Breast inflammation is a relatively common condition affecting breastfeeding women encompassing a range of conditions such as engorgement, a blocked duct, mastitis or abscess. Mastitis is associated with a range of distinctive symptoms from a sore, painful breast to feeling unwell or having a fever (rise in body temperature). Breast inflammation is thought to be due to the body’s reaction to a build up of breast milk in the breast. It is thought that when breasts are over full or engorged, high pressures on the delicate milk ducts in the breast can trigger inflammation.
This article looks at the symptoms and causes of breastfeeding related mastitis, and ways to prevent and treat it. Related articles include Engorged Breasts, Blocked Milk Duct, Breast Lumps and Do I Have a Breast Abscess?
Symptoms of mastitis
The symptoms of mastitis can include:
- Soreness, pain, heat and swelling (inflammation) in the breast
- A sore lump or tender spot inside the breast
- Colour changes to the skin. In lighter skin tones there may be areas of red or pink skin on the surface of the breast which may include red streaks or lines. In darker skin tones areas of skin with mastitis may look brown or purple as well as red or changes in skin tone may not be visible.
- Flu-like symptoms such as feeling achey, shivery or run down, headache.
Mastitis is not always associated with a bacterial infection. Mastitis symptoms often clear on their own after a day or two of careful preventative treatment—see below. If a bacterial infection is present, this is usually due to Staphylococcus aureus (Staph) or Streptococcus (Strep) but breastfeeding can continue. The US based Academy of Breastfeeding Medicine (ABM) explains:
Bacterial mastitis is not a contagious entity and does not pose a risk to the infant nor require an interruption in breastfeeding.
What causes mastitis?
Different authors have different opinions on the causes of inflammation of the breast. One explanation is that high pressures in the milk making tissue and ducts cause mechanical strain which can rupture cell membranes and lead to inflammation.1 Causes of such a high pressure under this model include:
Poor position and attachment
Poor positioning (the way baby is held to breastfeed) or a suboptimal latch (the way a baby attaches to the breast) can make it more difficult to drain or “milk” the breast. During breastfeeding a baby needs a big mouthful of breast tissue as well as the nipple in their mouth, see our Latching Tips. Incorrect positioning and attachment, including a poorly fitted nipple shield, could lead to sore or cracked nipples, engorgement, blocked milk ducts or mastitis.
A baby who is not breastfeeding often enough, perhaps due to scheduled feeds, separation from mother, frequent use of a pacifier to delay feeds, busy holiday/stressful periods or a mother or baby who is feeding less due to illness.
Massage and vibration
Vigorous massage, vibration, or something pressing firmly into the breast throughout a feed could interfere with milk flow such as a finger, a tight bra or other clothing, the straps of a heavy bag, mother’s sleeping position or a poorly fitted breast pump.
Additional risk factors that have been highlighted by other authors include:
- Oversupply A true oversupply of breast milk2
- Smoking increases the risk of breast abscess and inflammation in the ducts behind the nipple (breast periductal inflammation).34
- Breast trauma for example a toddler knocking the breast, or any scarring within the breast or nipple including previous breast or nipple surgery; breast implants, reduction surgery, nipple piercing or skin infection.5
- A history of mastitis 6
- Diet and inflammation. Eating a high proportion of inflammatory omega-6 polyunsaturated fatty acids (PUFAs) while having very few anti-inflammatory omega-3 PUFAs may promote inflammation in the body including breast tissue. In addition, a diet high in refined sugar discourages a healthy microbiome (friendly bacteria within our bodies) favouring bacteria that may contribute to inflammation and disease instead.7 One study found that eating traditional fermented foods such as kefir or homemade yoghurt may be protective against mastitis. 8
- Using nipple creams and gel pads 9 including using antifungal cream, either due to thrush or perceived thrush (Foxman et al, 2002).
- A mother who does a lot of vigorous exercise especially using the upper arms and chest (Wambach and Spencer, 2021 p 285).
