1. Nellie Turner presented with symptoms of lactational mastitis including breast engorgement, erythema, firmness, and fever. She was initially treated with cephalexin antibiotics but symptoms persisted. 2. After consultation, she was prescribed trimethoprim/sulfamethoxazole which resolved her symptoms within 10 days of treatment. Continued breastfeeding and supportive measures were encouraged to aid recovery. 3. Lactational mastitis requires prompt treatment, usually with antibiotics, to prevent complications while encouraging continued breastfeeding for optimal infant and maternal health outcomes.

1. KEEPING
ABREAST
Therapeutic choices for the
treatment of lactational mastitis.
Valerie Rzepka, NP-PHC Student

2. Nellie Turner
History of Presenting Illness: 31 years old
• Mid-October, presented at ER (pseudonym)
with:
• right breast engorgement
• erythema
• Firmness
• edema
• generalized malaise
• fever
• chills
• Treated for lactational mastitis
with Cephalexin 500mg po, qid x
10 days
• Returned after completion of
antibiotics for continued
unresolved symptoms.
• Cephalexin extended for 5 days.
• Returned 1 week later with
continued, unresolved
symptoms

3. Nellie Turner
Past Medical History 31 years old
(pseudonym)
• Nellie reports her health to be
quite good:
• Planned pregnancy, previously used
NuvaRing for contraception.
• Mild anemia during pregnancy
• Mild eczema in the winter months,
• Occasional migraines
• Chronic neck and back pain
secondary to MVC in 1996
• Deviated nasal septum – ENT Surgery
deferred due to pregnancy.
• No chronic medical conditions,
• No known allergies,
• She denies weight loss and change in
diet.
• Reports significant change in her
energy, activity level and sleep
pattern since the onset of the
infection.

4. Nellie Turner
Past Medical History
31 years old
(pseudonym)
• Gravida 1, Para 1. Followed by
Nottawasaga Midwives for this
unremarkable first pregnancy.
• Spontaneous Vaginal Delivery of
a healthy baby boy at 38 weeks
gestation on July 10, 2012.
• Baby is solely breastfed every
three to four hours or on
demand.
• Aside from cracked nipples,
treated with a lanolin-based
over-the-counter ointment, has
had no issues with lactation,
latch or suck.

5. Nellie Turner
31 years old
Baby Jonah (pseudonym) (pseudonym)
• Baby born via SVD, weight: 3620g.
(7.9lbs)
• Satisfactorily growing and gaining
weight according to the growth
chart.
• Currently 4 months
old, active, alert, and is meeting
all of his developmental
milestones.
• Feeds every 3 to 4 hours, and has
6 to 7 heavy wet diapers per
day, along with 2 to 3 yellow
seedy stools.
• Since initiation of antibiotics in
October, Nellie reports Jonah
has been having loose green
stools, but no other ill effects.

6. Engorgement Erythema
Edema
Firmness
Generalized
Malaise
Chills
Fever
Diagnosis: Lactational Mastitis5

7. • Inflammatory condition of the breast3,5
• May or may not be accompanied by infection.1,3.
• Usually associated with lactation, so it is also called
“lactational mastitis”1
• Occurs in 9-12% of all breastfeeding women2,3,4,5
• Most common in the 2nd or 3rd week of
breastfeeding, but can occur at any time. 2,5
• Usually associated with Staphylococcus aureus (S.
aureus), introduced through a break in the skin
(cracked nipple), which characteristically can also
cause abscess development.4
• Nellie reports having cracked nipples in the week
prior to the infection.

8. • Risk Factors associated with Mastitis:5
• Cleft lip or palate
• Cracked nipples
• Infant attachment difficulties
• Local milk stasis
• Missed feedings
• Nipple piercing
• Plastic-backed breast pads
• Poor maternal nutrition
• Previous mastitis
• Primiparity
• Restriction from a tight bra
• Short frenulum in infant
• Sore nipples
• Use of a manual breast pump
• Yeast infection

9. #1 Cause of mastitis:
Milk Stasis1

10. 1. To provide prompt and effective
treatment so to prevent complications
such as an abscess.
2. To provide effective pain relief.
3. To encourage continued
breastfeeding.

11. Non-Pharmacological
• Improved breastfeeding technique/ alternative positions. 5
• Continuation of breastfeeding, especially on affected breast, as often as
possible.
• Milk from a breast with mastitis contains increased levels of some anti-inflammatory
components that may be protective for the infant.
• Some infants may dislike the taste of milk from the infected breast, possibly because of
the increased sodium content.5
• Holding the infant with the chin towards the affected part of the breast, helps to
facilitate milk removal from that section
• Apply heat: warm compresses, warm bath or shower;
• Gentle massage of any lumpy areas while the infant is feeding to help the
milk to flow
• Avoid anything that could obstruct the flow of milk, such as tight clothes or
bra
• Mom should drink plenty of fluids and get lots of rest 5
• Application of Cabbage Leaves 17 or Sliced Potatoes 16 to the breast have no
scientifically proven efficacy, but anecdotal reports are supportive.

