Managing Mastitis

Mastitis is a common and debilitating condition that affects up to 33% of breastfeeding mothers (Angelopoulou et al. 2018).

Characterised by an area of inflamed breast tissue and accompanied by pain and fever, it is a distressing condition which can negatively impact a mother’s ability to breastfeed.

Most episodes of mastitis occur in the first two months postpartum with recurrence rates of up to about 10% commonly reported (Cullinane et al. 2015).

Milk stasis is usually considered the primary cause of mastitis, as the accumulated milk causes an inflammatory response which may or may not progress to an infection.

Signs and Symptoms of Mastitis

Mastitis should be suspected if a woman has:

• A painful breast;
• Fever or general malaise;
• A tender, red, swollen and hard area of the breast, usually in a wedge-shaped distribution.

Differential Diagnosis

One of the challenges in caring for women with mastitis is that it’s not possible to distinguish clinically between infectious and non-infectious mastitis. Infection is more likely if:

• The mother has a nipple fissure that is infected.
• Symptoms do not improve or are worsening after 12 - 24 hours, despite effective milk removal.
• Bacterial culture of the breast milk is positive.

A severe complication of mastitis is the formation of an abscess, or localised collection of pus within the breast, which can occur even without any apparent preceding mastitis.

Based on recent evidence collected by Cullinane et al. (2015) it’s estimated that approximately 3% of mastitis sufferers go on to develop a breast abscess.

A breast abscess should be considered if the woman has:

• A history of recent mastitis.
• A painful, swollen lump in the breast, with redness, heat, and swelling of the overlying skin.
• Fever and/or general malaise.

(NICE 2018)

Predisposing Factors

Cullinane et al. (2015) note that the most common cause of mastitis is the presence of S. aureus on the nipple, or in the breast milk.

Recent studies have suggested that coagulase-negative staphylococci may also play an important role, but further research is needed to confirm this.

Other common factors thought to contribute to mastitis developing include:

• Nipple damage;
• Oversupply of breast milk;
• Use of nipple shields;
• Maternal stress and fatigue;
• Attachment difficulties;
• Milk stasis;
• Restrictions from a tight fitting bra.

Expressing breast milk has also been linked to mastitis, but again further high-quality evidence-based research is needed to confirm this as many of the studies to date seem to be flawed.

For example, Cullinane et al. (2015) report on a study using a case-control design which found an association between using breast pumps and mastitis.

However, questionnaire data were collected retrospectively, not at the time of the inflammation, so it is unclear if use of the breast pump was a risk for, or a consequence of, mastitis

Treating Mastitis

Early management of a woman with mastitis involves general measures to improve drainage of the breast and reduce inflammation.

It can be an alarming condition for a new mother and reassurance that the breast will return to normal following treatment is important.

Midwives and doulas have a key role to play supporting and encouraging mothers to keep breastfeeding throughout a mastitis attack, as the condition can be exacerbated if feeding is suddenly stopped.

For mild cases, giving advice on hygiene and encouraging good breastfeeding techniques are often the only steps that are needed.

Start4Life (2020) also reinforces the point that after feeds, any leftover breast milk should be drained either by expressing by hand or with a pump.

NICE (2018) also recommends simple treatment methods such as the use of analgesics, applying a warm compress to the breast before feeding and maintaining adequate hydration.

Important Observations

Supporting the breastfeeding mother, or checking breast health if the mother chooses to bottle feed is a core midwifery skill but when mastitis is suspected the following observations become particularly important:

• Assess vital signs and monitor for signs of systemic infection.
• Assess breasts and note the presence of any swelling, erythema or tenderness.
• Note skin quality and presence of cracked nipples that may increase the risk of infection.
• Monitor for signs of potential abscess development.
• Observe the baby’s position and latch whilst feeding.
• Check the baby to exclude any anatomical reason for poor latching.

Alternative Approaches

Old wives’ tales, alternative medicine, and self-help measures are often topics that mothers want to talk about concerning breastfeeding difficulties.

