Mastitis during breastfeeding: symptoms and ways to ease it

Breastfeeding mastitis can take several forms, of varying severity.

A diagnosis is made when there is localised inflammation of the mother's breast: it becomes tender, red, warm, and painful.

It can appear gradually or suddenly, presenting as a flu-like syndrome with body aches, chills, fatigue, and a fever above 38.5°C.

If not treated promptly and appropriately, it can lead to complications such as an abscess. The risk of weaning is particularly significant when support is poor and/or advice is inappropriate, such as being told to stop breastfeeding during medical treatment…

There are classically two types of mastitis.

Inflammatory mastitis

Inflammatory mastitis is caused by engorgement or a mechanical blockage of a milk duct, but there is not necessarily an infection.

That said, engorgement or blockages can develop into an infection. Areas of the breast that are not drained, or where the milk ducts are blocked, can become focal points for bacteria to settle and trigger an infectious process [1].

Infectious/bacterial mastitis

It typically comes on suddenly, with flu-like symptoms (including fever, chills, and body aches).

In most cases, antibiotics are required. Effective breast drainage, combined with immune responses, can sometimes help eliminate the bacteria and resolve the infection.

The first signs are often confined to one area. Part of the breast becomes tender, red and warm, and sometimes feels firmer, as though a small lump has formed. This often corresponds to a blocked milk duct or engorgement that has not resolved.

As the inflammation progresses, other symptoms may appear within a few hours: severe fatigue, chills, body aches and a fever above 38,5 °C. Many mothers describe it as feeling like flu coming on suddenly.

A fever is not always present: inflammatory mastitis may cause only symptoms in the breast. If symptoms do not improve within 24 to 48 hours despite rest and frequent feeds, or if they worsen, it is time to seek medical advice (see below for what to do if you have mastitis).

Mastitis is fairly common among breastfeeding mothers. Studies report a prevalence of 3 to 20% [2] [3] [4]. Some studies estimate that around a quarter of mothers will experience one or more episodes of mastitis while breastfeeding [5]!

They may be common, but they are certainly not inevitable!

Many cases could be avoided with good breastfeeding practices, rest and making sure your baby is well positioned at the breast to help limit engorgement, particularly during the postpartum period. Most cases occur within 6 weeks of birth, so it is a time to keep a close eye on symptoms.

Causes of inflammatory mastitis during breastfeeding

Mastitis is caused by insufficient drainage of milk, which can trigger an inflammatory reaction behind the blockage. This build-up of milk is called “milk stasis”.

Sometimes, when the inflammation is severe, it can increase permeability to the interstitial fluid surrounding the mammary gland. As a result, substances from the blood plasma, particularly immune proteins and sodium, pass into the milk, and milk production decreases.

This increased permeability can change the composition of the milk, particularly by raising its sodium level [5]. In cases of mastitis, this level can increase 34-fold, while the lactose level falls! The milk then tastes different: saltier and less sweet. Usually, this salty taste is only temporary (around one week) [6].

Causes of infectious mastitis during breastfeeding

One cause is damage to the nipples. The organism responsible is most often Staphylococcus aureus, but sometimes faecal streptococci or Escherichia coli.

In some cases, mastitis can become infectious following inflammation and blockage of the milk ducts.

It is worth noting that, under normal conditions, milk is not a favourable environment for the growth of pathogenic microorganisms (specific microbiota, IgA, lactoferrin, lysozyme, white blood cells…), and the natural direction of milk flow also helps flush out any germs.

The main risk factors

• Cracked nipples
• Breastfeeding infrequently or to a fixed schedule
• If you do not breastfeed at night, particularly when your baby starts sleeping through the night
• A white spot on the nipple or a blocked milk duct
• Supplementing with infant formula or other foods, particularly in the first few months
• Using a dummy
• Poor latch or weak sucking (so the breast is not adequately « emptied » )
• Oversupply of breast milk
• Weaning too quickly
• A bra that is too tight and puts too much pressure on the breast
• Maternal fatigue or stress [7], [8]

There are other possible risk factors.

Returning to work

In 1991, a retrospective study showed that working full-time outside the home was associated with an increased risk of mastitis. This was partly due to long intervals between feeds and a lack of time to express milk.[9]

So if you return to work and continue breastfeeding, do not hesitate to ask for time to express milk. It is your right, and it matters! For more details on breastfeeding and work, read our article on the subject.

Nutrition

Studies have shown that nutrition plays a role in preventing mastitis during breastfeeding in animals. The risk of mastitis may be higher in cases of vitamin E, vitamin A, selenium or antioxidant deficiency[10].

But studies involving breastfeeding mothers are still lacking (yes, mastitis is studied more in animals than in us!)

