Mastitis: management, consequences, prevention

Management of mastitis: key principles

Here are the key principles of management of the breast inflammation commonly referred to as mastitis - even though mastitis technically applies to all breast inflammation because it means 'inflammation of the breast'! Mastitis in the commonly used sense is a localised acute inflammation of a lactating breast.

1. Frequent flexible milk removal (Principle #1). Milk removal and accompanying ejections may occur with

   • Negative pressure of the vacuum from the baby's suckling (which is the most efficient way to extract milk) or the breast pump, or

   • Positive pressure generated by gentle hand expression. Because positive pressure is required, hand expression runs the risk of causing microhaemorrhages in the highly vascular (hypaemic) breast tissue.

2. Cease massage, including lump massage, vibration, and Therapeutic Breast Massage of Lactation or Manual Lymphatic Drainage, which are light massages applied across the breast skin from the nipple towards the axillae (Principle #2).

3. Resolve any other external application of mechanical pressure (Principle #2), such as

   • Bra or garments applying pressure to breast tissue

   • Sleeping position at night which applies prolonged pressure on breast tissue

   • Use of silverettes, wearable pumps, or breast shells which may apply pressure on breast tissue.

4. Resolve any nipple and breast tissue drag or positional instability (Principle #2).

5. Some women with generous breasts may feel relief if they very gently move their breasts with the palms of their own hands (Principle #3). They may like to do this in a warm or hot shower.

6. If the mastits develops during weaning, the mother applies Principle #4, that is, delays downregulation of milk production until the breast inflammation has resolved. Afterwards, she aims downregulate her milk production without tipping a full breast into a mastitis due to the effects of backpressure in the alveoli. She will need to either

   • Wean baby from the breast in a more gradual way, or

   • Hand express or pump milk from her breasts frequently and flexibly on the affected side, if she isn't offering the breast to the infant, until signs and symptoms have resolved.

7. As much rest as possible.

8. Anti-inflammatory medication as required rather than regularly prescribed (ibuprofen two 200 mg tablets prn).

   • The use of warm showers and antipyretic prescriptions did not improve outcomes in the Kvist et al 2007 breast inflammation study.

   • By using non-steroidal anti-inflammatories (NSAIDs) in response to acute discomfort only, suppression of the mammary immune response may be avoided. The patient is educated that

     • The clinical benefit of NSAIDs is limited to symptom relief (not improved outcomes)

     • Overuse of NSAIDs increases risks.

9. Reasure the woman that breast inflammation typically resolves without antibiotics.

   • Consider sending the woman home with antibiotic script depending on clinical judgement

10. Daily or regular follow-up is important, timing your follow up according to your clinical judgement or risk.

11. Investigation with ultrasound imaging is essential if signs and symptoms of localised breast inflammation are severe and not resolving, or the lump is enlarging rather than resolving, or the lump is fluctant, to exclude abscess or other pathology. The indications for ultrasound imaging are discussed here.

Potential consequences of mastitis

The research links mastitis with

1. Subsequent low milk supply (Crepinsek 2020, evidence weak)

2. Introduction of formula and premature weaning (strong evidence here)

3. Abscess formation (develops in 3% of women with mastitis, regardless of whether or not antibiotics are prescribed).

Possible prevention of mastitis

A 2020 Cochrane review by Crepinsek et al analysed 10 RCTs investigating the prevention of mastitis and concluded: "We cannot be sure what the most effective treatments are for preventing mastitis because the certainty of evidence is low due to risk of bias, low numbers of woman participating in the trials, and large differences between the treatments which make it difficult to make meaningful comparisons." Crepinsek et al found a moderate certainty of evidence that acupoint massage helped prevent mastitis.

From the perspective of the mechanobiological model, the preventive strategies which are likely to have substantial impact, requiring research investment, relate to the mechanical impact of elevated intra-alveolar and intra-ductal pressure, which trigger inflammatory cascades and breast inflammation. Applying this theoretical frame, prevention focusses on Principles 1-4, discussed elsewhere.

• Frequent flexible milk removal (Principle #1), and

• Elimination of mechanical forces which cause high intraluminal pressures (Principle #2), are fundamental.

• Avoidance of producing milk beyond the baby's caloric needs is important in the medium and long term, discussed here.

