Mastitis and Breastfeeding

“ I was surprised by how suddenly I felt ill. We went to a wedding and I only missed one feed. Within a couple of hours I felt fluey and achy. My GP was reluctant to prescribe antibiotics, saying they were often not needed if I kept feeding and massaging my breast. I also took ibuprofen tablets which helped me cope. I was surprised how well the self-help worked and that I never needed a prescription. I felt very miserable and depressed when I had the symptoms, wondering whether breastfeeding was worth all this – but once I felt better I remembered how good it feels” Mastitis and breastfeeding

Mastitis means inflammation of the breast.

The first sign of mastitis is a red, swollen, usually painful, area on the breast. The redness and swelling is not necessarily a sign of infection (WHO, 2000) . Harmful bacteria are not always present: antibiotics may not be needed if self-help measures are started promptly. Very rarely mastitis can develop into sepsis which needs urgent hospital admission and IV antibiotics (RCOG, 2012) .

You may get mastitis when milk leaks into breast tissue from a blocked duct. The body reacts in the same way as it does to an infection – by increasing blood supply. This produces the inflammation (swelling) and redness.

National Breastfeeding Helpline: 0300 100 0212 Supporterline: 0300 100 0210 the signs of mastitis

• a red area on part of the breast, often the outer, upper area, which may be painful to touch • a lumpy breast which feels hot to touch • the whole breast aches and may become red • flu-like symptoms – aching, increased temperature, shivering, feeling tearful and tired (Jahanfar 2013) this feeling can sometimes start very suddenly and get worse very quickly NB You may not have all of the above signs during mastitis.

Prevention of mastitis • try to avoid suddenly going longer between feeds – if possible cut down gradually • make sure your breasts don’t become overfull • avoid pressure on your breast from clothing and fingers • start self-help measures at the first sign of any red area on your breast

Factors which make mastitis more likely • difficulty with attaching your baby to the breast – this may mean that the breast is not being drained well and milk may leak into the breast tissue • pressure from tight fitting clothing, particularly your bra, or a finger pressing into the breast during feeds • engorgement or a blocked duct • sudden changes in how often the baby is feeding, leaving the breasts feeling full • injuries, such as bumps or knocks from toddlers Mastitis starts with poor milk drainage. If your baby is not well attached to your breast, or has difficulty feeding, it may be hard for the baby to take milk effectively and some parts of your breast may not be drained during a feed. Unless this is improved you may get mastitis again and again. If in doubt, contact your midwife, health visitor or volunteer breastfeeding supporter for help with attaching your baby for feeding.

Signs that the baby is well attached: • Your baby's chin is firmly touching your breast • Your baby's mouth is wide open • Your baby has a large mouthful of breast • If you can see the dark skin around your nipple, you should see more dark skin above your baby's top lip than below your baby's bottom lip • It doesn't hurt you when your baby feeds (although the first few sucks may feel strong) • No change in shape or colour of the nipple after feeds eg it should not be lipstick shaped or have a pressure line across the nipple • Your baby's cheeks stay rounded during sucking • Your baby rhythmically takes long sucks and swallows (it is normal for your baby to pause from time to time) • Your baby finishes the feed and comes off the breast on his or her own • Your baby produces regular soaked/heavy nappies; bowel motions (poo) should be soft and yellow from day 4/5 with 2 or more dirty nappies a day with poos at least the size of a £2 coin © Jenny Richardson

If your mastitis comes back after you have taken a full course of antibiotics, or is unusually severe, it is good practice to send a sample of milk for bacteria tests. This will help the GP choose the correct antibiotic for your symptoms (Jahanfar 2013). For public health reasons we try to avoid antibiotics that are not essential or are unlikely to be effective. It is important that you finish the whole course of antibiotics to make sure that you recover fully and also to help prevent the mastitis coming back with resistant bacteria (NICE NG15). Self-help measures – these will also help to clear blocked ducts and engorgement • keep on breastfeeding – you may feel ill, in pain, miserable and discouraged but continuing to breastfeed is the quickest way to get better – and won’t hurt your baby • feed your baby more frequently or express between feeds if your breasts feel uncomfortably full • feed from the sore side first to drain it as thoroughly as possible. If necessary express gently after feeds • check that your baby is well positioned and attached to your breast – if in doubt seek help from your midwife, health visitor or volunteer breastfeeding supporter (often ‘good’ positioning and attachment can be made even ‘better’) • try feeding with your baby in different positions • soften your breast, by expressing a little milk or running warm water over it, so that the baby finds it easier to feed well • warmth on your breast before feeds may help you to feel more comfortable as may cold compresses after feeds • use a wide toothed comb with rounded teeth to stroke gently over the red area and towards the nipple to help the milk flow, or massage gently or softly hold the back of an electric toothbrush against the red area • check for any clothing which is pressing into your breast, this includes a bra – some women find it helpful to go without a bra If you feel these symptoms beginning again, start self-help measures right away.

