Preventing mastitis

What can I do to prevent breast infections?

There are several ways to lower the risk of mastitis. One is to make sure that nipple damage is treated, since bacteria that cause mastitis can enter the breast through broken skin on the nipple. Another way is to avoid expressing a lot of milk in addition to or instead of breastfeeding. Expressing a lot keeps the milk supply artificially high and increases the risk of mastitis. Mothers should ensure that they breastfeed often enough, emptying the breasts regularly and effectively. They should avoid skipping feeds without expressing, and if using a nipple shield, should make sure it doesn’t prevent milk from leaving the breast. Mothers should try to optimize their health. Repeated episodes can also be caused by abnormalities in the breast. 

A) Mastitis can return

Some mothers have repeated episodes of mastitis. In one study (Dener 2003), 10% of the mothers had a second or third episode. Any woman who has had mastitis with her current or previous child has a higher risk of having it again unless the underlying problems are fixed (Kinlay 2001; Mediano 2014; Scott 2008).

Mastitis comes on quickly. Our clinic advises patients who have a higher risk of mastitis to keep a prescription at home in case of another episode. In this way, mothers can avoid unnecessary delays in treatment. Talk to your health-care providers about this.

Abscess are much less likely to occur and even less likely to come back. 

The following are ways to prevent both mastitis and abscesses.

B) Treat damaged nipples

Mastitis of the left breast. The nipple skin is damaged and has allowed bacteria to enter the breast.

Mothers with nipple damage have a very high risk of getting mastitis (Foxman 2002; Wilson 2020). Broken skin, as seen with nipple damage, allows bacteria to infect the wound and move from there into the tissues of the breast (Cullinane 2015). Not surprisingly, both mastitis and nipple damage most commonly happen during the first month after delivery (Wilson 2020).

We have found that mastitis rates peak 10 to 14 days after the baby starts breastfeeding, but it can happen any time as long as the wounds remain open. Once the nipples heal, the risk of mastitis decreases.

C) Empty the breasts regularly and effectively

Ensure you are breastfeeding often enough:

Ensure the breasts are emptied well:

D) Address a large milk supply

1) A large milk supply

Some mothers have a large milk supply, which increases the risk of mastitis. In general, it can take a month or two for a milk supply to decrease to meet the baby’s needs.

Mothers with a large milk supply are likely to have the same with each baby and a risk of mastitis with each baby (Foxman 2002). 

Some mothers with a large supply struggle with repeated episodes of mastitis. A very small number may need to actively decrease their milk production to reduce the number of episodes. 

2) Excess expressing

Some mothers keep their milk supply artificially high by expressing a lot of milk in addition to breastfeeding or if only expressing, do so for large amounts. This can increase the risk of mastitis (Cullinane 2015).

Consider slowly decreasing the amount you express as your fullness allows. A typical approach is to decrease the amount by 30 to 60 millilitres (1 to 2 U.S. fluid ounces) a day. Ensure you don’t become too full while doing this or you may trigger another mastitis.

E) Look after yourself

Mothers should try to optimize their health. Eat well, rest when you can, and see your health-care provider to check for possible health problems including low iron levels (anemia)  or thyroid abnormalities (Mediano 2014). If you are diabetic, work with your health-care providers to manage your sugar levels.  

Mothers with weakened immune systems and smokers are more prone to mastitis (Bharat 2009). In particular, smoking can increase the risk of a specific infection that creates abscesses under one or both areolas (subareolar abscesses [Zuska-Atkins disease]) (Zhang 2018).

F) Probiotics

Breast milk was once thought to be sterile, but more recent studies show it contains many types of microbes and together, they create a microbiome. The microbiome of the breast benefits babies, but it may also protect mothers from mastitis.

It is possible for mothers to reduce the numbers of mastitis-causing bacteria in breast milk by using probiotics (Zaidi 2021). Studies of products marketed for this purpose have been criticized over design problems and conflicts of interest (Amir 2016; Barker 2020; Fernández  2016; Hurtado 2017; Paricio-Talayero 2018). There may be a role for fermented milk products, such as yoghurt and kefir, as they contain large varieties of helpful bacteria (Basım 2020).