Preventing and managing mastitis
New insights into traditional ways of preventing and managing inflammatory conditions of the breast continue to evolve.10 Recent publications to guide us include The Academy of Breastfeeding Medicine’s Protocol #36 The Mastitis Spectrum (2022) and a series of papers by Australian doctor and breastfeeding specialist Pamela Douglas.111213 The following is a summary of recommendations for preventing and managing breast inflammation taking new and previous information into account.
#1 Breastfeed often on demand
Breastfeeding frequently on demand with your baby in a deep, comfortable latch (see #2) will help prevent and manage mastitis. If your baby is not breastfeeding, or not able to breastfeed well yet, frequent hand expressing or pumping can be used to regularly remove breast milk instead (see #3). It is important that your baby, hands or your pump remove enough milk from your breasts to stay comfortable at the first sign of engorgement or a blocked duct. Strategies to support frequent feeds include maximising skin-to-skin contact between mother and baby after birth, offering each breast about 12 times in a 24 hour period (no need to watch the clock) and letting baby suckle for comfort as well as nutrition (Douglas, Vol 18: 1–29 2022).
#2 Good position and attachment
A good position and latch helps prevent or resolve breast inflammation.14 See Breastfeeding Positions for Newborns, Breastfeeding Videos and Latching Tips or seek help from your IBCLC lactation consultant or breastfeeding specialist to check your baby’s latch. Douglas writes that prolonged or unequal pressures on the breast could exacerbate breast inflammation and cautions against deep massage, firmly shaping or compressing the breast during feeds, tight or overly supportive bras or using a pump that is poorly fitted (Douglas, Vol 18: 1–20 2022).
Although nipple shields may have a helpful role for some mothers (Douglas, Vol 18: 1–29 2022) the Academy of Breastfeeding Medicine protocol #36 recommends avoiding shields although this is based on consensus or opinion rather than high quality research (Mitchell et al, 2022) .
#3 Hand express or pump to comfort
During bouts of breast inflammation, frequent breastfeeds and/or expressing enough milk to stay comfortable is recommended to reduce inflammation and so that the milk volume will naturally adjust to your baby’s needs (Mitchell et al, 2022; Douglas, Vol 18: 1–20 2022). If your baby can’t breastfeed, isn’t feeding well yet or can’t keep up with the volume of milk, you may need to hand express or use a breast pump for a while. Bear in mind pumping with a poorly fitted flange can cause breast inflammation see Do I Need a Breast Pump? and How to Increase Milk Supply When Pumping for tips on finding the right fit.
Don’t over pump
Excess milk removal (regularly pumping more milk than your baby can drink) could be counter productive by stimulating milk supply further and perpetuating a cycle of too much milk and inflammation. It is therefore not necessary to over pump to try to empty the breasts, or to reach the hind milk as a general breastfeeding strategy.
#4 Reduce a milk supply gradually
To avoid or manage engorgement it is important to remove milk frequently. It is not a good time to feed less often, try to reduce a milk supply or stop breastfeeding while a breast is painfully engorged and inflamed. Where needed, down regulating a milk supply slowly will protect against engorgement and similarly if you want to stop breastfeeding this is best done gradually (Douglas, Vol 18: 1–20 2022), see How to Stop Breastfeeding.
#5 Breast movement but no deep massage
- Breast massage may worsen inflammation. There is some disagreement between practitioners on whether massaging a lactating breast can help or hinder inflammation. One study found careful use of very gentle light touch massage combined with hand expression may help to drain an engorged breast thoroughly to prevent mastitis developing.15 Newer thinking cautions that a deep or vigorous massage could traumatise a breast and worsen engorgement and inflammation (Douglas, Vol 18: 1–20 2022, Mitchell et al, 2022). If considered, any massage technique should use no more pressure than applying cream to the skin or stroking a pet, see Engorged Breasts, and Blocked Milk Duct.
- Breast gymnastics. Natural breast movement may prevent breast inflammation yet bras and sedentary lifestyles can restrict breast movement (Douglas, Vol 18: 1–20 2022). Douglas says the type of breast massage sometimes called breast gymnastics may have a role in preventing breast inflammation (Douglas, Vol 18: 1–20 2022). Douglas explains that breast gymnastics involve lifting and gently moving the breasts in various directions, often with circular movements using the whole of the hand or palm laid gently over the breast. For more information on bras see Nursing Bras FAQ on this website.
