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Mastitis

Mastitis is an inflammatory condition of the breast tissue, most frequently occurring during lactation, and may be infectious or non-infectious.^[1] It typically manifests as localized tenderness, redness, swelling, and warmth in the affected breast, accompanied by systemic symptoms such as fever, chills, fatigue, and body aches.^[2] While primarily associated with breastfeeding, mastitis can also develop in non-lactating individuals due to infections from skin or nipple damage, periductal inflammation, or granulomatous processes.^[3] Mastitis encompasses a spectrum of breast inflammations, ranging from non-infectious to infectious forms.^[4] Lactational mastitis, the most common form, affects approximately 10-20% of breastfeeding women within the first few months postpartum, with some systematic reviews estimating rates as high as 25% during the initial 26 weeks.^[5] The primary causative agents in infectious cases are bacteria such as Staphylococcus aureus and coagulase-negative staphylococci, which may enter through cracked nipples or milk ducts.^[6] Risk factors include milk stasis, nipple trauma, microbiome dysbiosis, stress, fatigue, and improper latching during breastfeeding.^[4] Diagnosis is primarily clinical, based on symptoms and physical examination, though imaging or cultures may be used to rule out abscesses or other conditions like inflammatory breast cancer.^[7] Treatment involves supportive measures such as continued breastfeeding or pumping to promote drainage, warm compresses, and pain relief; antibiotics are used if bacterial infection is suspected.^[4] Prompt management is essential to prevent complications such as breast abscesses, which occur in about 5-11% of untreated cases, or premature weaning.^[8] Prevention strategies emphasize proper breastfeeding techniques, hygiene, and early recognition of engorgement.^[9]

Types

Lactational mastitis

Lactational mastitis refers to inflammation of the breast tissue in breastfeeding women, most commonly caused by bacterial infection entering through cracked nipples or milk ducts.^[6] It typically arises due to the physiological changes during lactation, where milk production and flow can facilitate bacterial proliferation if stasis occurs.^[10] Epidemiological data indicate that lactational mastitis affects 3% to 20% of lactating individuals worldwide, with higher rates reported in some regions due to variations in breastfeeding practices and hygiene.^[11] The condition is particularly prevalent in the early postpartum period, underscoring its ties to the initial challenges of establishing breastfeeding.^[12] The acute infectious form is the most common subtype and often resolves with appropriate care. While milk stasis is frequently associated with its development, the Academy of Breastfeeding Medicine's Protocol #36 clarifies that it is not primarily caused by "clogged ducts" but by multifaceted inflammatory responses involving immune activation and microbial factors. The typical timeline for onset is within the first 3 months postpartum, with the majority of cases occurring in the initial 2-3 weeks as milk supply establishes.^[10] General symptoms such as breast pain, swelling, and fever often accompany the localized inflammation.^[6]

Nonlactational mastitis

Nonlactational mastitis refers to inflammation of the breast tissue occurring outside of pregnancy or lactation periods, encompassing a range of benign inflammatory conditions not associated with milk production or stasis.^[6] This form contrasts with lactational mastitis by lacking involvement of breastfeeding dynamics and often presenting in diverse clinical contexts, such as postpartum nonlactational cases or idiopathic variants.^[13] Key subtypes include periductal mastitis, which involves chronic inflammation around the subareolar ducts often linked to duct ectasia and bacterial involvement, characterized histopathologically by duct dilation, plasma cell infiltration, and squamous metaplasia.^[14] Another subtype is idiopathic granulomatous mastitis, a rare lobulocentric granulomatous inflammation of unknown etiology that mimics autoimmune processes, featuring noncaseating granulomas and multinucleated giant cells without evidence of infection or systemic disease.^[15] Additional forms encompass granulomatous mastitis with autoimmune-like features and secondary nonlactational mastitis arising from trauma, immunosuppression, or underlying conditions that predispose to inflammation.^[6] Nonlactational mastitis is less common than its lactational counterpart, accounting for a smaller proportion of breast inflammatory disorders, with periductal mastitis representing approximately 5% to 25% of symptomatic breast diseases in affected cohorts.^[6] Idiopathic granulomatous mastitis has an estimated annual prevalence of 2.4 per 100,000 women, primarily impacting those aged 20 to 40 years.^[15] It tends to occur primarily in women of reproductive age, with increased risk in individuals with comorbidities such as diabetes, which impairs immune response and healing in breast tissue.^[16] A distinguishing characteristic of nonlactational mastitis is its propensity for chronicity and recurrence, often persisting or relapsing due to ductal pathology or immune dysregulation rather than transient infectious triggers tied to lactation.^[13] For instance, periductal mastitis shows a strong association with modifiable risks like smoking, which alters ductal epithelium and promotes inflammation in up to 90% of cases.^[17] These features underscore the need for targeted management addressing underlying etiologies beyond acute antibiotic therapy.^[18]

