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Referral and warning signs
When to refer
Refer to Hospital (HC4/H) if: Suspected abscess, Severe mastitis, Failure to improve on oral antibiotics, Recurrent mastitis.
Red flags
- Palpable fluctuant mass
- Signs of sepsis
- Skin necrosis
- Failure to respond to antibiotics
- Suspicion of inflammatory breast cancer
Signs and symptoms
- Mastitis: Painful, tender, swollen, warm, red area of breast (wedge-shaped). Usually unilateral. Fever, chills, malaise.
- Breast Abscess: Progression from mastitis. Palpable, tender, fluctuant mass. Skin may be shiny/thin. Persistent fever despite antibiotics.
Risk factors
- Milk stasis (engorgement, poor emptying, blocked duct).
- Nipple damage (cracked nipples, poor latch).
- Previous mastitis.
- Tight bra.
- Stress, fatigue.
- Abrupt weaning.
Diagnosis
Clinical assessment
Mastitis: Localized breast inflammation +/- systemic symptoms. Abscess: Palpable fluctuant mass. Differentiate from engorgement, blocked duct, galactocele, inflammatory breast cancer.
Investigations
- Clinical diagnosis usually sufficient (mastitis).
- Breast Ultrasound: Confirm suspected abscess, guide aspiration.
- Breast Milk Culture: If severe/recurrent/non-responsive.
- Needle Aspiration of Abscess: Culture + therapeutic.
Diagnostic criteria
Mastitis: Clinical findings. Abscess: Palpable fluctuant mass +/- ultrasound confirmation.
Management
Non-pharmacological management
- Effective Milk Removal (KEY): Continue Breastfeeding frequently (start on affected side if tolerable) OR Express milk regularly. Correct latch.
- Supportive: Rest, fluids, Warm compresses BEFORE feeds, Cold compresses AFTER feeds, Supportive bra.
- Abscess Drainage: Needle Aspiration OR Surgical Incision & Drainage (I&D).
Pharmacological treatment
- Analgesia: Paracetamol OR Ibuprofen.
- Antibiotics (Mastitis): If severe/nipple fissure/no improvement after 12-24h milk removal. Cover S. aureus. Cloxacillin 500mg PO QID x 10-14d (First line). Alternatives: Cephalexin, Clindamycin (if MRSA).
- Antibiotics (Abscess): Required + Drainage. Same choices.
Monitoring
Monitor symptom resolution. Assess milk drainage. Follow up 24-48h. Monitor abscess site post-drainage.
Complications
- Breast abscess.
- Recurrent mastitis.
- Chronic inflammation/scarring.
- Fistula (rare).
- Premature weaning.
- Sepsis (rare).
Prevention
- Correct breastfeeding technique.
- Frequent/effective milk removal.
- Avoid stasis.
- Treat nipple damage.
- Good hygiene.
Patient education
- Importance of CONTINUED milk removal.
- Antibiotic adherence.
- Pain relief.
- Breastfeeding technique support.
- Signs of worsening/abscess.
- Hygiene.
Uganda-specific notes
Common. Emphasize continued BF/expression. Cloxacillin standard. Ultrasound access variable. I&D at hospital.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.6.3