Even though recommending alternative approaches to treatment is outside the scope of professional practice for many midwives, it can still be helpful to have an awareness of what they are.

For example, the application of cold cabbage leaves, often described as the poor man's poultice, is a well-known home remedy for breast engorgement and mild mastitis.

As Woodman (2003) reflects, it’s an ancient remedy that has stood the test of time and still remains popular today.

Risk Reduction

As soon as mastitis has been diagnosed, it is quick and easy to treat. But prevention is always better than cure and maternity staff are ideally placed to offer advice for mothers to reduce the risk of mastitis occurring.

The most important points being:

• When possible, breastfeed exclusively.
• Feed frequently and on-demand to avoid a build-up of breastmilk.
• Ensure the baby latches on properly to avoid nipple damage.
• Wait for the baby to finish feeding and release the nipple naturally. To stop breastfeeding, cut down feeds gradually.
• Avoid tight clothing and bras that could put pressure on the breasts.

(Start4Life 2020)

Implications for Practice

Abou-Dakn et al. (2010) make the point that because most cases of mastitis occur once the mother has gone home it’s important to cover education on preventative measures before discharge.

It’s a theme echoed by Khanal et al. (2015) who recommend that traditional breastfeeding practices should be encouraged and that the management of mastitis should be included as part of breastfeeding promotion.

Alongside advising new mothers, Cantrill, Creedy and Cooke (2003) also suggest that knowledge variations amongst midwives’ needs to be addressed following reports of conflicting advice experienced by breastfeeding women.

It’s just one of the many areas in maternity care where further research might help to close the gap between theoretical knowledge and actual practical support.

References

• Abou-Dakn, M, Richardt, A, Schaefer-Graf, U and Wöckel, A 2010, ‘Inflammatory Breast Diseases during Lactation: Milk Stasis, Puerperal Mastitis, Abscesses of the Breast, and Malignant Tumors – Current and Evidence-Based Strategies for Diagnosis and Therapy’, Breast Care, [online] 5(1), pp.2-2, viewed 23 January 2020, https://www.karger.com/Article/Abstract/272223
• Angelopoulou, A, Field, D, Ryan, C, Stanton, C, Hill, C and Ross, R 2018, ‘The Microbiology and Treatment of Human Mastitis’, Medical Microbiology and Immunology, [online] 207(2), pp.83-94, viewed 23 January 2020, https://europepmc.org/article/MED/29350290
• Cantrill, R, Creedy, D and Cooke, M 2003, ‘An Australian Study of Midwives’ Breast-Feeding Knowledge’, Midwifery,[online] 19(4), pp.310-317, viewed 23 January 2020, https://www.sciencedirect.com/science/article/abs/pii/S0266613803000469
• Cullinane, M, Amir, L, Donath, S, Garland, S, Tabrizi, S, Payne, M and Bennett, C 2015, ‘Determinants of Mastitis in Women in the CASTLE Study: a Cohort Study’, BMC Family Practice, [online] 16(1), viewed 23 January 2020, https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0396-5
• Khanal, V, Scott, J, Lee, A and Binns, C 2015, ‘Incidence of Mastitis in the Neonatal Period in a Traditional Breastfeeding Society: Results of a Cohort Study’, Breastfeeding Medicine, [online] 10(10), pp.481-487, viewed 23 January 2020, https://www.liebertpub.com/doi/abs/10.1089/bfm.2015.0080
• NICE 2018, Mastitis and Breast Abscess, NICE [online], viewed 23 January 2020, https://cks.nice.org.uk/mastitis-and-breast-abscess#!scenario
• Start4Life 2020, Mastitis | Breastfeeding Challenges, Start4Life, [online] viewed 23 January 2020, https://www.nhs.uk/start4life/baby/breastfeeding/breastfeeding-challenges/mastitis/
• Woodman, H 2003, ‘Cabbage Leaves: Cabbage Leaves are Poor Man's Poultice’, BMJ, [online] 327(7412), pp.451-c-451, viewed 25 January 2020, https://www.bmj.com/content/327/7412/451.4