Pathophysiology

Infectious processes

Infectious mastitis arises from bacterial invasion of the breast tissue, triggering a localized inflammatory response. The primary pathogens responsible are Staphylococcus aureus, which is the most frequently isolated bacterium and accounts for up to 22% of cases, including methicillin-resistant S. aureus (MRSA) strains that have demonstrated a prevalence of approximately 29.6% among S. aureus isolates in breastfeeding-related infections as of 2025.^[19]^[20] Other significant contributors include coagulase-negative staphylococci, such as Staphylococcus epidermidis (the most common isolate at 87.6% in some cohorts), and Streptococcus species, particularly those in the viridans group like Streptococcus mitis and Streptococcus oralis.^[19]^[12] Bacteria enter the mammary gland primarily through disruptions in the epithelial barrier. In lactational mastitis, the most common route is via cracked or fissured nipples, which provide a portal for oral bacteria from the infant, such as staphylococci and streptococci, to ascend into the milk ducts during breastfeeding.^[18] In nonlactational mastitis, pathogens gain access through skin fissures, ductal ectasia, or other breaches in the breast skin surface, often involving skin flora.^[16] The host immune response to bacterial entry involves rapid activation of innate immunity, dominated by cytokine release from mammary epithelial cells and resident immune cells. Pro-inflammatory cytokines, including interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α), are upregulated, inducing vasodilation, vascular permeability, and chemotaxis of leukocytes—predominantly neutrophils—to the infected site, resulting in tissue edema and the characteristic inflammatory swelling of mastitis.^[21] This response facilitates phagocytosis and bacterial clearance but can amplify tissue damage through excessive neutrophil infiltration if the infection persists.^[22] Untreated bacterial proliferation within the ductal and lobular structures can overwhelm local defenses, leading to liquefactive necrosis of tissue and accumulation of pus, culminating in breast abscess formation—a complication observed in up to 10% of unresolved infectious mastitis cases.^[6]

Non-infectious processes

Non-infectious processes in mastitis involve inflammatory responses in the breast tissue without evidence of microbial invasion, often triggered by physiological or mechanical factors that disrupt normal mammary gland function. These mechanisms primarily manifest as sterile inflammation, characterized by localized edema, ductal narrowing, and hyperemia, leading to pain and swelling without systemic infection signs. Recent understandings emphasize that such inflammation arises from imbalances in milk production and clearance rather than physical obstructions. A key mechanism is milk stasis, where incomplete milk removal causes alveolar distension and vascular congestion, promoting chemical irritation from accumulated milk components like proteases and cytokines that exacerbate local inflammation. According to the 2022 Academy of Breastfeeding Medicine (ABM) protocol, updated in ongoing reviews through 2025, milk stasis is postulated as an instigator but lacks proven causation, with emphasis shifting to hyperlactation—excessive milk production from overstimulation—as a primary driver that worsens ductal narrowing through stromal edema and disrupts feedback inhibition of lactation. This view prioritizes managing hyperlactation to reduce inflammatory milk components over treating hypothetical "blockages," as mammary ducts are too numerous and microscopic for macroscopic obstructions to significantly contribute. In granulomatous mastitis, a subtype of non-lactational mastitis, autoimmune aspects play a prominent role, involving dysregulated T-cell responses that lead to chronic granuloma formation. Idiopathic granulomatous mastitis features an immune-pathogen imbalance where regulatory T cells (Tregs) fail to suppress excessive inflammation, resulting in T-helper cell-mediated attacks on breast tissue, often with lymphocytic infiltration. The possible link to Corynebacterium species remains debated, with some evidence suggesting it acts as a trigger for autoimmune reactions rather than a direct infectious agent, as cultures are inconsistently positive and inflammation persists post-antibiotics.^[23]^[24] Traumatic causes contribute to non-infectious mastitis through direct tissue injury, inducing localized sterile inflammation without microbial involvement. Nipple trauma from poor latch, friction, or mechanical stress can cause epithelial damage and secondary edema, mimicking infectious symptoms via inflammatory mediator release. Iatrogenic factors, such as breast biopsies, duct explorations, or improper pump use, similarly provoke fat necrosis or hematoma formation, leading to inflammatory responses that resolve with conservative measures rather than antimicrobials.^[6] The role of Candida in persistent non-infectious mastitis cases involves fungal overgrowth as colonization rather than true infection, contributing to ongoing inflammation in susceptible breastfeeding individuals. Per 2025 reviews, Candida species like C. albicans may colonize nipple fissures or milk ducts, exacerbating pain through hypersensitivity or biofilm formation, but evidence shows it is often incidental and overdiagnosed, with symptoms persisting due to underlying mechanical issues rather than invasive candidiasis. Treatment focuses on addressing colonization via hygiene and antifungal creams only if confirmed, avoiding unnecessary systemic therapy.^[25]^[26]

