast signs such difficulties involved in breastfeeding, general 7. Amir LH, Lumley J. Women’s experience of lacta- as inflammatory breast cancer and can facilitate practitioners can help mothers while providing tional mastitis – ‘I have never felt worse’. Aust Fam ultrasound guided biopsy if indicated by the support, encouragement and reassurance that 8. Francis-Morrill J, Heinig MJ, Pappagianis D, Dewey their milk is extremely valuable to the health of KG. Diagnostic value of signs and symptoms of their child, and is safe for their baby when they mammary candidosis among lactating women. J are taking appropriate antibiotics. The Australian 9. Mass S. Breast pain: engorgement, nipple pain and Breastfeeding Association is an excellent source mastitis. Clin Obstet Gynecol 2004;47:676–82.
10. Amir LH, Forster D, McLachlan H, Lumley J. Incidence of free information and support and women of breast abscess in lactating women: report from an should be encouraged to use this resource. Australian cohort. BJOG 2004;111:1378–81.
11. Crepinsek MA, Crowe L, Michener K, Smart NA. Interventions for preventing mastitis after childbirth. Cochrane Database Syst Rev 2010;(8):CD007239.
Lactational breast infections are common and 12. Amir LH. Candida and the lactating breast: predis- require prompt and effective management to 13. National Breast Cancer Centre. Investigation of a minimise associated morbidity. Management new breast symptom: a guide for general practition- of mastitis includes antibiotic therapy and ers. NBCC report: Evidence relevant to guidelines encouragement of milk flow from the affected for the investigation of breast symptoms. 2nd edn. breast, ideal y with ongoing breastfeeding. Close 14. Elder EE, Brennan M. Nonsurgical management monitoring is important to detect poor responders, should be first-line therapy for breast abscess. World trigger investigation and identify breast abscess to 15. Antibiotic Expert Group. Therapeutic Guidelines: encouraged for women with mastitis and/or al ow urgent referral for specialist management. antibiotic. Version 14. Melbourne: Therapeutic breast abscess. Emptying of the breast can Resources
The Australian Breastfeeding Association provides advice for health professionals and support for Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011 979


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