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Updated: Dec 1 2021


  • Snapshot
    • A 29-year-old, G1P1, woman presents with a painful and erythematous right breast. Since the birth of her first son 3 weeks ago, she has been exclusively breastfeeding. Upon physical exam, there are visible small fissures around the nipple. The breast feels warm. Purulent discharge from the nipple is noted.
  • Introduction
    • Clinical definition
      • inflammation of the breast often associated with milk stasis during lactation
  • Epidemiology
    • Incidence
      • 3-20% of lactating women
    • Demographics
      • occurs in lactating women
      • any inflammatory breast in a post-menopausal woman is cancer until proven otherwise
      • often occurs within first 12 weeks post-partum
    • Risk factors
      • lactation
      • injury to nipple
      • poor attachment of infant to breast
      • history of prior mastitis
  • Etiology
    • Pathophysiology
      • pathophysiology
        • milk stasis, or accumulation of milk, may cause inflammatory response
        • milk stasis also creates favorable conditions for growth of bacteria
          • infection often starts from nipple fissures
          • often due to Staphylococcus aureus and Staphylococcus albus
          • can also be due to yeast, especially if infant has oral candidiasis or diaper dermatitis
  • Presentation
    • Symptoms
      • primary symptoms
        • tender, hot, and swollen breast
          • usually unilateral
        • flu-like myalgia
        • chills
        • fever
    • Physical exam
      • inspection
        • localized redness on the breast
          • often wedge-shaped
        • warmth and induration on the breast
        • cracked nipples or visible fissure
        • swollen lump may indicate breast abscess
        • may have purulent nipple discharge
      • suspect yeast mastitis if
        • pain out of proportion to clinical findings
          • shooting pain from nipple to chest wall
  • Imaging
    • Ultrasound
      • indications
        • if breast abscess is suspected
      • findings
        • fluid pocket seen inside breast
  • Studies
    • Labs
      • may see elevated white blood cell count
      • milk culture
        • indications
          • if no response to initial antibioitics
          • if recurrent or chronic mastitis
          • if there is presence of abscess
    • Diagnostic criteria
      • mastitis is typically diagnosed clinically based on physical exam
  • Differential
    • Engorgement
      • pain relief and resolution of symptoms with emptying of milk, ice packs, and analgesics
    • Fibroadenoma
      • no signs of infection
  • Treatment
    • Conservative
      • continue breastfeeding
        • safe for infants
        • contraindicated in women with human immunodeficiency virus (HIV)
      • empty breasts of milk every 6 hours
        • indication
          • for mild symptoms lasting less than 1 day
        • outcomes
          • may shorten duration of mastitis
          • may improve rates of normal lactation
    • Medical
      • dicloxacillin or cephalexin
        • indications
          • symptoms persist after 1 day of effective, regular milk removal
          • milk culture indicates infection
          • visible nipple fissure
          • breast abscess
      • clindamycin or trimethoprim-sulfamethoxazole
        • indication
          • if methicillin-resistant Staphylococcus aureus (MRSA) is suspected
      • fluconazole
        • indication
          • if yeast mastitis is suspected
        • outcomes
          • successful if mother and infant are treated
    • Operative
      • surgical drainage
        • indication
          • breast abscess is diagnosed
        • techniques
          • first-line
            • needle aspiration with or without ultrasound guidance
          • otherwise
            • incision and drainage for large abscesses
  • Complications
    • Breast abscess
      • 3-12% of women with mastitis develop breast abscess
      • treatment
        • surgical drainage
    • Vertical transmission of HIV infection from mother to infant
      • 10-20x higher load of HIV RNA in milk during mastitis
      • treatment
        • cessation of breastfeeding
  • Prognosis
    • Prognostic variable
      • favorable
        • appropriate antibiotic treatment
    • Survival with treatment
      • very good
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