Risk factors

Modifiable risk factors

Modifiable risk factors for mastitis encompass behavioral and environmental elements that can be addressed through education, lifestyle adjustments, and supportive interventions to lower incidence rates. These factors primarily contribute to milk stasis, bacterial entry, or immune compromise, particularly in lactational cases, but also influence nonlactational forms. Interventions targeting these areas, such as breastfeeding education programs, may reduce occurrences in supported populations.^[8] Poor breastfeeding technique represents a key modifiable risk, where infrequent feeding or improper latch results in milk retention and stasis, fostering bacterial overgrowth and inflammation. Nipple damage or cracked nipples from suboptimal positioning or latching increases mastitis odds by 2- to 4-fold or higher, often linked to incomplete breast emptying. This risk can be mitigated through lactation consulting and education on frequent, effective feeds, which optimizes milk flow and reduces stasis.^[27]^[28]^[8]^[5] Hygiene issues, including unclean hands, contaminated breast pumps, or inadequate nipple care, facilitate bacterial introduction into the breast ducts, elevating infection risk. Poor hygiene has been associated with higher Staphylococcus aureus colonization, a common pathogen in mastitis cases, particularly when combined with cracked nipples. Simple modifications like thorough handwashing before feeds, sterilizing pump parts, and using protective barriers can substantially decrease this risk, as evidenced by reduced infection rates in hygiene-focused interventions.^[29]^[5]^[30] Tight clothing or bras that compress breast tissue can obstruct milk ducts, promoting stasis and inflammation, especially during engorgement phases. Constrictive underwire bras or fitted garments have been linked to plugged ducts preceding mastitis in observational studies, with pressure impeding drainage. Switching to supportive, non-restrictive bras and loose clothing alleviates this pressure, serving as a straightforward preventive measure.^[31]^[8]^[2] Stress and fatigue impair immune function and delay milk ejection, indirectly heightening mastitis susceptibility by exacerbating stasis or reducing vigilant hygiene. Maternal reports and cohort data show associations with fatigue, often tied to sleep deprivation in early postpartum periods. Addressing this through rest support, delegation of tasks, or stress-reduction techniques like mindfulness can bolster resilience and lower incidence.^[1]^[32]^[33] Smoking elevates risk in nonlactational mastitis, particularly periductal forms, by inducing ductal ectasia and epithelial damage via toxic smoke components. Smokers face 3- to 5-fold higher odds of recurrent periductal mastitis compared to non-smokers, with cessation recommended as a primary intervention to restore ductal integrity.^[34]^[29]^[35]

Non-modifiable risk factors

Non-modifiable risk factors for mastitis encompass inherent demographic, genetic, and health-related characteristics that cannot be altered and predispose individuals to the condition, particularly through influences on immune response or physiological susceptibility. Primiparity, or being a first-time mother, has been associated with lactational mastitis in some studies, potentially due to inexperienced breastfeeding techniques contributing to milk stasis and subsequent infection, though evidence from systematic reviews is mixed, with some indicating approximately doubled risk (AOR 1.80) and others showing no increase or lower risk.^[5] Maternal age also plays a role, varying by mastitis type. For lactational mastitis, some studies suggest higher prevalence in younger women (15-24 years), though associations may not be statistically significant, potentially due to factors like incomplete breast development and limited prior exposure to breastfeeding challenges. In contrast, nonlactational mastitis shows elevated risk in older women (over 35 years), potentially linked to age-related immune decline and hormonal changes that facilitate ductal inflammation.^[36]^[12] Genetic predispositions are rare but significant, particularly in idiopathic granulomatous mastitis, a non-infectious form where whole-exome sequencing has identified variants in immune-related genes, suggesting a hereditary component in familial cases that impairs inflammatory regulation.^[37] Comorbidities that compromise immunity further heighten susceptibility across mastitis types. Diabetes mellitus, especially in nonlactating women, increases the risk of periductal mastitis and breast abscesses due to impaired wound healing and higher infection vulnerability, with studies showing prevalence rates exceeding 70% in affected cohorts. HIV infection elevates the incidence of subclinical mastitis in breastfeeding women by weakening local immune defenses in breast tissue, thereby promoting bacterial entry. Similarly, rheumatoid arthritis, an autoimmune condition, is linked to granulomatous mastitis through systemic inflammation and potential overlaps in immune dysregulation, as evidenced in case series of patients with positive rheumatoid factors.^[38]^[39]^[40]^[41] A history of previous mastitis episodes constitutes a key non-modifiable risk, with recurrence rates in lactational cases ranging from 8% to 30%, often due to persistent anatomical or immunological vulnerabilities that facilitate repeated infections.^[42]

Signs and symptoms

General presentation

Mastitis is characterized by acute inflammation of the breast tissue, manifesting primarily through local and systemic symptoms that facilitate early recognition and intervention. Local signs typically involve unilateral breast tenderness, erythema, warmth, and swelling, often confined to a wedge-shaped area of the breast. These symptoms arise due to localized infection or inflammation, affecting one breast in the majority of cases. Systemic manifestations commonly accompany the local findings, including fever greater than 38.5°C, chills, malaise, and flu-like fatigue, which can significantly impact daily functioning. The condition usually has a sudden onset, with symptoms developing rapidly over hours to a day, and resolves within 24-48 hours under proper management. Variations in presentation occur depending on the type of mastitis. Lactational mastitis, associated with breastfeeding, frequently features more intense flu-like systemic symptoms in addition to the local inflammation. Nonlactational mastitis, by contrast, tends to involve more persistent or chronic pain with potentially milder systemic effects, such as subareolar masses or induration rather than acute fever. Untreated progression may lead to complications like abscess formation.

Complication-specific symptoms

Complications of mastitis can manifest with distinct symptoms when the condition progresses untreated or becomes severe, particularly in forms like breast abscesses, chronic mastitis, or rare systemic dissemination. Breast abscesses, a common complication occurring in 3-11% of lactational mastitis cases, present with localized fluctuance—a soft, fluid-filled area palpable on examination—accompanied by severe, focal pain and swelling in the affected breast region.^[6] Patients may also experience purulent nipple discharge or drainage from the abscess site, indicating pus accumulation that requires prompt intervention to prevent further spread.^[43] These symptoms often arise from bacterial proliferation in untreated infections, exacerbated by factors such as poor hygiene leading to nipple cracks.^[5] Chronic mastitis, including granulomatous subtypes, features persistent induration—a firm, hardened area in the breast tissue—that does not resolve with standard acute treatment and may endure for months.^[6] In granulomatous forms, such as idiopathic granulomatous mastitis, patients commonly report ongoing tenderness, skin erythema, and ulceration, with fistulas—abnormal tracts connecting the breast tissue to the skin surface—leading to recurrent drainage and scarring.^[44] These manifestations reflect a prolonged inflammatory response, often mimicking malignancy and necessitating biopsy for confirmation.^[15] Systemic spread from mastitis is rare but can result in sepsis, characterized by systemic signs including high fever, tachycardia (heart rate exceeding 100 beats per minute), chills, and hypotension (low blood pressure), alongside the localized breast symptoms.^[6] This life-threatening progression typically occurs in immunocompromised individuals or with delayed treatment, potentially requiring hospitalization and intravenous antibiotics.^[45] As of 2025, there is growing recognition of recurrent inflammatory episodes in mastitis that mimic true complications like abscesses or chronic disease, often due to non-infectious causes such as subclinical inflammation or dysbiosis from prior antibiotic use, emphasizing the need for differentiated diagnostic approaches to avoid overtreatment.^[46]

