The Academy of Breastfeeding Medicine (ABM) updated their clinical protocol on management of mastitis spectrum disorders in May 2022, marking a shift in both the understanding and management of mastitis, a condition that can impact breastfeeding success. This article highlights key takeaways and considerations for professionals caring for lactating individuals.
What is lactational mastitis?
Lactational mastitis is inflammation of the mammary gland, the gland that produces milk. This inflammation leads to narrowing of the tubes that milk flows through and inflammation of the tissue that supports milk production. It typically presents as unilateral breast pain, redness, and warmth and can also be associated with systemic responses such as fatigue, fever, and chills.1,2 With the updated ABM clinical protocol, mastitis is considered a spectrum of disorders inclusive of the following inflammatory conditions:
- Inflammatory mastitis - Inflammation of breast tissue and the mammary gland, can lead to a systemic response such as fever and chills
- Bacterial mastitis - Similar in presentation to inflammatory mastitis, though with a bacterial cause; typically identified by worsening reddening and thickening of the skin and/or non-response to conservative treatment within 24 to 48 hours
- Plugging - Also referred to as ductal narrowing, describes inflammation and narrowing of the ducts
- Nipple bleb - Ductal inflammatory cells that reach the surface and cause a blockage
- Phlegmon - Fluid collection in the breast in the setting of inflammation
- Abscess - A fluid collection in the breast in the setting of bacterial mastitis or a phlegmon that requires drainage
- Galactocele - A collection of milk due to a ductal narrowing that prevents milk passage
Note: Many images in medical textbooks do not portray breast infections and inflammation on a variety of skin tones. This can make inflammatory conditions of the breast/chest more challenging to identify for the clinicians. For a resource with a diverse representation of brown skin, we recommend the Melanated Mammary Atlas.
What causes it?
As much as we wish there was one clear cause of mastitis, the causes are multifactorial and often remain illusive, particularly since human milk production is such a dynamic process.1,2 To date, no causal link between mastitis spectrum disorders and any one specific factor has been identified, however factors specific to the lactating individual, microbial factors, and medical factors all potentially predispose a person to mastitis.1,2
The most widely accepted predisposing factors include excess milk production (hyperlactation), change in the mammary microbiome (dysbiosis), and history of mastitis and can be additionally impacted by nipple trauma, use of antibiotics and probiotics, environmental characteristics, and individual characteristics of the bacterial microbiome of both the lactating individual and the milk itself.2
Why did the guidelines change?
Before we delve into the new guidelines, let’s look at the “why” behind this change in guidelines. The majority of these guideline changes can be best understood by recognizing a change in the understanding of mastitis spectrum disorders and the pathophysiology of lactational mastitis.
Mastitis used to be understood and treated as a bacterial and milk flow issue. The view was that there was a clog somewhere in the ductal system and that clog, and likely infection, needed to be treated to resolve the symptoms. Recommendations centered around helping move things though this system and eliminating any bacteria that might be exacerbating the issue. This resulted in recommended management revolving around clearing out the system through heat, extensive massage, and antibiotic use.2
Now, mastitis spectrum disorders are best understood as a spectrum of inflammatory conditions. The milk ducts are not clogged with something, rather they are inflamed, making them narrower which can hinder milk flow.2 The recommendations now revolve around managing the inflammation that promotes symptom development in a more conservative manner.
What are the new recommendations for the management of mastitis?
Provide anticipatory guidance: All clinicians treating individuals with suspected mastitis spectrum disorders are encouraged to provide clear information about progression of mastitis and possible outcomes. This includes encouraging a lactating individual to continue expressing milk, providing education about anatomy and physiology relating to lactation, and reviewing strategies or making referrals to support stress management and self-care of the lactating individual.
Choose ice over heat: Heat was previously the recommended treatment course for mastitis, however now that mastitis spectrum disorders are better understood as inflammatory in nature, ice is recommended to support reduction in inflammation and symptom management.2
Don’t make big changes to feeding and pumping schedules: Recommendations previously focused on pumping more frequently and feeding until the breast was completely empty in an attempt to remove “clogged” milk. Now, it is recommended that a lactating individual nurse on demand and pump as they typically would.2
Since mastitis spectrum disorders are better understood as inflammatory in nature, removing “clogs” such as through squeezing out milk blebs may work against the bigger goal of reducing inflammation because this can cause more tissue damage.2 Similarly, attempts to work against “milk stasis” by pumping more frequently or feeding until empty can lead to hyperlactation which can lead to increased risk of inflammation.2
Additionally, encouraging appropriate, as opposed to excessive, pump usage, including determining appropriate fit and suction may reduce risk of nipple trauma.2
More massage isn’t always better: Deep massage can increase inflammation and cause microvascular injury which can exacerbate symptoms of mastitis spectrum disorders.2 Using a gentle technique by a trained professional or therapeutic ultrasound is recommended.1,2
Treat inflammation: Treating pain and inflammation with NSAIDS. While acetaminophen may help reduce discomfort, it does not directly target the inflammation present in mastitis spectrum disorders.2
Use antibiotics judiciously and consider probiotic use: Antibiotic usage is recommended judiciously, only if no improvement has been noted with conservative measures after 24 to 48 hours of treatment.1 Use of specific strains of probiotic, limosilacto-bacillus fermentum or ligilactobacillus salivarius, show some promise in treatment of mastitis causing pathogens, however additional research is indicated.2
What is still unknown or requires more research?
The exact cause of mastitis spectrum disorders is still largely unknown. While there are associations that have been identified, it is near impossible for healthcare professionals to predict who will develop inflammatory or bacterial mastitis and who will not.
While there is improving understanding of these conditions and how to provide supportive care, there is not one curative approach. More research around the mammary microbiome is likely needed to better understand the specific environmental conditions that lead to mastitis spectrum disorders and guide professionals with supportive management.
Key takeaways:
Mastitis spectrum disorders is an umbrella term that refers to disorders caused by inflammation of the mammary gland and subsequent narrowed lumens and stromal edema.
Mastitis spectrum disorders are caused and mediated by a complex interplay of factors specific to the lactating individual, microbial factors, and medical factors.
A lactating individual with pain, swelling, and induration should be screened and treated for mastitis spectrum disorders using conservative treatment for 24 to 48 hours followed by antibiotics if not responsive.
Conservative management of mastitis spectrum disorders consists of self-care, inflammation reducing interventions, and feeding on demand. Management no longer includes immediate antibiotic use, deep massage, or excessive pumping and feeding.
References
1Louis-Jacuqes, A., Berwick, M., & Mitchell, K. (2023). Risk factors, symptoms, and treatment of lactational mastitis. JAMA, 329(7), 588–589. https://doi.org/10.1001/jama.2023.0004
2Mitchell, K., Johnson, H., Rodríguez, J., Eglash, A., Scherzinger, C., Zakarija-Grkovic, I., Cash, K., Berens, P., Miller, B., & Academy of Breastfeeding Medicine (2022). Academy of Breastfeeding Medicine Clinical Protocol #36: The mastitis spectrum, revised 2022. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 17(5), 360-376. https://doi.org/10.1089/bfm.2022.29207.kbm
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