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Mastitis Care Pathway Overview


Red Flags
  • signs of sepsis (such as tachycardia, fever and chills)
  • the infection progresses rapidly
  • the woman is haemodynamically unstable or immunocompromised
  • if there is an underlying mass or breast cancer is suspected - arrange an urgent 2-week wait referral
  • if a breast abscess is suspected - refer urgently to a general surgeon

Mastitis usually only affects one breast, and symptoms often develop quickly. Symptoms of mastitis can include:

  • a red, swollen area on the breast that may feel hot and painful to touch
  • a breast lump or area of hardness on the breast
  • a burning pain in the breast that may be continuous or may only occur when mothers are breastfeeding
  • red streaks on the breast from areola to underarm
  • nipple discharge, which may be white or contain streaks of blood or pus

Women may also experience flu-like symptoms, such as aches, a high temeprature (fever), chills and tiredness

Differential Diagnosis

If there is an underlying mass or breast cancer is suspected - arrange an urgent 2-week wait referral.

If a breast abscess is suspected - refer urgently to a general surgeon.

Initial Primary Care Assessment

In breastfeeding women, mastitis is often caused by a build-up of milk within the breast, known as milk stasis. Milk statis can occur for a number of reasons including:

  • A baby not properly attaching to the breast during feeding, this could be due to:
    • infant mouth abnormalities (for example, cleft lip palate)- this may also lead to nipple damage which can cause pain and provide an entry point for bacteria
    • a short frenulum (tongue-tie) in the infant-please see frenulotomy information.
  • Infrequent feeds or missing feeds which could be due to:
    • partial bottle feeding, changes in feeding regimen (common when the infant first starts to sleep through the night), and rapid weaning from breast milk
    • painful breasts
    • use of the dummy or bottle- this may also result in poor infant attachment to the breast
    • having a preferred breast for feeding, leading to milk accumulation in the other breast
    • maternal stress and fatigue

Pressure on the breast, for example from tight clothing or bra, a car seat belt, or prone sleeping position.

In some cases build-up of milk can also become infected.

Guidelines for Prevention, Diagnosis, Treatment, Management and Care of Breast Feeding Mothers with Mastitis - Gloucestershire Health and Care Services (GHC)

The aim of this guideline is to provide health professionals with the most up to date information on the diagnosis, treatment, management and care of mothers with mastitis. This will enable health professionals to provide consistent information and help to mothers based on the best available evidence.

Please follow the resource link below to view.

Initial Primary Care Management

If immediate admission or referral is not indicated:

that her breast should return to normal shape, size and function after adequate treatment and that it is safe to feed her baby.

  • prescribe a simple analgesic. Paracetamol is the analgesic of choice during breastfeeding. However, if a nonsteroidal anti-inflammatory drug (NSAID) is clinically indicated, Ibuprofen is preferred but should only be used short-term
  • advise the woman to place a warm compress on the breast, or bathe or shower in warm water, to relieve pain and help milk to flow.
  • increase fluid intake

including from the affected breast. Please see Countywide Infant Feeding Pathway.

Milk stasis is often the initiating factor in lactational mastitis, therefore the most important management step is frequent and effective milk removal. If necessary, involve a breastfeeding specialist (contact health visitor if baby is over 28 days or midwife is baby is under 28 days for support in the first instance, if more specialist advice is needed the midwife or health visitor may refer on to the infant feeding specialists) to assist the woman in improving the infant's attachment to the breast. This will improve milk removal and prevent nipple damage.

  • if breastfeeding is too painful, or the infant refuses to breastfeed from the affected breast, advise the woman to express the milk (by hand or with a breast pump) until she is able to resume breastfeeding from that breast.
  • more information on expressing breast milk can be found here.
  • if the affected breast is not completely empty after feeding, advise the woman to express the remaining milk (by hand or using a breast pump).

  • advise the woman to rest and avoid wearing a bra, especially at night
  • ensure good breastfeeding technique and maintenance of good hygiene
  • if there is nipple soreness or damage
    • advise on considering the application of a thin layer of white soft paraffin or expressed breast milk, if the nipple is cracked, fissured, or there is nipple exudate.
    • if there is a suspected bacterial infection, prescribe fusidic acid 2% cream to be applied to the nipples after every breastfeed for 5-7 days.
    • if there is suspected Candida infection, provide treatment for the woman and the infant at the same time, to prevent re-infection. If the nipples are red and inflamed, prescribe hydrocortisone 1% cream in addition.
    • if nipple symptoms persist or are severe, continue topical treatment and consider treating for bacterial or Candida ductal infection, depending on clinical judgement.
  • See CKS topic on Breastfeeding problems for detailed information on management

the woman has a nipple fissure that is infected or if symptoms have not improved (or are worsening) after 12-24 hours despite effective milk removal. Please also see prescribing section.

symptoms fail to settle after 48 hours of antibiotic treatment

  • mastitis is severe or recurrent
  • hospital-acquired infections likely
  • there is severe deep 'burning' breast pain (indicative of ductal infection)
When to refer

Arrange hospital admission if:

  • there are signs of sepsis (such as tachycardia, fever, and chills).
  • the infection progresses rapidly.
  • the woman is haemodynamically unstable or immunocompromised.
    • the infant should be admitted with her to allow continuation of breastfeeding

Arrange an urgent 2-week wait referral if there is an underlying mass or breast cancer is suspected

Refer urgently to a general surgeon if a breast abscess is suspected

Ongoing Care

If symptoms fail to settle after 48 hours of first-line antibiotic treatment:

  • check that the woman has taken the antibiotic correctly
  • consider the possibility of an alternative diagnosis (such as breast cancer or breast abscess) and the need for referral or admission
    • if an abscess is suspected, be aware that malaise and fever may be subsided if antibiotics have been started
  • if an alternative diagnosis is unlikely
    • send a sample of breast milk for microscopy, culture, and antibiotic sensitivity (if this has not already been done)
    • prescribe second-line antibiotic, co-amoxiclav 500/125mg three times a day, for 10-14 days; review this choice when breast milk culture results become available. Seek specialist advice if the woman is allergic to penicillin.
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