Table of contents
Lactational mastitis
What's new
Added 2024 AAFP and 2022 ABM guidelines for the prevention and management of lactational mastitis.
Background
Overview
Definition
Lactational mastitis is a spectrum of inflammatory conditions of the breast in breastfeeding women, characterized by milk stasis, hyperlactation, and/or mammary dysbiosis, which can lead to infection.
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Pathophysiology
The primary factor in the pathophysiology of lactational mastitis is milk stasis due poor milk drainage or ductal obstruction, which triggers an inflammatory response. Disruption of the milk microbiome is another contributing factor. Acute bacterial mastitis is often caused by Staphylococcus and Streptococcus strains.
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Epidemiology
Lactational mastitis is estimated to occur in 2-33% of breastfeeding women.
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Risk factors
Risk factors for lactational mastitis include nipple trauma or fissures, plugged milk ducts, wearing a tight bra, deep breast massage, hyperlactation, frequent breast pumping, abrupt weaning, history of mastitis in previous pregnancies, as well as maternal obesity and smoking.
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Disease course
The clinical course of lactational mastitis typically begins with localized breast pain, tenderness, erythema, and warmth, progressing to systemic symptoms if untreated.
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Prognosis and risk of recurrence
The prognosis for lactational mastitis is generally good with appropriate management. Most cases resolve within 48-72 hours of initiating treatment. However, recurrence is possible, particularly in the presence of underlying risk factors.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of lactational mastitis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024) and the Academy of Breastfeeding Medicine (ABM 2022).
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Diagnostic investigations
Milk culture
As per ABM 2022 guidelines:
Consider obtaining milk culture to evaluate for resistant and/or less common pathogens, such as MRSA, if there is no symptomatic improvement after 48 hours of first-line therapy. Consider obtaining local susceptibility testing and resistance patterns and proceed to empiric therapy.
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Consider obtaining early milk culture in mothers expressing breast milk for an immunocompromised infant in the NICU, healthcare workers in areas with a high prevalence of MRSA, and patients with recurrent infections.
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Psychosocial assessment
Medical management
Supportive care: as per AAFP 2024 guidelines, offer breast rest, ice application, and NSAIDs for the management of mastitis spectrum disorders.
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Antibiotic therapy
Management of postpartum engorgement
Management of phlegmon
Management of abscess
Management of galactocele
Management of subacute mastitis
Management of recurrent mastitis
Nonpharmacologic interventions
Therapeutic procedures
Patient education
Preventative measures
Choice of bra: as per ABM 2022 guidelines, advise wearing an appropriately fitting supportive bra, as lactating breasts are highly vascular and require support to avoid dependent lymphedema and back and neck pain.
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Breast pumping
Breast emptying
Breast massage
Nipple shields
Local measures