Clogged Ducts & Mastitis

Dealing with a clogged duct, or even mastitis, can be really stressful and honestly annoying. I remember when I was about 3-4 months postpartum, I developed a pretty painful clogged duct which ended up turning into mastitis. I had recently returned to work from maternity leave, so I think it probably happened because I wasn’t pumping enough at work and my body was adjusting to being away from my baby. Regardless of why it happened, I didn’t treat it in the greatest way. This was 2021 mind you, and the Academy of Breastfeeding Medicine (ABM) didn’t update their protocol (#36) for clogged duct and mastitis treatment until 2022. So, I was going off of old recommendations. And let me tell you, it’s no wonder that my clogged duct turned into mastitis in less than 24 hours. Now with more research, we know more about what we now call the “mastitis spectrum” and have new and improved recommendations for treatment. Let me tell you about the updated protocol so that you can have the information to treat yourself and when to seek help from your healthcare provider.

So, what is the mastitis spectrum?

We used to think of a clogged duct and mastitis as two separate conditions, but with further research we now know that they’re part of a spectrum of conditions that result in ductal narrowing and inflammation. Honestly, calling it a “clogged duct” isn’t really the most accurate way to describe what’s happening inside the breast. When milk builds up in the breast due to lack of removal, this causes the body to respond by creating inflammation and swelling. In turn, this inflammation and swelling causes your milk ducts to narrow, thus restricting the flow of milk through the ducts. Think of it this way. Lets say you have a straw in your hand and this represent a milk duct. If you were to press on the sides of the straw with your fingers, the inside of the straw would get smaller and more narrow. If you were to try to put fluid through this straw, less fluid would be able to pass through the straw because of the pressure you’re putting on the outside of it. If this inflammation and narrowing isn’t treated, this can lead to a bacterial infection in the breast, also known as mastitis. Lets break down each condition further.

Hyperlactation (milk building up in breast) —-> Ductal narrowing —-> Inflammatory mastitis —-> Bacterial mastitis —-> Abscess

Ductal Narrowing “Plugging”

Like I said before, there really is no such thing as a “clogged duct” or a “plugged duct.” It was once though that an actual congealed mass of milk would create an actual physical clog/plug within a single milk duct. However, according to ABM Protocol #36, “Ducts in the breast are innumerable and interlacing and it is not physiologically or anatomically possible for a single duct to become obstructed with a macroscopic milk plug”. It is now thought that inflammation and swelling from a build up/overproduction of milk in the breasts applies pressure on the milk ducts and causes ductal narrowing.

Ductal narrowing/engorgement can affect the whole breast or be localized to one area and symptoms include, firmness, tenderness, redness, and/or warmth to the touch. In many cases, this can resolve on it’s own within a few days. Attempts to “get the plug out” with excessive nursing/pumping or aggressive massage can actually make it worse and lead to mastitis. I’ll go over what to do to treat each stage later on.

Inflammatory Mastitis

When ductal narrowing worsens and the inflammation in the breast increases, inflammatory mastitis can develop. This often looks like an increase in pain, redness, and swelling in the breast. Other symptoms that can develop are a fever, chills, and increased heart rate. Although, all of this can happen and you can technically still not have a bacterial infection yet. Meaning, you may not need antibiotics just yet.

Bacterial Mastitis

As you can imagine, if ductal narrowing and inflammation persist and gets worse despite treatment, this can develop into a bacterial infection that requires antibiotics. If you have bacterial mastitis, your breast will likely be extremely painful, very red, and extremely swollen and inflamed. If you have a fever or increased heart rate for more than 24 hours, it’s most likely bacterial mastitis and you need to be seen by a medical professional as soon as possible. Keep in mind, bacterial mastitis is not contagious so you can continue feeding baby your milk.

Abscess

Developing a breast abscess if quite rare, but I wanted to go over it briefly just to make sure you have all the information you could possibly need. A breast abscess is when bacterial mastitis progresses into a infected fluid collection in the breast that will need to be drained. Only about 3-11% of women with bacterial mastitis develop an abscess. A breast abscess is usually diagnosed by a medical professional, often by using ultrasound. We often see breast abscesses develop if the bacterial mastitis doesn’t respond to the antibiotic given, or if the patient doesn’t finish all of the antibiotics given to them.

So, what causes all of this to happen?

Ok, so we’ve talked about what each part of the mastitis spectrum is, but you’re probably wondering how does it happen? Some moms do tend to be more prone to having recurrent “clogs” or even mastitis. We see this often in moms who are natural overproducers. While having an over supply can have it’s advantages, it also has it’s drawbacks. Moms who are over producers often have large amounts of milk in their breasts at any given time. And as we talked about before, a build up of milk in the breast leads to inflammation, which leads to ductal narrowing.

