Prevention of Mastitis During Lactation
by Anne Eglash MD, IBCLC, FABM
Mastitis is inflammation of the breast that most often occurs during lactation, with or without infection. When mastitis is due to bacterial infection or bacterial imbalance in the breast, and is often associated with fever, headache, weakness, and painful, red inflamed breast tissue. Individuals can become very ill, resulting in bacterial infection in the blood, abscess formation, and may require hospitalization with intravenous antibiotics and/or drainage of the abscess. Known risk factors for mastitis include plugged ducts, oversupply, insufficient latch, and cracked nipples. Because mastitis increases the risk of early weaning, understanding ways to prevent mastitis is important for maternal/child health.
This week’s article is a Cochrane review of evidence regarding effective strategies to prevent mastitis. The authors identified 10 randomized controlled trials involving 3034 breastfeeding women. The interventions aimed to either facilitate milk expression, provide education on breastfeeding technique, or to exert anti-inflammatory and anti-infective properties.
Their conclusions were that acupoint massage, breast massage, and probiotics were considered better than routine care for preventing mastitis. Unfortunately, most of this evidence is not strong (low certainty). If you want to learn more, check out the question below!
- Massage provides the strongest evidence (moderate certainty) for prevention of mastitis.
- Using antibiotic ointment on sore cracked nipples appears to prevent mastitis.
- Probiotics not only reduce the risk of mastitis but there is also strong evidence that they reduce the risk of chronic breast pain.
- Daily oral antibiotics have been shown to prevent mastitis.
- Research studies have shown that oral lecithin supplementation prevents mastitis.
- Complete breast emptying has been shown to prevent mastitis in humans.
See the Answer
Despite the health benefits of breastfeeding, initiation and duration rates continue to fall short of international guidelines. Many factors influence a woman's decision to wean; the main reason cited for weaning is associated with lactation complications, such as mastitis. Mastitis is an inflammation of the breast, with or without infection. It can be viewed as a continuum of disease, from non-infective inflammation of the breast to infection that may lead to abscess formation.
To assess the electiveness of preventive strategies (for example, breastfeeding education, pharmacological treatments and alternative therapies) on the occurrence or recurrence of non-infective or infective mastitis in breastfeeding women post-childbirth.
We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 October 2019), and reference lists of retrieved studies.
We included randomised controlled trials of interventions for preventing mastitis in postpartum breastfeeding women. Quasi-randomised controlled trials and trials reported only in abstract form were eligible. We attempted to contact the authors to obtain any unpublished results, wherever possible. Interventions for preventing mastitis may include: probiotics, specialist breastfeeding advice and holistic approaches.
Data collection and analysis
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and assessed the certainty of the evidence using GRADE.
We included 10 trials (3034 women). Nine trials (2395 women) contributed data. Generally, the trials were at low risk of bias in most domains but some were high risk for blinding, attrition bias, and selective reporting. Selection bias (allocation concealment) was generally unclear. The certainty of evidence was downgraded due to risk of bias and to imprecision (low numbers of women participating in the trials). Conflicts of interest on the part of trial authors, and the involvement of industry funders may also have had an impact on the certainty of the evidence. Most trials reported our primary outcome of incidence of mastitis but there were almost no data relating to adverse effects, breast pain, duration of breastfeeding, nipple damage, breast abscess or recurrence of mastitis.
Probiotics versus placebo
Probiotics may reduce the risk of mastitis more than placebo (risk ratio (RR) 0.51, 95% confidence interval (CI) 0.35 to 0.75; 2 trials; 399 women; low-certainty evidence). It is uncertain if probiotics reduce the risk of breast pain or nipple damage because the certainty of evidence is very low. Results for the biggest of these trials (639 women) are currently unavailable due to a contractual agreement between the probiotics supplier and the trialists. Adverse effects were reported in one trial, where no woman in either group experienced any adverse elects.
Antibiotics versus placebo or usual care
The risk of mastitis may be similar between antibiotics and usual care or placebo (RR 0.37, 95% CI 0.10 to 1.34; 3 trials; 429 women; low certainty evidence). The risk of mastitis may be similar between antibiotics and fusidic acid ointment (RR 0.22, 95% CI 0.03 to 1.81; 1 trial; 36 women; low-certainty evidence) or mupirocin ointment (RR 0.44, 95% CI 0.05 to 3.89; 1 trial; 44 women; low-certainty evidence) but we are uncertain due to the wide CIs. None of the trials reported adverse effects.
Topical treatments versus breastfeeding advice
The risk of mastitis may be similar between fusidic acid ointment and breastfeeding advice (RR 0.77, 95% CI 0.27 to 2.22; 1 trial; 40 women; low-certainty evidence) and mupirocin ointment and breastfeeding advice (RR 0.39, 95% CI 0.12 to 1.35; 1 trial; 48 women; low-certainty evidence) but we are uncertain due to the wide CIs. One trial (42 women) compared topical treatments to each other. The risk of mastitis may be similar between fusidic acid and mupirocin (RR 0.51, 95% CI 0.13 to 2.00; low-certainty evidence) but we are uncertain due to the wide CIs. Adverse events were not reported.
Specialist breastfeeding education versus usual care
The risk of mastitis (RR 0.93, 95% CI 0.17 to 4.95; 1 trial; 203 women; low-certainty evidence) and breast pain (RR 0.93, 95% CI 0.36 to 2.37; 1 trial; 203 women; low-certainty evidence) may be similar but we are uncertain due to the wide CIs. Adverse events were not reported.
Anti-secretory factor-inducing cereal versus standard cereal
The risk of mastitis (RR 0.24, 95% CI 0.03 to 1.72; 1 trial; 29 women; low-certainty evidence) and recurrence of mastitis (RR 0.39, 95% CI 0.03 to 4.57; 1 trial; 7 women; low-certainty evidence) may be similar but we are uncertain due to the wide CIs. Adverse events were not reported.
Acupoint massage versus routine care
Acupoint massage probably reduces the risk of mastitis compared to routine care (RR 0.38, 95% CI 0.19 to 0.78;1 trial; 400 women; moderate-certainty evidence) and breast pain (RR 0.13, 95% CI 0.07 to 0.23; 1 trial; 400 women; moderate-certainty evidence).
There is some evidence that acupoint massage is probably better than routine care, probiotics may be better than placebo, and breast massage and low frequency pulse treatment may be better than routine care for preventing mastitis. However, it is important to note that we are aware of at least one large trial investigating probiotics whose results have not been made public, therefore, the evidence presented here is incomplete.
The available evidence regarding other interventions, including breastfeeding education, pharmacological treatments and alternative therapies, suggests these may be little better than routine care for preventing mastitis but our conclusions are uncertain due to the low certainty of the evidence.
Future trials should recruit sufficiently large numbers of women in order to detect clinically important differences between interventions and results of future trials should be made publicly available.
This review demonstrates that current research on prevention of mastitis is scant and of low quality. The interventions that we typically employ in clinical practice including breastfeeding education on attachment, breast emptying, management of oversupply, and use of lecithin, have not been studied adequately or at all to say that they make a difference.
Breast massage stands out as an evidence-based effective intervention that is low cost. All mothers should be taught breast massage at some point, either prenatally or in the first few days postpartum, for prevention and management of both engorgement and mastitis.
Probiotic treatment may not be ready for prime time, given the risk of cost, lack of knowledge regarding the optimal probiotic balance, and most effective products to purchase.