Mastitis is a very common condition developed by breast feeding women, usually in the first few weeks after giving birth. Mastitis is often the result of a milk duct becoming blocked for various reasons, that hasn’t cleared. Some of the milk banked up behind the blocked duct can be forced into nearby breast tissue, causing the tissue to become inflamed. This inflammation is called mastitis. Infection in the breast tissue may or may not be present. Up to 33% of breastfeeding women will develop mastitis. Unfortunately, mastitis is the most common
cause of weaning in the first 12 weeks. The biggest indicator for developing mastitis, is a previous episode of mastitis. Therefore, it is essential that each and every case be effectively treated to prevent any further recurrences and establish a happy and healthy breastfeeding experience.
Mastitis is most commonly non-infective and due to an inflammatory process caused by engorgement or a blockage in the ducts. However, some cases may be caused by a bacterial infection. It is impossible to distinguish between non-infective and infective mastitis without a milk culture sample being tested. Both present exactly the same and both are inflammatory in nature. Therefore by treating inflammation, both forms can be effectively treated. As most cases of mastitis are non-infective inflammatory conditions, antibiotics are often unnecessary. Therefore, it has been suggested that antibiotics are often prescribed unnecessarily. It is normal to find a high level of bacteria in a healthy woman’s milk, including strains such as staphylococci, streptococci, lactococci, lactobacilli and enterococci. In Australia, 74% of women who present to their GP with mastitis are prescribed antibiotics, compared to 15% in Sweden. If antibiotics are required, Flucloxacillin is a targeted antibiotic, specific for the treatment of mastitis.
Signs of mastitis can include a tender, hot, swollen, wedge shaped area, sometimes with a red flare over the affected area of the breast and often, but not always associated with a
temperature of 38.5° or higher, chills and “flu-like” aching. Women often associate these symptoms with an infection, however redness, pain and heat may all be present when an area
of the breast is engorged or “blocked”/”plugged” with no infection present.
The most common site that women develop mastitis is in the outer upper and lower aspects of the non-preferred feeding side. This is often the right breast. It is thought that this is due to most women being right handed, which means that the non-dominant hand is responsible for attaching the baby to the right breast.
The most common cause of mastitis is due to a mechanical issue such as engorgement or a blocked duct. Breasts are often very engorged in the first few weeks after your milk comes in, which makes them very susceptible to developing mastitis. Engorgement is caused by a build-up of milk, blood and other fluids in the breast tissue. The ducts are highly compressible, especially in the early days due to this swelling. The increased pressure on the ducts makes it very easy for the duct to become compressed and blocked. Therefore, any firm pressure on the breast tissue (i.e. pads, ill-fitting bras, firm hand/finger pressure) can cause a blockage.
Think of milk ducts like a paper bag, it can hold the milk for a certain amount of time, but if the milk spends too much time sitting in the duct (i.e. a blockage in the duct or leaving milk
sit in the breast too long due to a delayed feed etc.), the milk will leak out of the duct and into the surrounding breast tissue, causing a significant inflammatory reaction. This can also be
caused by a large ‘let-down reflex’, where the pressure inside the duct is too high and can force the milk across the ductal wall, into the surrounding breast tissue. Inflammation results
in swelling, which then compresses more of the surrounding ducts, rapidly escalating, and in severe cases, resulting in hospitalisation within 48hrs of the first symptom of mastitis.
The Australian Breastfeeding Association is a wonderful source of information and support. Their website is: www.breastfeeding.asn.au. Breastfeeding helpline: 1800 mum 2 mum (1800 686 268)
RISK FACTORS AND CAUSES OF DEVELOPING MASTITIS
Feeding pattern issues
– Sudden changes in supply and demand are a major cause of developing mastitis.
If the milk supply suddenly outweighs the demand, the intra-ductal pressure drastically increases and if the milk is left in the breast tissue too long, it will leak into the surrounding tissue. Therefore, setting off a sudden and dramatic inflammatory process, leading to a downward spiral. Examples of this include:
Scheduled, interrupted or erratic feeding patterns
Sudden change in number of feeds; infant sleeping longer overnight
Skipped feeds; switching to 2nd breast before 1st is finished
– Good attachment causes no nipple pain and drains the breast well
– Poor attachment often results in:
*Incomplete drainage of the breast. This results in milk sitting in the ducts too long, and therefore has the potential to set off an inflammatory reaction and thereby mastitis.
