Breastfeeding mastitis: how to relieve it?

Breastfeeding mastitis can take several forms, of varying severity.

A diagnosis is made when there is localised inflammation of the mother's breast: it becomes tender, red, warm, and painful.

It can appear gradually or suddenly, presenting as a flu-like syndrome with body aches, chills, fatigue, and a fever above 38.5°C.

If not treated promptly and appropriately, it can lead to complications such as an abscess. The risk of weaning is particularly significant when support is poor and/or advice is inappropriate, such as being told to stop breastfeeding during medical treatment…

There are classically two types of mastitis.

Inflammatory mastitis

Inflammatory mastitis is caused by engorgement or a mechanical blockage of a milk duct, but there is not necessarily an infection.

That said, engorgement or blockages can develop into an infection. Areas of the breast that are not drained, or where the milk ducts are blocked, can become focal points for bacteria to settle and trigger an infectious process [1].

Infectious/bacterial mastitis

It typically comes on suddenly, with flu-like symptoms (including fever, chills, and body aches).

In most cases, antibiotics are required. Effective breast drainage, combined with immune responses, can sometimes help eliminate the bacteria and resolve the infection.

Mastitis is a fairly common issue among breastfeeding mothers. Studies report a prevalence of 3 to 20% [2] [3] [4]. Some studies estimate that around a quarter of mothers will experience one or more episodes of mastitis during their breastfeeding journey [5]!

While they can be common, they are by no means an inevitable part of the journey!

Many of these could indeed be avoided with good breastfeeding practices, rest, and ensuring the baby is "latching correctly" to limit engorgement, particularly during the postpartum period. The majority occur within the 6 weeks following birth, making this a period to monitor closely.

Causes of inflammatory breastfeeding mastitis

Mastitis is caused by insufficient drainage, which leads in particular to an inflammatory reaction upstream of the blockage. This phenomenon of milk blockage is known as "stasis".

Sometimes, when it is very significant, this leads to increased permeability with the interstitial fluid surrounding the mammary gland. As a result, plasma substances pass into the milk, in particular immuno-proteins and sodium into the breast, along with a reduction in milk production.

This permeability can cause changes in the milk, notably an increase in sodium levels [5]. Sodium levels can be multiplied by 34 in cases of mastitis, while lactose levels drop! The milk then changes in taste: it becomes saltier and less sweet. Generally, this salty taste is only temporary (around one week) [6].

Causes of infectious breastfeeding mastitis

The cause is notably linked to lesions at the level of the nipples. The most common pathogen responsible is Staphylococcus aureus, but sometimes also faecal Streptococcus or Escherichia coli.

In some cases, mastitis can become infectious following inflammation and obstruction of the milk ducts.

It is worth noting that under normal conditions, milk is not a favourable environment for the growth of pathogenic micro-organisms (specific microbiota, IgA, lactoferrin, lysozyme, leucocytes…), and the natural "direction" of milk flow also helps flush out any potential pathogens.

The main risk factors

- Nipple cracks or fissures

- Breastfeeding infrequently or at fixed times

- If you are not breastfeeding at night, particularly when the baby starts sleeping through the night

- Milk bleb on the nipple, or blocked milk duct

- Use of infant formula supplements or other foods, particularly in the first few months

- Use of a dummy/soother 

- Poor latch or weak suckling (meaning the breast is not properly "emptied")

- Hyperlactation

- Weaning too quickly

- Bra that is too tight, causing excessive pressure

- Maternal fatigue or stress [7], [8]

Other possible risk factors have been identified.

Returning to work

In 1991, a retrospective study showed that working full-time outside the home was associated with an increased risk of mastitis. This is notably due to the long intervals between feeds and the lack of time for expressing. [9]

So if you return to work and continue breastfeeding, don't hesitate to ask for time to express your milk. It is your right and it matters! For more details on breastfeeding and work, please see our article on this topic.

Nutrition

Studies have notably shown the role of nutrition in the prevention of mastitis during breastfeeding in animals. The risk of mastitis may be higher in cases of deficiency in vitamin E, vitamin A and selenium, or antioxidants [10].

But studies in breastfeeding mothers are still lacking (and yes, mastitis is more studied in animals than in humans!)

Having previously had mastitis 

This recurrence may be explained in particular by an unresolved breastfeeding issue. [11], [12] In the event of mastitis, it may be worth consulting an IBCLC lactation consultant to ensure that the latch is correct and that breastfeeding is being managed optimally. She will also be able to advise you during and after, to help prevent your milk supply from dropping too much and to allow you to continue breastfeeding with confidence.