Diagnosis

Clinical evaluation

The clinical evaluation of mastitis primarily relies on a thorough history and physical examination to confirm the diagnosis in the absence of advanced testing. During history taking, clinicians assess the patient's breastfeeding status, including frequency, duration, and any challenges such as incomplete emptying or poor latch, as lactational mastitis most commonly occurs in the early postpartum period, peaking between weeks 2 and 3 after delivery.^[47] The onset and progression of symptoms are inquired about, typically revealing abrupt breast pain that may precede systemic signs, along with fever patterns such as intermittent chills or malaise starting within hours to days.^[6] Inquiry into risk factors, such as nipple trauma, milk stasis from skipped feedings, or prior episodes, helps contextualize the presentation without requiring exhaustive listing.^[48] Physical examination involves careful inspection and palpation of the affected breast. Inspection often reveals localized erythema, which may appear as a wedge-shaped area of redness extending from the nipple, particularly in early stages, along with swelling or warmth that can be subtle on darker skin tones.^[1] Palpation assesses for focal tenderness, induration, or a firm mass in the involved quadrant, while the unaffected breast is examined for comparison to rule out bilateral processes like engorgement.^[6] Axillary lymph nodes are checked for tenderness or enlargement, which may indicate regional involvement, and the nipple is evaluated for cracks or fissures that could serve as entry points for infection.^[2] Systemic signs, such as tachycardia or temperature elevation above 100.4°F (38°C), are noted during vital signs assessment.^[6] Diagnosis is established clinically based on the triad of focal breast tenderness, overlying erythema, and systemic illness, often without need for further confirmation in typical cases.^[8] This presentation, especially with wedge-shaped inflammation suggesting ductal involvement, raises high suspicion for mastitis in breastfeeding individuals.^[49] If features are atypical, such as persistent mass without resolution or non-lactational context, differentials like inflammatory breast cancer should be considered briefly before proceeding.^[48]

Differential diagnosis

The differential diagnosis of mastitis is crucial, as several conditions can present with similar symptoms such as breast pain, swelling, and erythema, potentially leading to misdiagnosis if infection signs like fever or leukocytosis are absent.^[6] Perinatal mood and anxiety disorders (PMADs) may mimic mastitis through psychosomatic breast pain or heightened sensitivity without evidence of inflammation, infection, or focal tenderness; women with a history of anxiety or depression report higher rates of such symptoms, necessitating screening for mental health issues alongside physical evaluation.^[50] Inflammatory breast cancer (IBC) can resemble mastitis with rapid-onset redness, swelling, and peau d'orange skin texture due to lymphatic obstruction, but it typically lacks systemic infection indicators like fever and occurs more often in non-lactating women over 40; persistent symptoms despite antibiotics warrant imaging or biopsy to differentiate it.^[7]^[51] Other non-infectious mimics include breast engorgement, which is often bilateral and resolves with frequent feeding without signs of infection; blocked ducts, presenting as localized tenderness without systemic symptoms like fever; and galactoceles, which appear as discrete, fluctuant cystic masses on palpation or ultrasound.^[6] Key differentiators across these conditions involve the absence of infectious features such as leukocytosis, purulent discharge, or response to antibiotics in non-mastitis cases; if symptoms persist beyond 48-72 hours of treatment, further investigation including ultrasound for abscess detection or biopsy may be required.^[6]

Management

Supportive measures

Supportive measures form the cornerstone of initial management for lactational mastitis, focusing on symptom relief and promoting breast drainage to facilitate recovery without immediate reliance on medications. These approaches are particularly emphasized in early stages, where many cases resolve conservatively within 24 to 48 hours.^[6] Continuing breastfeeding or expressing milk from the affected breast is crucial to empty the ducts and alleviate engorgement, thereby reducing the risk of complications such as abscess formation. According to the Academy of Breastfeeding Medicine's Clinical Protocol #36 (revised 2022 and current as of 2025), frequent, on-demand feeding or pumping—starting on the affected side—helps maintain milk flow and supports resolution, with guidelines underscoring that interruption can worsen stasis and inflammation.^[52]^[6] Proper latch and positioning are advised to ensure effective drainage during feeds.^[6] Warm compresses applied before nursing or pumping, combined with gentle massage directed toward the nipple, can improve milk flow and reduce localized tenderness by softening the breast tissue. This technique, often performed in a warm shower or with a moist cloth for 10-15 minutes, aids in dislodging any blockages and promoting circulation without exacerbating swelling. Following feeds, cold compresses or ice packs wrapped in cloth (applied for 10-20 minutes) are recommended to minimize inflammation and pain in the affected area.^[6]^[53] Adequate rest and increased fluid intake are essential to bolster immune function and overall recovery, with women encouraged to prioritize sleep when possible and consume plenty of fluids to prevent dehydration amid fever and increased metabolic demands.^[6] For discomfort and fever, nonsteroidal anti-inflammatory drugs like ibuprofen (400-600 mg every 6-8 hours as needed) or acetaminophen (500-1000 mg every 4-6 hours) provide effective relief and are safe for breastfeeding mothers, helping to reduce pain, swelling, and systemic symptoms without antibiotics. These should be used at the lowest effective dose and in consultation with a healthcare provider.^[6]^[52]