#6 Pain relief
- Cold compresses. A cold compress such as frozen peas or crushed ice in a damp cloth placed against the sore, and engorged areas for up to 20 minutes at a time16 can help reduce pain and breast inflammation between feeds (Mitchell et al, 2022) . Some mothers have found that chilled cabbage leaves slipped inside the bra cup around the affected breast can also be a way to soothe the area.
- Warm compress? Some mothers may find a warm compress on the breast is soothing and helps with pain relief. Warmth across the nipple can help release hormones to trigger the let-down before you breastfeed or express. However warm compresses or showers could cause blood vessels to widen (dilate) and bring even more fluid to the area adding to any engorgement. Warmth has not been shown to help mastitis in studies (Mitchell et al, 2022; Douglas, Vol 18: 1–20 2022).
- Traditional remedies. Around the world there may be traditional local remedies for breast inflammation. In France some mothers use a green clay poultice as a topical remedy to soothe breast inflammation.17 One traditional remedy of using a poultice of grated raw potato or carrot to reduce pain and discomfort is mentioned in The Nursing Mother’s Herbal 2003, p.149 by Sheila Humphrey.
- Compatible pain-killers or anti-inflammatory medication may help mothers cope with pain and inflammation (ABM 2022). Ibuprofen and paracetamol are compatible with breastfeeding.18 However, Douglas points out that over reliance on medications to bring down a fever can interfere with the body’s own mechanisms to down regulate the inflammatory response (Douglas, Vol 18: 1–20 2022).
#7 Self care
Rest, remember to eat and drink plenty of fluids. Lawrence and Lawrence state bed rest is recommended during mastitis.19 What we eat can influence the levels of inflammation in the body (see above) (Hurd, 2015; Hurd-Reeves, 2019; Basim, 2020).
Medication or supplements for mastitis
If you are not starting to feel better after 12-24 hours of treatment, contact your health care professional for advice in case medication is required (NICE, 2021; ABM 2022).
Most women with inflammatory mastitis recover without antibiotics or interventions other than control of symptoms, knowledge of the physiological anti-inflammatory response, and regular communication with their health professional (Mitchell et al, 2022). The Academy of Breastfeeding Medicine says it is important to reserve antibiotics for bacterial mastitis and explains:
Use of antibiotics for inflammatory mastitis disrupts the breast microbiome and increases the risk of progression to bacterial mastitis. Furthermore, nonselective use of antibiotics promotes development of resistant pathogens. Prophylactic antibiotics have not been shown to be effective in the prevention of mastitis. It should be noted that many antibiotics and antifungal medications have anti-inflammatory properties, and this may explain why women experience relief when taking these.
A health care professional will prescribe compatible antibiotics if a bacterial infection is suspected after 24 hours of a mastitis action plan, or if the mother is very poorly(Mitchell et al, 2022) . The organisations below discuss specific antibiotic choices and doses and currently recommend a 10–14 day course of antibiotics:
- Management of mastitis and breast abscess in lactating women. NICE, 2021 (UK based)
- ABM Clinical Protocol #36: Mastitis, Academy of Breastfeeding Medicine, Revised 2022 (USA based)
Nisin is an antibacterial peptide produced by the bacterium Lactococcus lactis that kills other bacteria and is used as a food preservative. One study found swabbing nipples with a nisin solution was an effective alternative to antibiotics in treating mastitis due to stahylococcus.20
The results of studies on the use of probiotics to prevent or treat mastitis are not clear. Arroyo et al 21 compared giving mothers strains of Lactobacillus species isolated from breast milk with conventional antibiotic treatment. They found that women who took the probiotics improved more and had lower recurrence of mastitis than those who took antibiotics. Another industry funded study found improvement in the risk of mastitis after giving the mothers a probiotic.22 However, Amir et al 23 describe a number of concerns about the validity of Arroyo’s study, and similar trials, and call for high quality randomised control trials to establish whether probiotics are an effective treatment for mastitis. Douglas states that there is little evidence to justify use of probiotics for prevention of mastitis (Douglas, Vol 18: 1–20 2022).
