Mastitis

Mastitis literally means "inflammation of the breast."

 

If your breast is tender, hot, swollen and red in an area, then you have mastitis.

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And if you have redness, and a temperature of 101.3°F or more, with chills and body aches, you also have mastitis.

 

Mastitis seems to begin with engorgement, and progresses to non-infective mastitis, then to infective mastitis, and then maybe, to a breast abscess, but we really don't know this is how it happens for sure. The important thing to remember is that when an area of your breast is engorged, blocked or plugged, it may, or may not, be caused by a bacterial infection.

 

Mastitis is fairly common with up to 20% of lactating women experiencing it at some point. Most cases occur during the first 6 weeks, but it can occur at any time, even during pregnancy. There are not many research studies about this affliction and there are many aspects of mastitis that need more research, including a proper definition of mastitis!

 

We also need more research to know when antibiotics are needed, which antibiotics are appropriate, and how many days they should be taken. Probiotics are often recommended but we don't know if they actually do anything.

 

And we know massage helps prevent and treat breast engorgement and infection, but we don't know when to do it, or what techniques actually work best. We generally assume that milk is blocked and stagnant. It may develop into an illness and it may not. 

 

These factors are often associated with mastitis:

 

    •    Stressed, exhausted or sick mother 

    •    Sick baby

    •    Poor attachment, or suckling that doesn't soften the breast

    •    Cracked nipples, especially if exposed to Staphylococcus aureus 

    •    Blocked milk duct, milk blister, bleb or white spot on the nipple

    •    Oversupply of milk and/or engorgement

    •    Weaning too quickly

    •    Pressure on the breast (underwire, tight bra, side or stomach sleeping)

 

From this we assume that preventing mastitis begins with good hygiene, good attachment, milk flow and adequate rest. Your baby's attachment to the breast should be deep and comfortable. Feeds should be frequent, with your breast soft after feeding.

 

Your role as a mother is to breastfeed your baby, eat, and when you feel tired, rest. Your family, friends and healthcare team are there to help you, even though they may need reminding that you need their help.

 

Practice good hygiene.

 

Wash your hands frequently, shower daily and regularly wash breast pump parts with soap and hot water. 

Risk factors for mastitis

 

If you are having breastfeeding difficulties such as sore or damaged nipples, a fussy baby, persistent engorgement, or low milk production, it's time to seek skilled care from a lactation consultant. Many of these problems can be quickly and easily treated, once the underlying problem is identified by someone who is knowledgeable.

Keep your milk moving

 

Feed your baby or pump at least 10 times in 24 hours. Overly full breasts should be relieved by hand expression and/or pumping, especially if your baby is having difficulty nursing. This is needed to have good milk production, as well as prevent mastitis. As a note, if your baby isn't gaining enough weight, feed all the milk you express. When you pump, be sure the flange is resting on your breast, not digging in, which can block your milk flow. 

 

Sleeping can cause mastitis!

 

Try to sleep on your back or shift positions, so your breasts are not compressed while you sleep. If you have a long sleep or miss a feed, act immediately and remove fullness by feeding and or pumping. If you notice a plugged duct is starting, be sure to nurse or pump before you go to sleep, no matter how tired you are.

Keep a "weather eye" out

 

Check your breasts for lumps, pain, or redness when you are showering or nursing. Also, check for marks left by your bra. You should not see red dots or stripes from seams, or an underwire after you take your bra off. Your bra should be stretchy and soft. Underwires should rest on your ribcage and the cups should completely cover your breasts with nothing bulging out.

 

If you do notice lumps, pain, or redness, you need to rest and increase your frequency of milk removal.

 

Mastitis can escalate quickly!

If your symptoms are mild and started less than 24 hours ago, effective milk removal, rest and more help around the house may be sufficient treatment.

 

If your symptoms don't improve within 12–24 hours of starting treatment, or you feel sick, like "you got hit by a bus", then a visit or televisit with your doctor is needed. Many doctors will prescribe a 10–14 day course of antibiotics, in case you do have a bacterial infection.