Pharmacological interventions

Pharmacological interventions for mastitis primarily target bacterial infections and inflammation, with antibiotics serving as the cornerstone for infectious cases. Antibiotics should be reserved for confirmed or highly suspected bacterial mastitis, as per the mastitis spectrum concept in the Academy of Breastfeeding Medicine's Clinical Protocol #36 (revised 2022 and current as of 2025), to avoid unnecessary use that may disrupt the breast microbiome.^[54] For bacterial mastitis, first-line therapy consists of anti-staphylococcal antibiotics such as dicloxacillin 500 mg orally four times daily or cephalexin 500 mg orally four times daily, administered for 10 to 14 days to cover common pathogens like Staphylococcus aureus.^[55]^[56] These agents are selected for their efficacy against gram-positive organisms and safety during breastfeeding. In cases where methicillin-resistant Staphylococcus aureus (MRSA) is suspected or confirmed, alternative antibiotics such as clindamycin 300 mg orally four times daily are recommended, reflecting updated guidelines emphasizing coverage for resistant strains prevalent in community settings.^[56]^[57] Trimethoprim-sulfamethoxazole (160 mg/800 mg) twice daily may also be used as a second-line option for MRSA, particularly in non-penicillin-allergic patients.^[58] Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen 400-600 mg orally every 6-8 hours as needed, are employed to alleviate pain, reduce swelling, and manage inflammation, especially in non-infectious or inflammatory mastitis.^[59] Ibuprofen is preferred due to its established safety profile in lactating women and its dual action on pain and edema.^[50] When Candida colonization is suspected and confirmed via culture or clinical signs like persistent nipple pain despite bacterial treatment, topical antifungals such as miconazole 2% cream or clotrimazole applied to the affected area twice daily for 2 weeks are indicated.^[60]^[8] These agents target fungal overgrowth without systemic absorption risks during breastfeeding. Treatment duration typically spans 10 to 14 days for antibiotics, with clinical improvement expected within 48 hours of initiation; if no response occurs, milk culture should be obtained, and therapy switched accordingly to address potential resistance or alternative pathogens.^[6]^[61] Pharmacological interventions are integrated with supportive measures to optimize recovery.^[50]

Invasive procedures

Invasive procedures are indicated when mastitis progresses to form a breast abscess, typically presenting as a painful, fluctuant mass that fails to respond to initial antibiotic therapy.^[8] Abscess formation occurs in approximately 5-11% of untreated or inadequately managed lactational mastitis cases and requires drainage to prevent further complications such as sepsis.^[62] The primary invasive interventions include needle aspiration and incision and drainage (I&D), with ultrasound-guided needle aspiration preferred for breast abscesses less than 3 cm in diameter due to its minimally invasive nature and lower risk of complications compared to open surgery.^[63]^[64] Indications for these procedures include lack of clinical improvement after 48-72 hours of appropriate antibiotic treatment or the presence of a palpable fluctuant mass confirmed by ultrasonography.^[65]^[66] For smaller collections, conservative management with antibiotics and warm compresses may suffice, but larger or multiloculated abscesses often necessitate repeated aspirations or transition to I&D if initial drainage is incomplete.^[63]^[67] Ultrasound guidance enhances precision, reduces recurrence rates to below 20% in many series, and allows for outpatient performance in suitable cases.^[68]^[69] Following drainage, patients should continue antibiotic therapy tailored to culture results, typically for 10-14 days total, to address any residual infection.^[45] Breastfeeding or milk expression from the affected breast is encouraged if feasible, as aspiration preserves ductal integrity better than I&D, though expressed milk may need to be discarded until resolution to avoid contaminating the infant.^[8] Close follow-up with serial ultrasounds is recommended to monitor for reaccumulation, with success rates exceeding 80% for ultrasound-guided approaches in lactational abscesses.^[70]^[71] In rare instances of refractory or chronic granulomatous mastitis unresponsive to repeated drainage and medical therapy, more extensive surgery such as wide excision or mastectomy may be considered, particularly in cases with recurrent fistulas or extensive tissue destruction.^[72] Mastectomy, often with immediate reconstruction, has shown complete remission rates approaching 100% in selected patients with idiopathic granulomatous mastitis after multiple failed interventions, though it is reserved for severe, non-resolving disease due to its morbidity.^[73]^[74]

