The Truth About Lactation Disorders

Lactation disorders may be considered by many to be simple and straightforward, however, they are actually quite complex. They are multifactorial in nature and are often a common reason for mothers ceasing breastfeeding¹. The guidelines for diagnosis and management of these conditions are regularly being updated based on emerging evidence. It is clear that timely, accurate, multidisciplinary, evidence-based care ensures effective treatment that can avoid progression into more serious conditions and avoid recurrence².

Given that the World Health Organisation recommends exclusive breastfeeding for the child’s first six months³, it is important that health professionals support mothers to continue to breastfeed through optimal management and treatment of lactation disorders.

This article will explore common misconceptions and truths that surround Inflammatory Conditions of the Lactating Breast (ILCB).

There Are Different Types Of ICLB

Previously, mastitis was regarded as a single pathological entity, however evidence now shows that mastitis encompasses a spectrum of Inflammatory Conditions of the Lactating Breast (ICLB)². All ICLB’s share common signs and symptoms but not all women present with the same symptoms, severity or impact. Individualised assessment with a trained health professional is essential to differentiate between these conditions.

The range of ICLB include:

Engorgement
Ductal narrowing
Inflammatory Mastitis
Bacterial Mastitis
Breast phlegmon and abscess

Engorgement

Approximately 15-50% of women experience engorgement, usually early in the postnatal period⁴. Engorgement is defined as the pathological overfilling of the breast with milk⁴. Signs of engorgement are usually bilateral and include hard, painful, swollen, tight breasts with any combination of inflammatory symptoms including redness, pain, fever and breast tension.

Ductal Narrowing

The term ‘blocked duct’ is more commonly used clinically, however, there are an infinite number of interweaving ducts within breast tissue, therefore it is implausible for a single duct to become totally blocked, instead they become narrowed.² Ductal narrowing can occur due to lymphatic congestion and alveolar oedema, which leads to reduced milk flow and obstruction². This presents as a painful, sometimes hard, lump that may also be accompanied by local redness. This can be in a specific area or can be more global. There are usually not associated systemic symptoms.

Mastitis:

Mastitis is described as a hot, tender, swollen, wedge shaped area of breast associated with a temperature of at least 38.5°C, chills and flu-like aching and systemic illness⁵. Prevalence ranges from 3-20% of breastfeeding mothers⁵, where inflammatory mastitis develops first and then acute bacterial mastitis may follow².

Inflammatory mastitis develops if narrowed ducts continue or worsen and further inflammation occurs. Symptoms include erythema, oedema and pain in the breast, as well as systemic symptoms of fever, chills and tachycardia². Mitchell et al’s 2022 article emphasises that “systemic inflammatory response syndrome may occur in the absence of infection”².

Bacterial mastitis is a progression from inflammatory mastitis, where there are persistent systemic symptoms (eg fever or tachycardia) that are not responding to conservative measures. If management to control inflammation is not successful and symptoms persist, strategies to control infection are appropriate at this stage.

Recurrent Mastitis
Patients may describe having mastitis symptoms such as fever, breast redness, breast swelling, and/or breast pain occurring every 2–4 weeks. Risk factors for recurrent mastitis include fluctuating periods of hyperlactation (where there is an oversupply of milk), dysbiosis (disruption of the milk microbiome), and inadequate management of prior episodes of mastitis where the cause of mastitis has not been addressed².

Breast Abscess:

This can develop as a progression from bacterial mastitis or phlegmons (fluid collections that occur in the setting of inflammation²) to an infected fluid collection that requires drainage to clear. Approximately 3-11% of women with acute mastitis will develop an abscess, which present as a palpable fluid collection in a well-defined area of the breast². Ultrasound can also be required to confirm diagnosis of an abscess.

The BISSI is a Great Outcome Measure To Assess ICLB

At Women’s and Men’s Health Physiotherapy (WMHP), we use a Patient Reported Outcome Measure (PROM) to help with diagnosis, treatment selection and clinical monitoring to provide the best care and management of ICLB. This PROM is called the BISSI and allows each woman to objectively report on the presence and severity of each symptom they are experiencing.⁶

The BISSI not only assesses physical symptoms such as pain, redness, hardness, size of affected area but also overall sickness and the impact that it is having on their life, which can be quite significant when breastfeeding.