The mother's immunity

Components of breast milk such as IgA and lactoferrin are not only beneficial for the baby but also help protect the breast from infections. For example, lactoferrin strengthens the adhesion of leucocytes to tissue, for a tenfold increase in effectiveness! [13]

In a study of Gambian women, it emerged that the milk of mothers who had recurrent mastitis contained low levels of IgA, C3 and lactoferrin, compared to that of other mothers. [14]

Nature is well designed: at the time of weaning and breast involution, the level of these immuno-proteins increases in the milk, to protect against all infections when engorgement is more frequent during weaning [15].

Studies conducted in industrialised countries report a prevalence of between 20 and 30%. Yet in other studies conducted in Africa, notably in Gambia, under more challenging conditions, an incidence of only 2.6% was found! [16] One hypothesis is that our societies are too "hygienist", with insufficient exposure to pathogenic germs during childhood, which in particular leads to poor functioning of our immune system.

Fortunately, breastfeeding mastitis is not inevitable, even during the first weeks of breastfeeding!

Avoid wearing a bra that is too tight

They risk impeding milk flow, and can therefore promote mastitis. A bra may either interfere with venous or lymphatic drainage of the breast, or restrict milk flow. One study notably recorded variations in the volume of the lactating breast of up to 600 ml within a single day!

Preventing engorgement

The first thing to do is to make sure engorgement does not set in. You can express milk manually if your breasts feel too full.

Looking after our nipples

To prevent sore nipples, see our article on breastfeeding cracks. It is best to avoid applying too many creams to the nipples, as these can contribute to blocking the ducts.

Watch for signs of "milk stasis"

If you start to feel blockages or hard areas in the breast, rest and increase the frequency of feeds. You can also gently massage the firmer areas.

Wash your hands thoroughly

To prevent infections, make sure to wash your hands thoroughly, especially in hospital. This recommendation applies to everyone (family members, the other parent). If you use a breast pump, wash it thoroughly with soapy water after each use.

Recognising the early warning signs of mastitis and acting quickly.

If you miss a feed and your breasts are very engorged with early signs of inflammation, or if you start to feel unwell: to bed, with your baby, so you can feed frequently!

Put your baby to the breast more frequently, and start with the affected breast. If the pain inhibits the let-down reflex, you can start with the unaffected breast and switch as soon as you feel the let-down coming.

You can also have your baby's latch checked by a specialist IBCLC consultant.

And rest, drink plenty of fluids, and eat well!

Don't stop breastfeeding!

Production in the affected breast may drop for a few days, but it is important that your baby continues to feed from that side to prevent the infection from developing into an abscess. [17], [18], [19]. If needed, you can take a food supplement for breastfeeding women to support your milk supply. 

Continuing to breastfeed even in cases of infectious mastitis is safe according to numerous studies, including in cases of Staphylococcus aureus infection. [17]

Warm and cold compresses

To relieve pain and encourage milk flow, you can:

- Apply a warm compress to the affected breast,

- Soak the affected breast for 10 minutes by leaning over a basin of warm water (three times a day). This also helps to remove dried secretions that may be blocking the flow.

- Take a warm shower.[20]

To do just before a feed, while your breast is still warm, to try to clear the blocked duct.

Afterwards, applications of breastfeeding pad cold can help reduce pain, swelling and inflammation.

Our breast pads can be used warm or cold to provide relief in any situation. 

Bye bye bra!

Remove your bra for a few days if possible, opt for soft bralettes, and at the very least avoid any underwired bra. Free the nipples!

Massage the area

Gently massage the affected area while your baby feeds (using your fingertips or the palm of your hand on the warm, painful area, moving towards the nipple).

Do be careful with massage — always proceed gently so as not to further inflame the breast tissue.

You can also use a food-grade oil to help relax the area. Massage should always be performed from the outer breast towards the nipple.

Encouraging milk drainage

To encourage drainage, try positioning your baby with their chin facing the affected part of the breast to help clear it. [20] You can also try expressing milk manually if you suspect a blocked duct. [21] For more information, see our article on how to express milk.

You can try the all-fours position or lying on your back. A little unusual, but it can sometimes help to clear a blockage!

If things do not improve within 24 hours, contact your doctor or midwife.

Pain relief

Your healthcare professional may prescribe painkillers (such as paracetamol), and sometimes anti-inflammatories such as ibuprofen. Pain relief can help trigger the let-down reflex, so it is perfectly fine to take some.

It should be noted that NSAIDs (non-steroidal anti-inflammatory drugs) are compatible with breastfeeding. According to the CRAT, "The amount of ibuprofen ingested through milk is very low: the child receives less than 1% of the usual paediatric dose (20 to 30 mg/kg/day). In the literature, no particular events have been reported among around twenty breastfed infants of mothers taking ibuprofen. Furthermore, there is significant experience of ibuprofen use during breastfeeding."[22]

One study also showed that "ibuprofen is undetectable in milk after maternal doses of up to 1.6 g/day."[23]

NSAIDs can, however, mask an infection or even worsen it, so always check with your doctor before taking anything.