Having had mastitis before

This recurrence could be due, in part, to an unresolved breastfeeding issue. [11], [12] If you have mastitis, it may be helpful to see an IBCLC lactation consultant to check that your baby is latching correctly and that breastfeeding is going well. She can also advise you during and afterwards, particularly on how to avoid a significant drop in milk production so you can continue breastfeeding with confidence.

The mother's immune system

Components of breast milk such as Ig A and lactoferrin are not only beneficial for the baby; they also help protect the breast against infection. For example, lactoferrin strengthens the attachment of white blood cells to tissue, increasing their effectiveness tenfold![13]

A study of Gambian women found that the milk of mothers who had recurrent mastitis contained low levels of Ig A, C3 and lactoferrin compared with that of other mothers.[14]

Nature has a way of helping: during weaning and breast involution, levels of these immune proteins rise in the milk, helping to protect against infections when engorgement becomes more common during weaning [15].

Studies in industrialised countries have found a prevalence of between 20 and 30%. Yet other studies conducted in Africa, particularly in The Gambia, found an incidence of just 2.6% despite more difficult conditions! [16] One hypothesis is that our societies are too "hygiene-conscious", with too little exposure to pathogens during childhood, which may affect how our immune systems function.

Fortunately, breastfeeding mastitis is not inevitable, even in the first few weeks of breastfeeding!

Avoid wearing a bra that is too tight

They may obstruct milk flow and thus contribute to mastitis. A bra can interfere with venous or lymphatic drainage from the breast, or restrict milk flow. One study found that the volume of a lactating breast could vary by as much as 600 ml in a single day!

Prevent engorgement

The first thing to do is prevent engorgement from developing. If your breasts feel too full, you can express milk by hand.

Care for your nipples

To help prevent cracks, see our article on cracked nipples from breastfeeding. Avoid applying too much cream to your nipples, however, as it may contribute to blocked ducts.

Watch for signs of “milk stasis”

If you start to feel blocked areas or hard patches in your breast, rest and breastfeed more frequently. You can also gently massage any areas that feel a little hard.

Wash your hands thoroughly

To help prevent infections, remember to wash your hands thoroughly, particularly in hospital. This advice applies to everyone, including family members and your partner. If you use a breast pump, wash it thoroughly with soapy water after use.

Recognise the early signs of mastitis and act quickly.

If you miss a feed and your breasts become very engorged, with early signs of inflammation, or you start to feel unwell, get into bed with your baby so you can breastfeed very frequently!

Breastfeed your baby more frequently, starting with the affected breast. If pain inhibits the let-down reflex, you can start with the unaffected breast and switch as soon as you feel the let-down begin.

You can also ask a specialist IBCLC lactation consultant to check your baby’s position at the breast.

And make sure you rest, drink enough fluids and eat well!

Don’t stop breastfeeding!

Milk production in the affected breast may fall for a few days, but it is important that your baby continues to breastfeed from that side to prevent the infection from developing into an abscess. [17], [18], [19]. If needed, you can take a food supplement for breastfeeding women to support your milk supply.

According to numerous studies, it is safe to continue breastfeeding even if you have infectious mastitis, including in cases of Staphylococcus aureus infection. [17]

Warm and cold compresses

To relieve pain and encourage milk flow, you can:

• Place a warm compress on the affected breast,
• Soak the affected breast for 10 minutes by leaning over a basin of hot water (3 times a day). This also helps remove dried secretions that could block milk flow.
• Take a warm shower.[20]

Do this just before a feed, while your breast is still warm, to try to clear the blocked duct.

Afterwards, applications of breastfeeding compress cold compresses may help reduce pain, swelling and inflammation.

Our breast pads can be used warm or cold to provide relief when you need it.

Bye-bye, bra!

If possible, go without a bra for a few days. Choose soft bras instead, and at the very least avoid underwired bras. Free the nipples!

Massage the area

Gently massage the affected area while your baby feeds, using your fingertips or the palm of your hand to massage the warm, painful area towards the nipples.

Be careful when massaging: always be gentle to avoid further inflaming the breast tissue.

You can also use an edible oil to help relax the area. Always massage from the outer part of the breast towards the nipple.

Encourage milk drainage

To encourage milk drainage, try positioning your baby with their chin facing the affected part of the breast. [20] You can also try expressing milk by hand if you think a duct is blocked. [21] For more information, see our article on how to express breast milk.

You can try getting on all fours or lying on your back. It may feel a bit strange, but it can sometimes help clear the blockage!

If things do not improve within 24 hours, contact your doctor or midwife.

Painkillers

Your healthcare professional may prescribe painkillers, such as paracetamol, and sometimes anti-inflammatories such as ibuprofen. Pain relief can help the let-down reflex occur, so taking it is an option.