Here are some scenarios that can lead to a build up of milk in the breasts.

• Skipped/missed feedings
• Excessive pumping/pumping more than you need to
• Baby not latching well = inadequate milk removal
• Baby suddenly sleeping longer stretches at night
• Weaning abruptly or too quickly
• Having an oversupply/being an overproducer
• Baby is nursing less due to illness, teething, distractions, etc.

So, what’s the treatment?

Remember how I said in the beginning of this post that when I had a “clogged duct” I totally made it worse and it turned into mastitis overnight? Thankfully we have new and updated recommendations for treatment by the Academy of Breastfeeding Medicine in their Protocol #36.

So, let me break down these recommendations for you so you don’t do what I did.

• Nurse your baby or pump as often as you normally would, not more and not less. There is no need to pump or nurse more frequently to “empty the breasts” or to “get the clog out.” Honestly, the biggest mistake people make (myself included) is over pumping and/or nursing. Doing so will just tell your body to make even more milk, cause more inflammation, and then more ductal narrowing.
• Apply ice to breasts in between feeds or every hour as needed to reduced inflammation.
• Take an anti-inflammatory like Ibuprofen to help alleviate inflammation and pain. You can also take Tylenol to help with pain. ABM recommends 800mg of Ibuprofen every 8 hours and 1,000mg of Tylenol every 8 hours.
• Wear a good fitting bra. If you’re wearing a bra that is too tight or digs into your breast, this can make inflammation worse.
• Do light lymphatic drainage massage to the affected breast. This type of massage is very light, almost like petting a cat. And focuses on sweeping motions towards the armpit to promote fluid and inflammation to leave the breast via the lymph nodes located in your armpit area. It’s important to be very gentle with this, as rough massage can make things worse. Watch this video here by La Lactation on how to properly do lymphatic drainage massage.
• Sunflower or soy lethicin is something you can consider taking. ABM recommends 5-10mg daily to reduce inflammation in ducts and emulsify milk. Most IBCLC’s would caution you against taking this routinely. It probably should only be used when you have active ductal inflammation or mastitis because it can cause some GI issues if taken long term.
• Consider taking a probiotic. Some studies have shown that taking a probiotic can be effective in both prevention and treatment of mastitis.

What NOT to do:

• Nurse or pump excessively
• Apply heat (can make inflammation worse)
• Aggressive, rough breast massage. Some people even have used electric toothbrushes or lactation massagers with pointy ends to try to pinpoint a “clog”
• Saline soaks, castor oil, topical products, or Epsom salt soaks. Some old recommendations used to suggest filling a haaka with Epsom salt and water and then placing in on the breast to “drag the clog out.” There isn’t much scientific evidence to back this up.
• Sterilizing pump and bottle parts. Mastitis is not contagious, so this isn’t necessary for this in particular.
• Excessive/aggressive hand expression in a hot shower (doesn’t really help if you have mastitis, and again can make inflammation worse.)
• Dangle nursing or pumping. It’s not going to hurt you per say to do this, but their isn’t much evidence to support that it helps at all.

When should I call my doctor?

You’ve tried all the recommendations from the ABM and it’s not getting better or maybe it’s even getting worse. What should you do and when should you call your doctor?

• If your symptoms don’t improve or get worse after 24-48 hours
• If you develop of 101F (38.5C) or greater at any time

If these things are happening, you most likely have bacterial mastitis and will need antibiotics prescribed by your doctor. You can still nurse or given your baby your pumped breast milk while taking antibiotics. No need to pump and dump.

To wrap this up…

How we think about “clogged ducts” and mastitis has really changed over the past couple of years. We now know that a “clogged duct” is not a physical blockage of milk (or milk plug) that stops the flow of milk from the breast. What’s really happening is inflammation caused by a build up of milk in the breast is causing the milk ducts to narrow, which then causes pain, swelling, redness, and reduced milk production. If this inflammation and narrowing isn’t treated, it can lead to bacterial mastitis which then requires antibiotics to treat.

Having ductal narrowing and inflammation can be really frustrating, painful, and annoying. If you’re an over producer, you may end up dealing with it more than others. By biggest piece of advice is to not panic. I know, easier said than done. Trust me, the couple of times it has happened to me since the first time, I have felt worried and stressed too. Just stick to the ABM Protocol #36 recommendations, and give it time. But remember, if it gets worse or you develop a fever, call your doctor as soon as possible to get evaluated.

Hang in there friend!! I hope this post helps you if you’re in the trenches of a “clogged duct” or mastitis

-Janelle

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