The food supplement lecithin is sometimes suggested to help reduce the constituency (thickness) of breast milk so reducing the risk of blocked ducts and associated mastitis.2425 However not everyone agrees with the idea of thickened milk causing obstructions and Douglas says that current studies don’t support the ingestion of lecithin to thin breast milk (Douglas, Vol 18: 1–20 2022). Dr Tom Hale of Hale’s Medications and Mothers’ Milk [paywall] says lecithin would be broken down in the stomach and intestines long before being absorbed and there isn’t any evidence for its use. See Blocked Milk Duct for more information.
Some practitioners recommend a mother ensures she is taking plenty of vitamin C during mastitis see Vitamin C and Breastfeeding for more information.
If you keep getting episodes of mastitis or blocked ducts an IBCLC lactation consultant or breastfeeding specialist can be very helpful to identify the most likely reasons why. They will review your history fully, and check whether your positioning, latch or breastfeeding management could be the underlying cause for mastitis to keep returning. Other risk factors for recurring mastitis include:
- Incomplete treatment of the original infection or mastitis which is not treated promptly or had less than 10 days treatment with antibiotics26
- Breastfeeding on a schedule instead of whenever baby wants (on demand)
- Stopping breastfeeding abruptly on the affected side during an episode of mastitis.
- Deep or vigorous massage could traumatise delicate breast tissue and may cause more inflammation (Morgensen et al, 2020; Mitchell et al, 2022; Douglas, 2022).
- Diet and inflammation. Recurrent blocked ducts and associated mastitis may be linked with a diet that is high in refined carbohydrates (sugar) and/or a high proportion of inflammatory omega-6 PUFAs coupled with few anti-inflammatory omega-3 PUFAs (Hurd, 2015).
- Mother being anaemic or very stressed 27
Preventing recurrent mastitis
In most cases, addressing the above causes will resolve repeated mastitis. Additional clinical guidance includes:
- Culture specimens from breast milk and send nasal swabs from both the mother and baby for culture (NICE, 2021).
- Consider chronic bacterial infection, pseudomonas infection, secondary fungal infection, underlying breast disease such as a cyst, tumour or other medical cause.28
- Pay attention to hygiene eg discard any potentially contaminated nipple creams or ointments, wash pump equipment thoroughly (NICE, 2021). Note: The Academy of Breastfeeding Medicine says there is no evidence to support poor hygiene as a cause of bacterial mastitis (Mitchell et al, 2022).
Other causes of breast inflammation
If mastitis does not seem to respond to treatment or keeps recurring there may be something else happening. For a review of other causes of deep breast pain associated with breastfeeding see Why Does Breastfeeding Hurt? and see below:
- Subacute mastitis. The term subacute mastitis has been used in some papers however there is no clear definition between authors. Jiménez et al put forward a theory for subacute mastitis due to specific strains of bacteria that cause inflammation of the ductal system without the classic symptoms of mastitis that may be mistaken for a fungal infection (thrush).29 The recent ABM protocol talks of bacterial biofilms narrowing the milk ducts however Douglas says the biofilm theory is not supported by evidence (Mitchell et al, 2022; Douglas, Vol 18: 1–15 2022).
- Thrush. Fungal infection has historically been described as a cause of deep breast pain30 however more recent research highlights multiple other conditions to explain these symptoms casting doubt on breast thrush.31
- Not mastitis? Check with your health professional if mastitis does not improve with treatment. Although rare, other conditions such as cellulitis or inflammatory breast cancer can be mistaken for mastitis.32
Frequently asked questions
#1 Can I continue breastfeeding my baby if I have mastitis?
Yes, even if antibiotics are needed, breastfeeding can continue during mastitis (Mitchell et al, 2022). Antibodies in breast milk will help protect the baby from any infection and stopping breastfeeding abruptly could cause more problems. Breast milk is sometimes said to taste slightly salty from a breast with mastitis but this doesn’t usually pose a problem to the baby.
