Lactational Mastitis

Comments from Expert Advisory Group

• Continuation of breastfeeding (and/or breast pumping) and anti-inflammatory measures are the key interventions. Patients with lactational mastitis should be educated on effective milk removal to prevent or reverse milk stasis and on appropriate pain management. Such measure include:
  • unlimited skin-to-skin contact and responsive feeding (at least 10-12 times per day) to encourage milk flow
  • hand expressing and/or reverse pressure softening
  • gentle breast compression during feeding
  • avoiding switching from breastfeeding to formula (unless medically indicated)
  • drinking to thirst and avoiding over-hydration
  • if wearing a bra, ensuring it is non-wired and correctly fitted
  • applying ice packs after feeds
  • taking paracetamol and/or ibuprofen for pain relief unless contraindicated
  • avoiding excessive heat and deep tissue massage
• See Factsheet: Engorgement, Ductal Narrowing, Mastitis and Abscess by the National Healthy Childhood Programme for breastfeeding and pain management advice and details on engorgement, duct narrowing, mastitis and abscess.
• Consider antibiotic therapy if there is evidence of bacterial infection e.g. in patients with focal breast findings and systemic symptoms. Antibiotics should be given as an addition to clinical management of symptoms, not a replacement.
• Breast milk culture is generally not helpful in the General Practice setting.
• Advise patient to return at or within 48 hours if symptoms are not improving as treatment failures do occur and referral to hospital may be necessary if not responding to treatment. If improving but not fully recovered, continue treatment course. In rare circumstances symptoms may be due to malignancy.
• Antibiotic treatment course can be extended to 10 days if symptoms are improving but not fully resolved after 5 days.

Treatment

Mastitis Empiric Antibiotic Treatment Table Advise patient to return at or within 48 hours if symptoms are not improving as treatment failures do occur and referral to hospital may be necessary if not responding to treatment. If improving but not fully recovered, continue treatment course. Antibiotic treatment course can be extended to 10 days if symptoms are improving but not fully resolved after 5 days.
Drug	Dose	Duration	Notes
1st choice option
Flucloxacillin	500 mg - 1 g every 6 hours	5 days, then reassess*	Avoid in penicillin allergy. To optimise absorption, take on an empty stomach (either 1 hour before food or 2 hours after food)
2nd choice option / Penicillin Allergy
Clindamycin	300 mg - 450 mg every 6 hours	5 days, then reassess*	Caution: Risk of C. diff

* at least 5 days treatment is needed but treatment should not be extended beyond 10 days.

Useful Resources

• Factsheet: Engorgement, Ductal Narrowing, Mastitis and Abscess. The National Healthy Childhood Programme.

Patient Information

• Visit HSE My Child website for further information.
• An information sheet on ‘Antibiotics and breastfeeding' is available from the Breastfeeding Network UK.
• Further information on Antibiotics and Breast-feeding can be found on the Mother to Baby website (USA) (Search or Use Browse by Medications category).

Safe Prescribing (visit the safe prescribing page)

• Doses are oral and for adults unless otherwise stated
• Dosing in children quick reference dosage/weight guide
• Penicillin allergy – tips on prescribing in penicillin allergy
• Renal impairment dosing table
• Safety in Pregnancy and Lactation
• Drug interactions table.
• Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

---

Reviewed December 2024