Engorgement, Blocked Ducts & Mastitis - How do I clear a blockage? What does the research say?

The thought of mastitis and blockages is something that often fills us with dread when we are breastfeeding, and if it’s something that we’ve experienced before we’re often pretty afraid of it happening again. So in this blog I want to explore a bit about this topic. What is a blockage and why does it happen? What’s the difference between a blocked duct and mastitis? Crucially - how do we clear a blockage? Are antibiotics always needed?

The guidance for mastitis and blockages has undergone a massive rethink recently. Where many women used to be advised to deeply massage (to remove a plug), pump or feed excessively ("feed, feed, feed") and use heat to get milk moving, we now know that these are not evidence based recommendations and are not helpful. They may make the problem even worse. The Academy of Breastfeeding Medicine recently updated it's protocol for mastitis and blockages and it is the evidence base that they used that I am working from in this blog.

What’s a blocked duct? Is it different from mastitis? What's engorgement?

Mastitis means inflammation of the breast. "Mast" (to do with the breast) and "itis" (inflammation). Inflammation can be on a spectrum from mild inflammation to very severe inflammation and in the same way inflammation of the breast is a spectrum from mild engorgement on the mild end, through blockages, through mastitis right up to abscesses on the extreme end.

Breastfeeding is all about flow of milk. It’s created, and it is removed. It’s created and it’s removed. Constant flow. Think of it like a stream or a river flowing through thousands and thousands of little tributaries. There are an enormous number of ducts in the breast and they are interlinking and interlacing, like a web. They are really dense and milk easily flows from one to another on the way to the nipple.

Engorgement & How to Resolve

Engorgement occurs when there is a lot of milk in the breast. This might happen in the early days when the breast is suddenly getting increased volumes of milk day by day. We can also experience it if our baby sleeps much longer than usual or skips a feed. In those cases the body is making milk faster than we are removing it so we get a build up of milk in the breast. We start to feel uncomfortably full. As we get more and more pressure in the breast, we start to experience inflammation as well as fullness from the milk. That causes a build up of other fluid in the breast as well. All of this fluid and inflammation in the breast around the ducts creates pressure on the ducts and that pressure causes them to narrow. Image the ducts are like roads. Normally they are like motorways and several lanes across. Lots of cars can travel down them. When the breast is really congested however there is so much fluid between one road and the next that it squeezes the roads. Now the 3 lane motorway becomes a 1 lane street. Its much harder for all that milk to travel now.

If they narrow significantly, we can even find it hard to remove the milk at all. That can feel a bit scary.

So what are the techniques to resolve engorgement:

1. Cold therapy (ice). This will reduce inflammation and slow milk production allowing the breast to slightly down regulate and recover.

2. Continue to just feed /express when your baby needs it - this will allow you to feed your baby, to keep milk moving BUT will not overstimulate the breast. Do not feed or express any more regularly than normal. The old idea of increasing milk removal stimulates your body to produce more milk. This actually increases the fluid in the breast causing increased congestion and making it harder to get the milk out! If no milk is coming out, don't panic. Some light lymphatic drainage massage can help.

2. Lymphatic drainage - this is very light movement on the breast to help encourage the excess fluid in the tissues to be drained away by the lymphatic system. A good set of movements can be the following:

- Holding the breast with both hands, lift the breast up and down, then left and right, then move it clockwise and then anti-clockwise. The breast may feel a bit softer after this.

- If still very full, try lying down on your back and massaging in long flowing movements from all around the breast towards your armpit. The pressure should be similar to applying a moisturiser. After this the pressure within the breast should have lessened a bit. Do not press too hard. Pressing too hard will just cause more inflammation and congestion. Gentle is key.

3. Anti-inflammatories - anti-inflammatory medications can be helpful to reduce the inflammation as part of engorgement, and will also decrease pain. Ice is also helpful (frozen veg etc), as it will help to reduce the inflammation.

A meta-analysis of 8 studies looking at treatment for engorgement found that cabbage leaves, cold packs, gel packs, oxytocin treatment and ultrasound treatment were all ineffective (Snowden et al 2002). Anti-inflammatories significantly improved symptoms however. So although cabbage levels or cold packs might feel soothing (and soothing measures are helpful to how we manage the condition), they don’t resolve the engorgement itself, and perhaps that’s not surprising as they can’t actually remove the fluid that is there. With that in mind I’d also urge some caution around using heat - which I’ve also seen suggested. Heat is generally not good to apply to an inflamed area, as it increases the inflammation. It’s usually suggested to increase milk flow, but it increases milk flow by increasing milk volume which is not what we want when the breast is already congested.

