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Mastitis and Breast Abscess in Lactating Women

(Redirected from Mastitis)
Original Editor - Kalyani Yajnanarayan
Top Contributors - Sophia Elina Potthoff, Vidya Acharya and Syeda Bushra Zehra Zaidi


Introduction

A mother nursing an infant.
A mother nursing an infant

Mastitis is an inflammation of the mammary gland, whilst a breast abscess is a localised collection of pus within the breast tissue representing a potential complication of mastitis. Both are common yet often underestimated complications of the postpartum period that can affect a mother's health and her ability to continue breastfeeding.[1] Despite their prevalence, awareness of the full range of available management options, including the role of physiotherapy, remains limited.[2] This page aims to provide an overview of the condition with a focus on how physiotherapy can support recovery in lactating women.



Epidemiology

Inflammatory conditions of the lactating breast (ICLB), including blocked ducts, mastitis, and breast abscess, are common complications during the postpartum period. ICLB affects more than one in five lactating women.[3] The incidence of mastitis varies across the literature. A systematic review by Wilson (2020) reported that approximately one in four women who breastfeed for up to 25 weeks postpartum may experience mastitis.[1] Reported rates ranged from 25% to 33% depending on the population studied, diagnostic criteria applied and the healthcare setting.[1] [4]

Most women with mastitis recover without complications. However, in some cases, the infection can develop into a breast abscess (between 0.4% and 11%). Roughly 1 to 3 in every 100 breastfeeding women may be affected overall.[5]

Pathophysiology

Breast Anatomy

Lactational mastitis is now understood to represent a spectrum of inflammatory conditions within the breast. It is ranging from ductal narrowing through to bacterial mastitis and abscess.[6] Whilst bacterial entry via cracked or damaged nipples remains one recognised pathway, with Staphylococcus aureus as the most commonly identified organism,[2] current evidence highlights two additional primary drivers: hyperlactation and mammary dysbiosis (disruption of the normal breast milk microbiome).[6] [7] Ductal lumens can become narrowed by oedema and hyperaemia associated with hyperlactation. Mammary dysbiosis results from a complex interplay of factors including maternal genetics, antibiotic exposure, probiotic use and caesarean birth.[6] Together, these processes create an environment that promotes inflammation and, if untreated, bacterial infection. It should be noted that the evidence base in this area is evolving and remains the subject of clinical debate.[8]

If mastitis is not treated promptly, it can progress to a breast abscess. The soft tissue of the lactating breast, combined with milk stasis, makes it easier for the infection to spread rapidly through the breast tissue and milk ducts. In the early stages, the pus within the tissue is confined to one area. However, as the condition progresses, it can spread to several segments of the breast. In most cases, the abscess is found in the peripheral area of the breast.[9]

Clinical Presentation

Mastitis typically presents as a tender, warm, swollen, and wedge-shaped area of the breast, with typical signs of inflammation. It is often accompanied by systemic symptoms including fever, chills, malaise, and flu-like aching.[9] Additional features may include decreased milk outflow, breast firmness, erythema, and enlargement of the axillary lymph nodes.[9]

When mastitis progresses to a breast abscess, the above symptoms persist but are accompanied by a fluctuant mass within the breast. This mass may not always be palpable if the abscess is located deep within the tissue of the breast.[9]

Risk Factors

Bacteria: S. Aureus

The literature identifies risk factors for lactational mastitis from various areas. These include physical factors, behaviour and living conditions, social and psychological factors, and infectious causes.[1] However, it is noted that these are interlinked and that none is identified as the sole cause of mastitis. One example of this is whether wounds trigger mastitis or vice versa. Wilson et al. identified the following risk factors in a systematic review on lactational mastitis.[1]


Infections

Bacterial infection is one of the primary driver of lactational mastitis, with one organism most frequently implicated:[1]

  • Infections with Staphylococcus aureus[1]

Behaviours and Personal Circumstances

Certain feed-related behaviors and personal habits can disrupt effective milk removal, increasing the risk of mastitis:[1]

  • Shortened breastfeeding sessions due to stress or work
  • Incorrect latching technique
  • Use of breast pumps or nipple shields (potential source of infection)
  • Tight clothing which may constrict the milk ducts[1]

Social and Psychological Factors

Wider social and psychological circumstances can also influence a mother's risk, often by affecting feeding frequency or overall wellbeing:[1]

  • Increased stress levels
  • High workload and higher education level as it may correlate with earlier return to work and short feeding sessions[1]

Physical Factors

Physical changes or complications affecting the breast tissue itself are commonly associated with the development of mastitis:[1]

  • Wounds or damaged nipples
  • Milk congestion
  • Mastitis during previous breastfeeding periods[1]