Prevention

Breastfeeding practices

Frequent and effective breastfeeding is a key practice to prevent milk stasis, which can contribute to the development of mastitis. Breastfeeding every 2 to 3 hours, including nighttime feeds, ensures complete emptying of the breasts and helps maintain milk flow, reducing the risk of engorgement and subsequent infection. This frequency, typically 8 to 12 feedings per day, promotes optimal lactation and minimizes bacterial proliferation in stagnant milk.^[8]^[75] Proper latch and positioning during breastfeeding are essential to avoid nipple trauma, a common entry point for bacteria leading to mastitis. A good latch involves the infant's mouth covering a significant portion of the areola, with the tongue positioned under the nipple, allowing for efficient milk removal without causing cracks or soreness. Varying positions—such as cradle hold, cross-cradle, or football hold—across feedings further prevents localized pressure and trauma. Mothers should seek guidance from lactation consultants if latching issues arise, as optimizing technique can significantly lower mastitis incidence.^[76]^[77]^[1] When using breast pumps, maintaining strict hygiene is crucial to reduce the introduction of bacteria that could cause mastitis, particularly in cases involving pathogens like methicillin-resistant Staphylococcus aureus. Pump parts should be disassembled, washed with hot soapy water after each use, and sterilized daily by boiling or using a dishwasher's sanitizing cycle, especially for infants under 2 months or those with weakened immune systems. Air-drying parts completely and storing them in a clean, dry area prevents contamination.^[78]^[79] Early recognition and prompt treatment of breast engorgement are vital to halt its progression to mastitis. Engorgement, characterized by swollen, tender breasts due to milk buildup, should be addressed by increasing feeding frequency, using warm compresses before feeds, and gentle massage to facilitate drainage. If needed, hand expression or pumping can relieve pressure, but excessive expression should be avoided to prevent oversupply. Consulting a healthcare provider early ensures timely intervention and supports continued breastfeeding.^[1]^[80]

Hygiene and lifestyle measures

Maintaining proper hand hygiene is a fundamental preventive measure against mastitis, as it reduces the introduction of bacteria through skin contact with the breasts or pumping equipment. Women are advised to wash their hands thoroughly with soap and water for at least 20 seconds before touching the breasts, expressing milk, or assembling and using breast pumps, which helps minimize microbial contamination that could lead to infection. ^[79] ^[81] ^[43] Nipple piercings pose an additional infection risk for mastitis, particularly in nonlactating individuals or during breastfeeding, as they can introduce bacteria through trauma, with infections occurring in 10-20% of cases. To prevent complications, it is advisable to avoid getting nipple piercings during pregnancy and lactation; if already present, jewelry should be removed before feeds, and the area kept clean with saline washes, monitored for signs of infection such as redness or discharge.^[82]^[83]^[84] Wearing appropriately fitted clothing is another key hygiene practice to prevent duct compression and subsequent milk stasis, which can predispose individuals to mastitis. Tight bras, underwire supports, or restrictive garments should be avoided, as they can exert pressure on breast tissue, impairing circulation and milk flow, particularly in the postpartum period. ^[76] ^[85] ^[86] Lifestyle modifications, such as smoking cessation, play a significant role in reducing the risk of nonlactational mastitis, especially periductal forms associated with tobacco use. Smoking damages subareolar ducts, increasing susceptibility to recurrent infections, and quitting has been shown to lower recurrence rates substantially when implemented as an adjuvant strategy alongside other treatments. ^[6] ^[87] ^[45] Supporting overall immune resilience through balanced nutrition and stress management is essential for mitigating mastitis risk across both lactational and nonlactational types. A nutrient-rich diet providing adequate vitamins, minerals, and fluids bolsters immune function and helps prevent deficiencies that could heighten infection vulnerability, while effective stress reduction techniques, such as mindfulness or relaxation practices, address the immunosuppressive effects of chronic stress. Emerging evidence as of 2025 suggests that probiotic supplementation with specific strains like Ligilactobacillus salivarius (formerly Lactobacillus salivarius) during late pregnancy and early lactation may reduce infectious mastitis incidence by modulating the breast microbiome; women should consult healthcare providers before starting probiotics. ^[85] ^[76] ^[88] ^[89] ^[90] Prioritizing maternal rest is increasingly emphasized in contemporary guidelines to counteract fatigue-induced immune suppression, which may elevate mastitis susceptibility, particularly in the early postpartum phase. Adequate sleep and rest periods allow for recovery from physical demands, enhancing the body's natural defenses against potential infectious entry points in breast tissue. ^[85]

Outcomes

Prognosis

The prognosis for acute lactational mastitis is favorable, with the majority of cases resolving rapidly following initiation of appropriate treatment, such as antibiotics combined with continued breastfeeding and supportive care. Studies indicate that over 90% of patients experience symptom improvement within 48 hours, and full resolution typically occurs within 2-3 days.^[6]^[81] However, recurrence affects 6.5-30% of women, often linked to incomplete treatment or persistent milk stasis, underscoring the need for adherence to the full antibiotic course.^[81]^[91] In contrast, nonlactational mastitis carries a higher risk of chronicity and prolonged recovery, particularly in forms like idiopathic granulomatous mastitis, where up to 50% of cases may recur or persist despite intervention, potentially leading to breast scarring and deformity.^[6]^[92] These variants often require multidisciplinary management, including corticosteroids or surgery, to mitigate long-term tissue damage.^[93] Complications such as breast abscess formation occur in 3-11% of untreated or inadequately managed cases, delaying recovery by weeks and necessitating drainage procedures, while progression to sepsis remains rare at less than 1%.^[6]^[45] Despite these risks, the impact on breastfeeding is minimal with timely intervention; guidelines from the Academy of Breastfeeding Medicine (Protocol #36, revised 2022, affirmed in 2025 reviews) confirm that most affected women successfully continue lactation without cessation, supported by recommendations emphasizing milk expression to aid resolution.^[6]^[94]^[95]

