3-8
of a duct. Infection is not present but MAY RESULT if the duct remains blocked. See end of this section
for treatment.
Breast Engorgement - Gradual onset in the immediate postpartum period (peak on days 2-4) of bilateral breast
swelling and warmth. Pain is generalized. Fever may occur but is rarely over 101°F. The breasts feel better
after they are emptied. Caused by inadequate emptying of the breasts. A risk factor for mastitis. See end
of this section for treatment.
Breast Abscess - Painful, fluctuant mass. 10-15% of women who delay treatment of mastitis will develop a
breast abscess. Should be suspected if a patient on antibiotics for mastitis does not improve after 72 hours of
antibiotic therapy. See Breast Abscess Incision and Drainage Procedure description in following section.
Breast Cancer - Very rare. Unilateral, unchanging lump or mass that persists despite treatment for
engorgement. Plugged duct or persistent mastitis must be evaluated by appropriate radiological and surgical
approaches, if possible.
Plan:
Treatment for Mastitis
Primary:
- Ensure infant nurses on both breasts, starting on the unaffected side. Even after feeding the affected
breast may need to be more thoroughly emptied by manual expression or pumping. - Put mother on bedrest. Maternal fatigue and stress are risk factors for recurrent mastitis. The baby
should be right next to the mother either in the same bed or readily available in a nearby crib to facilitate
frequent emptying of the breast. - Ensure mother completes full course of therapy:
a. Dicloxacillin or cephalexin 500 mg po q 6 hrs x 10 days
b. Patients allergic to penicillin: clindamycin 300 mg po q 6 hours x 10 days or erythromycin 500
mg po q 6 hours x 10 days
c. If patient does not improve after 48 hours of rest and therapy, switch to Augmentin (amoxicillin/
clavulanate) bid if 875/125 mg or tid if 500/125 mg. - Apply ice packs or warm packs to the breast (whichever the mother prefers). Hot packs provide drainage
and pain relief. - Ensure mother drinks plenty of fluids.
- Give ibuprofen or acetaminophen for pain relief.
- Advise mother to wear a support bra or other supportive clothing that does not cause painful pressure
on the breast.
Alternate: Patients who are intolerant of oral medications may need IV therapy. You may use nafcillin
or oxacillin 2.0 gm q 4 hrs IV or cefazolin 1.0 gm IV q 8 hours. Penicillin allergic patients can be given
clindamycin 300 mg IV q 6 hrs.
Primitive: If antibiotics are not available, initiate rest, hydration and MOST IMPORTANTLY, drainage (nursing)
of the affected breast. Mastitis will recur in at least 50% of women not treated with antibiotics, and the breast
abscess rate will be high.
Patient Education
General: Counsel family to assist the mother.
Activity: Bedrest. If patient is improving she may gradually increase her activity level after 72 hours of
strict rest.
Diet: Fluids and well-balanced diet
No Improvement/Deterioration: Improvement in systemic symptoms is expected in 24-48 hours. The focal
breast tenderness should be significantly improved in 72 hrs then gradually resolve in 7-10 days.
Follow-up Actions
Return evaluation: 48-72 hrs. Reassess vital signs and perform breast examination for mass or fluctuance
(evaluate for abscess). Reemphasize compliance with antibiotic therapy and rest. Assess breastfeeding
frequency and nutritional status of the infant. Be sure the mother is emptying the infected breast. If the patient
is not improving, consider changing antibiotics to Augmentin.