Rockville Lactation

Lynnette Hafken, MA, IBCLC

Lactation Consultant

text (fastest response) or call: (240) 888-2123

email: [email protected]

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IMPORTANT NOTE RE: FORMULA SHORTAGE: If you are using formula and cannot find it (or you can and want to let parents know where), see findmybabyformula.com

Engorgement and Mastitis Spectrum Conditions:

Plugged/Clogged Ducts, Breast Infections, Blebs/Milk Blisters

The picture above represents the milk ducts in the human breast. In addition to ducts, there are sacs where milk is made, blood vessels, fat, nerves, and fluid called lymph. Despite how tangled everything is, it all usually works together beautifully to make and deliver milk to babies. However in some circumstances, the system gets out of whack, and mothers experience painful fullness, lumps, infections, and hardened areas in their breasts. 

New research summarized by the Academy of Breastfeeding Medicine (ABM) in their 2022 Mastitis Spectrum Protocol clarifies what is going on in there, and how to care for your breasts to restore them to comfort and normal functioning. 

Note: The recommendations presented here are not comprehensive (I am not convinced by some of the ABM’s suggestions and will not include them). Please feel free to read the original Protocol linked above if you are interested in further ideas.

So, What Is  Going On in There?

There is a spectrum of conditions that the ABM now refers to as the Mastitis Spectrum, which comprises the following:

  • ductal narrowing (colloquially called “plugged/clogged ducts”)
  • inflammatory mastitis
  • bacterial mastitis
  • subacute mastitis
  • phlegmon (i.e., inflammation of soft tissue under the skin)
  • abscess (an infected lump filled with pus, usually painful)
  • galactocele (a benign milk-filled cyst)

Postpartum engorgement shares some features with mastitis spectrum conditions, so will be discussed herein, but it is not an abnormal condition; it is part of the normal progression of lactation (despite how much it can hurt!).

General Recommendations for All  Breast Conditions

  • Get enough rest (by any means necessary!)
  • Aim to produce only as much milk as your baby is drinking—breastfeed on demand or pump only 25–35 oz/day for a singleton, adjusted to what your baby typically takes; avoid intentionally “emptying” the breast unless advised to do so by an IBCLC or MD, or you need to increase your milk supply
  • Wear a comfortable, supportive bra that does not dig into your breasts or cut off any circulation
  • Use clean pump parts; sterilization is not recommended by the ABM, however the CDC recommends doing so once/day. Either is probably fine; but if you have a premature or immunocompromised baby, sterilizing is appropriate
  • Avoid deep massage and vibration (appropriate massage techniques shown below)
  • Avoid saline soaks and excessive moisture (e.g., wet breast pads) on nipples
  • Apply ointments such as lanolin or nipple butter before and after feeding/pumping if skin is broken or damaged
  • Sunflower or soy lecithin (5–10 g/day) can reduce inflammation and is thought to emulsify milk (keeping the milk fat mixed in with the rest of the liquid)
  • Treat oversupply (hyperlactation) by normalizing the milk supply to the baby’s need (see block feeding)
  • Therapeutic ultrasound can be used for persistent symptoms
  • Keep an eye on your mental health; breastfeeding problems (especially painful ones) can cause or worsen depression, anxiety, and other negative emotions.
  • Use lymphatic drainage (see pic and video below) to reduce fluid and pressure in breasts; this works best while lying on your back, flat or reclined

Lymphatic drainage means that you are encouraging excess fluid in the breast to move out into the rest of your body, by using gentle moving of the tissue towards veins that carry the fluid away. Massage from the nipple towards those veins:

  • Reverse pressure softening before breastfeeding or pumping 
  • Decrease inflammation and pain: “ice can be applied every hour or more frequently if desired”; cold cabbage has been used traditionally, but it can be contaminated with listeria. Filling a disposable diaper with ice water makes a good compress, or a bag of frozen peas wrapped in a pillowcase. Ibuprofen reduces inflammation and pain, and acetaminophen/paracetamol reduces pain. The ABM says that ibuprofen can be dosed up to 800 mg every 8 h, and acetaminophen up to 1,000 mg every 8 h. Ask your doctor about what the appropriate dosage is for you.
  • Heat “may worsen symptoms, [but] it also may provide comfort for some patients” (yes, that's confusing; I'd interpret it as brief periods of heat are fine if you find it soothing, but no longer than a few minutes).