Epidemiology

Mastitis primarily affects breastfeeding women, with lactational mastitis occurring in 2% to 33% of cases worldwide, depending on study definitions, population, and diagnostic criteria.^[96]^[12] Nonlactational mastitis is far less common, accounting for less than 1% of cases in the general population and representing only 1-2% of all symptomatic breast conditions.^[16]^[97] Demographically, lactational mastitis is more prevalent among women in developed countries where breastfeeding initiation rates are moderate to high, often reaching 70-90% in places like the United States and Europe, compared to variable rates in other regions.^[98] The condition peaks during the first postpartum month, with over 70% of cases occurring within the initial three to four weeks after delivery.^[99] As of November 2025, population-level data indicate stable incidence rates for lactational mastitis globally (2-33%), with some studies noting an upward trend in certain populations despite improved breastfeeding education and support programs.^[100] However, cases involving methicillin-resistant Staphylococcus aureus (MRSA) have risen as an emerging concern, particularly in community settings, with proportions around 5-7% in recent U.S. and European studies.^[101] Geographic variations show higher rates in low-resource settings, where poor hygiene and limited access to clean water contribute to elevated incidence among breastfeeding women, sometimes exceeding 20% in parts of sub-Saharan Africa and South Asia.^[102] In contrast, developed regions report lower per-capita rates but higher detection due to better healthcare access.^[103]

Veterinary aspects

Mastitis in livestock

Bovine mastitis is the most prevalent and economically significant disease affecting dairy cattle worldwide, primarily involving inflammation of the mammary gland due to bacterial infection.^[104] It is extensively studied in livestock, particularly in cows, where it leads to substantial reductions in milk production and quality. The condition is classified into clinical and subclinical forms, with clinical mastitis presenting acute signs and subclinical cases detected through indirect measures like elevated somatic cell counts in milk.^[105] The primary pathogens responsible for bovine mastitis are divided into contagious and environmental types. Contagious pathogens, such as Staphylococcus aureus, spread between cows during milking and colonize the udder, leading to persistent infections.^[106] Environmental pathogens, including Escherichia coli, originate from bedding, water, or manure and typically cause acute, severe cases.^[107] Clinical symptoms include udder swelling, heat, redness, and pain, often accompanied by abnormal milk appearance such as clots, flakes, or watery consistency.^[104] Subclinical mastitis is indicated by a somatic cell count exceeding 200,000 cells/mL in milk, signaling inflammation without visible signs and contributing to decreased milk quality.^[108] Prevalence varies by region and management practices, but clinical mastitis incidence typically ranges from 15 to 40 cases per 100 cow-years in dairy herds.^[109] Annually, subclinical cases affect a significant portion of herds, with herd-level prevalence often exceeding 50%.^[110] In the United States, mastitis imposes major economic losses on the dairy industry, estimated at approximately $2 billion annually, stemming from discarded milk, reduced yields, veterinary costs, and premature culling.^[111] Management of bovine mastitis in livestock emphasizes prevention and targeted interventions tailored to production cycles, differing markedly from approaches in other contexts by prioritizing herd-level strategies. Dry cow therapy, administered as intramammary antibiotics at the end of lactation, is a cornerstone for eliminating existing infections and preventing new ones during the dry period.^[112] Selective dry cow therapy, based on somatic cell counts and infection history, reduces antibiotic use while maintaining efficacy, often combined with teat sealants to block pathogen entry.^[113] Overall control involves hygiene during milking, environmental management, and monitoring, as infectious processes share similarities with those in other species but require farm-specific adaptations.^[104]

Mastitis in companion animals

Mastitis in companion animals, particularly dogs and cats, is an inflammatory condition of the mammary glands most commonly affecting postpartum females during lactation. It is typically caused by bacterial infections, such as those from Escherichia coli, Staphylococcus spp., or Streptococcus spp., which enter the glands via ascending infection through the teat canal, often due to poor hygiene in the whelping environment or associated with metritis in the dam.^[114]^[115] In dogs (bitches), it is more frequently reported than in cats (queens), where it remains a rarer occurrence, though both species share similar pathophysiology involving bacterial ascension or hematogenous spread.^[116]^[117] Clinical symptoms in affected animals include firm, swollen, and painful mammary glands, often with a hot or discolored appearance, accompanied by purulent or discolored milk discharge from the affected teats. Systemic signs such as anorexia, lethargy, fever, and dehydration may develop, particularly in severe cases, and puppies or kittens may refuse to nurse from infected glands, leading to inadequate nutrition.^[114]^[118] In cats, the condition can progress to gangrenous mastitis if untreated, characterized by necrotic tissue and rapid deterioration.^[119] Diagnosis typically involves physical examination, cytology of milk or gland aspirates, and bacterial culture to identify the pathogen and guide therapy.^[114] The prevalence of mastitis is estimated at 0.1-1% among breeding female dogs, with higher rates observed in those with oversized litters (e.g., ≥9 puppies), where increased nursing trauma and prolonged gland patency facilitate bacterial entry.^[120]^[121] In cats, it is uncommon, affecting less than 1% of lactating queens, though exact figures are limited due to underreporting.^[116] Risk factors include large litter sizes, dystocia, or unsanitary conditions, which are more pronounced in companion animal settings compared to controlled breeding programs.^[122] Treatment focuses on antimicrobial therapy tailored to the isolated pathogen, typically broad-spectrum antibiotics like amoxicillin-clavulanate or cephalexin for 2-3 weeks, combined with supportive care such as warm compresses to promote drainage and hand-milking or stripping of the affected glands to relieve engorgement.^[114]^[118] Pain management with NSAIDs and fluid therapy are essential, and in severe or abscessed cases—more common in cats—surgical drainage or gland resection may be required.^[123] Species-specific adjustments include temporary weaning of kittens to prevent exposure to infected milk, while in dogs, supportive nursing can often continue with monitoring. Prognosis is generally good with prompt intervention, though untreated cases can lead to septicemia or mammary necrosis.^[124]