Reverse Pressure Softening

If, after the lymphatic drainage above you are finding it difficult to latch your baby on due to the firmness of your areolar area, then reverse pressure softening may help, as it moves fluid back from the nipple. This is a method of using your hands to soften the area directly around the areola to help your baby latch. This is how it is described in the original published paper (Cotterman 2004):

1. All that is really necessary are clean hands and fingernails
2. Choose one method described, depending on fingernail length,
3. to painlessly exert steady, gentle, but firm positive pressure,
4. on a 1- to 2-cm radius of the whole central areola, right at its junction
with the base of the nipple,
5. in an inward direction perpendicular to the mother’s chest wall,
6. for a period of 1 to 3 full minutes,
7. repeating once (or more), depending on severity of swelling,
8. immediately before each attempt to latch (or express or pump with
short trials of intermittent, minimum vacuum),
9. until engorgement has resolved well enough for easy latching

So basically, wash your hands. Place your fingertips around the areola at the base of the nipple. Press inward towards the chest wall for 1-3 mins. This will push milk and fluids back from the areolar area, softening it and allowing your baby to latch.

Blocked Ducts / Mastitis & How To Resolve

If the inflammation from engorgement gets worse we may experience "a blockage". In the past we thought this meant there was a largish clog in one large duct. We thought that we needed to move that one clog out and that resolved the problem. We thought that if we massaged we could move it, or break it up. We now know this isn't accurate as ducts are microscopic and interlacing, and that massage just causes them to collapse and be bruised (causing more inflammation). Vibration using something like a vibrating toothbrush will not be helpful and will likely cause more inflammation.

Symptoms are usually something like:

1. Tenderness in that area of the breast, with some heat and possible redness.

2. If the blockage is close to the skin you may feel a firmness (assess this with the palm of your hand, not your fingertips. It is normal to feel lumpy areas in a lactating breast - often what you are feeling is alveoli full of milk. It's easy to get concerned about normal lumpiness. To avoid this, use the palm of your hand).

3. There are no systemic systems (no fever etc)

To resolve this "plug" - which is actually an area of the breast where the ducts are narrowed, follow the same recommendations above as for engorgement - ice, don't overstimulate the breast, and lymphatic drainage and anti-inflammatories.

Inflammatory Mastitis

If the ductal narrowing continues (through overstimulation of the breast, or massage etc) then mastitis can develop. This is an inflammatory mastitis (not bacterial). Symptoms are usually:

1. Fever

2. Tiredness

3. Breast tenderness (usually localised to the area of the congestion / ductal narrowing), with redness and heat

4. Headache and flu like muscle aches

The treatment for mastitis has always been to drain the breast and clear the blockage, and this has often encouraged the advice to "feed feed feed". The new protocol from ABM on mastitis turns this on it's head, because we now understand we need to down regulate the milk production, not increase it. Guidance is now to reassure that inflammatory mastitis resolves best with the measures above (ice, don't overstimulate the breast, and lymphatic drainage and anti-inflammatories). Antibiotics are not required at this stage, and the NICE guidance has said for many years that there should be self care for 24 hours before considering antibiotics. Usually 24 hours of self care above will create improvement. Minimise breast pump usage - unless you are exclusively pumping. If you are exclusively pumping, do not pump more than usual. Lecithin may also be helpful.

It's really important to remember that normal lactating breasts are lumpy. Often once people start to feel unwell they get more hypervigilant to lumps and bumps in the breast, and a bit afraid of them. This can lead them to try to massage them out, and try to clear them and this causes more inflammation and compresses the ducts further. In fact the less we do this, the breast gets the feedback that less milk is required right now. The rate of milk production slows, and that in conjunction with the ice and anti-inflammatories allows the milk to start flowing again.

Bacterial Mastitis

In the past it has been thought that bacteria enter the breast through nipple trauma and this is what causes bacterial mastitis. The new protocol and evidence casts doubt on this. It is now thought to be linked to dysbiosis of the breast microbiome. Most people are now aware that we have many species of bacteria in our gut, and they help us to digest our food and impact our immune function. This is our gut microbiome. We also have a breast microbiome - bacterial species which line the milk ducts. This is normal and healthy, however just like in our gut, we can sometimes get an overgrowth of harmful bacteria. This overgrowth may even occur from hyperlactation (producing more milk than the baby needs through extra pumping/expressing). As the bacteria overgrow they narrow the duct, making it harder for milk to get through causing the same issues described above.

Symptoms:

1. Redness and swelling in the breast

2. Fever

Blebs

A bleb is a little white lump on the nipple itself. This is an area of inflammation on the nipple. The guidance is not to unroof the bleb. Opening it with a needle will simply cause further trauma and inflammation, narrowing the duct ending further. To treat a bleb the ABM mastitis protcol recommends taking oral lecithin, and using a topical steroid cream to thin the skin on top of the bleb. The steroid should be wiped off before feeding.

