Incidence: Affects approximately 20% of breastfeeding Australian women in the first 6 months postpartum.
Timing: Most common in the first 6 weeks of breastfeeding, with the highest incidence during the second and third weeks.
Spread: Initially localized to one segment of the breast; if untreated, it can spread to the entire breast.
Breast Abscess: Around 3% of lactating women with mastitis will develop a breast abscess, though an incidence of up to 11% has been reported.
Risk Factors and Prevention
Primary Risk Factor: Breastfeeding during the early postpartum period.
Common causes:
poor attachment to breast
nipple damage
too long btw feeds
breasts too full
blocked milk ducts
stopping breastfeeding too quickly
overly tight bra
Contributing Factors:
Milk stasis and cracked nipples, although evidence for this is inconclusive.
Previous mastitis.
Maternal fatigue.
Primiparity.
Risk Factors for Breast Abscess:
Past history of mastitis.
Maternal age over 30 years.
Gestational age greater than 41 weeks.
Prevention Strategies:
BF as often as your baby needs (8-12x/24hrs for new baby)
don’t miss or put off BF
wake your baby for a feed if breasts become too full or if baby doesn’t want to feed express a small amount for comfort
ensure attaching correctly
offer both breasts if baby only feeds at one offer the alternate breast at next feed
express a small amount of milk after feeds
A Cochrane review found no significant impact from anti-secretory factor cereal, mupirocin ointment, fusidic acid ointment, or breastfeeding advice on mastitis incidence.
Microbiology
Common Causative Organism: Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA) in hospital-acquired infections.
Other Organisms: Streptococci, Staphylococcus epidermidis.
Mixed Flora: Higher incidence in patients with recurrent breast abscesses, including anaerobic organisms.
Rare Cases: Candida albicans, which can cause parenchymal infection.
Signs of inflammation: erythema, localized tenderness, heat, engorgement, swelling.
Signs of nipple damage.
General observations: temperature, pulse, blood pressure to exclude sepsis.
Breast Abscess
Symptoms:
Similar to mastitis but includes a discrete tender lump (tense or fluctuant).
Skin necrosis suggesting the abscess is “pointing” (close to the skin surface).
Occasionally presents as a non-tender lump without erythema (“cold abscess”).
Examination of the Infant and Breastfeeding
Infant Examination: Ensure adequate growth and hydration, examine the mouth for candida infection (white film on buccal mucosa) or anatomical conditions (e.g., cleft palate, tongue-tie).
Breastfeeding Observation: Check for difficulties with attachment, potentially involving a lactation consultant.
Investigation
Initial Diagnosis: Clinical, without need for initial investigations.
Non-Improving Infection: Breast ultrasound to differentiate between inflammation (mastitis) and abscess, guide aspiration, and exclude malignancy if necessary.
Mammography: Not first-line but indicated if there are clinical, sonographic, or biopsy features suspicious for malignancy.
Differential Diagnosis
Inflammatory Breast Cancer: Consider if mastitis is unresponsive to treatment.
Non-Breast Causes of Fever: Urinary tract infection or endometritis, especially if fever is the primary symptom rather than breast pain and erythema.
Management
Ibuprofen or paracetamol for pain
early antibiotic therapy is important to prevent abscess formation.
Abx =
dicloxacillin 500 mg orally, 6-hourly. For 10 days OR
flucloxacillin 500 mg orally, 6-hourly. for 10 days
Nb: if Candida infection (Intense pain, particularly after breast empties, absence of breast erythema🡪 fluconazole 200-400mg daily for 2-4wks
Nb: if tenderness & redness persist beyond 48hrs & an area of induration develops then a breast abscess has formed 🡪 hospital for IV abx, USS +/- aspiration OR rarely surgical drainag
Analgesia: Regular oral paracetamol as first-line treatment. Nonsteroidal anti-inflammatory drugs can be added; both are safe in breastfeeding.
Hot and Cold Packs:
Gentle massage and warm compress prior to feeding may encourage milk flow.
Cold packs after feeding may help alleviate pain.
Cabbage leaves show inconsistent effects, similar to ice packs in some studies but no effect in others.
Support for Continued Breastfeeding
Goals: Continue breastfeeding, fully empty the breast with each feed to relieve symptoms and reduce abscess risk.
Breast Pump: Use if attachment is painful until infection settles.
Lactation Consultant: Referral may be helpful.
Australian Breastfeeding Association: Useful for support and resources.
Early and Frequent Review
Initial Review: Within 24-48 hours to ensure inflammation is settling.
Follow-Up: If minimal improvement, breast ultrasound to detect abscess and guide aspiration.
Other Causes: Identify or exclude other causes of inflammatory breast signs, facilitate biopsy if needed.
Identification and Drainage of Breast Abscess
Presentation: Often late with established, large-volume abscess.
Traditional Management: Surgical incision and drainage under general anaesthetic.
Preferred Management: Percutaneous aspiration under local anaesthetic in specialist clinics, better outcomes than surgical management.
Rural Settings: Surgical incision and drainage may be necessary due to limited access to specialist clinics.
Psychological Issues
Emotional Impact: Mastitis is associated with severe physical pain and complex emotions (depression, distress, anxiety, tearfulness, helplessness).
Support: Acknowledge difficulties, provide support and reassurance about the safety and value of breast milk, encourage use of the Australian Breastfeeding Association.