Antibiotics: not automatically needed in cases of breastfeeding mastitis!

80% to 90% of mothers who consult for mastitis are prescribed them.

This treatment is not necessarily required, particularly in cases of inflammatory mastitis.

This prescription may be made if:

- Presence of superinfected crack(s) is noted

- No improvement after 24–48 hours despite thorough breast drainage

When taking antibiotics, the risk of mammary and vaginal candidiasis in women is increased — and antibiotics also have an impact on gut flora. This is why they should only be taken when truly necessary.

Very rarely (in fewer than 3% of cases) does it progress to an abscess. [24] If the area remains hard, red and painful despite treatment, seek medical advice as soon as possible.

Need to have your milk analysed?

There is no need for bacteriological analysis in cases of mastitis, even when it is infectious.

Many breastfeeding women carry potentially pathogenic bacteria in their milk without having mastitis [25]… Around 20% of the population carries Staphylococcus aureus. And the reverse is also true: many women with mastitis have milk that is free of pathogenic bacteria!

Doctors may then decide to analyse it with a bacterial culture and sensitivity test if the prescribed antibiotics have no effect after a few days, if the mastitis recurs, or in the case of an allergy to the treatments usually used.

Reducing saturated fat intake

If your ducts are frequently blocked and the latch is optimal, you can try reducing saturated fats in your diet and taking a tablespoon of lecithin per day.

Herbal remedies

Traditional Chinese medicine uses plant extracts (Fructus gleditsiae) to relieve mastitis.[26]

Traditional remedies for relieving engorgement

The warm bottle method

This method was recommended in the WHO mastitis guide to relieve engorgement and/or blocked ducts. [27]

You will need:

- a wide-necked glass bottle to cover the nipple fully

- a kettle of hot water to fill the bottle

- cold water to cool the neck of the bottle

- a thick cloth to protect your hand when holding the bottle

Instructions:

- Pour a little hot water into the bottle to start warming it up, then fill it almost completely, but not too quickly as it may crack.

- Leave the bottle to rest for a few minutes so the glass heats up.

- Wrap it in the cloth and empty it into the saucepan.

- Cool the neck of the bottle with cold water, both inside and outside (to avoid burning the skin)

- Place the neck of the bottle over the nipple so that it adheres to the surrounding skin, creating a seal. Hold the bottle in place.

- After a few minutes, it cools down, creating a suction effect, and the nipples are gently drawn inside

- Heat helps trigger the let-down reflex and encourages milk flow. Keep it in place for as long as milk is flowing. You can repeat the process if needed.

Cabbage leaves

The use of refrigerated or room-temperature cabbage leaves is sometimes recommended to relieve the symptoms of engorgement.[28]

A 2015 study suggests that applying refrigerated cabbage leaves to an engorged breast provides similar relief to a warm compress.[29] Hollyhock leaf compresses combined with other remedies may also help reduce engorgement.[30]

Many books support the theory that refrigerated cabbage leaves contain a compound absorbed transdermally that is capable of reducing oedema. However, no published or clinical evidence has so far supported this claim. Coolness and compression alone have a soothing effect, and cabbage leaves, as carriers of these factors, may therefore help reduce inflammation [31].

La Leche League method for relieving engorgement with cabbage leaves:

- Clean, dry and refrigerate several cabbage leaves for the breast you wish to treat.

- Remember to remove or soften the central rib of each leaf, or cut the leaves into large pieces for greater comfort and flexibility.

- Hold the cabbage leaves against your breasts or slip them into a loose-fitting bra to keep them in place. Keep your nipples uncovered, especially if they are sore, cracked or bleeding.

- After twenty minutes, or when the cabbage leaves start to feel warm, remove them.

- Discard the cabbage leaves.

- Gently wash your breasts afterwards if you wish. Do not reuse the same leaves.

If you are not in the process of weaning, you can apply them for twenty minutes three times a day, but no more. Excessive use of cabbage leaves can lead to a reduction in milk supply.

Breastfeeding mastitis can therefore be prevented with good preventive measures.

If you notice the early signs of engorgement or mastitis, don't wait! Increase feeding frequency and don't hesitate to apply the various tips outlined above.

Consult your healthcare professional if symptoms persist or worsen within 24 hours.

Do also seek support from an IBCLC, particularly to avoid early weaning. If the breast is not drained properly, milk production may decrease and lead to breastfeeding coming to an end.

Take care mama !

Please do not self-supplement or self-medicate without advice from a doctor, midwife, or pharmacist. This guidance does not replace medical advice or any ongoing medical treatment.