12. Non-Pharmacological –
Lactation Consultation and Counselling
• Mastitis is painful and frustrating, makes many women
feel very ill, and can leave infants unsatisfied after
feeding.
• In addition to effective treatment and control of pain,
a woman needs emotional support.
• May have received conflicting advice from
professionals, family members or friends. May have
been advised to stop breastfeeding, or given no
guidance either way. May be confused and anxious,
and unwilling to continue breastfeeding.
• Needs reassurance about value of breastfeeding; it is
safe to continue; milk from the affected breast will not
harm infant, and that breast will recover both its
shape and function subsequently.
• Needs encouragement
• Needs clear guidance about all measures needed for
treatment, and how to continue breastfeeding or
expressing milk from the affected breast.
• Will need follow up to give continuing support and
guidance until she has recovered fully.

13. Non-Pharmacological

14. Mastitis Adapted from: Mastitis Lactational Algorithm
http://www.thewomens.org.au/MastitisLactationalAlgorithm
Heat, rest and drain the 24 hrs
breast
• Keep feeding frequently
• Heat before feeds
• Massage during feeds
• Analgesia (Tylenol or Advil)
No Pharmacological
Generalized Alternatives
symptoms present?
• Fever
• Aches
• Lethargy
Yes

15. Pharmacological Commence
Alternatives Antibiotics
If no overall
improvement
Redness/
in 48 hours,
hard after 5
return to
If improving: days:
clinic.
Complete Continue
course of antibiotics
antibiotics. x 10 days
Milk for
Ultra C&S
sound
to r/o
abscess
Refer/ Admission
Adapted from: Mastitis Lactational Algorithm for IV Abx
http://www.thewomens.org.au/MastitisLactationalAlgorithm

16. Pharmacological
• Antibiotic treatment is indicated if either:
• cell and bacterial colony counts and culture are available and indicate
infection, or
• a nipple fissure is visible, or
• symptoms do not improve after 12-24 hours of improved milk removal, or
• symptoms are severe from the beginning.

17. Pharmacological : 5, 7,9, 10, 11, 12, 13, 14, 15
• Amoxicillin/clavulanate, (AmoxiClav) 875 mg twice daily
• Cephalexin, (Keflex), 500 mg four times daily
• Ciprofloxacin, (Cipro), 500 mg twice daily
• Clindamycin, (Biaxin), 300 mg four times daily
• Cloxacillin, 500 mg four times daily
• Trimethoprim/sulfamethoxazole (Bactrim, Septra), 160 mg/800 mg twice
daily
Usual courses of oral antibiotics are 10 to 14 days.
If patient wishes to continue breastfeeding, safety of the infant
must be considered.

18. Nellie Turner
31 years old
(pseudonym)
Prescription Drug Name etc. Dose, Route, Freq, Duration Rating (1-5) NP Pick
C A S E S
Amoxicillin/clavulanate, 875 mg, bid x 10 days 4 1 4 1 ✓
(Clavulin)
Cephalexin, 500 mg, qid x 10 days 4 5 3 1 5 ✓ ✓
(Keflex)
Ciprofloxacin, 500 mg bid x 10 days 4 1 5 1 ✓
(Cipro)
Cloxacillin 500 mg qid x 10 days 4 5 3 2 5 ✓
Trimethoprim/ sulfamethoxazole 160 mg/800 mg bid x 10 1 1 1 3 1 ✓ ✓
(Bactrim, Septra) days
Ref: 5, 7,9, 10, 11, 12, 13, 14, 15

19. Nellie Turner
31 years old
Consultation – Collaborating physician 10: (pseudonym)
• Nellie returned after her 10-day course of Cephalexin 500mg qid with
unresolved symptoms
• Cephalexin was extended for 5 days, and Nellie was ordered a breast
ultrasound
• She returned again once antibiotics were complete, with continued
unresolved symptoms. Ultrasound was clear.
• Collaborating physician was consulted, and recommended a course of
Trimethoprim/ Sulfamethoxazole 160/800mg bid x 10 days.

20. Referral10 - General Surgery:
• if ultrasound shows breast abscess;
• for needle aspirate, or incision and drainage of abscess.

