Engorgement, Blocked Ducts and Mastitis

On the whole, engorgement is a great reassurance for mothers and lovely feedback to tell her breasts are responding to their newborn’s demands, but equally, engorgement is uncomfortable and, if not resolved or if in the presence of feeding issues, can lead to blocked ducts or mastitis. A mother with a baby who feeds efficiently, frequently or for long periods of time and without restrictions/supplements in the first few days after birth is least likely to encounter painful engorgement. Therefore early support and realistic expectations for the mother are the best prevention for associated problems. A sleepy baby may need waking to prevent discomfort.

Signs of engorgement:

● the mother’s baby is between 2-6 days old, or older and has been missing feeds. ● feeding is infrequent/baby is sleepy. ● breasts feel uncomfortably full. ● skin on breast is tight. ● areola is hard. ● nipple has possibly been pulled flat. ● engorgement usually affects the whole breast.

How to prevent engorgement:

● positive, timely breastfeeding initiation. ● helpful assistance with latch and positioning. ● frequent and unrestricted nursing. ● waking sleepy newborns every 3 hours with some 4-5 hours stretches for longer sleeps. ● wearing a well fitting bra may be helpful.

How to relieve engorgement:

● increased feeds with particular attention to good attachment and positioning. ● letting the baby finish one breast before offering the other one. ● Use of cool compress (Therapearl/cool pack) to provide relief. ● use of moist heat (compress/shower/heat pack/Therapearl) and gentle massage right before a feed ● draining the breast with an efficient breastpump (link to breastpumps) can potentially decrease severe engorgement by mimicking an efficiently feeding baby. It can also decrease venous and lymphatic congestion in the breast in general and therefore relieve swelling. ● hand expressing a small amount of milk to soften the nipple may ease difficulties in latching a newborn, who may then effectively drain the breast. ● reverse pressure softening works well for some mothers (Cotterman 2003)

Plugged Ducts

A plugged duct is a common complaint in breastfeeding mothers. It has multiple potential causes which need to be explored in order to help avoid a pattern of recurring plugged ducts and subsequent mastitis.

Signs of a plugged duct:

● gradual onset of symptoms. ● hard lump or wedge within the breast which may or may not move location. ● mild to moderate pain, possibly increased before feed and reduced after. ● lumpy area may become smaller after feed but not disappear. ● generally no warmth or redness in the affected area. ● mother is generally well apart from the localised breast discomfort. ● no fever/normal temperature. ● potentially decreased yield from the affected breast if pumping. ● stringy or fatty looking lumps in expressed milk.

How to prevent a blocked duct:

● make sure latch and positioning are good to enable good milk transfer. ● ensure unlimited access to breast/feeding on cue. ● be mindful of restrictive clothing/sling/bags and adjust if necessary. ● feeding position may contribute to uneven pressure on the breast and lead to a blocked duct. ● a lecithin supplement (Scott 2005)

How to relieve a blocked duct:

● most of the preventative and relieving measures for engorgement are likely to be helpful in relieving and preventing further episodes of painful blocked ducts. ● rest with baby. ● always feed from the affected side first. ● moist heat and massage before a feed either with a compress, Therapearl, immersion or shower. ● massage can be done manually or with a wide toothed comb (use oil, HPA Lanolin or soap to make the comb glide smoothly). ● moist heat and massage DURING a feed to facilitate draining the blockage within the ducts (baby’s position may have to be adjusted to allow this – Baby’s chin over the affected part may also help). ● pumping sessions in between feeds may be necessary. ● breast compressions may help. ● cold compresses (Therapearl) after feeds to reduce swelling and pain can be used. ● anti-inflammatory/analgesic treatment with ibuprofen can be very effective. ● keep in mind a plugged duct may also be caused by a nipple bleb, a thin membrane of skin covering one of the milk ducts exiting the nipple. It often presents as painful nipple when latching. Attempting to hand express often shows up the bleb, looking similar to a whitehead on the nipple. Softening the skin covering the bleb with some olive oil on a cotton wool ball may be enough for the skin to be lifted off it during the next feed. Sometimes lifting the skin off the bleb with a sterile needle can bring forth an immediate spray of milk and relief for the mother.