G) Consider other causes

Mastitis can also be caused by other problems in the breast, such as cysts, benign tumours, and breast cancer (Amir 2014; Belmajdoub 2017).

Mothers should see their health-care providers and consider an ultrasound if:

  • The area that was infected is not completely normal after treatment.
  • The mastitis does not clear within the expected amount of time.
  • They have had two episodes in the same part of the breast.
  • A lump develops in an area of mastitis.  

References

Amir LH; Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #4: Mastitis, revised March 2014. Breastfeed Med. 2014 Jun;9(5):239-43

Amir LH, Griffin L, Cullinane M, et al. Probiotics and mastitis: evidence-based marketing? InternationalBreastfeeding Journal. 2016;11:19

Azagra-Boronat I, Tres A, Massot-Cladera M, et al. Lactobacillus fermentum CECT5716 supplementation in rats during pregnancy and lactation affects mammary milk composition. J Dairy Sci. 2020 Apr;103(4):2982-2992

Barker M, Adelson P, Peters MDJ, et al. Probiotics and human lactational mastitis: A scoping review [published online ahead of print, 2020 Mar 4]. Women Birth. 2020;S1871-5192(19)30847-9

Basım P, Özdenkaya Y. Can Traditional Fermented Food Products Protect Mothers Against Lactational Mastitis. Breastfeed Med. 2020 Mar;15(3):163-169

Belmajdoub M, Jayi S. [Cystic fibroadenoma detected incidentally in a patient with postpartum infectious mastitis]. [Article in French] Pan Afr Med J. 2017 Oct 17;28:148
 
Bharat A, Gao F, Aft RL, et al. Predictors of primary breast abscesses and recurrence. World J Surg. 2009 Dec;33(12):2582-6
 
Cullinane M, Amir LH, Donath SM, et al. Determinants of mastitis in women in the CASTLE study: a cohort study. BMC Fam Pract. 2015 Dec 16;16:181
 
Dener C, Inan A. Breast abscesses in lactating women. World J Surg. 2003 Feb;27(2):130-3
 
Fernández L, Cárdenas N, Arroyo R, et al. Prevention of Infectious Mastitis by Oral Administration of Lactobacillus salivarius PS2 During Late Pregnancy. Clin Infect Dis. 2016 Mar 1;62(5):568-573
 
Foxman B, D'Arcy H, Gillespie B, et al. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002 Jan 15;155(2):103-14

Hurtado JA, Maldonado-Lobón JA, Díaz-Ropero MP, et al. Oral Administration to Nursing Women of Lactobacillus fermentum CECT5716 Prevents Lactational Mastitis Development: A Randomized Controlled Trial. Breastfeeding Medicine. 2017;12(4):202-209
 
Kinlay JR, O'Connell DL, Kinlay S. Risk factors for mastitis in breastfeeding women: results of a prospective cohort study. Aust N Z J Public Health. 2001 Apr;25(2):115-20
 
Mediano P, Fernández L, Rodríguez JM, et al. Case-control study of risk factors for infectious mastitis in Spanish breastfeeding women. BMC Pregnancy Childbirth. 2014 Jun 6;14:195

Paricio-Talayero JM, Baeza C. Re: "Oral Administration to Nursing Women of Lactobacillus fermentum CECT5716 Prevents Lactational Mastitis Development: A Randomized Controlled Trial" by Hurtado et al. (Breastfeed Med 2017;12:202-209). Breastfeed Med. 2018 Jul/Aug;13(6):453-454

Scott JA, Robertson M, Fitzpatrick J, et al. Occurrence of lactational mastitis and medical management: a prospective cohort study in Glasgow. Int Breastfeed J. 2008;3:21. Published 2008 Aug 25

Wilson E, Woodd SL, Benova L. Incidence of and Risk Factors for Lactational Mastitis: A Systematic Review. J Hum Lact. 2020;890334420907898

Zaidi AZ, Moore SE, Okala SG. Impact of Maternal Nutritional Supplementation during Pregnancy and Lactation on the Infant Gut or Breastmilk Microbiota: A Systematic Review. Nutrients. 2021 Mar 30;13(4):1137

Zhang Y, Zhou Y, Mao F, et al. Clinical characteristics, classification and surgical treatment of periductal mastitis. J Thorac Dis. 2018 Apr;10(4):2420-2427