Understanding Lactational Mastitis & Breast Abscess Among Lactating Mothers

Lactational mastitis, or puerperal mastitis, is breast tissue inflammation occurring in breastfeeding women that may be associated with infection.

Lactational mastitis & breast abscess are usually caused by milk stagnation leading to milk duct blockage and commonly occurs during the first three months of breastfeeding. Studies suggest that 3-20% of breastfeeding mothers develop mastitis. Inadequate treatment can result in breast abscess formation.

An estimated 0.4-11% of all lactating women develop a breast abscess. Treatment delays cause premature breastfeeding cessation and can be devasting for the mother and the infant.

What are the Risk Factors & Etiology?

These include:

• Advanced maternal age
• Late-term/post-term delivery at greater than 41 weeks
• Primiparous (first-time mothers)
• Infrequent feeding
• The ineffective feeding technique (improper latching/weak suckling)
• Milk overproduction
• Maternal/infant disease
• Birth anomalies
• Uncomfortable bra
• Cracked nipple
• Rapid weaning
• Prior mastitis
• Poor hygiene
• Working mothers (employment outside the home)
• Breast trauma
• Diabetes

All of these lead to milk stasis, and organisms (from the infant’s mouth or mother’s skin) enter through the damaged nipple resulting in infection.

The commonest causative organisms are of bacterial origin, with Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) being the main culprits. Other organisms include Escherichia coli, Salmonella, Hemophilus influenza, and Streptococcus.

Breastfeeding mothers are at more risk of abscess formation during lactational mastitis & breast abscess:

• The first month of nursing is due to inexperience, especially in the first pregnancy. 85% of breast abscesses occur in the first month of delivery.
• At weaning, breasts become engorged due to lesser feeding. Additionally, the infant starts teething around this time, which increases the incidence of nipple trauma.

What are the Symptoms & Signs of Breast Abscesses?

Breast engorgement and a clogged milk duct precede inflammation. Symptoms of engorgement are an enlarged, swollen, painful breast with red areas, a stretched-out nipple, and difficulty in milk expression.

A clogged duct presents as a painful lump with overlying redness. Blockage at the duct opening manifests as a small, aching white spot on the nipple called “bleb.” With inflammation, the patient develops a fever with a focal, hard, swollen, and painful area in the affected breast.

A breast abscess is a localized pus collection within the breast. Symptoms include a well-demarcated, fluctuant, painful, red, tender-to-touch lump in the affected breast, fever, malaise, and swollen axillary (armpit) lymph nodes.

Evaluation, Investigations & Diagnosis

Diagnosis is made on history and physical examination. Milk samples are seldom tested as they are not sterile, and the mere presence of organisms within the sample does not mean mastitis. Therefore, the WHO guidelines for testing milk samples include:

• Recurrent breast infection
• No response to antibiotics
• Allergic reaction to antibiotic use

Breast ultrasound is the modality of choice in monitoring abscess progression and response to treatment. Mammography is rarely performed but doctors recommend to rule out malignancy in patients over 30 years of age and those with non-resolving abscesses.

Treatment/Management

Supportive treatment includes continuous milk removal from the affected side through frequent feedings and a pump/hand expression. Breastfeeding is considered safe and abrupt cessation can lead to breast abscess development.

Infants may show reluctance to feed from the affected side due to decreased milk outflow or saltier-tasting milk; in such cases, a breast pump or hand expression should be used.

Hot showers and hot compresses before feeding can facilitate milk flow. Cold compress usage post-feeding can help decrease pain and inflammation. Patients need to advised to massage the skin from the areola to the armpits (lymphatic massage).

Bleb management includes puncturing with a sterile needle or massaging with a warm cloth after nipple warming (with hot water). Antibiotics need to use when the symptoms do not resolve within 12-24 hours of starting treatment.

The most commonly used drugs are Cephalexin, Amoxicillin-Clavulanate, Dicloxacillin, Clindamycin, Erythromycin, and Trimethoprim-Sulfamethoxazole (TMP-SMX). TMP-SMX contraindicates in babies less than one-month-old, those jaundiced, sick, premature, or have G6PD deficiency.

Most clinicians recommend antibiotic usage for 10-14 days. Antibiotic change may consider if no improvement is noted after 48 hours of use. One complication noted with antibiotic use is a nipple yeast infection which presents as burning/stabbing pain during or post-feeding. Topical antifungals for the mother and the infant for a week are the mainstays of treatment.

Painkillers, NSAIDs (Ibuprofen, paracetamol), and topical steroids aid in pain and inflammation relief. For breast abscesses, ultrasound-guided aspiration combined with antibiotic therapy is recommended.

Surgical incision and drainage may be necessary in some cases. Post-surgery, continue breastfeeding in a position disallowing direct contact between the infant’s mouth and the wound; if that is impossible, then breast pump or hand expression should be practiced, as continuous milk removal can facilitate healing.

Final Thoughts

We understand that breastfeeding with mastitis can be extremely unpleasant, but, mamas, persistent breastfeeding is the key to resolution and can prevent abscess formation. Additionally, when using topical gels/ointments, always remember to wipe them off before the next feeding properly.