Prevention

To prevent lactational mastitis, various interventions have been tested. However the current evidence remains limited.[10] Acupoint massage currently has the strongest evidence, while probiotics show some potential.[10] Also breast massage combined with low frequency electrical pulse treatment may reduce the risk of mastitis.[10] It is also commonly recommended to focus on correct breastfeeding technique. This ensures a proper infant latch and supporting natural, physiological breastfeeding rather than relying on breast pumps where avoidable.[7] However, high-quality evidence directly supporting these recommendations remains insufficient.[10]

Management

Mastitis and breast abscess require a timely and coordinated approach to prevent symptom progression and support of the continuation of breastfeeding. Management varies depending on the severity of the condition and ranges from conservative treatment through to medical, surgical and physiotherapy interventions.[3]

Medical and Surgical Management

The foundation of mastitis management centres around relieving symptoms and ensuring the affected breast is regularly emptied. Basic supportive measures include analgesia (such as ibuprofen, which also acts as an anti-inflammatory) and cold application (e.g. an ice pack wrapped in a cloth) to reduce oedema and discomfort.[6] [7] Mothers should be encouraged to continue breastfeeding or expressing milk from the affected side.[9]

In mild cases without systemic involvement, these measures alone may be sufficient. Where symptoms persist or worsen, antibiotic therapy becomes necessary. However certain antibiotics are contraindicated in breastfeeding mothers as they transfer into breast milk and carry risk of harm to the infant.[9] If symptoms persist beyond 48-72 hours despite appropriate antibiotics, further evaluation is needed.[7] May include imaging to rule out complications. Persistent symptoms resistant to antibiotics may warrant investigation to exclude other conditions like breast cancer.[7]

Unlike mastitis, a breast abscess will rarely clear with antibiotics alone. Drainage of the collected pus is almost always required alongside antibiotic cover. The approach to drainage depends on the size and condition of the abscess from needle aspiration to small or large incisions and drainage.[9]

Role of the Physiotherapist

Physiotherapists are often under-recognised in supporting lactating women experiencing breast complications such as mastitis and breast abscess. Through a combination of hands-on treatment, education, and self-management guidance physiotherapists can help reduce symptoms. The following interventions can help promote recovery of the inflamed breast and empower mothers to continue breastfeeding with greater comfort and confidence.[11]

Therapeutic Ultrasound

Therapeutic ultrasound is commonly used to manage inflammatory breast symptoms though evidence for its specific effectiveness remains limited.[12] A typical protocol includes:

  • Delivered in pulsed mode for 5 minutes per session
  • Frequency: 1 MHz - Intensity: 1.8 W/cm²
  • Small probe moved slowly across the breast at approximately 4cm/sec
  • Targets deep tissue to reduce lumps, pain, and engorgement
  • Improvements were sustained up to 3 months after treatment[11]

Vodder Method performed by a Physiotherapist

The Vodder Manual Lymphatic Drainage strategy extends the activity of lymphatic pumps through rhythmic, alternating pressure. Gentle pushing followed by light, pressure free contact, always guided in the direction of lymphatic flow.[13] Its goal is to relieve pain, firmness, and breast engorgement. [14]

This is how it would be performed on women with Mastitis. Patient lies on their back in supine position whilst the physiotherapist performs a sequence applied to the affected breast. The overall aim is to encourage fluid and lymphatic drainage away from the congested breast tissue toward the armpit reducing swelling, pain, and blockage.[11]

  1. Gentle sweeping strokes across the chest from the sternum outward toward the armpit (x3)
  2. Small circular movements on the outer edge of the breast, first in the same direction then alternating (x3 each)
  3. Two handed technique - one hand gently pushes fluid from the inner chest toward the nipple, while the other guides it from the nipple onward toward the armpit
  4. Alternating circular strokes along the ribcage just underneath the breast (x3)
  5. Gentle sustained pressure where the ribs meet the breastbone in the centre of the chest
  6. Large sweeping circles along the side of the body, moving upward from the waist to the armpit (x3)
  7. Repeat the above sequence two to seven times
  8. Soft sweeping strokes and circles along the lower ribcage and beneath the breast (x3)
  9. Slow, light gliding strokes across the upper chest to complete the treatment[11]


Patient Education and Self-Massage

Knowledge transfer plays a central role in physiotherapy. Here, too, knowledge about breast symptoms, feeding techniques, lifestyle adjustments and hot/cold therapy should be covered. The breast massage technique should then be demonstrated. Use light pressure only as the massage should feel comfortable, not painful. The patient should then try to replicate the technique as shown.[11]

  1. Begin by wiping the breast with a warm towel, then apply a cream or oil
  2. Stroke gently from the areola toward the armpit (x3)
  3. Knead the breast with your palm in clockwise then counter-clockwise circles (x3)
  4. Knead both sides of the breast toward the nipple using your knuckles (x3)
  5. Tap around the breast in a circular motion using your fingertips (x3)
  6. Repeat the kneading and tapping steps 10 times
  7. Finish with the gentle stroking step again[11]