Engorgement

Engorgement is a term used for the swelling of the breasts when the milk comes in, or extreme fullness at any time. There are two types of “engorgement”—the first type is benign though uncomfortable breast fullness; the second type is pathological engorgement. 


If your breasts are full and uncomfortable, but the tissue is somewhat pliable, like the tip of your nose, that is just fullness; all you need to do is feed your baby on demand or pump the amount of milk you expect them to drink at the next feeding. However, if your breasts are hard, the skin is shiny, and/or they feel as hard as your forehead when you touch them, that is true pathological engorgement, which needs to be addressed immediately to ensure ongoing robust milk production. 


Milk supply is dependent on milk removal, so if all the milk remains “stuck” in the breast (as often happens when engorgement is severe), there is the risk of lowered milk supply if the situation persists too long. Doing nothing  can cause milk to dry up completely.

What To Do

Simply follow the above suggestions for general breast conditions.

Plugged Ducts

Surprisingly, according to the ABM, the traditional approach of firmly massaging behind “clogs” and frequently emptying the breasts can worsen the problem rather than fixing it. Remember this picture:

Imagine if one of the roads was narrowed down to one lane; cars would build up behind the narrowing resulting in a “clog” of cars. Pushing on those cars with a giant plow would not help; in fact it would just put additional pressure on the one free lane, impeding merging and making it difficult for single cars to go through that lane.

How in the world does this relate to plugged ducts? Basically, the ABM's new protocol states that milk ducts cannot be “plugged” by a hardened clump of milk. Ducts are not rigid tubes that can have something stuck in them. What is happening when mothers experience the sensation of clogs is the following: swelling in the breast narrows the milk ducts (just like a highway going to one lane), causing milk buildup and further swelling behind the narrowing. When there is milk buildup, the body starts reabsorbing some of the fluid, resulting in milk thickening, first becoming the consistency of jello and then like toothpaste. There is no need to do anything to get it out, as the body will deal with this thickened milk on its own, but it will be helpful to implement strategies to loosen things up .

The last thing we want to do is push on that area. Firm massage increases swelling and inflammation, and because milk ducts are arranged like a plate of spaghetti rather than being straight lines leading directly to the nipple, the “clog” will likely just move around and push on other structures rather than coming out easily. It may come out eventually, but the effort put into massage is likely to cause further swelling and narrowing of ducts, causing a recurrence. Frequent pumping (or encouraging baby to breastfeed more than they would normally do) can also make the problem worse. Increased milk removal increases milk production, adding more “cars” to the narrowed highway and putting more pressure on the system. Avoid trying to “empty” your breasts.

The tomato sauce represents the intertwined blood vessels and capillaries, which also prefer to be treated gently! (Photo by D. Laird via Flickr.com)

While we have always believed that not removing milk from full breasts was a contributing factor to the development of “clogged ducts” and mastitis, the ABM points out that there is no evidence showing that unrelieved fullness causes these conditions (though it can and does decrease milk production).

What to Do

Simply follow the  above suggestions for general breast conditions.

Inflammatory and Infectious Mastitis

[Under Construction]

The ABM suggests that “mammary dysbiosis,” meaning a disruption to the natural and healthy bacteria in and around the breast, can cause these problems. It is unclear what to do about this, except for keeping hands and anything else that touches your breasts clean. We don't really know what the ideal breast microbiome is, or what is normal for each woman, so it would be hard to make recommendations about how to treat a “dysbiosis.”

With regard to yeast overgrowth in breast tissue (“ductal thrush”), they state: “[d]espite the common perception that yeasts cause ‘candida mastitis,’ no scientific evidence exists to support this diagnosis.”