The new mastitis protocol

The thought of mastitis often brings feelings of dread and fear to breastfeeding women, and with good reason. Mastitis can be a painful, difficult, and debilitating condition for women. Current statistics suggest 1 in 5 Australian women will experience mastitis in the first six months after birth. The prevention and treatment of mastitis is fundamental to a woman’s health and the health of her child and essential to the prevention of early cessation of breastfeeding and to increase a woman’s satisfaction with her breastfeeding journey. Research and the application of research into evidence-based practice is essential for the provision of effective treatment for conditions such as mastitis. The Academy of Breastfeeding Medicine (ABM) provides valuable protocols that act as guidelines for managing breastfeeding-related conditions. Recent research developments in the understanding of the pathophysiological of mastitis have led to an update in the ABM protocol for mastitis, presenting an exciting opportunity for women to benefit from evidence-based care. This change is a crucial development as a new understanding of the physiology of mastitis fundamentally shifts how mastitis is treated and the immediate advice women receive.

What causes mastitis?

Mastitis can be defined as inflammation of the breast tissue that may or may not involve a bacterial infection. Historically, mastitis has been considered an isolated event caused by milk remaining in the breast due to inadequate milk drainage or a blockage. New evidence has demonstrated that mastitis involves a spectrum of conditions caused by inflammation and oedema [see Figure 1]. Multiple factors contribute to the mastitis spectrum; however, the primary factors are hyperlactation and mammary dysbiosis.

Figure 1: Spectrum of mastitis conditions.

Figure 2: Explanation of the spectrum of mastitis conditions.

Hyperlactation

Hyperlactation is the production of breastmilk greater than what an infant requires. The production of breastmilk relies upon a dynamic feedback inhibition mechanism: the more breastmilk that is removed from the breast, the more breastmilk is produced; the less breastmilk is consumed, and the more breastmilk that stays in the breast, the less breastmilk will be produced. Hyperlactation can occur due to excessive breastfeeding, expressing, or a combination of both. This increased production of milk causes swelling, and increased blood flow causing milk ducts to narrow and milk flow to be reduced. This physiological process is directly opposed to the prior understanding of mastitis and has caused the greatest change in the treatment of mastitis.

Mammary dysbiosis

Mammary dysbiosis is the disruption of the milk microbiome within a woman’s breasts. This disruption also causes the narrowing of the milk ducts and an increase in vascular flow, followed by reduced milk flow and potential for milk obstruction. Factors contributing to dysbiosis include medical conditions, antibiotic exposure, probiotics, regularly expressing with a breast pump, caesarean births, and genetics. Maternal nutrition is essential for the development and maintenance of the mammary microbiome.

Prevention and treatment of mastitis

Prompt and effective treatment is vital to prevent the progression of the mastitis spectrum. Based on the new understanding we have of the mastitis spectrum, historical treatments would cause or worsen mastitis spectrum conditions for women. New treatment recommendations and strategies now also act as preventative measures and should be encouraged for all women. The table below identifies the historic understanding and recommendations for mastitis that should now be avoided, and the new understanding and recommendations that should be implemented for the prevention and treatment of the mastitis spectrum.

It is important to be aware of the changes to how we prevent and treat mastitis during your pregnancy so you can be on the front foot as soon as you notice signs of mastitis. Prevention can start in the third trimester with particular strains of probiotics shown to reduce the likelihood of experiencing mastitis by up to 59%.

Outdated Practice		Current Evidence-Based Practice
Old Understanding	Old Recommendation	New Understanding	New Recommendation
Milk is not emptied from the breast, causing inflammation.	Breastfeed and express milk to ‘empty breasts’ and keep them as empty as possible.	Breast milk production depends on a feedback loop. Increased milk removal increases milk production and can lead to hyperlactation which is a major cause of ductal narrowing and inflammation.	Breastfeed on demand when baby is hungry and do not aim to ‘empty your breast’.
Express milk to help milk removal and quicken recovery from mastitis.	After breastfeeding express milk by hand or with pump to ‘empty breasts’ as much as possible.	Breasts pumps can increase milk production without the effective extraction of breastmilk that a baby’s sucking provides. Pumps can also increase the risk of trauma to the nipple and breast. Pumping limits the bacterial exchange between baby and breast which can change the microbiome and cause mammary dysbiosis.	Minimise breast pump usage whenever possible. Aim to limit expressing to when mother and baby are separated.
Massage breast to help removal of milk from the breast.	Massage ‘lumps’ or blockages in breast towards the nipple while breastfeeding or pumping.	Massage can increase inflammation and the risk of phlegmon formation and intensify the progression of the mastitis spectrum.	Avoid deep tissue breast massage and only use lymphatic drainage massage with light strokes. Avoid commercial massage or vibrating devices.

Further universal recommendations to prevent the mastitis spectrum include:

Wearing a well-fitting, supportive bra without an underwire
Avoiding the use of nipple shields
Avoiding the routine sterilisation of breastfeeding items
Using ice, nonsteroidal anti-inflammatory medications and paracetamol to reduce oedema, inflammation, and pain
Avoiding the application of topical ointments or soaking breasts in salt water, which can increase the risk of mammary dysbiosis
Taking sunflower or soy lecithin to help emulsify milk and reduce inflammation in milk ducts
Start taking specialised probiotics in the third trimester if you’re planning to breastfeed
Discussing with your doctor the appropriateness of antibiotic use for bacterial mastitis.

The new evidence and understanding of mastitis spectrum conditions highlight the complex microbiology of the breast and breast milk and the intricate balance of breast milk removal and production as directed by an infant within the mother-infant dyad, and the role each play in the prevention and treatment along the mastitis spectrum. For anyone experiencing conditions along the spectrum of mastitis, it’s essential to seek guidance and support from professionals who specialise in lactation and clinical nutrition. By consulting with an International Board Certified Lactation Consultant (IBCLC) and a Clinical Nutritionist, you can receive expert care tailored to your specific needs.

Are you currently breastfeeding or planning to breastfeed? Book a consultation with Court to discuss breastfeeding nutrients and preventing and treating mastitis.

This article was co-written with Megan Colville, IBCLC, from True Natal. If you need support on your breastfeeding journey, you can contact Megan or find her on Instagram.

If you’re interested in taking any supplements, please discuss this with your practitioner to ensure you’re taking the correct dose and form for you. This article is not intended to be medical advice and is purely for education purposes.