Mastitis: Everything You Need to Know!

This just in! The guidelines around the treatment of mastitis, a common complication of breastfeeding, have largely changed! On today’s episode, Drs. Sarah and Alicia provide an overview of the updated clinical protocol from the Academy of Breastfeeding Medicine - and let us (possibly) be the first to tell you that the new guidelines are almost the exact opposite of what was previously recommended. A must listen!

For clarification, the probiotics we were referring to are called limosilactobacillus fermentum ligilactobacillus salivarius. Additionally, this Pregnancy for Professionals Podcast episode on Intrusive Thoughts, while intended for providers, is a great deeper dive into postpartum mental health.

And last but not least, our friends at Happy Health Eaters have offered our listeners 15% off of their great course on Starting Solids Confidently, using this link and the code SFH15! Super helpful for new parents everywhere!

What is Mastitis?

Simply put, mastitis refers to a spectrum of issues that results in the inflammation and swelling of the ducts and tissue engaged in chest or breastfeeding. Sometimes it leads to infection requiring antibiotics - but not always! It’s also important to clarify that mastitis is not the same as engorgement, which usually presents itself in both breasts, whereas mastitis commonly occurs in one. Engorgement also involves pain, firmness, and swelling in both breasts, and typically goes away on its own, or with conservative treatment such as eliminating the use of ill fitting bras, icing, or over-the-counter anti-inflammatories.

Who is at risk?

There are a few factors which contribute to the risk of contracting mastitis, including;

1. Hyper-lactation or an over-supply of milk
2. Mammary Dysbiosis, a disruption in the milk microbiome

Ultimately they are a result of a complex interplay of several things, including genetics of the feeding parent, underlying medical conditions, exposure to antibiotics, use of probiotics, regular use of breast pumps, people who bind their chest or breasts, and a history of Caesarean birth. Well fitting bras or binding materials are also key - we recommend keeping them a little looser than normal while breastfeeding!

The Stages of Mastitis

Ductal Narrowing: The first stage of mastitis is typically described as ductal narrowing. This is caused by inflammation at the ductal level - the area that leads the mammary tissue out to the nipple through which the milk flows. For the patient, this presents as a localized area of breast tissue that is firm, tender, and often a little bit red, or erythematous, as we refer to it, but without any symptoms from a whole body perspective such as fever and chills.

Inflammatory Mastitis: It’s important to understand that this isn't actually a plug, like formally considered, but rather the ductal tissue getting inflamed and irritated, therefore blocking the passage for the milk to get through. This is a really important distinction. Previously when mastitis was defined as a blockage of ducts, “squeezing out” the block through massage or extra feedings was recommended - but you can’t squeeze out an inflammation! Likewise with more frequent feeding, the inflammation is unlikely to improve, and will be uncomfortable and painful. If the mastitis progresses, you may feel whole body symptoms such as fever, chills, and even a bit of an elevated heart rate - your body’s response to the inflammation.

Infectious Mastitis: in some cases, mastitis is caused by infection that might need to be treated with antibiotics.

Treatments!

Regardless of the cause, even if bacterial, it does not pose a risk to your infant and you can continue to safely feed your baby from either the affected or unaffected breast, or pump milk!

For most people, symptoms will resolve with a few simple measures, including:

For ductal mastitis:

1. Feed on demand on the affected side, but don’t feed to empty. Overfeeding from the affected side perpetuates the cycles of hyper lactation, which can lead to further inflammation. If it’s too painful to feed, hand express a little, but don’t pump
2. Wear an appropriately fitting bra or support - remember not too tight!
3. Avoid breast massage! This is a big one as it was previously recommended. But a massage is actually putting more pressure and aggravating the issue. If you have a sprained ankle and start pushing on it, it's going to make it worse, right?

For Inflammation:

1. Decrease inflammation with rest, ice, and anti-inflammatories (like ibuprofen)
2. Taking sunflower or soy lethicin (5-10 grams), especially if you have reoccurring symptoms
3. Probitocis may be useful but the data is limited on this. If probiotics are for you, the evidence recommends limosilactobacillus fermentum and/or ligilactobacillus salivarius
4. Lymphatic drainage: talk to your provider about appropriate technique - pelvic physios can provide support with this!
5. Do not pop nipple blebs! If you've breastfed before you have probably experienced nipple blebs - inflammatory cells from your ducts that have made it to the surface of the skin and gotten stuck! It is not recommended popping them as it can lead to trauma and a further narrowing of the duct.
   Another alternative is oral LEFTS (!?) or a prescription steroid cream to recuse the inflammation on the surface of the nipple. Steroid cream is safe with breastfeeding - you can wipe off any excess with a damp tissue or towel before feeding your infant.


For infection:

1. If nothing helps and other full body symptoms like fever and chills manifest and persist more than 24 hours, please see your care provider. If the problem is infectious, antibiotics will be needed.

Last but not least, problems with breastfeeding, which can in part be caused or exacerbated by mastitis, can take their toll on your mental health. If you find yourself struggling with postpartum depression or intrusive thoughts, don't hesitate to seek help from medical professionals or your community.

To sum up, not all mastitis is infectious, meaning not all mastitis needs to be treated with antibiotics. If you begin suffering from recurrent mastitis, we really do recommend seeking support from a knowledgeable provider. There could be underlying issues at play like hyper lactation, a problem with the latch, or inadequate treatment of a previous infection that could warrant more investigation and treatment.