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BREASTFEEDING CONNECTION
CAROL BARTLE POLICY ANALYST
CLINICAL UPDATE: THE MASTITIS SPECTRUM
The Academy of Breastfeeding Medicine (ABM) recently updated their clinical protocol about the mastitis spectrum (Mitchell et al, 2022). This new protocol #36 has replaced the ABM previous mastitis protocol (#4) and also the engorgement protocol (#20).
As midwives are well aware, mastitis is an inflammatory condition of the breast and a relatively common condition in women who are breastfeeding. It does contribute to early cessation of breastfeeding, but a systematic review suggests that the substantial burden of mastitis might be preventable (Wilson et al, 2020). A study in Scotland found that out of a cohort of 420 breastfeeding women, 74 [17.6%] experienced at least one episode of mastitis (Scott et al, 2008). The majority of these women with mastitis experienced the first episode within the first six weeks post-birth, and 10% received inappropriate advice and were advised to stop breastfeeding from the affected breast, or to discontinue breastfeeding totally. A prospective cohort study in Melbourne with 346 participant women found that 20% (70/346) developed mastitis (Cullinane et al, 2015). An increased risk of developing mastitis was associated with nipple damage, over-supply of breast milk, nipple shield use, and expressing milk several times a day. Staphylococcus aureus on the nipple also increased the risk.
Midwives and other health practitioners have followed recommendations for the treatment of blocked ducts and mastitis using breast massage, a breast pump to remove more milk from the affected breast, and hot compresses as treatment. The latest ABM evidence-based guidance challenges these practices and recommends a fresh approach. The breast in lactation is dynamic, responds to both internal and hormonal stimulation, and regulates milk via a feedback inhibition process. The new guidelines pay more attention to lactation physiology, and present evidence that traditional recommendations have lacked.
The ABM identifies mammary dysbiosis – disruption of the milk microbiome – as resulting from a complex interplay of factors including maternal genetics and medical conditions, exposure to antibiotics, use of probiotics, regular breast pump use and caesarean birth. Narrowing of the ductal lumens in mastitis can be associated with oedema and hyperlactation. Intravenous fluids given during labour can exacerbate oedema and engorgement, and minimising the amount of fluid used is recommended. Inflammatory mastitis develops when ductal narrowing persists or worsens, and inflammation progresses. ABM emphasise the importance of a healthy milk microbiome in the prevention of mastitis and the need to address the risk factors for dysbiosis. They also emphasise that a systemic inflammatory response may occur in the absence of infection.
A summary of the mastitis spectrum-wide ABM key recommendations is presented below. The protocol is 16 pages long with a large number of images, and condition specific recommendations, including recurrent, and sub-acute mastitis and galactocele, so directly accessing the full clinical protocol is advisable.
ABM RECOMMENDATIONS: “ANTICIPATORY GUIDANCE AND BEHAVIOURAL INTERVENTIONS”
• Providing reassurance to mothers that many mastitis symptoms will resolve with conservative care, counselling and support. Rest is recommended, and is the lone survivor of the three suggestions in the commonly used blocked duct/mastitis
‘mantra’, which were ‘heat, rest and empty the breast’.
• Supporting continuation of breastfeeding, strategies to decrease stress, increased opportunities for rest, and help to resolve early signs of inflammatory mastitis are recommended.
• Pain, feelings of discomfort and palpable glandular tissue are often interpreted as a diagnosis of a plugged area. Experiencing breast fullness or palpable lumps is not abnormal and reassurance is advised.
Sweating and hot flushes can be caused by hormonal shifts and may mimic a fever. • Another key point is that infection does not develop quickly over several hours.
Pain and redness that may be present after a period of sleep without breastfeeding activity is described as representing alveolar distension, oedema and inflammation, rather than infection. Provision of information about normal breast anatomy and physiology is recommended. • Responsive, cue-based feeding is recommended, with a reminder that the breast does not require ‘emptying’.
Increasing milk removal increases production. A cycle of hyperlactation is a major risk factor for increasing inflammation and oedema.
