The mastitis spectrum – everything you need to know

‘I’ve never felt that terrible before’, is usually the reply one receives when asking a breastfeeding mom about her bout of mastitis.

Mastitis is the name for a collective group of symptoms/conditions linked to inflammation of breast tissue in a breastfeeding mother. In 2022 the Academy of Breastfeeding Medicine updated their protocol on the management of mastitis and related conditions, completely changing how we view and treat these.

Please note that this feature is part of our series on ‘ The Updated Protocols on Engorgement, Mastitis and Breast Tissue Complications’. Please click here to visit the main article in the series, which explains the basics and will also give you access to all other supportive content.

Please also note that this feature is detailed, as this site aims to give information to moms that goes beyond the common copy-and-paste features on the internet. If you feel that you simply cannot read this much, click here for our cheat sheet with the basics.

What is Mastitis?

Mastitis means ‘inflammation of the breast’, and can present as breasts that are painful, warm, swollen and red. It can occur in one or both breasts, and can involve the whole breast or only a section of the breast.

Engorgement on its own will involve breast fullness, but the inflammatory cascade described in our man feature hasn’t yet started. Once this has happened a woman’s immune system will start sending inflammatory markers to the rest of the body via the breasts’ very rich blood supply, and she will start feeling ill. Common symptoms include body aches, chills, flu-symptoms and fever. She now has Inflammatory Mastitis. If this is not treated correctly and effectively it can indeed progress to Bacterial Mastitis, where a bacterial infection is involved. If the latter is neglected it may result in a breast abscess.

It’s important to remember that the presence of a fever does not mean that there is an infection; it may simply be due to this inflammation, and the use of antibiotics at this point is unnecessary and ineffective.

Remember as well that the hormonal changes in the days after birth may result in sweating and hot flushes, as well as anxiety (which may give heart palpitations). These symptoms may mimic mastitis, so be sure to keep this in mind when speaking to your doctor.

Risk factors for mastitis

• Latching difficulties
• Anatomical variations in baby’s mouth like a tongue or lip tie, or a high palate.
• Anatomical variations of the breast like inverted nipples.
• A sleepy baby not feeding well, which can happen due to prematurity, infection, jaundice, or pain medication given to mom in labour.
• Mom that is tired, anxious and stressed out (which many moms are, especially if they have other small children at home).
• A weakened immune system.
• Busy schedule with irregular feeding (often happens while travelling or on holiday).
• Baby suddenly sleeping through the night.
• Not feeding on demand.
• Using a dummy to stretch baby’s time between feeds.
• If mom has had a blocked duct or mastitis before.
• Wrong advise that leads to moms feeding on a schedule, removing baby before baby has finished feeding from a breast, and stretching feeds.
• Overstimulating with a breast pump or silicone milk collector.
• Using massage as a treatment option for engorgement.
• The unnecessary use of medication to increase milk supply (which in South Africa is prescribed routinely by some doctors).

Baseline treatment of all forms and stages of mastitis

The following treatments should be your first-line of defense, for all types of mastitis. Scroll down for extra tips on Bacterial Mastitis.

Nurture and support

• Firstly, although this is stressful, don’t loose hope. With the correct management you should be able to continue feeding your baby soon.
• This is the time to line up all your support. Your aim should be to rest, stay in bed with baby, eat healthy and to drink enough fluid. Nurture your body so it’s normal physiological processes can find their balance and function again.

Feeding your baby (don’t aim to empty your breast)

• Neither Inflammatory or Bacterial Mastitis is a reason to stop breastfeeding or to not give your baby your breast milk!
• In order to feed effectively your baby needs a proper latch. If you are experiencing nipple pain or suspect that baby is not latching well, you should urgently seek the assistance of a certified lactation consultant. It would in any case be a good idea to see someone to ensure that your are managing the mastitis correctly, You can email us on info@allthingsbreastfeeding.co.za for assistance in finding someone in your area.
• Feed your baby on demand in a position comfortable to you. Do not force feeding on the affected side. The goal with treatment is no longer to empty the breast (as this is not going to happen anyway, seeing as it’s not just milk but swelling and inflammation causing the fullness).
• If you are exclusive pumping, express only the volume that your baby needs. Click here for more tips on using a breast pump during mastitis.
• If you are not managing to express milk with your pump, rather stop and try to hand express small volumes.
• If you are also not managing to express any milk via hand it would be best to stop completely and allow your breast to rest.
• Note that during the acute phase of mastitis swelling (breast oedema) may make it impossible to get any milk out. If this is the case it’s best to use ice and lymphatic drainage (see below) to reduce swelling and inflammation, and simply let the breast rest.
• All of the above will affect your supply, but it can be augmented (boosted) again once the mastitis has cleared. The latter should be your goal.

