Mastitis

Question 1

What is it?

Answer 1

Mastitis refers to inflammation of breast tissue and is a common complication of breastfeeding. It can occur with or without associated infection.

Mastitis can be caused by an obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this from occurring.

Mastitis can also be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacterial cause is Staphylococcus aureus.

Question 2

Presentation?

Answer 2

Mastitis presents with:

Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever

Question 3

Management?

Answer 3

Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.

When conservative management is not effective, or infection is suspected (e.g., they have a fever), antibiotics should be started. Flucloxacillin is the first line, or erythromycin when allergic to penicillin. A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.

Women should be encouraged to continue breastfeeding, even when an infection is suspected. It will not harm the baby and will help to clear the mastitis by encouraging flow. Where breastfeeding is difficult, or there is milk left after feeding, they can express milk to empty the breast.

A breast abscess is a rare complication if mastitis is not adequately treated. This may need surgical incision and drainage.

Question 4

Candida of the nipple?

Answer 4

Candidal infection of the nipple can occur, often after a course of antibiotics. This can lead to recurrent mastitis, as it causes cracked skin on the nipple that creates an entrance for infection. It is associated with oral thrush and candidal nappy rash in the infant.

Candida infection of the nipple may present with:

Sore nipples bilaterally, particularly after feeding
Nipple tenderness and itching
Cracked, flaky or shiny areola
Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

Both the mother and baby need treatment, or it will reoccur. Treatment is with:

Topical miconazole 2% to the nipple, after each breastfeed
Treatment for the baby (e.g., oral miconazole gel or nystatin)