8.3 Breast Problems
Teaching mothers about ideal breastfeeding practices and how to avoid nipple damage will ensure their breasts remain healthy and less prone to this infection.
Blocked (Plugged) Duct
Blocked ducts are a common occurrence for breastfeeding mothers at any stage of lactation. Milk ducts become blocked and distended and are palpable as a tender, small lump in the breast. The skin over the lump may be reddened and warm to touch.
Blockage may occur as a result of
- occlusion of a duct from pressure applied by an ill-fitting bra, clothing or compressing the breast throughout the feed
- excessive movement of the breasts such as running or aerobics
- poorly drained breast - poor positioning, latch, not 'finishing the first breast first'.
It has been noted that some mothers who experience repeated duct blockages have thicker milk, or the blockage may contain more fatty material than usual. 1 2 ( Note: this should not be your first assumption - always investigate other causes first )
Management involves
- identification of the cause
- meticulous attention to position and latch
- warm compresses to the affected area or a soak in warm water prior to gentle, but firm massage
- massage the lump towards the nipple as the baby suckles, or when hand or pump expressing
- feed more frequently until lump clears
- massage and hand expressing under a warm shower
If a blocked duct fails to be cleared it may progress to mastitis; infective mastitis may follow.
Mastitis
Lactational mastitis occurs most commonly during the first four postnatal weeks, either as a result of mis-management of lactation initiation, or the infective organism having been hospital-acquired. 3 4 2
However it may occur at any stage of lactation.
Causes
Mastitis means inflammation of breast tissue. The inflammatory process in lactational masitis is caused by either milk stasis or infection.
" Without effective removal of milk, non-infectious mastitis was likely to progress to infectious mastitis... " 5
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Milk stasis is non-infective, but may progress to an infective state if good clinical management is not implemented. Milk stasis is most commonly associated with:
- engorgement
- infrequent feeds, or scheduling the frequency and/or duration of feeds
- poor latching leading to inefficient removal of milk
- missing feeds, eg. overnight or because baby has received a bottle feed
- pressure on the breast (eg. tight bra, car seatbelt)
- a blocked nipple pore or duct
- rapid weaning
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Associated factors which increase incidence of mastitis
- nipple damage - especially if colonised with Staphylococcus aureus
- illness in mother or baby
- oversupply of milk
- maternal stress or fatigue
- anaemia or malnutrition
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Infection
- usually by a penicillinase-resistant Staphylococcus aureus
- less commonly the organism is a streptococcus or Escherichia coli
(Sources: WHO 6 ABM protocols 7 )
Milk stasis and mastitis causes movement of sodium and chloride into the milk space 8 and milk supply will fall as synthesis temporarily slows in the affected area. The infant may fuss during breastfeeds as a result of these factors.
Preventing Mastitis
Educate mothers about the importance of good breastfeeding management, caring for themselves and their breasts.
- A well-latched baby who breastfeeds according to his needs will help to regulate the mother's milk supply and avoid nipple damage.
- Teach mothers to hand express to prevent engorgement.
- Encourage rest and a healthy diet to support her immune system.
- Encourage an awareness of breast lumps or areas of milk stasis and discuss treatment with massage, extra feeding, expressing and heat packs.

An ounce of prevention ...
During pregnancy, and as you educate mothers about effective breastfeeding focus ongood positioning and latch, and effective breast drainage as the basis for all markers of good breastfeeding. Mothers will understand that problems such as mastitis can be avoided - if the mother enters her breastfeeding relationship feeling confident and is well-educated about breastfeeding she is less likely to encounter problems.

Workbook Activity 8.6
Complete Activity 8.6 in your workbook.
Diagnosis
Diagnosis is usually made by clinical presentation.
- inflamed area of the breast
- a painful wedge-shaped lump
- associated with fever of 38.5ºC (101.3ºF) or greater, and
- chills, flu-like aching and systemic illness.
One researcher9 desribes her criteria for mastitis as "at least 2 breast symptoms (pain, redness or lump) AND at least one of fever or flu-like symptoms."
Laboratory cultures of the breastmilk are rarely performed unless it does not respond to classical management strategies, or the mother has repeated episodes.

