Mastita post-partum

Postpartum mastitis is an inflammatory disease of the mammary gland sometimes associating a bacterial infection, which usually develops after delivery, being also associated with lactation.

Mastitis is usually due to a low flow of milk. When lactation begins, milk invades the mammary tissue, which responds with inflammation and predisposes to infection. Also, the infection develops when the nipple becomes cracked and irritated (usually due to an improper breastfeeding technique), allowing the penetration of bacteria.

In non-breastfeeding women, mastitis can occur due to the dilation or irregularities in the duct, breast damage (cut or bite), and very rare due to breast cancer or tuberculosis.

During breastfeeding, mastitis usually affects one breast and starts with a painful, hot and reddened area. Fever, chills, neuralgia and pseudogripal symptoms (flu-like) may occur. In this case, the doctor’s intervention is required.

The worsening of mastitis is manifested by damage to the axillary lymph nodes on the side of the affected breast, which are increased in volume and painful, and also pulse acceleration and the aggravation of influenza symptoms. Mastitis can evolve to breast abscess, which presents itself as a firm and painful form.

Risk factors

During lactation, mastitis can occur at any time. The period with the highest risk is in the first two months after birth, before breastfeeding habits are regulated.

Risk factors for the appearance of mastitis during breastfeeding include:

• the existence of an earlier mastitis episode;

• incomplete or delayed breast emptying, which favors engorgement;

• blockage of mammary channels;

• cracked and irritated nipples due to incorrect breast positioning of the baby;

• various affections or anemia (anemia favors fatigue and decreases body resistance to infections, such as mastitis);

• using breastfeeding devices that block the flow of milk, also multiplying the germs on the nipple surface, thus increasing the risk of infection. These devices can be:

  • plastic coatings, that favors air circulation to the nipple;

  • plastic shields used to protect the nipple;

  • nipple rubber shields used to help the baby breastfeed easier;

  • pillows that cover the breast used to absorb excess milk;

  • inappropriate bras;

  • straps (loins) for breasts used to stop lactation.

Diagnosis

The doctor can diagnose mastitis based on symptoms and physical examination. If the infection does not respond to treatment, the mother’s milk cultures can help to identify the type of bacterium that causes the infection.

Symptoms

The symptoms of mastitis usually occur within the first 4-6 months after birth. Consult your doctor if symptoms of mastitis occur early.

In case of mastitis, at the onset there may be no­ticed:

• a painful area on one of the breasts, which can be erythematous and hot;

• chills, neuralgia and flu-like symptoms;

• a raising of the body temperature to about 37.8 °C or more.

These onset symptoms may occur after the treatment of a mammary channel blockage.

When the mastitis gets worse, one can notice:

• pulse increase (over 100 beats per minute);

• a yellowish and dense leakage from the nipple;

• the axillary lymph nodes of the affected breast are increased in volume and sensitive.

Breast abscess

Occasionally, symptoms of mastitis may worsen and an abscess may appear in the infected area. Symptoms of breast abscess include:

• a firm and painful breast formation;

• an erythematous area of the breast;

• the aggravation of influenza symptoms.

Aphthae

Aphthae (“yeast” infection) can appear in the child’s mouth and can spread to the nipple and mammary channels. If there are mastitis symptoms that do not disappear after treatment – such as pain in the nipple area during and after breastfeeding, sharp breast pain between breastfeeds or pink nipples –, these suggest the presence of aphthae. It can also begin with pain or sudden burns during breastfeeding that progress smoothly.

If there are symptoms suggesting the presence of the aph­thae, the breasts and baby’s mouth should be inspec­ted. The treatment of aphthae applies to both the mother and the baby, even though there are no symptoms.

Investigations

Usually, the diagnosis of mastitis can be determined based on the symptoms and the examination of the affected breast.

Breast milk cultures

If the infection does not improve after treatment, a culture from the mother’s milk can be harvested. To obtain the sample, a small amount of milk from the affected breast is taken on a sterile swab. The results of the culture will confirm the presence of bacterial mastitis.

Occasionally, it takes more than an antibiotic cure to treat a mammary infection. If there is no response to antibiotic treatment, the results of the culture can determine the antibiotic most effectively.

In some cases, a pus bag is formed in the erythematous area of the breast. If the abscess is too deep to palpate it, an ultrasound of the breast can be performed. The ultrasound can also be used for abscesses that need to be punctured to be drained. Usually, a culture is drawn from the extracted liquid to determine the infecting organism.

Treatment – generalities

The most important factor to remember about mastitis is that the early antibiotic treatment and continued breastfeeding (or pumping) are essential for its healing. Delaying treatment may result in breast abscesses. The relief of symptoms can be achieved by resting, consuming high amounts of fluids and by using cold applications at the painful breast. You can safely administer acetaminophen (paracetamol) for pain and ibuprofen for pain and inflammation. If necessary, both can be administered, alternating doses.

Although it is painful, breastfeeding from the affected breast is safe for the baby. If your nipples are too cracked and too painful to breastfeed, use a pump to empty your breasts every time you cannot breastfeed.

This is the right time for the mother to seek the advice of a lactation consultant. Changing breastfeeding positions and providing a proper suction for your baby can help you breastfeed more effectively without pain and thus prevent future episodes of mastitis.

Mastitis will not disappear without treatment. If there are symptoms suggestive of mastitis, a specialist consultation is needed. Rapid treatment prevents the worsening of the infection and relieves symptoms in about two days.

Mastitis treatment usually includes:

• Oral antibiotic therapy to destroy the bacterium that causes the infection.

• Regularly emptying breasts by breastfeeding or pumping. Appropriate emptying of the affected breast prevents enlargement and may shorten the course of infection. The baby is the most effective breast pump. The baby can safely feed on mother milk because any bacteria will be destroyed by digestive juices.

• Before breastfeeding apply a clean, warm and moist cloth on the affected breast for 15 minutes (for milk to flow more easily); try this method at least three times a day. Thus, lactation is stimulated. The same can be done by massaging the affected breast.

• If possible, breastfeeding continues on both breasts. It is preferable to start breastfeeding with the affected breast because it is essential that it is completely emptied. If it is too painful to start with this breast, it can be nourished from the healthy breast. After the milk flow has been initiated, it nurses from the sick breast until it becomes soft and continues from the healthy breast.

• Pump or manually express milk from the affected breast if it is too painful to breastfeed. Nipple pain can be caused by sucking on an already painful area.

Treatment of breast abscesses

If the mastitis occurs due to blocking the mammary channels and delaying treatment, the infection may evolve to an abscess. The treatment of abscesses includes:

• draining abscesses (healing abscesses can take 5-7 days);

• oral antibiotic treatment to destroy the bacteria causing the infection (antibiotics are administered intravenously only for severe infections);

• complete and regular emptying of breasts through breastfeeding or pumping is essential to maintain a proper milk reserve.

Most women can continue to breastfeed during the healing of the abscess. With the doctor’s consent, you can cover the affected area with a gauze during breastfeeding.

If the doctor recommends stopping breastfeeding from the affected breast while healing the abscess, breastfeeding may continue from the healthy breast. Pumping or the manual expression continues from the sick breast periodically.  

Conflict of interests: The authors declare no conflict of interests.