21. Nellie Turner
31 years old
(pseudonym)
The Therapeutic I Community Health Centre
123 University Avenue, Anytown, ON. N0N 0N0
Phone 416-321-0987
_________________________________________________
Name: Nellie Turner (DOB: January 1, 1981, NKDA)
Address: 1000 Fantasy Lane, Anytown, ON. L0R1B0
Date: November 22, 2012
Trimethoprim/ sulfamethoxazole 160 mg/800 mg
bid x 10 days.
Take one tablet by mouth, twice daily until finished.
M: 20 tabs
R: 0 repeats
Nancy Nurse RN (EC), 54321 (signed)
Nancy Nurse, RN (EC), 54321 (printed)

22. Nellie Turner
Monitoring and Follow up
31 years old
(pseudonym)
• Important to monitor baby Jonah to signs of
dehydration, or secondary infection (e.g. thrush)
• Client returned after the 10-day course of, reporting
that symptoms have nearly entirely resolved, her
energy level had returned, and the erythema and had
engorgement had disappeared.
• The painful, firm thickening has nearly completely
resolved.
Acceptability
• Client was satisfied with resolution, happy to return to
normal functioning, and glad that Baby Jonah continued
to do well.

24. 1. WorldHealthOrganization. (2000). Mastitis: Causes and management. Geneva:WHO.
Retrieved from:
http://www.who.int/maternal_child_adolescent/documents/fch_cah_00_13/en/
2. Foxman, B., D'Arcy, H., Gillespie, B., Bobo, J. K., & Schwartz, K. (2002). Lactation
Mastitis: Occurrence and Medical Management among 946 Breastfeeding Women
in the United States. American Journal of Epidemiology 155(2) pp. 103-114.
3. Jahanfar S, Ng CJ, Teng CL. (2009). Antibiotics for mastitis in breastfeeding women.
Cochrane Database of Systematic Reviews 1.
4. Amir, L.H., Forster, D., McLachlan, H., & Lumley J. (2004). Incidence of breast
abscess in lactating women: report from an Australian cohort. BJOG: an
International Journal of Obstetrics and Gynaecology 111. pp. 1378–1381
5. Spencer, J. (2008). Management of mastitis in breastfeeding women. American
family physician. 78 (6). PP.727-732.
6. The Royal Womens’ Hospital. (2012). Mastitis: lactational (algorithm). Parkville, VIC.
Australia. Retrieved from:
http://www.thewomens.org.au/MastitisLactationalAlgorithm.
7. Lawrence R.A., & Lawrence, R.M. (2011). Breastfeeding: A Guide for the Medical
Professions. 7th ed,. Maryland Heights, MO: Elsevier Mosby.
8. Academy of Breastfeeding Medicine Protocol Committee (ABMPC). Berens, P. (ed).
(2009) ABM clinical protocol #20: engorgement. Breastfeed Med 4(2):pp. 111-3.
Retrieved from:
http://www.guideline.gov/content.aspx?id=15183&search=Pumps%2C+Breast +

25. 9. National Library of Medicine. Toxicology Data Network (TOXNET). *2011)
Trimethoprim-sulfamethoxazole. Drug and Lactation Database (LACTMED).
Retrieved from: http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~vP0pfa:1.
10. Clavulin. [CPhA Drug Monograph]. Retrieved from e-Therapeutics+: e-CPS:
https://www.e-therapeutics.ca/cps.showMonograph.action
11. Sulfamethoxazole-Trimethoprim [CPhA Drug Monograph]. Retrieved from e-
Therapeutics+: e-CPS: https://www.e-
therapeutics.ca/cps.select.preliminaryFilter.action?simplePreliminaryFilter=sulfamet
hoxazole#
12. Cephalexin. [CPhA Drug Monograph]. Retrieved from e-Therapeutics+: e-CPS:
https://www.e-
therapeutics.ca/cps.select.preliminaryFilter.action?simplePreliminaryFilter= cephalex
in
13. Ciprofloxacin. [CPhA Drug Monograph]. Retrieved from e-Therapeutics+: e-CPS:
https://www.e-
therapeutics.ca/cps.select.preliminaryFilter.action?simplePreliminaryFilter= ciproflox
acin
14. Cloxacillin.. [CPhA Drug Monograph]. Retrieved from e-Therapeutics+: e-CPS:
https://www.e-
therapeutics.ca/cps.showMonograph.action?simpleQuery=Cloxacillin% 20
15. College of Nurses of Ontario. (2011). Practice Standards: Nurse Practitioner Revised
2011. Toronto, ON: Author.

26. 16. Newman Breastfeeding Centre. (2009). Blocked ducts and mastitis. Retrieved from:
http://www.nbci.ca/index.php?option=com_content&view=article&id=7:blocked-
ducts-a-mastitis&catid=5:information&Itemid=17
17. Mangesi L, Dowswell T. (2010). Treatments for breast engorgement during lactation
(Review) The Cochrane Library. 9