Recommended resources

There is no research or biological rationale to support the belief that routine use of non-steroidal anti-inflammatories for mastitis treats inflammation

The pathogenic microbiota theory of breast inflammation lacks biological plausibility

The protective role of inflammation in the lactating breast: activation of milk microbiome, somatic cells, and fever

Clinical inflammation of the stroma of the lactating breast: NDC mechanobiological model

High staphylococcus counts are expected to result from high milk leukocyte counts and only occasionally proceed to end-stage inflammation (or infection)

Is the concept of human milk dysbiosis helpful?

Selected references

Amir LH, Crawford SB, Cullinane M, Gzreskowiak LE. General practitioners' management of mastitis in breastfeeding women: a mixed method study in Australia. BMC Primary Care. 2024;161:https://doi.org/10.1186/s12875-12024-02414-12874.

Amir LH, Coca KP, Da Silva Alves MdR. Management of mastitis in the hospital setting: an international audit study. Journal of Human Lactation. 2025;4(3):401-411.

Angelopoulou A, Field D, Ryan CA, Stanton C, Hill C, Ross RP. The microbiology and treatment of human mastitis. Medical Microbiology and Immunology. 2018;207:83-94.

Crepinsek MA, Taylor EA, Michener K, Stewart F. Interventions for preventing mastitis after childbirth. Cochrane Database of Systematic Reviews. 2020(9):CD007239.

Durham P. Why antibiotic resistance really is a tragedy. The Medical Republic. 2019:https://medicalrepublic.com.au/antibiotic-resistance-really-tragedy/21127.

Editorial. The antimicrobial crisis: enough advocacy, more action. The Lancet. 2020;395(10220):247. Foxman B, D'Arcy H, Gillespie B, JK B, K S. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. American Journal of Epidemiology. 2002;155:103-114.

Grzeskowiak LE, Kunnel A, Crawford SB, Cullinane M, Amir LH. Trends in clinical management of lactational mastitis among women attending Australian general practice: a national longitudinal study using MedicineInsight, 2011-2022. BMJ Open. 2024;14(5):e080128. doi: 080110.081136/bmjopen-082023-080128.

Hill-Cawthorne G, Negin J, Capon T, Gilbert GL, Nind L, Nunn M, et al. Advancing Planetary Health in Australia: focus on emerging infections and antimicrobial resistance. BMJ Global Health. 2019;4:e001283.

Jonsson S, Pukkinen MO. Mastitis today: incidence, prevention and treatment. Annals of Chiropractice Gynaecology. 1994;83:84-87.

Kvist L. Diagnostic methods for mastitis in cows are not appropriate for use in humans: commentary. International Breastfeeding Journal. 2016;11(2):doi 10.1186/s13006-13016-10061-13001.

Kvist LJ, Halll-Lord ML, Larsson BW. A descriptive study of Swedish women with symptoms of breast inflammation during lactation and their perceptions of the quality of care given at a breastfeeding clinic. International Breastfeeding Journal. 2007;2:2.

Kvist L, Larsson BW, Hall-Lord ML, Steen A, Schalen C. The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment. International Breastfeeding Journal. 2008;3(6):doi:10.1186/1746-4358-1183-1186.

Kvist LJ, Hall-Lord ML, Rydhstroem H, Larsson WB. A randomised-controlled trial in Sweden of acupuncture and care interventions for the relief of inflammatory symptoms of the breast during lactation. Midwifery. 2006;23(2):184-195.

Kvist L. Diagnostic methods for mastitis in cows are not appropriate for use in humans: commentary. International Breastfeeding Journal. 2016;11(2):doi 10.1186/s13006-13016-10061-13001.

Lesho EP, Laguio-Vila M. The slow-motion catastrophe of antimicrobial resistance and practical interventions for all prescribers. Mayo Clinic Proceedings. 2019;94(6):1040-1047.

Pileri P, Coco C, Lubrano C, et al. Antibiotic Resistance in Breastfeeding Diseases: A Multidisciplinary Study in an Italian Level III Medical Center. J Hum Lact. 2025;41(4):514-523. doi:10.1177/08903344251363599

World Health Organisation. Addressing the crisis in antibiotic development. 2020.