Mastitis
Christina C. Reed and Susan Drummond
Definition
A.Mastitis is an infection of breast tissue with potential for abscess formation.
Incidence
A.Mastitis has been estimated to occur in 2% to 10% of breastfeeding mothers. Less than 1% of these require hospitalization. Symptoms seldom appear before the end of the first week postpartum and are most often seen during the first 2 months postpartum.
Pathogenesis
A.During the period of lactation, the breast changes from an essentially nonfunctioning organ to a complex functioning organ of the body. The developing multiductal system becomes a rich environment for the growth of bacteria. The most common offending organism is Staphylococcus aureus (95%). The immediate source of the organisms that cause mastitis is almost always the nursing infant’s nose and mouth.
Predisposing Factors
Invasion of bacteria in the presence of breast injury, including:
A.Bruising from rough manipulation (pumping) or failing to break the neonate’s attachment to the areola and nipple before removing from breast.
B.Prolonged breast engorgement.
C.Milk stasis in a duct.
D.Cracking or fissures of the nipple.
E.Poor handwashing.
Common Complaints
A.Breast engorgement, usually bilateral.
B.Pain in the breast, usually unilateral.
C.Fever.
D.Red streak(s).
E.Flu-like symptoms: Body aches, headache, malaise, and chills.
Other Signs and Symptoms
A.Fever 100.0°F to 104.0°F, rapid rise.
B.Exquisitely tender breast tissue.
C.Hard mass in the breast.
D.Tachycardia and tachypnea.
E.Axillary lymphadenopathy.
Subjective Data
A.Elicit the onset, duration, and course of symptoms.
B.Note the frequency and length of time of the feeding or pumping.
C.Are there any red streaks on the breasts?
D.Are the nipples cracked and bleeding?
E.Quantify pain symptoms, relief measures tried, and results.
F.Review other symptoms to rule out other infections, such as wound infection, episiotomy breakdown, and urinary tract infection (UTI).
Physical Examination
A.Check temperature and blood pressure (BP), pulse, and respirations.
B.Physical exam should not be focused just on breast symptoms but should include a general ruling out of other potential problems, such as coexistent UTI or endometritis.
C.Inspect:
1.Visually inspect breasts.
2.Perform breast exam.
3.Check episiotomy or abdominal incision to rule out infection.
D.Palpate:
1.Perform breast exam. Observe breastfeeding for adequacy of latch, suck, swallow, jaw glide, and any clicking.
2.Palpate lymph nodes of the neck and axilla.
3.Palpate the abdomen.
4.Check costovertebral angle (CVA) tenderness.
E.Auscultate: Auscultate the heart and lungs.
Diagnostic Tests
A.Treatment usually initiated based on symptoms and exam.
B.Complete blood count (CBC): Leukocytosis in peripheral smear.
C.White blood cell (WBC), culture, and sensitivity of breast milk to identify bacteria for persistent signs of infection or if antibiotic treatment is unsuccessful.
D.Urine or wound cultures, if applicable.
E.Ultrasound considered if breast is not responding to treatment to evaluate for breast abscess.
Differential Diagnoses
A.Mastitis: Fever, chills, and malaise in conjunction with unilateral breast pain.
B.Breast engorgement: Bilateral presentation of breast discomfort.
C.Breast abscess: Discharge of purulent exudate from nipple, masses, or reddened areas that develop a bluish hue of the skin over the area of abscess.
D.Clogged milk duct.
E.Viral syndrome.
F.Inflammatory breast cancer.
Plan
A.General interventions:
1.Encourage self-care and support. Advise the family to assist the patient with self-care and infant care during this acute period. The woman may feel extremely ill for the first 24 to 48 hours of therapy and may find it difficult to continue breastfeeding, as well as perform self-care and newborn care activities.
B.Patient education:
1. 
See Section III: Patient Teaching Guide Mastitis.
2.Advise the patient to continue to breastfeed or pump to maintain milk supply.
3.Stress the importance of continuation of breastfeeding or pumping despite infection.
C.Dietary management:
1.There are no dietary restrictions.
2.Have the patient increase fluid intake with increased temperature (at least 10–12 glasses a day).
3.Encourage her to eliminate caffeine, if possible, or use in moderation.
D.Pharmaceutical therapy:
1.Antibiotics:
a.Nonsevere with no methicillin-resistant Staphylococcus aureus (MRSA) risk factors: Dicloxacillin 500 mg orally every 6 hours OR cephalexin 500 mg orally every 6 hours for 10 to 14 days to reduce relapse; however, 5 to 7 days can be used if rapid response occurs. If beta-lactam hypersensitive: Clindamycin 300 mg orally every 8 hours.
b.Nonsevere with MRSA risk factors: Clindamycin 300 mg orally every 8 hours. Trimethoprimsulfamethoxazole (breastfeeding toxicity) one doublestrength tablet orally every 12 hours.
c.Severe: Vancomycin 15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose depending on breast milk and blood culture results.
2.Advise the patient to complete the full course of antibiotics even if symptoms are improved sooner.
3.Candidal vaginitis may develop secondary to antibiotic therapy. The patient should be aware of the signs, symptoms, and treatment plan if it should occur.
4.Acetaminophen (Tylenol) or ibuprofen for pain management.
5.The patient may require pain medication if acetaminophen (Tylenol) or ibuprofen is not effective. Use acetaminophen with codeine phosphate (Tylenol No. 3) or other narcotic as needed for pain.
Follow-Up
A.Evaluate the patient in 48 hours if a breast abscess is suspected; assess need for surgical consultation.
Consultation/Referral
A.Consult a physician if a breast abscess is suspected, for persistent signs of infection, or if antibiotic treatment is unsuccessful. Treatment of a breast abscess may include surgical incision and drainage of the abscess.
B.Notify the pediatrician if mastitis is diagnosed.