Minimize breast pump usage

• On this point there is some controversy, but the new protocol advises moms to limit the use of breast pumps, as this can overstimulate supply and often sits behind the problem. This is probably true for moms pumping in addition to their babies feeding well.
• Ideally we want baby’s mouth to be in contact with mom’s breast, as they exchange good bacteria which keeps both the breasts and baby’s mouth and gut healthy. This can also help prevent mastitis (read on ‘dysbiosis’, or bacterial imbalances, in our main feature)
• It’s important to note that pumping in itself sometimes form part of a care plan, for example in a baby refusing to latch or a baby in NICU. If this is the case you are completely dependant on pumping for your supply.
• I want to add that not all pumps are equal. A mom with a good breast pump and a correct flange size will be less likely to develop mastitis in the first place, compared to a mom with a pump that stimulates the breasts without emptying it properly.
• For the same reasons nipple shields are also not advised; however, many babies only latch with a shield, which is why I don’t personally think one should use this statement with caution.
• Click here for our feature on how to safely use a breast pump during engorgement and mastitis.

Ice your breasts

• Icing the breasts is often the most effective treatment for mastitis
• Do not apply ice or iced packs directly to the skin; wrap in a cloth or use sports ice packs. A bag with frozen vegetables also works well.
• Applying ice reduces swelling and constricts the blood vessels in the breast (thus making them smaller). This will reduce pressure on the milk ducts and will enable milk to flow more freely.
• The above will assist in lymphatic drainage of fluid in the breast tissue.
• Ice will also help to reduce pain and discomfort.
• If you struggle with feeling cold, have a hot water bottle or wheat bag somewhere else against your body, for example against your lower abdomen or lower back.

Supporting your breasts

• Wear a supportive bra as lactating breasts are highly vascular and need support.
• Oedema (swelling) will collect at the bottom of the breast, like swollen ankles if sitting too long. A supportive bra acts like a compression stocking to prevent this.
• Be sure that it doesn’t contain a wire, or put pressure on areas in the breasts.
• Have a look at our Carriwell range of breastfeeding underwear for breast-friendly options.

Medication, remedies and other treatments

• Use a nonsteroidal anti-inflammatory drug (NSAID) like Ibuprofen 800mg every 8 hours. This will reduce inflammation and swelling, and will bring some relief to your symptoms.
• You can add Paracetamol (Panado) for further pain relief, 1000mg every 8 hours.
• Tip: vary the Ibuprofen and Paracetamol every 4 hours, so that you take each three times a day, but that they ‘overlapse’ to ensure that you continuously feel better.
• Gently apply Natura’s Arnica Gel or Heel’s Traumeel Gel to your breasts – these are homeopathic remedies and are safe to use in breastfeeding. Do not let the gel come onto your nipples. Note: applying other ointments like castor oil is not recommended.
• Natura’s homoepathic tissue salts number 4, 9 and 12 form a fantastic mix to encourage milk flow and prevent/treat mastitis. Use a tablet of each tissue salt every hour until you feel relief, and then gradually reduce it to three times a day.
• Use a sunflower lecithin supplement, as this is a natural fat emulsifier that can help to reduce the “stickiness” of the milk and deter fats from lumping together.
• If you have access to this you can also contact a physiotherapist that provides therapeutic ultrasound. This can make a big difference. Enquire at your hospital’s labour ward.
• YOU DO NOT NEED ANTIBIOTICS UNLESS YOU HAVE BACTERIAL MASTITIS!

How to (not) use massage

• At all cost, avoid deep massage of an engorged breast! This is one of the main reasons why mastitis progresses.
• If you do use massage, use light strokes of the skin rather than pressure.
• You can use very gentle compressions during feeding or pumping.
• Avoid vibrating devices like electric toothbrushes and breast massagers.
• Educate yourself on how to do lymphatic drainage – click here for a very useful handout. https://eadn-wc01-5994650.nxedge.io/wp-content/uploads/2021/08/Lymphaticmassagehandout2.pptx.pdf

Protect your bacterial profile (microbiome)

