Lactational Mastitis

Question 1

Lactational … is a relatively common condition affecting post-partum women.

Answer 1

Lactational mastitis is a relatively common condition affecting post-partum women.

Question 2

…: refers to inflammation of the breast tissue. … may be lactational (occurring in lactating women) or non-lactational. It can also be categorised as infectious or non-infectious.

Answer 2

Mastitis: refers to inflammation of the breast tissue. Mastitis may be lactational (occurring in lactating women) or non-lactational. It can also be categorised as infectious or non-infectious.

Question 3

Lactational mastitis affects around ..-..% of lactating women.

Answer 3

Lactational mastitis affects around 10-33% of lactating women.

Question 4

Lactational mastitis is normally caused by the blockage or reduced drainage of …

Answer 4

Lactational mastitis is normally caused by the blockage or reduced drainage of milk ducts.

Question 5

There are a number of factors that predispose patients to mastitis. These include …. Or …

Answer 5

There are a number of factors that predispose patients to mastitis. These include difficulty breastfeeding (e.g. due to poor attachment of the baby’s mouth to the nipple) or reduced breastfeeding (e.g. weaning of breast milk):

Question 6

There are a number of factors that predispose patients to mastitis:

Poor attachment to breast such as in …
… palate
Short …

Reduced feeding (number or duration):

Rapid …
… feeding
Breast …

Pressure on the breast:

…
… position
Tight …

Answer 6

Poor attachment to breast:
Cleft palate
Short frenulum

Reduced feeding (number or duration):
Rapid weaning
Unilateral feeding
Breast tenderness

Pressure on the breast:
Seat belts
Sleeping position
Tight bra

Question 7

When infection occurs (breast abscess) … … (including MRSA, particularly in the inpatient setting) is most frequently implicated.

Answer 7

When infection occurs staphylococcus aureus (including MRSA, particularly in the inpatient setting) is most frequently implicated. Typically breast abscesses follow the development of mastitis, however, in some cases, mastitis may be absent or not clinically evident.

Question 8

Preventing lactational mastitis:
At booking (the first appointment with a midwife, scheduled early in pregnancy), women who are at increased risk of lactational mastitis can be identified. An example taken from Epsom and St Helier guidance advises identifying the following women - (7)

Answer 8

Breast surgery (i.e. Augmentation/Reduction)
Problems relating to feeding her last baby
History of mastitis/breast abscess
History of Raynaud’s disease of the nipple, skin conditions on the breast or near the nipple area (e.g. psoriasis, eczema, nipple piercings)
Current un-investigated breast lump
Nipple piercing
Previous history of breast cancer/Paget’s disease

Question 9

Factors that may reduce the risk of mastitis include: (8)

Answer 9

Ensure skin to skin contact following birth and during inpatient stay
Effective positioning and attachment during breast-feeding
Frequent and baby-led feeding
Avoiding nipple trauma through effective technique
Promoting mother/baby bond
Avoid the use of dummies
Hand expression of breastmilk when needed
Avoiding pressure on the breast

Question 10

Local signs of mastitis (typically unilateral): (5)

Answer 10

Pain
Redness
Swelling
Hot
Lymphadenopathy (typically axillary)

Question 11

Signs of systemic upset (lactational mastitis) - 4

Answer 11

Malaise
Myalgia
Pyrexia
Tachycardia

Question 12

Infective vs non-infective lactational mastitis - how to clinically distinguish?

Answer 12

It can be difficult to clinically distinguish between infective and non-infective mastitis. Consider the timing of the presentation and whether there is clinical improvement. After around 12 hours (if symptoms and blockage are not resolving), infection is likely due to ongoing milk stasis. Fissuring or evidence of nipple infection is also indicative of infective lactational mastitis

Question 13

Simple lactational mastitis may be managed how?

Answer 13

Simple lactational mastitis may be managed without additional investigations.

Question 14

Breast milk …: not routinely required and practice tends to vary. NICE CKS advises sending a sample if mastitis is severe or recurrent, there is a risk of hospital-acquired infection or a deep burning indicative of ductal infection. It is normally sent in any patient requiring hospital admission.

Answer 14

Breast milk culture: not routinely required and practice tends to vary. NICE CKS advises sending a sample if mastitis is severe or recurrent, there is a risk of hospital-acquired infection or a deep burning indicative of ductal infection. It is normally sent in any patient requiring hospital admission.

Question 15

Outpatient care - mastitis

Answer 15

Patients who are systemically well, without significant co-morbidity and in the absence of rapidly developing symptoms or other cause for concern, management can be in the outpatient setting. A number of measures can give comfort and relieve symptoms:

Analgesia (e.g. ibuprofen, paracetamol)
Warm compress and warm water bathing

Question 16

Mothers who are breastfeeding should be encouraged to do what (with lactational mastitis?)

Answer 16

Mothers who are breastfeeding should be encouraged to continue this from both breasts wherever possible. If the breast is not completely empty (on the affected side), the remaining milk should be expressed (manual or with a breast pump).

Question 17

Where it is not possible to continue breastfeeding (maternal preference, pain etc) mothers should be encouraged to express milk at least … times each day.

Answer 17

Where it is not possible to continue breastfeeding (maternal preference, pain etc) mothers should be encouraged to express milk at least 8 times each day.

Question 18

Mastitis: if symptoms worsen, do not improve after 12-24 hours of effective milk clearance or milk culture is positive, clinically reassess and again consider the need for inpatient care. If not required commence oral antibiotics, antibiotics should also be given where there is evidence of an infected nipple fissure. If there is a positive milk culture use an appropriate antibiotic as per the sensitivity of the organism. Empirical treatment may be in the form of:

Answer 18

Flucloxacillin 500 mg QDS for 10–14 days
Penicillin allergic:
Erythromycin 250–500 mg QDS for 10–14 days or
Clarithromycin 500 mg BD for 10–14 days

Question 19

The development of a breast abscess requires urgent referral to hospital and a surgical review. As described above any patient presenting with signs of sepsis should be managed in line with the sepsis 6 principles with an immediate senior review.

The two main surgical techniques to treat an abscess are:

… and …
Needle …

Answer 19

The development of a breast abscess requires urgent referral to hospital and a surgical review. As described above any patient presenting with signs of sepsis should be managed in line with the sepsis 6 principles with an immediate senior review.

The two main surgical techniques to treat an abscess are:

Incision and drainage
Needle aspiration