*Nipple damage. Damage to the nipple is painful and can leave the breast open to possible infection.
NOTE: fewer than 50% of mastitis cases are associated with nipple damage. Therefore nipple damage does NOT equal mastitis
Things that may contribute to poor attachment include:
-Tongue Tie (short frenulum). The baby is not able to poke its tongue out far enough to massage the areola/breast properly, therefore causing significant damage to the nipple
-Poor positioning of you or your baby. This makes it difficult for the baby to get a good latch.
-Flat or inverted nipples. Can be due to your natural nipple shape or breast engorgement (breast becomes very hard, swollen, tender and the nipple flattens and becomes taut)
-Baby becomes overly distressed during attachment. Not recognising feeding cues early enough can result in the baby getting distressed and leading to poor/rushed attachment
If this happens regularly in the early days, this can result in the baby learning bad attachment habits, which becomes harder to fix as time goes by
-Being overly ‘hands on’ when attempting the ‘latch’. The baby has natural reflexes and instincts which help to get a good attachment, which can be affected with too much intervention. Use ‘baby lead’ attachment techniques whenever possible
-Breast Engorgement. Most common when your milk first ‘comes in’ (about 2-6 days after your baby is born). Milk ducts become more susceptible to getting compressed, leading to blockages
-Obstruction within ductal tissue caused by: Garments i.e. ill-fitting or poorly designed bras and seams in clothing, Finger/thumb pressure being too firm when getting the baby to latch, Flange on breast pump being pushed too firmly into breast, Trauma – a direct blow to the breast (often by accident)
– Oversupply. Rapid changes in supply can cause the milk to back up in the ducts and congest
-Lowered immune system due to: Stress, Sleep deprivation, Poor nutrition, Anaemia, & Poor hygiene
PREVENTION IS BETTER THAN A CURE
• Wear a good Maternity Bra
– Picking a well-fitting maternity bra is important. Maternity bras that have cups that don’t completely drop down when you feed, but leave a triangle of fabric around the breast, can compress the breast and restrict milk flow. This is most likely when your milk first comes in and your breasts are very engorged. You may need a couple of different sized bras for days when you are fuller than others.
• Be kind to your breasts!
-Milk flow can be restricted by a poorly fitting bra, poor positioning of you or the baby, compression from your fingers holding your breast too firmly or even sleeping on your stomach. A bump to the breast or the baby pulling at your breast can cause bruising and swelling which may restrict milk flow. If you still feel the need to direct your nipple, use only very gentle pressure.
-Positioning yourself and the baby during feeding is essential. Good posture is important for two reasons: firstly it helps protect you from neck and back pain from prolonged poor positions, and secondly, poor positioning especially leaning down towards the baby can kink the easily compressed ducts in your breast, block milk flow and result in incomplete emptying of the breast. If you are going to feed in a sitting position, try using a commercial breast feeding pillow or a few regular pillows to lift the baby up to your level, which helps maintain a good breastfeeding position. Try feeding in a variety of positions, including side lying and reclined/recumbent positions, to give your back and neck a rest and improve your baby’s attachment.
• Get to know your breasts
-GENTLY feel your breasts regularly. They should be soft and smooth after feeding (breasts are naturally lumpy) & have any persistent lumps checked out. If you know what your breasts normally feel like after a feed, you’ll pick up blocked ducts and other changes much faster.
