MASTITIS

I recently gave a lunchtime presentation to the excellent team of doctors and nurses at Doctors of South Melbourne on the Physiotherapy management of Mastitis. I thought I would share some of the key points here with a broader audience, especially for expecting mums, breastfeeding mums or any clinician working with this patient group.

WHAT IS MASTITIS?

Mastitis refers to inflammation of the breast, associated with post-partum breastfeeding.  It can be caused by blocked ducts (non-infective mastitis) or a bacterial infection (infective mastitis). The rate of incidence is up to 33% in the first 6 weeks post birth, with most episodes occurring in the first 2-3 weeks post-partum.

Generally a woman will present with a tender lump in the breast, which may be red and warm, and they will likely feel systemically unwell with body aches and fever (in the case of infective mastitis).

Traditional Physiotherapy management was to recommend the mother to continue to feed from the affected breast while massaging the lump towards the nipple to drain it, with advice to place a warm cloth on the breast (or have a warm shower) before feeding.  However, more recent research suggests that the classic “engorgement” and “blocked ducts” are actually a lymphatic issue, with fascial bands in the pectoral region restricting the movement of the fluid.  Therefore, current recommendations are that rather than massage the lump towards the nipple, you should instead do lymphatic drainage massage towards the axilla (armpit).

Ultrasound treatment can help to break down the lump before lymphatic drainage massage, with recent research suggesting that the ultrasound waves also help to break down the bacterial capsule, making the cell wall more permeable to antibiotics that are prescribed for infective mastitis.

Management also includes stretches of the pectoral muscles to reduce tension on the fascia and help create softness to the breast tissue.

As soon as a woman detects a lump in the breast she should seek treatment, and treatment is normally done over three consecutive days. 

FACTORS THAT PREDISPOSE A WOMAN TO BLOCKED MILK DUCTS

• Engorgement of the breast due to a missed or delayed feed

• A tight or ill-fitting bra

• Consistently lying in one position during sleep 

• Holding the breast too tightly when feeding

• Trauma to the breast such as pressure from a seatbelt

• Nipple trauma caused by incorrect attachment of the baby during feeds

• Use of nipple crease which can harbour bacteria

HOW TO MINIMISE THE RISK OF DEVELOPING MASTITIS

Feeding technique is a big part of reducing the risk of developing mastitis. When a baby attaches to the areola (nipple), they stimulate mechanoreceptors that send signals to the brain to release oxytocin.  The release of oxytocin makes the glands squeeze, which leads to milk moving down the duct and spraying into the baby’s mouth. Normally there is a 30-60sec delay in the time until the milk is let down.

When the gland squeezes there often isn’t an even emptying of the breast, rather the milk is more likely to come from where the baby’s chin is resting and applying pressure to the milk ducts. Therefore, with a “traditional” feeding position of holding the baby across the chest, in the outer part of the breast (closer to armpit), the milk is less likely to drain from the alveoli of the outer ducts.  When the milk remains and becomes stagnant in the duct it can leak into the surrounding breast tissue and form a hard lump, leading to mastitis.

Therefore, to ensure full drainage of breast, it is recommended to feed as long as you can on the first side, and before offering the second side check the breast - it should feel soft all the way around. If not, re-attach the baby on the same side and help them drain the rest of the milk with gentle pressure on the fuller part of the breast tissue.  One way to encourage this is to change the grip to a “football” grip under the arm, so the cheek of the baby is pressing against the outer breast. 

Once the breast is fully drained, it is recommended the mother offer the second side, but not to worry if the baby is full and doesn’t want any more - note which side you have fed from and do the opposite the next feed.

Remember to seek professional support and advice ASAP if you are worried you have developed mastitis, the sooner you can treat it the quicker the recovery and less likely you are to feel like you have to stop breastfeeding altogether due to pain.