Painful inflamed breasts and mastitis – All you need to know.

The pain and fatigue associated with inflamed breasts and mastitis can lead to mothers feeling they can’t continue breastfeeding.  Knowing how to manage inflamed areas of the breast (previously called blocked or plugged ducts) promptly and effectively can avoid the problem progressing to mastitis.

“Plugging” is a colloquial term for microscopic inflammation of the breast milk ducts, causing narrowing of the milk duct pathway. Scientific evidence now demonstrates that mastitis encompasses a spectrum of conditions (from mild to severe). If ductal narrowing and congestion of breast milk cells are worsened by overstimulation of milk production, then inflammatory mastitis can develop, and acute bacterial mastitis may follow. (ABM Protocol #36)

 Contributing factors could be poor attachment technique leading to poor milk transfer to baby, or something physical which affects the baby’s ability to breastfeed effectively – eg. jaundice, prematurity or tongue-tie.  Most commonly “hyperlactation” or oversupply of milk is present, and the mother typically has an abundant milk supply.

Frequent expressing by pump or silicone milk collection device in addition to breastfeeding can result in hyperlactation. Mechanical breast pumps stimulate breast milk production by extracting milk differently to direct breastfeeding. The repetitive vacuum/release action of a breast pump does not allow for pauses between bursts of suckling as happens naturally with breastfeeding. Silicone collection devices (eg Haaka) create a constant vacuum which is efficient for milk removal, however the effect on lactating breast tissue is not physiologically normal. Expressing does not provide the opportunity for bacterial exchange between the baby’s mouth and the mother’s breast, which may predispose to dysbiosis (altered microbiome). Nipple shields also provide a barrier for this physiological exchange of baby’s saliva to the breast.

Research indicates mastitis is more likely to occur following Caesarean birth, exclusive pumping, nipple shield use, and other circumstances that alter the milk microbiome. Other contributing factors can be delayed breastfeeds, such as when the baby sleeps for a longer period than usual, or the Mother has tried to extend the time between breast feeds eg “spacing feeds” strategies. Tight clothing especially bras that cause part of the breast to be compressed when it is full, or straps/pressure points from baby carriers or slings can also temporarily cause areas of the breast to be constricted and lead to a congested area of the breast. Incorrectly treated breast tissue congestion (eg. vigorous breast massage and frequent expressing) is a common cause of mastitis. Stress and fatigue are often identified by mothers as contributing to episodes of mastitis.

Whatever the cause, the milk flow in part of the breast has been impaired by narrowing of the milk duct which has caused inflammation in a defined area of the breast. Physiological breastfeeding and anti inflammatory measures provide the most effective treatment.

WHAT ARE THE SYMPTOMS? 

Symptoms include tenderness, heat and redness in the specific area of the breast which are signs of inflammation.  The mother is likely to feel hot (have an elevated temperature) and cold shivers (rigors), with aching muscles and joints. She will also feel very tired, and may have a rapid heart rate.  The breast will feel hot and sore, and a red area will surround the section of the breast which is affected. Mastitis is inflammation of the breast tissue which can lead to infection.

MANAGEMENT  

Continue Breastfeeding baby as normal. Most recent advice is to breastfeed baby from the UNAFFECTED BREAST first, and then offer the affected breast. (*This is the opposite of traditional advice). Application of heat to the affected breast before breastfeeding can provide comfort to the mother and assist milk to flow (letdown). Positioning the baby on the affected breast so his chin is pointing towards the congested area can be helpful, as well as alternating breastfeeding positions.

Avoid pumping the affected breast in addition to breastfeeds to remove larger volumes of milk, which will increase milk production. Instead, the aim is to down-regulate milk production of the inflamed affected breast, temporarily at least, but maintain function. If the mother is unable to breastfeed or usually pumps her milk for baby, only express the approximate volume baby would transfer from that breast.

Avoid vigorous massage of the breast. Deep, vigorous massage causes increased inflammation, tissue odema and breast tissue injury. Light, sweeping strokes over the breast towards the armpit area can help move odema (fluid in the breast tissue) – this is called lymphatic drainage. Gentle hand compressions of the breast during breastfeeding or pumping can provide a similar effect to hand expression, and is safe if excessive manual force is avoided.

Don’t miss or delay breastfeeds. Wake baby for a feed if your breasts become too full.  If baby doesn’t want to feed express some milk by hand. Avoid persistent pressure on the breast during breastfeeds from your hand position or clothing, eg bras, feeding tops and baby carriers.