• Deep massage of the breast causes increased inflammation, oedema and microvascular injury. Oedema may resolve faster with the use of ice and gentle lymphatic drainage. (See page 21 of the protocol for a pictorial explanation of lymphatic drainage). • Gentle breast compressions can provide an effect similar to hand expression, but excessive manual force should be avoided.
• Small amounts of milk can be hand expressed for comfort until milk production down-regulates to match infant needs. • Minimising the use of a breast pump is recommended. If a pump is used, expressing should mimic physiological breastfeeding in terms of frequency of pumping and milk volumes removed.
• Avoid the use of nipple shields. • Therapeutic ultrasound can reduce inflammation and reduce oedema.
• Women with a history of anxiety and depression experience higher rates of mastitis. Previous experiences with breastfeeding challenges can cause anxiety about breastfeeding, and milk supply, and this can contribute to the overuse of expressing/breast pumps.
DECREASING PAIN AND INFLAMMATION The protocol describes clinical interventions to reduce both oedema and inflammation, including the use of ice and non-steroidal anti-inflammatory medications (NSAIDs). Frequent application of ice and ibuprofen 800mg every eight hours is recommended. Paracetamol is also recommended - 1000mg every eight hours in the acute setting. Hale and Baker (2018) discuss the preferred NSAID for breastfeeding as being ibuprofen, as levels found in breast milk are very low, with less than 0.7% of the maternal dose transferring to the infant. Paracetamol taken at the recommended dosage is also described as compatible in terms of lactation risk by Hale and Baker, as the relative dose of paracetamol an infant will receive via breastfeeding is 8.824.2%, which is considered safe.
Heat is also described as potentially worsening symptoms but also as providing comfort for some women. Warm showers did not improve symptoms in a randomised controlled trial by Kvist et
al (2007). Sunflower oil or soy lethicin orally 5-10mgs daily is recommended to reduce inflammation in the ducts and to emulsify breast milk. The ABM protocol also recommends not to ‘unroof’ any associated nipple blebs but to use oral lethicin and a topical moderate potency 0.1% steroid cream applied to the nipple which can be wiped off before a breastfeed.
HYPERLACTATION AND MANAGEMENT OF AN OVERSUPPLY The treatment of an oversupply of breast milk may be necessary as hyperlactation can lead to congestion and inflammation. The Academy of Breastfeeding (ABM) Protocol #32 (Johnson et al, 2020) describes hyperlactation as being self-induced, iatrogenic, or idiopathic. Self-induced can occur with excessive pumping in addition to breastfeeding. It may be associated with maternal concerns about insufficient milk supply, and also in situations where women are trying to store high volumes of milk for future use – such as a return to the paid workforce. Iatrogenic causes include situations where medication to increase milk supply has been prescribed without close follow-up or guidance. Idiopathic hyperlactation describes mothers who have high oversupply without clear aetiology. The ABM suggests that hyperlactation can be distinguished from engorgement by the lack of interstitial oedema and persistence of symptoms beyond 1-2 weeks after birth. Management includes behavioural interventions and counselling to prevent self-induced and iatrogenic hyperlactation, block feeding under supervision (which involves restricting feeding on one breast for three hours or longer blocks of time before feeding on the other breast) (van VeldhuizenStaas, 2007), and a recommendation for cases of persistent idiopathic hyperlactation to utilise herbal therapies and/or prescription medicines. The ABM Protocol #32 provides detailed information about the pros and cons of herbal therapies and medications. In terms of behavioural interventions, the need for individualised and contextual advice regarding breastfeeding and expressing milk when necessary, rather than prescriptive advice, is recommended. This includes addressing maternal misconceptions about breastfeeding and the avoidance of unnecessary galactogogues.
BACTERIAL MASTITIS It is recognised that mastitis is associated with nipple trauma but the data is limited, and new evidence has found that mastitis is not caused by a retrograde spread of pathogenic bacteria from nipple trauma. Bacterial mastitis is represented by a progression from ductal narrowing and inflammatory mastitis to a condition requiring more than conservative treatment.
