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Mastitis
is a bacterial infection of the breast that usually occurs in
breastfeeding mothers. However, it can occur in women who are
not breastfeeding or pregnant, and can occur even in small
babies of either sex. Nobody knows exactly why some women get
mastitis and others do not. Bacteria may gain access to the
breast through a crack or sore in the nipple, but women without
sore nipples also get mastitis, and most women with cracks in
the nipple do not.
Mastitis needs to be differentiated from a plugged or
blocked duct, because a plugged or blocked duct does not need
treatment with antibiotics, whereas mastitis often,
but not always,
requires treatment with antibiotics.
A blocked duct presents as a painful, swollen, firm mass
in the breast. The skin overlying the blocked duct is often
quite red, similar to what happens during mastitis, but less
intense. Mastitis is usually also associated with fever and more
intense pain as well. However, it is not always easy to
distinguish between a mild mastitis and a severe blocked duct. Both
are associated with a painful lump in the breast.
Without a lump in the breast, one cannot make a
diagnosis of mastitis or a blocked duct. A blocked duct can,
apparently, go on to become mastitis. In France, physicians also
recognize something they call lymphangite
that is fever associated with skin which is hot and red, but
there is no underlying painful mass. They do not believe this
requires treatment with antibiotics. I have seen a few cases
that fit this description in my practice, and indeed, the
problem resolves without antibiotics. But then, often a full
blow mastitis also resolves without antibiotics.
As with almost all breastfeeding problems, a poor
latch, and thus, poor draining of the breast sets up the
situation where mastitis is more likely to occur.
Blocked
ducts
Blocked
ducts will almost always resolve spontaneously within 24 to 48
hours after onset, even without any treatment at all. During the
time the block is present, the baby may be fussy when nursing on
that side, as milk flow may be slower than usual, probably due
to pressure causing collapse of other ducts.
Blocked ducts can be made to resolve more quickly by:
1.
Continuing breastfeeding on the affected side.
2.
Draining the affected area better. One way of doing this
is to position the baby so his chin “points” to the area of
hardness. Thus if the blocked duct is in the outside, lower area
of your breast (about 4 o’clock), the football hold would be
best. Another way
of achieving better draining of the breast is using breast
compression while the baby is feeding, getting your hand
around the blocked duct and using steady pressure as the baby
sucks (See handout #15, Breast Compression).
3.
Applying heat to the affected area (with a heating pad or
hot water bottle, but be careful not to injure your skin by
using too much heat for too long a period of time).
4.
Trying to rest. (Not always easy, but take the baby to
bed with you.)
If
the blocked duct is associated with a small blister on the end
of the nipple, you can open it with a sterile needle. Flame a
sewing needle or a pin, let it cool off, and puncture the
blister. No need to dig around. Just pop the top or side of the
blister. Sometimes you can squeeze out a little toothpaste like
material from the duct and the duct will immediately unblock.
Or, put the baby to the breast and he may unblock it for
you. Opening the blister has the added benefit of decreasing
nipple pain, even if the blocked duct does not immediately
resolve. Come to the clinic if you cannot do it yourself.
If a blocked duct has not settled within 48 hours
(unusual), therapeutic ultrasound often
works. This can be arranged at a neighbourhood physiotherapy
office or sports medicine clinic. Many ultrasound therapists are
not aware of this use for ultrasound. The dose is:
2
watts/cm², continuous, for five minutes to the affected area,
once daily for up to two doses.
If two treatments on two consecutive days have not
worked, there is no point in continuing with ultrasound. Get the
blocked duct re-evaluated at the clinic or by your own
physician. Usually, however, if ultrasound is going to work, one
treatment is all that is needed.
Ultrasound also seems to prevent recurrent blocked ducts
that always occur in the same part of the breast. Lecithin,
one capsule (1200 mg) 3 or 4 times a day also seems to
prevent recurrent blocked ducts, at least in some mothers.
Mastitis
Here
is my approach to dealing with mastitis.
·
If the mother has symptoms consistent with mastitis for more
than 24 hours, she should start antibiotics. If the mother
has consistent symptoms for less
than 24 hours, I will prescribe an antibiotic, but suggest
the mother wait before starting to take it.
If, over the next 8-12 hours, her symptoms are worsening (more pain,
more spreading of the redness, enlargement of the hardened
area), then the mother should start the antibiotics. If, over
the next 24 hours, the mother has not worsened, but not
improved, she should start the antibiotics. However, if symptoms
are starting to decrease, there is no need to start the
antibiotics. The symptoms usually will continue to resolve and
will have disappeared over the next 2 to 5 days. Fever will
usually be gone within 24 hours, the pain within 24 to 48 hours,
and the breast hardness within the next few days. The redness
may remain for a week or longer. Once improvement begins, with
or without antibiotics,
it should continue. If the course of your mastitis does not
follow this pattern, contact the clinic.
·
Note:
Amoxicillin,
plain penicillin, and some other antibiotics often prescribed
for mastitis are usually useless for mastitis. If you need an
antibiotic, it must be effective against Staphylococcus
aureus. Effective
for this bacterium are: cephalexin, cloxacillin, flucloxacillin,
amoxicillin-clavulinic acid, clindamycin and ciprofloxacin.
The last two are effective for mothers allergic to
penicillin. You can and should continue breastfeeding while
taking these medications.
Remember:
·
Continue
breastfeeding, unless
it is just too painful to do so. If you cannot, at least express
your milk as best you can in the meantime. Restart breastfeeding
as soon as you are up to it, the sooner the better. Continuing breastfeeding helps mastitis to resolve more
quickly. There is no danger for the baby.
·
Heat
(hot water bottle or heating pad) applied to the affected area
helps healing.
·
Rest
helps fight
off infection.
·
Fever
helps fight
off infection. Treat fever if it makes you feel terrible, not
just because it is there.
·
Medication
(acetaminophen,
ibuprofen, others) for pain can be very good. You will feel
better and the amount that gets to the baby is insignificant.
Acetaminophen is probably less useful as it does not have
an anti-inflammatory effect.
Abscess: An
abscess occasionally complicates mastitis.
You do not have
to stop breastfeeding, not even on the affected side.
In the past, an abscess was almost always drained
surgically. Now,
more and more, repeated needle aspiration or drainage under
radiographic control is done, and interferes less with
breastfeeding. If
you need surgery, the incision should be kept as far away as
possible from the areola. Contact
the clinic.
A
lump which isn’t going away:
If
you have a lump that is not going away or getting smaller over
more than a couple of weeks, you should be seen by a
breastfeeding friendly physician or surgeon.
You don’t have to stop breastfeeding to get a breast
lump investigated (Ultrasound, mammogram, and even biopsy do not
require you to stop breastfeeding even on the affected side).
A breastfeeding friendly surgeon will not tell you that
you must stop breastfeeding before s/he can do tests for a
breast lump.
Questions?
(416) 813-5757 (option 3) or
drjacknewman@sympatico.ca
or my book
Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA)
Handout
#22 Blocked Ducts and
Mastitis. Revised January 2005
Written by Jack Newman, MD, FRCPC. © 2005
This
handout may be copied and distributed without further
permission,
on the condition that it
is not used in any context in which the WHO code on the
marketing of breastmilk substitutes is violated.
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