Public Comment

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* Name

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* Institution/Organization

Methodology
Strong Consensus If >90% of panelist rate a recommendation as either “strongly agree” or “agree” and the median score is 1
Consensus If > 75% and <90% of panelists rate a recommendation as either “strongly agree” or “agree” and the median is either 2 or 1
No Consensus any other rating scores



1. Initial Management

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* 1a. Clinicians should distinguish between noninfectious vs infectious mastitis for the initial management of patients with lactational mastitis. (Strong Consensus)

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* 1b. For patients with infectious and noninfectious lactational mastitis, clinicians should institute symptom relief measures. (Strong Consensus)

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* 1c. Lactating patients with noninfectious mastitis do not require antibiotics. (Strong Consensus)

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* 1d. Lactating patients with infectious mastitis presenting with well demarcated cellulitis, induration and/or a mass require antibiotics. (Strong Consensus)

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* 1e. Lactating patients with noninfectious mastitis whose symptoms do not improve within 24-48 hours should be started on antibiotics. (Strong Consensus)

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* 1f. Clinicians should prescribe dicloxacillin and/or cephalexin as the first line therapy for infectious lactational mastitis.(Strong Consensus)

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* 1g. For patients with infectious lactational mastitis presenting as a phlegmon on ultrasound, clinicians should consider prescribing longer-term antibiotics. (Strong Consensus)

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* 1h. For patients with infectious lactational mastitis with a phlegmon that does not resolve after a month despite treatment, aspiration or biopsy are recommended to rule out malignancy. (Strong Consensus)

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* 1i. Clinicians should counsel patients that it is safe to breastfeed from a breast with infectious or noninfectious mastitis or abscess. (Strong Consensus)

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* 1j. Clinicians should counsel patients with infectious lactational mastitis that “emptying” the breast with massage or excessive pumping is contraindicated. (Strong Consensus)

2.Percutaneous Interventions

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* 2a. Aspiration and culture can be attempted for lactating patients with fluid collections less than 3 cm. (Strong Consensus)

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* 2b. Stab incision and gravity drain placement should be done for lactating patients with fluid collections greater than 3 cm or who fail aspiration. Infected contents should be sent for culture. The drain should be removed after 3-5 days. (Consensus)

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* 2c. Ultrasound guidance is recommended to facilitate aspiration of fluid collection, proper placement of a drain, and complete evacuation of fluid. (Consensus)

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* 2d. Patients should be counseled that it is safe to breastfeed after lidocaine injection in the breast for percutaneous procedures performed for infectious lactational mastitis. (Strong Consensus)

3. Imaging

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* 3a. An ultrasound should be performed for patients with infectious lactational mastitis with a breast mass and cellulitis at presentation. (Strong Consensus)

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* 3b. An ultrasound should be performed for patients with infectious lactational mastitis with cellulitis who fail to resolve with medical or symptom management. (Strong Consensus)

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* 3c. Mammograms should be performed for patients with lactational mastitis if the symptoms are refractory to treatment in order to rule out a malignancy or if the patient qualifies for age-appropriate screening (when comfortable for the patient). (Strong Consensus)

4. Indications for Surgery

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* 4a. Patients with infectious lactational mastitis should undergo operative drainage in the operating room if they are unable to tolerate a percutaneous procedure in the office. (Strong Consensus)

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* 4b. Patients with infectious lactational mastitis should undergo operative drainage in the operating room if symptoms do not improve or worsen after a stab incision and drainage procedure in the office. (Consensus)

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* 4c. Patients with infectious lactational mastitis with heavily loculated and solidified contents should undergo operative drainage in the operating room. (Strong Consensus)

5. Performance of the Surgical Procedure

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* 5a. For patients with infectious lactational mastitis who require operative drainage, the incision to drain the area should be made as small as possible and as far away from the nipple areolar complex as possible. (Strong Consensus)

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* 5b. For patients with infectious lactational mastitis who require operative drainage, no wound packing is required but a drain should be placed.(Consensus)

6. Other non-Surgical Management

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* Not Applicable

7. Follow-up Care

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* 7a. Clinicians should counsel patients that recurrence of infectious lactational mastitis is low given that the aforementioned measures are adhered to. (Strong Consensus)

Appendix 2. Literature Search Results

A review of the literature was conducted in support of development of these pathway recommendations. Search parameters and resulting references are below.  

Search Parameters:

· Lactational mastitis, lactational abscess, breast phlegmon

o Filters applied: Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Systematic Review, in the last 10 years, English, Human

1. Wilson E(1)(2), Woodd SL(1), Benova L(1)(3). Incidence of and Risk Factors for Lactational Mastitis: A Systematic Review. J Hum Lact. 2020 Nov;36(4):673-686. doi: 10.1177/0890334420907898. Epub 2020 Apr 14.

2. Crepinsek MA(1), Taylor EA(2), Michener K(3), Stewart F(4). Interventions for preventing mastitis after childbirth. Cochrane Database Syst Rev. 2020 Sep 29;9(9):CD007239. doi: 10.1002/14651858.CD007239.pub4.

3. Deng Y(1)(2), Huang Y(1), Ning P(2), Ma SG(1), He PY(2), Wang Y(3). Maternal Risk Factors for Lactation Mastitis: A Meta-analysis. West J Nurs Res. 2021 Jul;43(7):698-708. doi: 10.1177/0193945920967674. Epub 2020 Oct 22.

4. Yu Q(1), Xu C(1), Wang M(1), Zhu J(1), Yu L(1), Yang Z(1), Liu S(1), Gao X(1)(2). The preventive and therapeutic effects of probiotics on mastitis: A systematic review and meta-analysis. PLoS One. 2022 Sep 9;17(9):e0274467. doi: 10.1371/journal.pone.0274467. eCollection 2022.