 

Although most women with mastitis manage it at home, the emergency room and sometimes hospital admission is needed. If you feel seriously ill, need intravenous antibiotics, and/or do not have supportive care at home, then admission is the best route to take. Rooming-in with your baby is recommended, so you can continue breastfeeding. In some hospitals, this may be discouraged, as it requires a hospital admission for the infant, but it is the best thing for you and your baby.

 

Usually when you have mastitis, your doctor will not order any lab work or other diagnostic test. But the World Health Organization publication on mastitis recommends a breastmilk culture if:

 

    •    You don't feel better after 2 days of antibiotics

    •    Mastitis recurs within a few weeks

    •    It started during your hospital stay, or have a severe case

    •    You are allergic to the usual antibiotics

 

Mothers with high bacteria counts and/or nasty bacteria often have worse symptoms and do feel sicker. If you feel something is really wrong and want a culture done, please advocate for yourself.

 

To provide a sample of milk to be cultured, you will hand-express your milk into a sterile collection container.

 

Wash your hands, clean your nipple, compress your breast and start your milk flowing. Then, taking care not to touch the inside of the container, catch a small quantity of milk mid-stream. Your skin has its own bacteria, so washing your hands, and cleaning your nipple prior to collection is important so you don't have a false-positive. 

 

Keep breastfeeding! 

 

A healthy, full term baby can continue breastfeeding from a mother with mastitis. There is no evidence that this is risky. If it's too painful to breastfeed, express milk from your breast by hand or pump, until the pain eases. If you suddenly stop breastfeeding, you have a greater risk of developing a breast abscess.

 

It is important to keep your breasts soft. 

 

Frequent, effective milk removal is the most important thing you can do, even during medical treatment. If your baby is not nursing well, hand express and pump, in addition to breastfeeding. Breastfeed more frequently, or at least 10 times per day, starting on the affected breast. If you are having trouble with the let-down because it hurts, begin feeding or pumping on the unaffected breast and switch to the side that hurts, after your milk lets down. 

 

Positioning is important. 

 

Make sure the baby has a deep attachment when they nurse with their chin, or nose, pointing to the blockage. If you aren't sure how to do this, ask for help from a lactation consultant. Some mothers find that nursing on their hands and knees with the baby underneath ("dangle feeding") is helpful.

 

As the baby nurses, massage your breast with an edible oil, or nontoxic lubricant, to help break up blockages. Massage directly below the lumpy areas moving toward the nipple. If you feel something like spaghetti inside your breast, use a gentle back and forth movement, rubbing across the strands.

 

Remember to be gentle with your breast tissue. You are only moving milk, not cement!

If you feel fullness after feeding, hand expressing or pumping may help drain your breast even more and shorten the time you are sick.


In addition, you can work on draining fluid back into the lymph system. 

 

Lie down or recline, so your breast is on top of your chest. Stroke your breast from your nipple back into your chest wall. This will help fluid drain toward the lymph nodes in your armpit. Again, this is gentle stroking of your delicate breast tissue. Don't hurt or bruise yourself. Milk moves by gravity and relaxation, not force.

Some massage therapists are trained to do this. Look for one with prenatal or maternity training in lymphatic massage.

 
Rest, adequate fluids, and nutrition are necessary and supportive.

 

You need to rest, and this means you will need help taking care of your household needs. Whether you have family or friends, or have to hire help, this is dedicated time for you to sleep, nurse, and focus on getting better. Doing all of these will shorten your illness.

 

Eat healthy foods and drink enough fluids.

 

This will vary according to how you feel, but comfort foods prepared with loving kindness, are healing in themselves. They play a big role in nourishing new mothers around the world and may be just what you need while you are battling mastitis.

 

Hot and cold packs can help.

 

Applying a hot pack to the area, soaking your breast in a bowl of warm water or showering just before feeding can help milk letdown and help the milk flow. Between feeds or expressing, cold packs on the painful area will reduce pain and swelling.