• Avoid sterilising anything and everything in the house, including breast pumps. You can click here for the FDA’s guideline on cleaning breast pumps. https://www.fda.gov/medical-devices/breast-pumps/cleaning-breast-pump
• Note that routine sterilisation is not recommended if you follow their steps. However, I recommend sterilising once a day, and possibly sterilising more frequently if you have a baby vulnerable to infection (like premature babies and babies with congenital heart disease).
• Don’t use antibiotics unnecessarily.
• Avoid cleaning the nipple, unless it is cracked and bleeding. If this is the case you can rinse it with salt water after a feed. Click here for our guide to nipple pain.
• Take care to follow a healthy diet, get enough rest, and avoid smoking and alcohol as all these things can bring down your immune system, which makes you more prone to problems.
• You may read about using a probiotic that contains Limosilactobacillus fermentum and Ligilactobacillus salivarius. At the time of writing this feature I haven’t yet managed to find a product containing both of these in South Africa, plus many of the products contain other herbs as well, which may not be advised in breastfeeding. I want to note that the research on this is also controversial – click here for an article offering some critique.

Nipple Care

• Once again, avoid cleaning the nipple, unless it is cracked and bleeding. If this is the case you can rinse it with salt water after a feed. Click here for our guide to nipple pain.
• Be sure to manage nipple blebs

Managing an oversupply

• Note: I am hesitant to even add this section, as an oversupply is not even a term that can be properly defined. It is also commonly overdiagnosed, and true oversupply is very rare.
• The below link offers good advice and information, and I am sharing it as the honest (and sad) truth is that I haven’t yet found time to provide a similar feature on this site. Be sure to follow their steps gradually, and take great care if you start experiencing engorgement because of not emptying your breast.
• Take care with their suggestion for massage, as this point is not supported by latest protocols.
• Having said that, La Leche league always offers useful information, and their feature is a good guide for moms. Click here for access to their article.

If inflammatory mastitis progresses to Bacterial Mastitis

Signs of Bacterial Mastitis

• Fever and fast heart rate lasting more than 24 hours
• Your breast didn’t respond to all the above measures
• Lab (blood) tests that confirm an infection

Local symptoms (in your breast):

• Abnormal swelling and/or a wedge of redness on the breast.
• A painful lump on the breast or general breast tenderness.
• Pain or burning while breastfeeding
• A breast that feels unusually warm or hot to the touch

Systemic symptoms (rest of your body):

• Flu-like symptoms
• Chills
• Fatigue
• Fever
• Fast heart rate

Management in addition to the above steps:

• You will need a doctor who may prescribe antibiotics.
• In rare cases hospitalization may become necessary.

Here are a few more methods no longer recommended as a treatment option for engorgement and mastitis:

• Applying heat in the form of compresses, warm showers and warm water soaks. This will simply worsen swelling and inflammation.
• Any form of massage to get rid of plugs and clogs.
• Applying saline soaks or castor oil to the skin – take note though that I personally recommend Heel’s Traumeel Gel or Natura’s Arnica Gel as these are homeopathic, safe in breastfeeding and anti-inflammatory. Simply apply it to the breast (not onto the nipple itself); don’t massage or rub it in.
• Trying to empty the breast through pumping – this often doesn’t empty much and simply stimulates even more supply.
• Using any form of vibrating device like a breast massager, an electric toothbrush or a vibrator.
• Dangling over baby or feeding baby in any other unusual position. Rather just choose a position comfortable to you and baby.
• Using silicone milk collectors to drain the breast – this will once again increase supply and may cause additional swelling.
• Applying cabbage leaves to the breasts – there is no evidence that this will work better than ice packs, and it carries the risk of listeria infections.

Should you continue feeding?

Yes, definitely! Sometimes moms are told to stop feeding while on the medication, or if they have blood or pus in the breast milk. It is important to note that this is not harmful to baby, and it is crucial that you keep on frequently and thoroughly emptying your breast. The medication prescribed for mastitis are also safe during breastfeeding.

If you stop feeding not only will it further affect your supply, but baby may also get used to drinking from a bottle and may end up refusing to go back onto the breast. Be sure to practice pace bottle feeding.

I should mention though that mastitis can temporarily affect the taste of the milk, so occasionally a baby may refuse the affected breast. If this happens you should carry on expressing and discard that milk, while feeding baby on the opposite side. Try putting baby back as soon as the worse symptoms have resolved.

Longer term effects of mastitis

If a blocked duct or mastitis are not treated efficiently it may lead to a breast abscess, probably the most unpleasant complication during breastfeeding.

Mastitis can unfortunately affect milk supply, especially if the breast is left full for long periods. You may need dedicated feeding and extra expressing to restore the production.

It can also recur, which is why it is important to find and address the underlying cause. If a blocked duct keeps recurring taking a Sunflower Lecithin supplement may sometimes help.

Extra reading:

https://llli.org/breastfeeding-info/mastitis/