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Blocked Ducts and Mastitis
Handout #22 Blocked Ducts and Mastitis. Revised
January 2005
Written by Jack Newman, MD, FRCPC. © 2005
Mastitis is a bacterial infection of the breast that
usually occurs in breastfeeding mothers. However, it can occur in
women who are not breastfeeding or pregnant, and can occur even
in small babies of either sex. Nobody knows exactly why some women
get mastitis and others do not. Bacteria may gain access to the
breast through a crack or sore in the nipple, but women without
sore nipples also get mastitis, and most women with cracks in the
nipple do not.
Mastitis needs to be differentiated from a plugged
or blocked duct, because a plugged or blocked duct does not need
treatment with antibiotics, whereas mastitis often, but not
always, requires treatment with antibiotics. A blocked duct
presents as a painful, swollen, firm mass in the breast. The skin
overlying the blocked duct is often quite red, similar to what happens
during mastitis, but less intense. Mastitis is usually also associated
with fever and more intense pain as well. However, it is not always
easy to distinguish between a mild mastitis and a severe blocked
duct. Both are associated with a painful lump in the breast.
Without a lump in the breast, one cannot make a diagnosis
of mastitis or a blocked duct. A blocked duct can, apparently,
go on to become mastitis. In France, physicians also recognize something
they call lymphangite that is fever associated with skin
which is hot and red, but there is no underlying painful mass. They
do not believe this requires treatment with antibiotics. I have
seen a few cases that fit this description in my practice, and indeed,
the problem resolves without antibiotics. But then, often a full
blow mastitis also resolves without antibiotics.
As with almost all breastfeeding problems, a poor
latch, and thus, poor draining of the breast sets up the situation
where mastitis is more likely to occur.
Blocked Ducts
Blocked ducts will almost always resolve spontaneously
within 24 to 48 hours after onset, even without any treatment at
all. During the time the block is present, the baby may be fussy
when nursing on that side, as milk flow may be slower than usual,
probably due to pressure causing collapse of other ducts. Blocked
ducts can be made to resolve more quickly by:
- Continuing breastfeeding on the affected side.
- Draining the affected area better. One way of doing this is
to position the baby so his chin “points” to the area
of hardness. Thus if the blocked duct is in the outside, lower
area of your breast (about 4 o’clock), the football hold
would be best. Another way of achieving better draining of the
breast is using breast compression while the
baby is feeding, getting your hand around the blocked duct and
using steady pressure as the baby sucks (See handout #15, Breast
Compression).
- Applying heat to the affected area (with a heating pad or hot
water bottle, but be careful not to injure your skin by using
too much heat for too long a period of time).
- Trying to rest. (Not always easy, but take the baby to bed with
you.)
If the blocked duct is associated with a small blister
on the end of the nipple, you can open it with a sterile needle.
Flame a sewing needle or a pin, let it cool off, and puncture the
blister. No need to dig around. Just pop the top or side of the
blister. Sometimes you can squeeze out a little toothpaste like
material from the duct and the duct will immediately unblock. Or,
put the baby to the breast and he may unblock it for you. Opening
the blister has the added benefit of decreasing nipple pain, even
if the blocked duct does not immediately resolve. Come to the clinic
if you cannot do it yourself.
If a blocked duct has not settled within 48 hours
(unusual), therapeutic ultrasound often works. This can
be arranged at a neighbourhood physiotherapy office or sports medicine
clinic. Many ultrasound therapists are not aware of this use for
ultrasound. The dose is:
2 watts/cm2, continous, for five minutes to the affected
area, once daily for up to two doses.
If two treatments on two consecutive days have not
worked, there is no point in continuing with ultrasound. Get the
blocked duct re-evaluated at the clinic or by your own physician.
Usually, however, if ultrasound is going to work, one treatment
is all that is needed. Ultrasound also seems to prevent recurrent
blocked ducts that always occur in the same part of the breast.
Lecithin, one capsule (1200 mg) 3 or 4 times a
day also seems to prevent recurrent blocked ducts, at least in some
mothers.
Mastitis
Here is my approach to dealing with mastitis.
- If the mother has symptoms consistent with mastitis
for more than 24 hours, she should start antibiotics.
If the mother has consistent symptoms for less than 24 hours,
I will prescribe an antibiotic, but suggest the mother wait before
starting to take it. If, over the next 8-12 hours, her
symptoms are worsening (more pain, more spreading of the redness,
enlargement of the hardened area), then the mother should start
the antibiotics. If, over the next 24 hours, the mother has not
worsened, but not improved, she should start the antibiotics.
However, if symptoms are starting to decrease, there is no need
to start the antibiotics. The symptoms usually will continue to
resolve and will have disappeared over the next 2 to 5 days. Fever
will usually be gone within 24 hours, the pain within 24 to 48
hours, and the breast hardness within the next few days. The redness
may remain for a week or longer. Once improvement begins, with
or without antibiotics, it should continue. If the course of your
mastitis does not follow this pattern, contact the clinic.
- Note: Amoxicillin, plain penicillin, and some
other antibiotics often prescribed for mastitis are usually useless
for mastitis. If you need an antibiotic, it must be effective
against Staphylococcus aureus. Effective for this bacterium
are: cephalexin, cloxacillin, flucloxacillin, amoxicillin-clavulinic
acid, clindamycin and ciprofloxacin. The last two are effective
for mothers allergic to penicillin. You can and should continue
breastfeeding while taking these medications.
Remember:
- Continue breastfeeding, unless it is just too
painful to do so. If you cannot, at least express your milk as
best you can in the meantime. Restart breastfeeding as soon as
you are up to it, the sooner the better. Continuing breastfeeding
helps mastitis to resolve more quickly. There is no danger for
the baby.
- Heat (hot water bottle or heating pad), applied to the
affected area helps healing.
- Rest helps fight off infection.
- Fever helps fight off infection. Treat fever if it makes
you feel bad, not just because it is there.
- Medication (acetaminophen, ibuprofen) for pain can be
very good. You will feel better and the amount that gets to the
baby is insignificant. Acetaminophen is probably less useful as
it does not have an anti-inflammatory effect.
Abscess: An abscess occasionally complicates
mastitis. You do not have to stop breastfeeding, not even
on the affected side. In the past, an abscess was almost always
drained surgically. Now, more and more, repeated needle aspiration
or drainage under radiographic control is done, and interferes less
with breastfeeding. If you need surgery, the incision should be
kept as far away as possible from the areola. Contact the clinic.
A lump which isn't going away: If you have
a lump that is not going away or getting smaller over more than
a couple of weeks, you should be seen by a breastfeeding friendly
physician or surgeon. You don’t have to stop breastfeeding
to get a breast lump investigated (Ultrasound, mammogram, and even
biopsy do not require you to stop breastfeeding even on the affected
side). A breastfeeding friendly surgeon will not tell you that you
must stop breastfeeding before s/he can do tests for a breast lump.
Questions?
see
my book Dr. Jack Newman's Guide to Breastfeeding (called
The
Ultimate Breastfeeding Book of Answers in the USA)
See the website www.thebirthden.com/Newman.html
which contains videos showing how to latch a baby on, how to know
a baby is getting milk, how to use compression, etc.
Handout #22 Blocked Ducts and Mastitis. Revised January
2005
Written by Jack Newman, MD, FRCPC. © 2005
This
handout may be copied and distributed without further permission,
on
the condition that it is not used in any context in which
the WHO code on the marketing of breastmilk substitutes is violated