© Goldfarb Breastfeeding Clinic
Management
Knowing that milk stasis is the most common predisposing factor to mastitis, it stands to reason that the first management strategy will be to ensure frequent and effective milk drainage from the affected breast.
Effective milk removal
- breastfeed baby frequently, beginning on the affected breast to enhance drainage
- ensure baby latching and suckling well. Observe the baby breastfeeding!
- warm breast soak or applying warm compresses prior to breastfeeding may help milk ejection
- massage the breast gently during the breastfeed
- review the frequency of breastfeeding; most babies will feed 6 to 18 times in 24 hours, and feeding should not be regulated by the mother 10
- hand expressing, or pumping after a breastfeed may be necessary
Supportive measures
- bed rest
- adequate fluids and nutrition
- practical help at home
- vitamin E-rich sunflower oil, echinacea and vitamin C supplements have been suggested to assist immune and inflammatory responses. 11
Pain relief
Researchers and clinicians have yet to conclude whether heat or cold is preferred, most suggesting both with heat being used prior to breastfeeding or expressing and cold afterwards.
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Use of moist heat...
- soak a cloth in warm water and apply to affected breast
- immerse the breast in a container of warm water. Some mothers have obtained relief from putting magnesium sulphate (Epsom Salts) into the water.
- limit use of heat if significant inflammation is present
- Application of cold - either a chilled moist cloth or a covered ice pack.
Paracetamol (acetaminophen) and ibuprofen are both safe analgesics to use during lactation; paracetamol (acetaminophen) having better antipyretic properties, while ibuprofen has better anti-inflammatory properties.
Antibiotics
If symptoms of mastitis are mild and have been present for less than 24 hours:
conservative management (effective milk removal and supportive measures) may resolve the problem without need for antibiotic therapy. 12
- If symptoms are not improving after 12-24 hours of conservative management (or if the woman is acutely ill): antibiotics should be started. 13
Preferred antibiotics are usually penicillinase-resistant penicillins (dicloxacillin or flucloxacillin).
Cephalexin is indicated in suspected penicillin allergy.
Clindamycin when penicillin hypersensitivity is severe. - Infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are being increasingly observed. 14,15

The mother wants to wean ...
Weaning now (as tempting as it may seem) is achieved by stopping breastfeeding and causing milk stasis. Milk stasis increases the inflammatory response, further increasing risk of worsening mastitis and possible development of a breast abscess.
It is important to clear the milk and allow the time for the breast to recover and heal before the mother considers weaning.

Workbook Activity 8.7
Complete Activity 8.7 in your workbook.

Educational material
Develop an information sheet to be discussed with mothers who have a blocked duct or mastitis, outlining the supportive measures they can take to facilitate a speedy recovery. This should be suitable for them to take home.
Complications
- pain, feeling very ill, loss of productivity
- reduced milk supply
- early weaning
- candida overgrowth
- breast abscess and drainage
What should I remember?

- The management of blocked ducts
- The predisposing factors for mastitis.
- Prevention of mastitis.
- The clinical and supportive management strategies for mastitis.
- At what stage antibiotics are indicated and which categories of antibiotics will be effective.
Self-test quiz
Click and drag the missing words below into their correct place
The missing words are: Staph antibiotic before blocked breastfeeds cold damaged drainage ducts express fever flu-like frequency infection inflammation inflammation lactational latch less lump massage position pressure rest stasis towards warm
Mastitis is __________ of the breast. When it occurs during breastfeeding it is called __________ mastitis. This condition may have its origin from milk __________ or __________.Initially, __________ __________ may be the result of the milk stasis. The recommended management of this situation would include:
- __________ compresses before the breastfeed
- gentle __________ of the lumps __________ the nipple during breastfeeding
- increase breastfeeding __________ until the blockages have cleared.
Milk stasis may be the result of externally applied __________ from tight bra or clothing. However, the main reason for milk stasis is ineffective __________ of the breast. This can be achieved by meticulous attention to __________ and __________ of the infant to the breast. If unresolved, milk forced into the tissues causes __________ and resultant further milk stasis.
Infection with organisms such as __________ aureus is the most common cause of infective mastitis. A strong risk factor for infective mastitis is __________ nipples. The mother will display breast symptoms such as a red, inflamed area over the site of a hard __________ and the mother may also have a __________ and __________ symptoms.
You can assist the mother to recover by suggesting supportive management such as __________, good fluid and nutritional intake.
During this time, the most important management is frequent drainage of the breast - this can be achieved by:
- increasing the number of __________
- warmth applied to the breast __________ a feed and application of __________ after the feed
- __________ regularly if the baby is not breastfeeding
Notes
- # Eglash A (1998) Delayed milk ejection reflex and plugged duct. Lecithin therapy
- # Fetherston C (1998) Risk factors for lactation mastitis
- # Amir LH et al. (2007) A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants
- # Kinlay JR et al. (1998) Incidence of mastitis in breastfeeding women during the six months after delivery: a prospective cohort study
- # Thomsen AC et al. (1984) Course and treatment of milk stasis, noninfectious inflammation of the breast, and infectious mastitis in nursing women
- # World Health Organisation (2000) Mastitis: causes and management
- # Academy of Breastfeeding Medicine (2008) Clinical Protocol 4
- # Nguyen DA et al. (1998) Tight junction regulation in the mammary gland.
- # Amir LH et al. (2007) A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants.
- # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
- # Riordan J (2005) Breastfeeding and Human Lactation
- # Jahanfar S et al. (2013) Antibiotics for mastitis in breastfeeding women.
- # World Health Organisation (WHO) (2001) The optimal duration of exclusive breastfeeding. Results of a WHO systematic review.
- # Saiman L et al. (2003) Hospital transmission of community-acquired methicillin-resistant Staphylococcus aureus among postpartum women
- # Reddy P et al. (2007) Postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus