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Plugged Ducts and Mastitis

By Kelly Bonyata, BS, IBCLC

How do I know if I have a plugged duct or mastitis?

PLUGGED DUCT
 A “plugged duct” (sometimes called ductal narrowing) is a localized area of breast inflammation where swelling slows milk flow. Although it may feel like a blockage, it is often caused by inflammation narrowing the ducts rather than a literal plug of milk.
Local symptoms
 Mom will usually notice a hard lump or wedge-shaped area of engorgement in the vicinity of the plug that may feel tender, hot, swollen or look reddened. Occasionally mom will only notice localized tenderness or pain, without an obvious lump or area of engorgement. Symptoms sometimes improve temporarily after nursing or milk removal, though this is not always the case. Nursing on the affected side may be painful, particularly at letdown.
Systemic symptoms
 There are usually no systemic symptoms for a plugged duct, but a low fever (less than 101.3°F / 38.5°C) may be present.
MASTITIS
 Mastitis is inflammation of the breast that may occur when milk flow becomes disrupted. Some cases are primarily inflammatory, while others involve bacterial overgrowth. Mastitis is more common when breastfeeding is disrupted by long stretches between feeds, oversupply, latch problems, or early weaning practices. Mastitis is most common in the first 2-3 weeks, but can occur at any stage of lactation. Mastitis may come on abruptly, and usually affects only one breast.
Local symptoms
 Local symptoms are the same as for a plugged duct, but the pain/heat/swelling is usually more intense. There may be red streaks extending outward from the affected area.
Systemic symptoms
 Typical mastitis symptoms may include

  • body aches
  • chills
  • redness
  • feeling unwell

Common (and not-so-common) side effects of plugged ducts or mastitis

Recurrent inflammatory area (or “Plugged duct”)

  • Milk supply and pumping output from the affected breast may decrease temporarily. This is normal and extra nursing/pumping generally get things back to normal within a short time.
  • Occasionally a mom may express “strings” or grains of thickened milk or fatty-looking milk.
  • After a plugged duct or mastitis has resolved, it is common for the area to remain reddened or have a bruised feeling for a week or so afterwards.

Mastitis

Side effects may be the same as for a plugged duct, plus:

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  • Expressed milk may look lumpy, clumpy, “gelatin-like” or stringy. This milk is fine for baby, but some moms prefer to strain the “lumps” out.
  • Milk may take on a saltier taste due to increased sodium and chloride content – some babies may resist/refuse the breast due to this temporary change.
  • Milk may occasionally contain mucus or blood.

Rarely, worsening symptoms such as increasing redness, severe swelling, persistent fever, or a growing painful lump may signal progression to an abscess or another complication and should be evaluated by a healthcare provider.

What are the usual causes of plugged ducts or mastitis?

Plugged duct Mastitis

Milk stasis / restricted milk flow

… may be due to:

Stress, fatigue, anemia, weakened immunity

Milk stasis (usually primary cause)

  • Same as for blocked duct.
  • Blocked duct is also a risk factor.

Infection

  • Sore, cracked or bleeding nipples can offer a point of entry for infection.
  • Hospital stay increases mom’s exposure to infectious organisms.
  • Obvious infection on the nipple (crack/fissure with pus, pain) is a risk factor.
  • Past history of mastitis is a risk factor.

Stress, fatigue, anemia, weakened immunity

What is the usual treatment for plugged ducts and mastitis?

It’s always best to treat a recurrent inflammatory area (“plugged duct”) immediately and aggressively to avoid escalating into mastitis.

CAUTION: Do NOT decrease or stop nursing when you have a plugged duct or mastitis, as this increases risk of complications (including abscess).
GENERAL SUPPORTIVE MEASURES
Plugged Duct

  • Rest
  • Adequate fluids
  • Nutritious foods will help to strengthen mom’s immune system
 Mastitis

  • Bed rest (preferably with baby)
  • Increase fluids, adequate nutrition
  • Get help around the house
BREASTFEEDING MANAGEMENT — SAME for plugged duct or mastitis
— important to start treatment promptly 
“Heat, Massage, Rest, Empty Breast”
General
  • Nurse frequently & empty the breasts thoroughly.Aim for nursing at least every 2 hrs. Keep the affected breast as empty as possible, but don’t neglect the other breast.
  • When unable to breastfeed, mom should express milk frequently and thoroughly (with a breast pump or by hand).
Before nursing

  • Gentle comfort measures may help symptoms and support milk flow.

    • Apply brief warmth if helpful for comfort. Some mothers find a warm compress or a few minutes of warmth before nursing helps milk begin flowing more comfortably. Warmth should be brief and soothing — prolonged heat may increase swelling and inflammation.
    • Try gentle breast softening if the breast feels very full. If swelling makes latching difficult, gentle hand expression or reverse pressure softening near the nipple may help baby latch more comfortably.
    • Avoid deep massage or trying to “work out” a plug. Vigorous rubbing, pressing hard on a painful area, using vibrating devices, or scraping at the breast tissue may worsen swelling and inflammation.
    • If touch feels soothing, use only very gentle strokes. Light sweeping motions from the affected area toward the armpit or collarbone may help reduce swelling. The pressure should be very light — more like stroking skin than massaging a muscle.
    • Wear loose, comfortable clothing and a well-fitting, non-restrictive bra. Tight bras, underwires, or pressure on the breast can worsen symptoms.
    • Choose a comfortable feeding position. Sometimes changing positions helps baby nurse more comfortably from the affected breast, but there is no need to point baby’s chin toward the affected area or use uncomfortable positions unless they feel helpful.
While nursing
  • Nurse on the affected breast first; if it hurts too much to do this, switch to the affected breast directly after let-down.
  • Ensure good positioning & latch. Use whatever positioning is most comfortable and/or allows the plugged area to be massaged.Note: Advice to point baby’s chin (or nose) toward the plugged area is not necessarily going to be helpful as it is based on the idea that the milk ducts take a nice, direct route to the nipple – recent research tells us that this is not true, and that a particular duct might begin in one area of the breast but can “wander” in many different directions before terminating in any area of the nipple.
  • Use breast compressions.
  • Massage gently but firmly from the plugged area toward the nipple.
  • Try nursing while leaning over baby (sometimes called “dangle feeding“) so that gravity aids in dislodging the plug.
After nursing
  • Pump or hand express after nursing to aid milk drainage and speed healing.
  • Use cold compresses between feedings for pain & inflammation.
MEDICATION *
Plugged duct Mastitis

Analgesia

  • Pain reliever/anti-inflammatory(e.g., ibuprofen)
  • Second choice – pain reliever alone(e.g.,acetaminophen)

Analgesia

  • Same as for plugged duct

Antibiotic?

  • No

Antibiotic?

  • No: If symptoms are mild and have been present for less than 24 hours.
  • Yes: If symptoms are not improving in 12-24 hours, or if mom is acutely ill.
  • Most common pathogen is penicillin-resistant Staphylococcus aureus.
  • Typical antibiotics used for mastitis:- Dicloxacillin, flucloxacillin, cloxacillin, amoxycillin-clavulinic acid- Cephalexin, erythromycin, clindamycin, ciprofloxacin, nafcillin
  • Most recommend 10-14 day treatment to prevent relapse. Do not discontinue treatment earlier than prescribed.
  • Consider probiotic to reduce thrush risk.
  • Several studies have shown that probiotic supplements (certain Lactobacillus strains) are effective in treating infectious mastitis and also resulted in a lower occurrence of repeat mastitis.
  • Some mothers also use natural treatments.
* Consult your health care provider for guidance in your specific situation. The medication information is taken from the references listed below and is provided for educational purposes only.

Does mastitis always require antibiotics?

No, mastitis does not always require antibiotics.

Mastitis is now understood as part of a spectrum of breast inflammation. Many cases begin with inflammation related to disrupted milk flow, oversupply, swelling, or breast tissue irritation. Some cases improve with supportive care alone, while others progress to bacterial mastitis and benefit from antibiotics.

Per the Academy of Breastfeeding Medicine’s Clinical Protocol for Mastitis:

“If symptoms of mastitis are mild and have been present for less than 24 hours, conservative management (effective milk removal and supportive measures) may be sufficient. If symptoms are not improving within 12-24 hours or if the woman is acutely ill, antibiotics should be started.”

If a mom with mastitis has no obvious risk factors for infection (as noted in the box below), it is likely that the mastitis is non-infectious and, if properly treated, will resolve without antibiotics.

In many cases, early mastitis symptoms improve with:

  • continuing to breastfeed or remove milk normally,
  • rest,
  • anti-inflammatory measures (such as ibuprofen, if medically appropriate),
  • cold packs or ice,
  • adequate fluids and nutrition,
  • reducing pressure on the breast.

When you have mastitis…

Talk to your DR about starting

antibiotics immediately if:

  • Mastitis is in both breasts.
  • Baby is less than 2 weeks old, or you have recently been in the hospital.
  • You have broken skin on the nipplewith obvious signs of infection.
  • Blood/pus is present in milk.
  • Red streaking is present.
  • Your temperature increases suddenly.
  • Symptoms are sudden and severe.

Follow-up

  • Re-evaluate treatment plan if symptoms do not begin to resolve within 2-3 days.
  • Investigate further if mom has more than 2-3 recurrences in the same location.
  • Consider the possibility of thrush if sore nipples begin after antibiotic treatment.

As always, consult your own health care provider to determine how this information applies to your specific circumstances.

References and additional information

@

@ other websites

Amir LH. Mastitis: Are we overprescribing Antibiotics? Current Therapeutics 2000 (April); 41:24-28.

Amir LH. Management of Mastitis. Current Therapeutics 2000 (April); 41:29.

Fetherston C. Mastitis in lactating women: physiology or pathology? Breastfeed Rev 2001 Mar;9(1):5-12.

Fetherston C. Risk factors for lactation mastitis. J Hum Lact 1998 Jun;14(2):101-9.

Foxman B, D’Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002 Jan 15;155(2):103-14.

Kinlay JR, O’Connell DL, Kinlay S. Risk factors for mastitis in breastfeeding women: results of a prospective cohort study. Aust N Z J Public Health. 2001 Apr;25(2):115-20.

Lawrence R, Lawrence R. Breastfeeding: A Guide for the Medical Profession, 6th ed. Philadelphia, Pennsylvania: Mosby, 2005, p. 299-301, 562-570, 1068-1071.

Livingstone VH, Willis CE, Berkowitz J. Staphylococcus aureus and sore nipples. Can Fam Physician. 1996 Apr;42:654-9.

Mohrbacher N, Stock J. Breastfeeding Answers Made Simple, Amarillo, Texas: Hale Publishing, 2010, p. 682-683.

Prentice A, Prentice AM, Lamb WH. Mastitis in rural Gambian mothers and the protection of the breast by milk antimicrobial factors. Trans R Soc Trop Med Hyg. 1985;79(1):90-5.

Riordan J. Breastfeeding and Human Lactation, 3rd ed. Boston and London: Jones and Bartlett, 2005, p. 248-253.

Riordan JM, Nichols FH. A descriptive study of lactation mastitis in long-term breastfeeding women. J Hum Lact. 1990 Jun;6(2):53-8.

Smith A, Heads J. Breast Pathology. In: Walker M, ed. Core Curriculum for Lactation Consultant Practice. Boston: Jones and Bartlett, 2002, p. 180-190.

Walker M. Breastfeeding Management for the Clinician: Using the Evidence. Boston: Jones and Bartlett, 2006, p. 388-394.