5. Witt AM(1), Bolman M(2), Kredit S(3), Vanic A(2). Therapeutic Breast Massage in Lactation for the Management of Engorgement, Plugged Ducts, and Mastitis. J Hum Lact. 2016 Feb;32(1):123-31. doi: 10.1177/0890334415619439. Epub 2015 Dec 7.

6. Zakarija-Grkovic I(1), Stewart F(2). Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2020 Sep 18;9(9):CD006946. doi: 10.1002/14651858.CD006946.pub4.

7. Yang L(1), Zhou G(2), Liu J(1), Song J(1), Zhang Z(1), Huang Q(1), Wei F(3). Tanshinone I and Tanshinone IIA/B attenuate LPS-induced mastitis via regulating the NF-κB. Biomed Pharmacother. 2021 May;137:111353. doi: 10.1016/j.biopha.2021.111353. Epub 2021 Feb 9.

8. Lai BY(1), Yu BW(1), Chu AJ(1), Liang SB(2), Jia LY(3), Liu JP(2), Fan YY(1), Pei XH(1)(4). Risk factors for lactation mastitis in China: A systematic review and meta-analysis.PLoS One. 2021 May 13;16(5):e0251182. doi: 10.1371/journal.pone.0251182. eCollection 2021.

9. Anderson L(1)(2)(3), Kynoch K(1)(2), Kildea S(3), Lee N(3). Effectiveness of breast massage for the treatment of women with breastfeeding problems: a systematic review. JBI Database System Rev Implement Rep. 2019 Aug;17(8):1668-1694. doi: 10.11124/JBISRIR-2017-003932.

10. Mangesi L(1), Zakarija-Grkovic I. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2016 Jun 28;2016(6):CD006946. doi: 10.1002/14651858.CD006946.pub3.

11. Milinco M(1), Travan L(2), Cattaneo A(1), Knowles A(1), Sola MV(3), Causin E(2), Cortivo C(4), Degrassi M(4), Di Tommaso F(4), Verardi G(4), Dipietro L(4), Piazza M(4), Scolz S(2), Rossetto M(5), Ronfani L(6); Trieste BN (Biological Nurturing) Investigators. Effectiveness of biological nurturing on early breastfeeding problems: a randomized controlled trial.Int Breastfeed J. 2020 Apr 5;15(1):21. doi: 10.1186/s13006-020-00261-4.

12. Zaidi AZ(1), Moore SE(2), Okala SG(2). Impact of Maternal Nutritional Supplementation during Pregnancy and Lactation on the Infant Gut or Breastmilk Microbiota: A Systematic Review. Nutrients 2021 Mar 30;13(4):1137. doi: 10.3390/nu13041137.

13. Fernández L(1), Cárdenas N(1), Arroyo R(1), Manzano S(1), Jiménez E(1), Martín V(1), Rodríguez JM(1). Prevention of Infectious Mastitis by Oral Administration of Lactobacillus salivarius PS2 During Late Pregnancy. Clin Infect Dis. 2016 Mar 1;62(5):568-573. doi: 10.1093/cid/civ974. Epub 2015 Nov 26.
14. Zhang Y(1), Gao Y, He X, Ding S, Gao H. Oral Lactobacillus fermentum CECT5716 in the patients with lactational abscess treated by needle aspiration: The late follow-up of a randomized controlled trial. Medicine (Baltimore). 2022 Jul 1;101(26):e29761. doi: 10.1097/MD.0000000000029761.

15. Irusen H(1), Rohwer AC, Steyn DW, Young T. Treatments for breast abscesses in breastfeeding women. Cochrane Database Syst Rev. 2015 Aug 17;2015(8):CD010490. doi: 10.1002/14651858.CD010490.pub2.

16. Zhang Y(1), Gao Y(2), Qin J(1), Li X(3), Jiang F(4), Cai Y(5), Feng H(6), Gu X(7), Gao M(8), Wang L(9), Lin Y(10), Fan Y(11), Xu B(12), Wang E(13), Shao Q(14). Breast microecology improvement using probiotics following needle aspiration in patients with lactational breast abscess: a multi-center randomized double-blind controlled trial. Sci Rep. 2022 Oct 6;12(1):16692. doi: 10.1038/s41598-022-20756-w.

17. Togo A(1)(2), Dufour JC(3), Lagier JC(1)(2), Dubourg G(1)(2), Raoult D(1)(2), Million M(1)(2). Repertoire of human breast and milk microbiota: a systematic review.Future Microbiol. 2019 May;14:623-641. doi: 10.2217/fmb-2018-0317. Epub 2019 Apr 26.

18. Maldonado-Lobón JA(1)(2), Díaz-López MA(3), Carputo R(3), Duarte P(3), Díaz-Ropero MP(1), Valero AD(1), Sañudo A(1), Sempere L(1), Ruiz-López MD(4)(5), Bañuelos Ó(1), Fonollá J(1), Olivares Martín M(1). Lactobacillus fermentum CECT 5716 Reduces Staphylococcus Load in the Breastmilk of Lactating Mothers Suffering Breast Pain: A Randomized Controlled Trial. Breastfeed Med. 2015 Nov;10(9):425-32. doi: 10.1089/bfm.2015.0070. Epub 2015 Sep 9.

19. Forte AJ(1), Cinotto G(1), Boczar D(1), Huayllani MT(1), McLaughlin SA(2). Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review. Cureus. 2019 Nov 25;11(11):e6227. doi: 10.7759/cureus.6227.

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* Please indicate in the box any general comments or global suggestions on the entire document.

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