The updated protocol on engorgement, mastitis and breast tissue complications

In 2022 the Academy of Breastfeeding Medicine brought out Clinical Protocol #36, an updated protocol on managing the mastitis spectrum. This protocol has replaced previous ones and completely changed how we look at engorgement, mastitis and other breast tissue complications like breast abscesses and plugged ducts.

Before I continue I want to thank and give credit to my colleague Christine Swanepoel, a SACLC and All Things Breastfeeding breast pump demo centre consultant in Boksburg. She has done an amazing job of deciphering this protocol and presenting it in a form where we could more easily use and apply it in our practices.

Before you start reading

This new protocol was published recently, and most healthcare professionals are not yet aware of it. Unless they take an interest in breastfeeding and make an effort to stay up-to-date, they are going to be offering the wrong advice for many years. The same can be said from most websites and online guides. Unless something was written by an educated expert after 2022, you will be reading old information.

If you want access to the full protocol you can click here. I would advise clients to take this protocol along when seeing a doctor about their condition, to ensure that they are offered the correct treatment.

I also want to give a heads-up that this whole series is quite detailed and technical. This is important to me as All Things Breastfeeding aims to be a resource that truly helps mothers find solutions to problems. Understanding how something works equips you to find solutions that last.

However, mom-brain is real, even more so if you’re struggling and not feeling well, so if you want to skip the heavy reading you can skip straight to our article on mastitis for all the treatment tips and tricks.

The Spectrum of Breast Tissues Complications

Previously we used to see breast engorgement as fullness because of too much milk, and mastitis as a bacterial infection in the breast.

We now know that it’s not so simple, and that these conditions are part of a whole range of symptoms linked to inflammation in the breast. Mostly, one thing leads to another.

Because of the amount of information, I have broken down this feature into smaller topics. You can click on the hyperlinks to read more on each.

Let’s start with all the definitions 

In the past the below terms were all see as separate conditions. We now know that they all fall under the spectrum of mastitis, just in different degrees of severity.

ENGORGEMENT is fullness and swelling in the breast. It can be both a symptoms of mastitis, or a condition on it’s own.

• Primary Engorgement occurs in the early days after birth when a mom’s milk ‘comes in’. This is considered normal and usually doesn’t cause further complications if managed correctly. Although it does not technically fall under the mastitis spectrum, the management is the same. If dealt with incorrectly it also has the potential to turn into mastitis.
• Secondary engorgement occurs after mom has been feeding comfortably for a period of time, and are now engorged because of something that interfered with proper emptying of her breast.

Click here to read more on breast engorgement’s causes and solutions.

MASTITIS refers to inflammation of the breast tissue. Engorgement treated incorrectly will turn into mastitis.

• Most cases of mastitis is just inflammatory mastitis (for which antibiotics is not needed).
• Some cases may proceed to bacterial mastitis, where an actual bacterial infection is to blame.
• Subacute mastitis can occur after bacterial mastitis has been treated ineffectively. There may be no flu-symptoms, but a mom may continue to struggle with burning breast pain, blockages, congestions and nipple blebs.

Click here to read more on the mastitis’ causes and solutions.

A BREAST ABSCESS occurs where bacterial mastitis was treated ineffectively and has now progressed to a a painful fluid collection (milk and pus) that formed in the breast, and that needs surgical drainage. Another form of ‘lump’ linked to chronic breast inflammation is a GALACTOCELE, which is a cyst-like cavity that forms after a milk duct was narrowed and obstructed for a longer period of time. A galactocele may or may not cause problems, and can progress to an abscess should it become infected.

Anatomy of the breast – what happens on the inside

It is only the last 20-30 years that we started gaining insight into what happens inside a breastfeeding woman’s breast.

If you understand how your breast is built, and what happens when it becomes engorged, you will understand why traditional treatment options like breast massage will do more harm than good.

We used to think that the breasts contain milk glands, with rather large ducts running to the nipple. This created the idea that duct can get blocked, or that milk simply gets stuck in an area.

Instead, with advances in sonar technology we now know that instead the breast is made of:

• Milk glands, most lying within 30mm of the nipple.
• Millions of microscopic, interlacing milk ducts that flows together and ends in 4-18 ductal openings on your nipple.
• Blood vessels, ligaments and fatty connective tissue.
• Muscle walls around the milk ducts.
• An extremely rich blood supply.
• Underlying muscles and ribs supporting your breast structure.
• Fat layers and skin covering your breast.

Click here for Medela’s fact sheet on the anatomy of the lactating breast.

Mastitis – what goes wrong?

There are two main role-players when a mom develops a mastitis spectrum condition.

HYPERLACTATION – basically this means that the breast is making more milk than the baby needs, or that the breast is never emptied properly over a period of time. There are many reasons why a mom would make too much milk, including excessive pumping and the unnecessary use of medication to increase supply. There are also many factors that influence breast emptying, including scheduled feeding, latching difficulties and giving formula top-up feeds. Read more on hyperlactation by clicking here.

DYSBIOSIS – There are millions and millions of micro-organisms in the human body, many of them present in breast milk and the milk ducts. These good bacteria (though they are not only bacteria, but fungi and protozoa as well) are essential for proper immune functioning. When there is an imbalance with one type being predominant over others, it creates a biofilm that clings to the side of the milk ducts (think of algae growing against the side of a swimming pool). This narrows the milk ducts and obstructs milk flow, which causes all the tissues in the area to have an inflammatory response. Milk is squeezed from the milk ducts into the tissue in-between ducts and glands. The lymph drainages system becomes overwhelmed.

In addition, the biofilm contains inflammatory cells that reacts with the cholesterol in breast milk and can come to the surface in the form of a ‘bleb’ or a milk plug. This becomes a different problem in itself.

Hyperlactation and dysbiosis forms an evil circle:

• Narrowed ducts and inflammation because of the biofilm makes it more difficult for milk to flow.
• Because of hyperlactation and incomplete emptying there is now more milk that needs space to flow.
• Because of milk not flowing the alveoli in the milk ducts (the small glands that makes milk) become congested.
• Milk now leaks through into the interstitial tissue (the tissue in-between the milk glands and ducts).
• This causes inflammation in these tissues.
• The inflammation and swelling in turn put more pressure on the ducts, further narrowing them and reducing milk flow.
• Fullness and pain are starting.
• Outcome: this is indeed the plugged duct that we always described, except it is not one single duct but hundreds or even thousands of small ducts, and it is not plugged by a single ‘lump’ of milk, but by cells and blood vessels and swelling.

At this point in time, mom has inflammatory mastitis. If managed correctly it should subside and breastfeeding can continue. If not it will complicate and progress, and can have devastating effects on mom’s breastfeeding journey.

A last point – Feedback Inhibitor of Lactation (FIL)

Feedback Inhibitor of Lactation (FIL) is a protein that can be found in the breast. It regulates supply by reducing milk production in breasts that are full (or not emptied properly).

As you read through the series you’ll see that Breast Rest is a common method recommended. This means just leaving your breast and not emptying it, while applying ice and implementing all the other methods discussed in this series.

You may wonder how on earth it could be useful to leave an overfull boob to remain overfull? Well, through FIL.

The more milk your breasts have in them the higher the levels of FIL. This means high levels when your breasts are engorged, which tones down supply. When you constantly empty your breasts they do not have as much FIL and your supply stays the same or increases depending on your baby’s behavior.

Usually we don’t want your breasts to remain full for long, as this is bad for milk supply. But in the case of engorgement and mastitis this becomes nature’s way to resolve the problem.

If you are interested in more details on exactly how this works you can click here.