Mastitis

Mastitis means inflammation/infection within the breast. It is sometimes difficult to differentiate between a severe blocked duct and mastitis and one can turn into the other fairly quickly if treatment is not prompt and effective. Antibiotic treatment is frequently not necessary, if the right treatment is given promptly. As with engorgement and blocked duct, the key to providing relief is to facilitate effective emptying of the breast, meaning that a review of positioning and attachment, and an oral exam to rule out any unusual anatomy in the baby’s mouth with always form part of your assessment.

Signs of mastitis:

● signs and symptoms are often very similar to the ones accompanying a blocked duct. ● pain and redness are usually more severe than with a blocked duct. There may be red streaking radiating from the affected part of the breast. ● mothers tend to feel unwell and have a temperature. They may also have body aches, nausea and chills. ● mastitis often comes on suddenly unlike a blocked duct which may develop more gradually. ● Mastitis is more likely if nipple trauma is present or has been recently, presenting an entry point for pathogens. ● previous history of mastitis makes diagnosis more likely. ● exposure to hospital pathogens may make infective mastitis more likely. ● a stressed/’run down’ mother is more likely to get mastitis. ● a mother with low iron count or history of poor diet generally is more prone to infection. ● potential breast aversion from baby due to elevated sodium and chloride levels in milk, making it taste salty.

How to prevent mastitis:

● see ‘How to prevent a blocked duct’ (* link)

How to treat mastitis:

● the treatments for a blocked duct are also applicable to mastitis treatment. ● treatment needs to be commenced promptly. ● bedrest with baby (Mohrbacher 2008); discuss safe co-sleeping, and advise responding to early feeding cues. ● possible antibiotic therapy for 10-14 days (a shorter course makes relapse more likely), indicated if fever/symptoms do not decrease after 24 hours or the fever suddenly increases. ● the most likely organism causing mastitis is staphylococcus aureus. ● consider a probiotic in case of antibiotic therapy to avert an increased risk of breast thrush (Gyte 2014) ● if mastitis does not seem to respond to treatment, consider culturing the milk to pinpoint pathogen. Keep in mind that re-occurring blocked ducts and mastitis originating in the same (quadrant of) breast may , in rare cases, be a sign of a breast tumour. Referral to a doctor may be indicated. Bilateral mastitis, though rare, may be a sign of hospital acquired infection and streptococcal in nature. Always advise women not to cease breastfeeds during an episode of engorgement, blocked ducts or mastitis. Milk removal is of utmost importance to avoid problematic recovery. Be vigilant to the formation of breast abscesses and refer to an appropriate clinician.

Bibliography/ References

Conner A (1979) “Elevated levels of sodium and chloride from mastitic breast.” Pediatrics 63:910

Cotterman (2003) “Too Swollen to latch on? Try Reverse Pressure Softening first”, Leaven, Vol. 39 No. 2, April-May 2003, pp. 38-40

Fetherston C (1998) “Risk Factors for lactation mastitis.” J Hum Lact; 14(2):101-09

Gyte, Dou and Vazquez (2014) “Different classes of antibiotics given to women routinely for preventing infection at caesarean section” Cochrane review. Wiley and Sons. Accessed April 2015 at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008726.pub2/full

Moon J. and Humenick S (1989) “Breast Engorgement: contributing variables and variables amenable to nursing intervention.” JOGNN; 18:309-15

Minchin M (1998) “Breastfeeding Matters.” 4th ed. Armadale, Australia: Alma Publications

Mohrbacher, N., Stock J. (2008) “La Leche League International: The Breastfeeding Answer Book, 3rd revised edition, LLLI

Scott CR. Lecithin (2005) “It isn't just for plugged milk ducts and mastitis anymore. Midwifery Today Int Midwife. 26-7