Avoid saline soaks, castor oil and other topical products. Do not use silicone vacuum devices (eg Haaka or similar) with Epsom Salts. These interventions can cause increased inflammation and maceration (damage) to the sensitive areola and nipple surface. Avoid excessive cleansing/sterilisation of pump parts and the breast/nipple area. Avoid giving formula feeds unless clinically necessary due to poor weight gain, or no breastmilk being available temporarily. Continue Breastfeeding!

TREAT THE SYMPTOMS

Pain relief – placing a cool pack or cold compress (wrapped in a cloth) on the affected breast after feeding can be soothing and reduce inflammation.  * A wet face washer placed in the freezer for a few minutes is ideal to use as a chilled compress. Repeat the cold treatment as often as necessary. Oral pain relief can be taken safely – Ibuprofen and/or Paracetamol according to the directions.

Rest (in bed) with baby is best, allowing free access for breastfeeds to continue, and drink plenty of water which will help the recovery. The fatigue is the last symptom to leave a mother who has had mastitis.

Hand expression prior to latching baby to breastfeed may help baby to suckle effectively. Reverse Pressure Softening by a Lactation Consultant can also assist milk flow. Doctors rely heavily on Lactation Consultants to review the breastfeeding mother and baby’s unique story, and to provide insight that they may not uncover during their own treatment of the case. GP’s rarely have time to observe a whole breastfeed to watch how the mother and baby are interacting, and examine breastfeeding technique.

Therapeutic Ultrasound – uses thermal energy to reduce inflammation and relieve odema (swelling), and can be provided by an accredited physiotherapist.

If the breast pain and inflammation does not respond to anti-inflammatory medications, cold treatments, rest and continued breastfeeding, the inflammation can progress to infection, which will need to be treated with antibiotics prescribed by a GP.

BLEBS – Sometimes a mother may have a white spot visible on the nipple pore (outlet), which can be a consequence of disturbed microbiome in the breast (dysbiosis). The white spot (called a bleb) does not cause a fever but the mother is likely to have increasing pain in the affected area if the congested area of the breast is not relieved quickly. Blebs may appear some time after an episode of mastitis. Oral lecithin and application of a topical moderate potency steroid cream such as 0.1% triamcinolone may be used to reduce inflammation on the surface of the nipple. This is safe with breastfeeding and can be wiped off with a tissue or towel before feeding the infant. The bleb should not be “unroofed” using a sharp instrument or needle.

IS THE BREASTMILK SAFE FOR BABY WHEN THE MOTHER IS ON ANTIBIOTICS?

 YES, the breastmilk from a mother who has mastitis and is on antibiotics is safe for baby to drink. A small amount of the antibiotics will pass to the baby via the milk and may cause some tummy rumbles and alteration of baby’s stools. The milk production in the affected breast is likely to reduce temporarily. Continuing breastfeeding from both breasts will support the recovery of the mother’s supply over the following weeks.

In some cases the mastitis has already become infective prior to treatment and an abscess can form in the breast. The collection of pus is identified by ultrasound examination and usually treated in hospital by needle aspiration during ultrasound examination to extract the fluid, and intravenous antibiotics may be given to the mother. It may take several treatments of needle aspiration to remove the abscess sufficiently for the antibiotics to reduce and eliminate the infection.  Even in this scenario, it is recommended for the mother to continue breastfeeding from the affected breast if possible, or to express the breastmilk by hand or pump to enhance the recovery of the breast from the infection.

Breastfeeding mothers who experience repeated episodes of blocked ducts and/or mastitis can benefit from taking Sunflower or soy lecithin 5-10gms daily by mouth which may reduce inflammation in ducts and emulsify milk. Probiotic treatment is usually recommended to assist the recovery of the mother’s breast microbiome following the administration of antibiotics.  QIARA is an Australian product developed specifically to aid mothers’ recovery from mastitis. The active ingredient of this probiotic was originally derived from human breastmilk and provides the specific strain of lactobacillus fermentum which the mastitis affected breast requires for recovery.

REFERENCES:

Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. https://www.betterhealth.vic.gov.au/health/healthyliving/breastfeeding-dealing-with-mastitis https://www.thewomens.org.au/health-information/breastfeeding/breastfeeding-problems/mastitis/#_information