ICLB Management Requires a Biopsychosocial Approach

Recent protocols for the management of ICLB include²:

Addressing individual risk factors and referral to other health professionals such as lactation consultants, GP’s and maternal child health nurses for assessment and diagnosis and breastfeeding counselling.
Reassurance that symptoms will resolve with conservative care and psychosocial support.
Support for mothers to find opportunities for rest.
Evaluation of perinatal mood and anxiety, paying particular attention to those appearing defeated or withdrawn.
Education on breast anatomy and breast feeding – for example - it is important to keep feeding the baby from the symptomatic breast but to avoid over-feeding and therefore hyperlactation. It is also important to feed the baby on demand and not feed from an empty breast.
Examination for pain out of proportion to the examination.

Mastitis Doesn't Always Require Antibiotics

Given that the majority of ICLB present with similar symptoms, historically, women were prescribed antibiotics quickly, especially if they have a fever. We now know that a fever is also a symptom of inflammation, not necessarily infection. Therefore, the use of NSAID’s may be more effective than antibiotics for inflammatory mastitis, which is vastly more common than bacterial mastitis. If antibiotics are used for inflammatory mastitis, it affects the microbiome which can lead to the progression to bacterial mastitis. Many antibiotics have an anti-inflammatory property which may explain why some women will experience some relief from them, even when they don’t have bacterial mastitis. Research demonstrates that taking antibiotics prophylactically is not effective in preventing mastitis.²

Cold Therapy Is Effective, Cold Packs May Be Best

Cold therapy can reduce oedema and inflammation and provide symptomatic relief². The efficacy of cabbage leaves is unclear as there is only very poor quality evidence supporting its use over cold gel pack⁴. The therapeutic effect is more likely to be caused from vasoconstriction from cold, rather than from a property of the cabbage leaf itself².

There Is No Need To Overfeed

Offering the affected side first every time, overfeeding from the affected breast or ‘pumping to empty’ contributes to a vicious cycle of hyperlactation and can increase the risk of development of further oedema and inflammation. Breast pump usage can also pre-dispose to dysbiosis (disruption of the milk microbiome) and can cause further breast/nipple trauma². Hand expressing for comfort can be a more effective way to manage the regulation of milk production.

Lymphatic Massage Is Best – Deep Massage Can Be Harmful

Deep massage of the breast can lead to increased inflammation and breast tissue injury. Manual lymphatic draining with light sweeping of the skin is more effective and causes less tissue trauma (level of evidence 1B)². Lymphatic massage should be towards the axilla, not the nipple and should be gentle, almost like patting a cat.

Therapeutic Ultrasound Can Be Effective In Treating ICLB

Ultrasound is a form of sound waves that is transmitted at a dose which assists in drainage of the breast ducts and reduces swelling and pain. Recent guidelines show that therapeutic ultrasound can be an effective component of treatment for ICLB if performed under the supervision of a Physiotherapist on a daily basis until symptoms are relieved.^2,4

We Can Support ICLB At WMHP

At Women’s & Men’s Health Physiotherapy we prioritise women with ICLB and ensure they are seen urgently. Our Physiotherapists understand the physical and emotional demands on a mother when breast feeding and provide evidence-based assessment and management for ICLB, including therapeutic ultrasound, in conjunction with their Lactation Consultant, GP or Maternal and Child Health Nurse. Our aim is to provide the necessary support to allow mothers to continue to breast feed for as long as they desire.

References

^1.Schwartz K, D’Arcy HJS, Gillespie B, Bobo J, Longeway M & Foxman B. Factors associated with weaning in the first 3 months postpartum. J Fam Pract. 2002; 51(5): 439-444

^2.Mitchell KB, Johnson HM, Rodriguez JM, Eglash A, Scherzinger C, Zakarija-Grkovic I, Cash KW, Berens P, Miller B. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum. Breastfeeding Medicine. 2022; 17(5): 360- 376.

^3.World Health Organization. Exclusive breastfeeding for six months best for babies everywhere. [Internet]. 2011 [cited 25th November].

^4.Mangesi L, Zakarija-Grkovic I. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2016; (6):1-59. doi:10.1002/14651858.CD006946.pub3

^5.Amir LH. ABM clinical protocol #4: Mastitis, revised March 2014. Breastfeed Med. 2014;9(5):239-43. doi:10.1089/bfm.2014.9984

^6.Cooper M and Lowe H. Development of a novel patient focussed symptom severity index for us in assessing and treating inflammatory conditions of the lactating breast: a Delphi study. Int J Evid Based Health. 2020; 18:231-240.

December 2022