Note that NSAIDs (non-steroidal anti-inflammatory drugs) are compatible with breastfeeding. According to CRAT, “The amount of ibuprofen ingested through breast milk is very low: the child receives less than 1% of the usual paediatric dose (20 to 30 mg/kg/day). In the literature, no particular adverse events have been reported among around twenty breastfed children whose mothers were taking ibuprofen. Furthermore, there is extensive experience of ibuprofen use during breastfeeding.”[22]

A study also found that “ibuprofen is undetectable in breast milk after maternal doses of up to 1.6 g/day.”[23]

However, NSAIDs can mask an infection or even make it worse, so always ask your doctor before taking anything.

To check whether a medicine is compatible with breastfeeding, you can visit the website of the Reference Centre for Teratogenic Agents (CRAT).

Antibiotics aren’t always needed for breastfeeding mastitis!

80% to 90% of mothers who seek medical advice for mastitis are prescribed them.

This treatment is not necessarily needed, particularly for inflammatory mastitis.

This may be prescribed if:

• One or more nipple cracks have become infected
• No improvement after 24-48h despite effective drainage of the breast

Taking antibiotics increases the risk of breast and vaginal thrush in women and also affects gut flora. That is why they should only be taken when necessary.

Very rarely, mastitis develops into an abscess (in fewer than 3% of cases). [24] If the area remains hard, red and painful despite treatment, seek medical advice as soon as possible.

Does your breast milk need to be tested?

A bacteriological test is not necessary for mastitis, even if it is infectious.

Many breastfeeding women have potentially harmful bacteria in their milk without having mastitis [25]… Around 20% of the population may carry Staphylococcus aureus. The reverse is also true: many women with mastitis have milk that contains no harmful germs!

Doctors may then decide to test the milk and carry out an antibiotic susceptibility test if the prescribed antibiotics have not worked after a few days, if the mastitis recurs, or if you are allergic to the treatments usually used.

Reduce your intake of saturated fat

If your ducts are frequently blocked and your baby’s latch is optimal, you can try reducing saturated fat in your diet and taking one tablespoon of lecithin a day.

Plants

Traditional Chinese medicine uses plant extracts (Fructus gleditsiae) to relieve mastitis.[26]

Traditional remedies to relieve engorgement

The warm bottle method

This method was recommended in the WHO mastitis guide to relieve engorgement and/or blocked ducts. [27]

You will need:

• a wide-necked glass bottle that completely covers the nipple
• a kettle of hot water to fill the bottle
• cold water to cool the bottle neck
• a thick cloth to protect your hands while holding the bottle

Instructions:

• Pour a little hot water into the bottle to start warming it, then fill it almost completely, but not too quickly, as the glass could break.
• Leave the bottle to stand for a few minutes so the glass warms up.
• Wrap the bottle in the cloth and empty it into the saucepan.
• Cool the bottle neck with cold water, inside and out (to avoid burning your skin)
• Place the bottle neck over the nipple so that it seals against the surrounding skin, creating a vacuum. Hold the bottle in place.
• After a few minutes, the bottle cools, creating suction that gently draws the nipples inside
• The warmth helps trigger the let-down reflex and encourages milk flow. Keep it in place while milk is flowing. You can repeat this if necessary.

Cabbage leaves

Refrigerated cabbage leaves, or leaves at room temperature, are sometimes recommended to relieve symptoms of engorgement.[28]

A 2015 study suggests that applying refrigerated cabbage leaves to a swollen breast provides similar relief to a warm compress.[29] Hollyhock leaf compresses combined with other remedies may also help reduce engorgement.[30]

Many books put forward the theory that refrigerated cabbage leaves contain a compound that is absorbed through the skin and can reduce swelling. However, no published or clinical evidence has yet supported this theory. Coolness and compression alone have a soothing effect, so cabbage leaves, by providing both, may help reduce inflammation [31].

La Leche League’s method for relieving engorgement with cabbage leaves:

• Wash, dry and refrigerate several cabbage leaves for the breast you want to treat.
• Remove or soften the central rib of each leaf, or cut the leaves into large pieces for greater comfort and flexibility.
• Hold the cabbage leaves against your breasts or tuck them into a loose bra to keep them in place. Leave your nipples uncovered, especially if they are sore, cracked or bleeding.
• Remove the cabbage leaves after twenty minutes, or when they begin to feel warm.
• Discard the cabbage leaves.
• Gently wash your breasts if you wish. Do not reuse the same leaves.

If you are not weaning, you can apply cabbage leaves for twenty minutes three times a day, but no more. Excessive use of cabbage leaves can reduce milk production.

Breastfeeding mastitis can therefore be prevented with appropriate precautions.

If engorgement or mastitis is starting, don’t wait! Breastfeed more frequently and try the different measures outlined above.

Consult your healthcare professional if symptoms persist or worsen within 24 hours.

Seek support from an IBCLC too, particularly to help avoid early weaning. If the breast is not drained properly, milk production may fall and breastfeeding may stop.

Take care mama !

Do not take supplements or self-medicate without advice from a doctor, midwife or pharmacist. This advice is not a substitute for medical advice or any ongoing medical treatment.