SSRMT Technique

In a previous version of this blog I recommended the SSRMT technique to remove blockages (Seven Step Recanalisation Manual Therapy). In a study of almost 3500 women this technique was found to be highly effective (Zhao et al 2014) in resolving symptoms of mastitis. After just one treatment 91.3% of the women had complete resolution of symptoms. A further 4.9% had marked improvement, 2.4% had some improvement and only 1.5% had no improvement. The 8.8% of the women who had not had a complete resolution had a further treatment 3 days later, and 7.6% had complete resolution, 0.8% had marked improvement and 0.4% had some improvement. NONE had no improvement after the 2nd treatment.

How does this fit with the new guidance? That's a good question. The SSRMT technique is an expression technique, and we now know that we shouldn't overstimulate the breast when we have inflammation. I think there are a few important points with SSRMT - in the study the treatment lasted about 5 mins per breast. This was not a long time compared to what people often do when expressing. I imagine this 5 min session might trigger one letdown and no more - it doesn't drain the breast completely. It removes a little milk but doesn't overstimulate. Number 2, it is not about deep massage - it is simply an effective hand expression technique because it helps to get a letdown stimulated through the nipple stimulation, and many people may not know how to trigger a letdown through hand expression before trying this technique.

Since that it has been shown to improve symptoms, I have maintained it in this blog, even though it is not listed in the new protocol. Given the new evidence however I am including it as a method of hand expression with the idea that this is in preference to using a pump. If your baby is breastfeeding then the new protocol suggest that you should just feed the baby as normal, on cue. If you are expressing anyway however, using this technique may be helpful in triggering a letdown and effectively removing milk. It is certainly preferable to any deep massage in and around an inflamed area with the idea of breaking up or moving a clog.

The technique comprises the following 6 steps:

1. Wash hands and get a clean towel /flannel

2. Stretch out the nipple with one hand. With the other, take the towel and wipe any bits of dried milk, dead skin cells etc from the nipple to clear the duct openings

3. Now the duct endings are clear we move back to clear the nipple of clogs. Hold, stretch, roll and extend the nipple in different directions. You may find that as well as flowing milk, clogs of milk or milky strings may emerge from the duct endings when doing this. What it also does is stimulate the nipple well in order to trigger the milk ejection reflex (the letdown).

4. Now that we have worked on the nipple we move back to the areola. Press and push (gently) the areola from lots of different directions while expressing.

5. Then move back again to the breast area. Knead (gently) and push (gently) the breast towards the nipple - this is what we usually do when we are hand expressing with our hands a bit further back from the nipple.

6. Finally, having worked backwards and expressed using our hands from nipple back through the breast area use the flat of 3 fingers to press over the breast looking for any areas where you can still feel any palpable lumps.

Once again - BE GENTLE. Handling the breast should be done with the pressure you use to apply cream, or to stroke a kitten. Please do not pay attention to some of the suggestions I hear online to massage really hard, or really "get in there and work out the clog". Breast tissue is delicate, and when you have a blockage / mastitis you are dealing with already inflamed tissue. It's very easy to damage it further. The SSRMT study above states that "special attention must be paid to avoid intolerable pain". It also says that a maximum of 2 SSRMTs were given in a single session to avoid injury. Steps 3-6 can be done in the bath with the breasts submerged in water and that has certainly been very helpful for many women I have worked with.

I'd also say - get used to handling your breasts. Often we aren't terribly familiar with our breasts and just what breasts full of milk feel like. You may be able to feel areas full of milk before a feed which aren't clogs - they are just full areas that empty during the feed.

Do I need antibiotics?

If you don't see any improvement after 24 hours of self care then the guidance is to see a GP to be evaluated for antibiotics. The vast majority of cases of mastitis are inflammatory rather than bacterial. Within 2-3 days of taking an antibiotic you should feel much better. You will still need to feed on cue but in general follow the guidance above about ice, not overstimulating the breast and using anti-inflammatories etc.

Breast Abscess

A small number of cases of mastitis may develop into a breast abscess ( at the other end of the spectrum from engorgement). In an abscess the body attempts to isolate an infection or fluid filled area by walling it off from the rest of the ductal system. This leads to a sealed off area of milk and pus which by design cannot drain through the nipple no matter what techniques you use or how much you express or feed. Often in fact it just continues to get bigger and bigger despite all your efforts to clear it. This is a clear sign that the breast needs to be scanned for the presence of an abscess. This would be done by ultrasound at your local breast clinic and if an abscess is confirmed then it will need to be drained by needle, as it is unable to drain through the nipple. 90% of abscesses appear to be caused by bacterial infection (Efrem 1995).

Summary

The key to avoiding blockages / mastitis is all about keeping your production in line with your baby's intake and avoiding too much inflammation in the breast. Production -> removal -> production -> removal with no sudden changes in the system like a very long gap between feeds for example can mean that the engorgement process doesn't get fired up to start with, but if you do get a blockage we now know we don't need to work out a clog of milk. We need to treat inflammation in the breast like inflammation in any other organ. Allow the breast to rest and recover with supportive measures like ice and anti-inflammatories, not to overwork the organ through increased removal.

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