Terminology

Etymology and pronunciation

The term mastitis derives from the Ancient Greek mastós (μάστός), meaning "breast" or "udder," combined with the suffix -îtis (-ῖτις), indicating inflammation, forming a medical Latin compound adopted into English.^[125]^[126] This etymology reflects the condition's characteristic swelling and infection of mammary tissue, with the word entering scientific nomenclature in the early 19th century.^[127] The earliest documented use of mastitis appears in 1827 within the Edinburgh Medical and Surgical Journal, initially describing cases of mammary inflammation, including in bovine contexts.^[126] In modern English, the term is pronounced /mæsˈtaɪtɪs/, often phonetically rendered as "mass-TYE-tiss."^[128]

Historical nomenclature

In the 18th and 19th centuries, mastitis was frequently referred to as "milk fever," a term that often conflated inflammatory breast conditions with simple engorgement or poor breastfeeding technique during the early postpartum period.^[12] This nomenclature reflected the era's limited diagnostic tools and understanding, attributing symptoms like fever, pain, and swelling to an overload of milk rather than bacterial infection.^[12] Following the widespread adoption of antibiotics in the mid-20th century, particularly after the 1950s, terminology evolved to better distinguish infectious processes, with "puerperal mastitis" specifying inflammation in the immediate postpartum period and "lactational mastitis" encompassing cases during ongoing breastfeeding beyond the puerperium.^[6] These distinctions arose as antibiotics like penicillin became standard treatment, reducing mortality and allowing for more precise classification based on timing and etiology rather than vague symptomatic overlap.^[6] In the 1970s, the term "idiopathic granulomatous mastitis" emerged to describe rare, non-infectious inflammatory variants characterized by granuloma formation without identifiable pathogens, first reported by Kessler and Wolloch in 1972.^[129] This addition highlighted growing recognition of autoimmune or hypersensitivity mechanisms in mastitis subsets. By 2022, the Academy of Breastfeeding Medicine revised its clinical protocol to discourage the use of "blocked duct" terminology, citing its potential to stigmatize mothers by implying inadequate care; instead, it promotes descriptions of ductal inflammation and microbial dysbiosis to foster supportive management.^[50] This shift aligns with etymological roots of "mastitis" from Greek mastos (breast) and -itis (inflammation), emphasizing the condition's inflammatory core.

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May 12, 2023 · In most cases, cats with mastitis will need to be given antibiotics for two to three weeks, but their condition should start improving within ...
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Feline gangrenous mastitis - PMC - PubMed Central - NIH
Most cases of mastitis can be managed on an outpatient basis (6). Treatment involves the use of antibiotics to which the causative organism is susceptible and ...
[113]
Lactation-related mammary gland pathologies-A neglected ...
Mastitis is a common reproductive disorder in bitches, reaching a prevalence of 0.71%. Mastitis has a wide range of forms, from asymptomatic to severe ...Missing: symptoms | Show results with:symptoms
[114]
Incidence and risk factors for canine mastitis and metritis in two ...
Risk factors for mastitis identified were colony, litter size where bitches that had large litter size of ≥9 pups (16.2 %) were 60 % more likely to develop ...
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Identifying risk factors for mastitis in postpartum bitches - Ivis.org
We hypothesized that age, breed, litter size, and whelping interventions are associated with risk of developing mastitis in postpartum bitch. A retrospective ...
[116]
Management of mastitis and abscessation of mammary glands ...
Feb 1, 2010 · Mastitis is an uncommon condition in cats, usu- ally developing in the periparturient period and often developing in association with trauma ...Missing: prevalence | Show results with:prevalence
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Mastitis in Cats - Pet Health Network
Antibiotics are often prescribed to treat the bacterial infection. Applying warm compresses to the infected teats helps them to open and drain.
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Mastitis - Etymology, Origin & Meaning
mastitis(n.) "inflammation of the mammary gland," 1842, medical Latin, from masto- "female breast" + -itis "inflammation.".
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mastitis, n. meanings, etymology and more - Oxford English Dictionary
The earliest known use of the noun mastitis is in the 1820s. OED's earliest evidence for mastitis is from 1827, in Edinburgh Medical & Surgical Journal.
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Understanding the genetic mechanisms underlying mastitis
The term “mastitis” originates from the Greek mastos, meaning “breast,” and -itis, a suffix meaning “inflammation.” Inflammation etymology can be traced to the ...
[121]
MASTITIS Definition & Meaning - Merriam-Webster
Oct 10, 2025 · The meaning of MASTITIS is inflammation of the breast or udder usually caused by infection.
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Idiopathic granulomatous mastitis - Bede - Annals of Breast Surgery
Also referred to as idiopathic granulomatous lobular mastitis, it is a rare and chronic condition characterized by relapsing sterile, draining breast abscesses.Missing: nomenclature | Show results with:nomenclature