There is no evidence that supports poor hygiene as a cause of bacterial mastitis. Bacterial mastitis presents as cellulitis – worsening erythema and induration – in a specific area of the breast that may spread further. Persistent systemic symptoms > 24 hours such as fever and tachycardia need evaluation and treatment. In cases where there are no systemic symptoms, but where conservative measures have not elicited relief from oedema and inflammation, a diagnosis of bacterial mastitis should also be considered. No interruption to breastfeeding is required.
ABSCESS This represents a progression from bacterial mastitis to an infected collection of fluid that requires drainage. Amir et al (2004), report that the incidence of breast abscess has often been estimated, and reported as 11% of women with mastitis, but accurate estimates are difficult due to the varied definitions of mastitis used in studies. In a study of 1,193 Australian breastfeeding women, 207 [17%] experienced mastitis and six [3%] of those women with mastitis developed a breast abscess (Amir et al, 2004).
Clinically, with the progress to abscess, there is a progressive induration and erythema, and there may be a palpable fluid collection in a well-defined area. If the initial systemic symptoms and fever resolve, this may be due to the body walling off the infection process, or symptoms may resolve and then reoccur. Symptoms may worsen until the area is drained (Mitchell et al, 2022). Management with needle aspiration enables a faster recovery, and facilitates continued breastfeeding (Amir et al, 2004). The ABM recommends continued breastfeeding from the affected breast, after aspiration or drain placement.
ANTIBIOTICS Antibiotics used for inflammatory mastitis disrupt the breast microbiome and increase the risk of a progression to bacterial mastitis. The relief that women with inflammatory mastitis may feel when taking antibiotics may be due to the anti-inflammatory properties of antibiotics and antifungal medications. Because there is a serious and growing global problem with antimicrobial resistance, the non-selective use of antibiotics should be avoided. In cases of bacterial mastitis when antibiotics are necessary, ABM suggest dicloxacillin, or flucloxacillin 500mgs QID for 10-14 days.
PROBIOTICS AND MASTITIS
Amir et al (2016) examined the marketing of probiotics for mastitis after becoming aware that health professionals in Australia were receiving marketing related to the prevention of mastitis, when probiotic/mastitis trials were still in progress. At that time, only one trial of probiotics for treating mastitis had been published. High-quality randomised controlled trials to assess the effectiveness of probiotics for both the prevention and treatment of mastitis are needed, and each bacterial strain requires individual testing as efficacy is species and strain-specific (Amir et al, 2016). Some controversy regarding the recommendation in the ABM protocol of specific probiotics has occurred due to a protocol author’s link with the infant formula industry, and the associated research related to probiotic strains. The ABM did make a disclosure statement about this conflict of interest, and also stated that the evidence for the use of probiotics is mixed, that strong recommendations for probiotics could not be made, that studied trials had limitations, and it was suggested that the use of probiotics warrants further research.
A recent systematic review and meta-analysis about the preventative and therapeutic effects of probiotics on mastitis (Yu et al, 2022) concluded there remained a need for high quality RCTs as there was still a lack of uniformity and scientificity in the selection of probiotic strains and intervention doses, and there was inconsistency in the diagnostic criteria and efficacy indicators for lactation mastitis. square
key messages
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Prevent mastitis, or reduce mastitis symptoms, by reducing iatrogenic interventions and using simple management techniques.
Prompt and effective treatment will halt progression from inflammatory mastitis to infective mastitis, and to abscess.
Most women with inflammatory mastitis have complete resolution of symptoms without need for interventions.
Address previous experiences with breastfeeding challenges which can cause anxiety about milk supply and overuse of a breast pump.
Responsive cue-based breastfeeding - physiological breastfeeding.
Caution needed when using a breast pump.
Manage oversupply issues.
Rest.
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Ice packs and cold compresses can reduce inflammation.
Heat can exacerbate inflammation.
Gentle lymphatic massage.
Anti-inflammatory medication such as ibuprofen.
Mastitis is often inflammatory and not bacterial - selective use of antibiotics.
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