Evidence of Physiotherapy

There is currently very little research looking specifically at physiotherapy treatment after a breast abscess. Because of this lack of evidence, it is not possible to make clear treatment recommendations at this stage. However, physiotherapy principles such as wound management and manual lymphatic drainage are well established in related conditions and may be applicable as post-drainage care.[11]

Summary

The following points summarise the most important aspects of mastitis and breast abscess for the clinical practice:

  • Inflammatory conditions of the lactating breast, including mastitis and breast abscess, affect more than one in five women who are breastfeeding
  • Mastitis is most commonly caused hyperlactation and mammary dysbiosis
  • If left untreated, mastitis can progress to a breast abscess, which requires drainage alongside antibiotic treatment
  • Continued breastfeeding or regular milk expression from the affected breast is strongly encouraged
  • Physiotherapy plays a valuable role in managing breast symptoms through therapeutic ultrasound, manual lymphatic drainage and patient education

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Wilson E, Woodd SL, Benova L. Incidence of and Risk Factors for Lactational Mastitis: A Systematic Review. J Hum Lact. November 2020;36(4):673–86.
  2. ↑ 2.0 2.1 Li D, Li J, Yuan Y, Zhou J, Xiao Q, Yang T, u. a. Risk factors and prognosis of acute lactation mastitis developing into a breast abscess: A retrospective longitudinal study in China. Mortazavi F., PLOS ONE. 1. September 2022;17(9):e0273967.
  3. ↑ 3.0 3.1 Heron E, Maselli T, McArdle A, De Oliveira BIR, McKenna L. Exploring physiotherapists’ clinical definition and diagnosis of inflammatory conditions of the lactating breast in Australia: a mixed methods study. Int Breastfeed J. December 2020;15(1):48.
  4. ↑ Koziol KJ, Smiley A, Latifi R, Castaldi MT. Predictive Risk Factors for Childbirth-Associated Breast Infections in the United States: A 10-Year Perspective. Int J Environ Res Public Health. 10. Juli 2023;20(14):6333.
  5. ↑ Kataria K, Srivastava A, Dhar A. Management of Lactational Mastitis and Breast Abscesses: Review of Current Knowledge and Practice. Indian J Surg. December 2013;75(6):430–5.
  6. ↑ 6.0 6.1 6.2 6.3 Mitchell KB, Johnson HM, Rodríguez JM, Eglash A, Scherzinger C, Widmer K, Berens P, Miller B, Academy of Breastfeeding Medicine. of breastfeeding medicine clinical protocol# 36: the mastitis spectrum, revised 2022. Breastfeeding Medicine. 2022 May 1;17(5):360-76.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Morcomb EF, Dargel CM, Anderson SA. Mastitis: Rapid Evidence Review. Am Fam Physician. August 2024;110(2):174–82. PubMed PMID: 39172675.
  8. ↑ Douglas P. Does the Academy of Breastfeeding Medicine’s Clinical Protocol #36 ‘The Mastitis Spectrum’ promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary. Int Breastfeed J. 5. September 2023;18(1):51.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 Boakes E, Woods A, Johnson N, Kadoglou N, Breast Infection: A Review of Diagnosis and Management Practices. Eur J Breast Health. 29. June 2018.
  10. ↑ 10.0 10.1 10.2 10.3 Crepinsek MA, Taylor EA, Michener K, Stewart F. Interventions for preventing mastitis after childbirth. Cochrane Pregnancy and Childbirth Group, Cochrane Database Syst Rev. 29. September 2020;2020(9).
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Lin KY, Shao W, Tsai YJ, Yang JF, Wu MH. Physical therapy intervention for breast symptoms in lactating women: a randomized controlled trial. BMC Pregnancy Childbirth. 14. November 2023;23(1):792.
  12. ↑ Mangesi L, Zakarija-Grkovic I. Treatments for breast engorgement during lactation. Cochrane Pregnancy and Childbirth Group, Publisher. Cochrane Database Syst Rev. 28. June 2016.
  13. ↑ H. Rostom E, B. Salama A. Vodder manual lymphatic drainage technique versus Casley-Smith manual lymphatic drainage technique for cellulite after thigh liposuction. Adv Dermatol Allergol. 2022;39(2):362–7.
  14. ↑ Doğan H, Eroğlu S, Akbayrak T. Comparison of the Effect of Kinesio Taping and Manual Lymphatic Drainage on Breast Engorgement in Postpartum Women: A Randomized-Controlled Trial. Breastfeed Med. 1. Januar 2021;16(1):82–92.
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