Take Your Medications!

 

More drugs...

Antibiotics come immediately to mind, but ibuprofen and acetaminophen also have their place in treating mastitis. These ease pain which helps milk to letdown. An anti-inflammatory such as ibuprofen may also be effective in reducing fever and swelling. Ibuprofen is not detected in breastmilk in doses up to 1.6 grams per day and is compatible with breastfeeding.  Although you may be reluctant to take medications while nursing, it's important to take them when they are needed. 

 

Most mothers respond within a day or two to antibiotic treatment. If your symptoms continue, you may have a resistant bacteria. The most common bacteria in infective mastitis is penicillin-resistant S. aureus.  Less common, are Streptococcus and Escherichia coli. Methicillin-resistant S. aureus (MRSA) is also increasingly seen in cases of mastitis and breast abscesses. 

 

If you have mastitis in the same area more than 2 or 3 times, your doctor will probably request an ultrasound to look for another reason like an abscess, an underlying mass, or very rarely, cancer. 

 

What is a Breast Abscess?

 

If the area of your breast remains hard, red, and tender despite milk removal, massage, rest and antibiotics, then you might worry that you have breast cancer. It is more likely though, that you have an abscess which develops in about 3% of women with mastitis. You may actually feel pretty good except for the hot, red, hard lump in your breast. An abscess is an infected area filled with lymph, pus and milk.

 

To confirm you have an abscess, your doctor will order a breast ultrasound to identify the lump. The lump will then be drained by needle aspiration. The aspiration can collect fluid for culturing and it can relieve pressure.  Aspirated fluid will be sent for culturing and identification. There may be a known resistant bacteria strain in a particular facility, as in a hospital. 

 

If the abscess is very large or if there are multiple abscesses, several needle aspirations may be required. Or you may need surgical drainage. Another treatment is a tube inserted into the abscess that will stay in place and drain until the abscess heals. You will be given antibiotics to prevent further infection and you should continue breastfeeding on the affected breast, even if you have a temporary drain. Obviously, your baby’s mouth should not come into direct contact with the drain, or any of the draining fluid. 

 

Candida infections may be an unwanted side effect

 

Using antibiotics and being rundown, can put you at increased risk for breast and vaginal candida infections.  Some candida infections show up as burning nipple pain or radiating breast pain symptoms. You may not have visible signs of candida on your nipples and this can make diagnosis difficult. Milk culture to study the microbe, also may not be reliable. Several studies have been done on this and the results conflict with each other. One promising technique for diagnosing and treating mothers with burning nipple and breast pain uses a nipple swab with a polymerase chain reaction test, but further research in this area is also needed. 

 

The current recommendation is to try anti-fungal medications, with or without doing a culture, and see if symptoms clear up. 

 

Mastitis produces overwhelming and painful symptoms that cause women to quit breastfeeding. 

 

Milk removal is the most important part of treatment because stopping will make pain and swelling worse, and increase the risk of an abscess developing. In some cases, a baby is not able to breastfeed well because of torticollis, a misaligned jaw, or tongue tie. Some babies have low muscle tone or are excessively sleepy. Focusing on breastfeeding and getting help from a lactation consultant can help you uncover and get treatment for problems like these.

 

If this is your first or second time with mastitis, try to look at it as an urgent call from your body to focus on your needs and your baby's. In the first few months after birth, you need to connect with your baby and take good care of yourself. The best way to do this is by allowing others to help you.

 

Reducing your workload, starting prompt, effective treatment, and empathy from your healthcare providers are key to moving through mastitis. Let everyone else handle everything else besides breastfeeding. If all you have to do is nurse your baby, it makes it much easier to continue breastfeeding. 

 

If you have repeated bouts of mastitis and are not finding a way to overcome it, then please take care of yourself by ending breastfeeding. It is a hard choice but for a few clients, it has been the best way to handle chronic mastitis.