• Monitor changes in demand
-Rapid changes in demand, are a major risk factor for developing mastitis (i.e if your baby suddenly changes from feeding every 4hrs to sleeping through the night). This can result in a dramatic case of over supply, which may cause the milk to spend too long in the ducts. To manage this, simply hand express or pump the excess milk off until the breast is comfortable again. DO NOT pump until the breast is completely empty or you may stimulate MORE MILK to be produced. If pumping is not producing any milk – DO NOT persist! The oedema (swelling) is blocking the duct, therefore you must manage the swelling first (i.e. with ice, NSAIDs, gentle massage to axilla etc)
-Getting a good attachment is vital for breast/nipple health, your comfort and effective feeding. It is normal to have initial discomfort for the first 5-10 seconds when the baby attaches, but if pain persists, SEE A LACTATION CONSULTANT ASAP.
-Attaching to the inflamed breast. If the baby won’t go to the inflamed breast – don’t force it. If they will go to the inflamed breast – use it. If the baby is having difficulty feeding –try feeding them when they are in the light sleep phase. This inhibits their learned attachment patterns, making it easier to retrain their attachment habits.
•Cracked nipple management
– Fix any attachment issues that may be causing the damage
– Offer a feed when the baby is showing early feeding cues and before they start to cry
– Allow your baby to self-attach as often as possible
– Express a few drops of milk & apply to the damaged area & allow to dry after each feed
– Nipple shields allow the nipple to heal while still feeding. It essential that you get the right size!
– If it’s still not healing – SEE A LACTATION CONSULTANT ASAP
• Hand hygiene
-Wash your hands regularly and/or use alcohol sanitiser prior to handling your breast
HOW TO MANAGE MASTITIS
If caught early enough, this condition can often be managed easily with conservative methods. However, if your symptoms fail to improve with physiotherapy treatment and self-
management techniques, antibiotics may also be needed. It is usually safe to continue feeding whilst taking antibiotics under direction from your doctor. Remember, a blocked duct can become mastitis within hours. If you can’t clear a blockage yourself within 6 hours,
seek help immediately from a women’s health physio or your doctor!
The key to managing and preventing mastitis is learning to trust your body, listen to your baby and let comfort guide your behaviour and choices.
Ice or Heat?
– Cold therapy is good for reducing inflammation/swelling. Washed, cold cabbage leaves fit inside a bra cup perfectly. Wet a face washer with cold water from the fridge or ideally, a flexible ice pack
-Heat. If it helps– use it prior to feeds. If there is no change or it makes it worse –DON’T USE IT!
If swelling is blocking the flow of milk, the heat may increase the swelling and over stimulate milk production, making the situation far worse
If in doubt, do what feels good –you wouldn’t apply heat to an acutely sprained ankle
– NSAIDs (ie Neurofen)are safe to use and very effective at reducing the inflammatory reaction and swelling in the first 24hrs after noticing mastitis symptoms. Speak to a medical professional about continuing on for longer use as required.
-Antibiotics. Flucloxacillin: has been found to be more effective than broad spectrum antibiotics (ie. Amoxycillin). It is almost always safe to continue feeding whilst taking antibiotics, however, be aware that your baby may be more fussy when feeding when taking antibiotics. This is due to the taste of the medication, not from infected milk.
-Step 1: Stimulate Your Lymph Nodes
Use a gentle circular motion (best done with a soft fist or finger pads) in the armpits and at the base of the neck to gently activate the lymph nodes to help process the inflammation
-Step 2: Massage
Use a light non-scented cream (ie. sorbolene cream)
Using a GENTLE & LIGHT sweeping pressure, start to ‘clear the traffic jam’
Start at the top of the breast, gently sweeping back towards the armpit. Gradually work your way closer to the nipple over several minutes, always sweeping back to the armpit before moving closer to the nipple. Take your time to work your way around the breast, always sweeping back to the armpit before moving on
-Step 3: Cold Pack
Apply a cold pack, cold cabbage leaf or face washer wet with cold water to the breast for several minutes
-Step 4: Repeat
Use this process several times a day to help keep the swelling and inflammatory reaction under control and therefore allow the milk to move through the breast unrestricted.
See a Physiotherapist
Physio can help by applying therapeutic ultrasound to the affected breast. Ultrasound can cause an increase in local blood flow which helps reduce local swelling and chronic inflammation.
Call us on 5504 7000 for more information or to book an appointment. We also offer Women’s health physiotherapy for treatment post childbirth and pilates including mum and bubs!