Most cases of infection based mastitis are caused by Staphylococcus aureus bacteria (staph). For more information about breastfeeding and staph infections including infection by methicillin-resistant Staphylococcus aureus (MRSA) see Staph, MRSA and Breastfeeding.
#2 What can I do if my baby can’t latch or my milk won’t flow?
Sometimes engorgement behind the nipple can change the nipple shape making it difficult for your baby to latch and having the effect of someone stepping on a hose, stopping the flow of liquid (i.e. breast milk!). If you’re struggling to express any milk at all or your baby can’t seem to latch due to engorgement, have a look at Engorgement Relief When Milk Won’t Flow for ideas to help you.
#3 What is the treatment for blocked milk ducts?
An untreated blocked duct (local build up of breast milk) can lead to mastitis. Treatment for a blocked duct is the same protocol for relieving engorgement or mastitis, see Blocked Milk Duct for more information.
#4 What does a white spot on my nipple mean?
If you have a small white spot on your nipple alongside symptoms of mastitis, this could be a “bleb”; a small blockage to one of the nipple pores. See the section about milk blisters or blebs in Blisters on Nipples for more information.
#5 Bra or no bra?
It’s important to ensure a tight fitting bra is not the cause of the mastitis. NICE (National Institute of Health and Care Excellence) guidance recommends avoiding wearing a bra, especially at night (NICE, 2021) whereas Lawrence and Lawrence say to wear a supportive bra during mastitis that doesn’t cause painful pressure (Lawrence, 2016). For more in depth discussion on the pros and cons see Nursing Bras FAQ.
#6 Why is my breast milk thick or lumpy?
Some mothers notice their pumped breast milk can be lumpy or clumpy 33 If milk has a thick or clotted consistency within the breast this has often been assumed to be a risk factor for breast inflammation, however Douglas says there is no evidence that sticky or clumped milk could block ducts (Douglas, Vol 18: 1–20 2022). Unless a mother expresses her milk, the presence of thicker or lumpy breast milk and whether it could sometimes be a variation of normal would not be apparent. Theories for causes of thickened milk include mastitis and diet.
- Mastitis. Some mothers may notice their expressed breast milk has lumps or clots forming in the collection container just after pumping, or seem to come directly from the nipple. In The Breastfeeding Atlas, 6e, p97 authors Wilson-Clay and Hoover share that clumpy, lumpy milk is an indication of early mastitis in the dairy industry and could also be linked to breast inflammation in humans as some women have reported clumpy milk during mastitis episodes. The cause of the lumpy milk may be a result of coagulase, a protein made by Staphylococcus microorganisms that produce fibrin; a substance that causes clotting.34 A culture of the lumpy milk may locate a particular organism for treatment.
- Diet. Lawrence and Lawrence suggest that the consistency of breast milk can be affected by the fats in one’s diet. They discuss anecdotal reports of increasing PUFAs and adding lecithin (an oily food supplement) to the diet to reduce the consistency of breast milk and so reduce frequency of blocked ducts or repeated episodes of mastitis.35 However some authors dismiss this as not evidence based, see above section “Lecithin?”.
Mastitis is the name for an inflammation in the breast thought to be due to a high pressure volume of milk in the breast. Mastitis can be very painful and a mother may have general symptoms similar to flu (shivers, temperature, feeling unwell) as well as a very painful sore breast (or two). At the first sign of engorgement or early mastitis—frequent breastfeeding, or hand expressing/pumping just enough so that the breast is comfortable again can help relieve symptoms. Sometimes mastitis is associated with a bacterial breast infection and may require antibiotics. There are several antibiotics for treating mastitis that are compatible with breastfeeding—there is no need to stop breastfeeding or stop frequent milk removal during an episode of mastitis. Stopping breastfeeding/removing milk when the breast is inflamed could lead to a breast abscess. If mastitis keeps coming back, check your baby’s latch and positioning with your breastfeeding specialist or IBCLC lactation consultant and stay in touch with your medical professional.