When should I contact my GP or health visitor? If you do not begin to feel better despite using self-help measures, especially if you start to feel worse, you should speak to your GP or health visitor. You may need to take antibiotics. You should feel some improvement in 12 to 24 hours. If there is no improvement seek further medical input. If the pattern of redness changes and the area becomes round and swollen. Mastitis can develop into an abscess (a painful collection of pus). When should I seek help urgently? If you feel seriously unwell, dizzy, confused, develop nausea, vomiting or diarrhoea or slurred speech along with the symptoms of mastitis you need to seek urgent medical attention. These can be signs that mastitis is developing into sepsis. If severe, this is a medical emergency that needs urgent hospital admission and IV antibiotics. (NHS Choices: Sepsis, RCOG, 2012:6.1) . Medical treatment for mastitis

Ibuprofen reduces the inflammation, relieves pain and reduces temperature. Take 400 milligrammes three times a day after food. Ibuprofen should not be taken by women who have asthma, stomach ulcers or are allergic to aspirin. The levels of ibuprofen which pass to the baby are small. Ibuprofen is safe to take whilst breastfeeding. Paracetamol relieves pain and reduces temperature but has no anti-inflammatory action. Take two 500 milligramme tablets four times a day.

Aspirin should not be taken by breastfeeding mothers.

Antibiotics may be needed if no improvement is seen with self-help measures. Most antibiotics can be safely taken whilst breastfeeding.

The World Health Organisation (WHO) recommend Flucloxacillin 500 milligrammes four times a day as first line treatment with erythromycin 250-500 milligrammes four times a day or cefalexin 250-500 milligrammes four times a day if the mother is penicillin allergic. Other options have been suggested by Jahanfar.

It is essential that breastfeeding is not interrupted during mastitis.

Note: Antibiotics can make the baby produce loose, runny motions and become irritable, colicky and restless, but your baby won’t be harmed and will get better when you finish the antibiotics. References

Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD005458. DOI: 10.1002/14651858.CD005458.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005458.pub3/abstract (accessed 12 August 2015)

Crepinsek MA, Crowe L, Michener K, Smart NA. Interventions for preventing mastitis after childbirth. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD007239. DOI: 10.1002/14651858.CD007239.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007239.pub3/full (accessed 12 August 2015)

Hale T., Medications and Mothers’ Milk 2014 (16th Ed)

NICE Postnatal care CG37 2014 www.nice.org.uk/guidance/cg37 (accessed Jun 2015)

World Health Organization. 2000, Mastitis: causes and management, WHO: Geneva http://apps.who.int/iris/bitstream/10665/66230/1/WHO_FCH_CAH_00.13_ eng.pdf?ua=1

NICE guidelines [NG15] Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use www.nice.org.uk/guidance/ng15 (accessed 09/09/2015)

NHS Choices: Sepsis www.nhs.uk/conditions/Blood-poisoning/Pages/Introduction.aspx (accessed 12 August 2015)

Royal College of Obstetricians and Gynaecologists (RCOG) (2012) Green–top Guideline No. 64b. Bacterial Sepsis following Pregnancy: 6.1. www.rcog.org.uk/globalassets/documents/guidelines/gtg_64b.pdf (accessed 12 August 2015

Further references are available on the website www.breastfeedingnetwork.org.uk a p p s l y t a

t r R S B w T P T L R T t © C O S o t i h a e

a e

e r h h n u o y O T p l e c a g g v l e o e e w h s p

h f u e i i

s e 0

l s t s s B B p r e s N

o 1 B p n e t

B t w

p r r

e t f o a r 0 d w e e

a e r o e r n c 3 o 9

a a r e a e a t d h 0 S . v o x t s s s . d i d

0 i e k 3 o t b e 0 d t t m o f

i f f p e 2 e n

0 n e e r 1 n n e d t

r u p r t l a e e g

d a o e 1

a e m i a n i S d d e i

n l n m m n v d e

1 N b l c i i d a g

n n e d e a w o 2

b e B

c - r

l N g g

o t s i t e t a b 9 6 0 l s r l

w l l r a p c r

N N l y e t . b

o w n t 3 p e o

2 e a P e e s W i a d 0 o d

0 f t r 0 n p t t c s

r a k

w w

n 0 a k k e 1 p e C t e

e o a

r 5 i S f 2 n o o t a

m o g

d s e e

m 0 u 1 o d r e r r m 1 l l e k k

p f . 0 o y i

d 5

e b e

a e r p d p

i i 0 e n r s s J r y o v i a

i y

e t o

v n a a n h r

e n 0 i n e t a n

a P y g e r C R n r c e 2 s

g y A r s

l e

N o s u t c s H i 1

g o

f a s

m 2 o n d P 0 a i e l i n v e l s . s h n

e p e t s

e l 3 8

t a e d a y p . m o d 3 r r

n Y

l 0 m e i T U i n o i y n w d 6 K B n u u

a f

3 g t L t n e

S e c o 9 i u t o s

c m i

h r

s v m o t o s t h r o i e b

. t t n a

a t e e W k l

t i n r

u s y d s 0 h d i

. e n t b 3

o a C P t y

0 e h r t

h r h G . 0 e y a a g u l

r r l n 1 i

, a t B

. k y 0 r c a u s u

0 N a

n c t

l t o k h o 0 l e

e M S 2 n

C 1 a a 0 2 n g 2 d .

7 a 0 0 7