“Help, I think I have a clogged duct. I have followed my doctor’s advice and everything I can find on Google: heat, massage, pumping, dangle feeding, vibration, nothing seems to work. In fact, it feels worse. What am I doing wrong?”
This is a frequent call or email we receive at the Growing with Baby Center home to lactation consultant and co-author of Suckle-Sleep-Thrive, Andrea Herron RN, MN, CPNP, IBCLC.
So why is the conventional treatment for what we previously called a plugged duct so often failing to treat the painful, recurring lumps on the breasts of these desperate women?
Basically, we misunderstood the cause of the debilitating symptoms many lactating persons were experiencing. Thanks to the contribution of the recently rising number of breastfeeding medicine physicians, we are seeing changes in the long-standing advice we give to treat this common problem. These dedicated physicians are applying their extensive knowledge of breast anatomy and physiology and disseminating their clinical expertise to change practice. The big game changer was the 2022 Breastfeeding Medicine Clinical Protocol on the Mastitis Spectrum. (1) Unfortunately, like all new findings, it takes a while for new treatments to become standard practice.
How did we explain a plugged duct?
In the past, it was thought that when a milk duct didn’t drain properly, the milk thickened and blocked the area. The area of the breast then became enlarged and painful. Sometimes thick stringy milk eventually would be expressed leading us to believe the area of the breast was blocked by the thickened milk. Suggested treatment was to apply heat, vigorously massage the area, and extra pumping or holding the baby in positions we thought would drain the breast while nursing. A plug diagnosis was differentiated from mastitis (infection) by symptoms. If a lactating parent feels well and it just hurts then it was called a plugged duct. If a woman had a fever and felt ill we suggested antibiotics, way too often. We now know that it is impossible for a single milk duct to become blocked because the ducts in the breast are numerous and interlacing.
What is really happening?
The working unit of the lactating breast is the alveoli where breast milk is produced, stored, and released. The alveoli are lined with lactocytes that secrete the milk. The lactocytes are tightly lined up around the alveoli (tight junctions) so that the milk components can only be transported to the alveoli where it is stored for the baby.
image from https://www.glowm.com/article/heading/vol-15–the-puerperium–global-aspects-of-breastfeeding/id/416233. A free and entirely CHARITABLE site to support women’s healthcare professionals.
It is hypothesized that when the ducts are overfilled by too much breast milk (more than the baby needs from an overproduction of milk or obstruction) it causes congestion and pressure it opens up the protective tight junctions between the lactocytes and allows fluids to leak into the surrounding tissue. This alerts the body’s immune system to think there is an infection. In response, antibodies and fighter cells are sent to the area to heal the area. The result is a swollen inflamed area. What causes this? It is believed that producing more milk than what your baby drinks or hyperlactation from overuse of a breast pump stresses the integrity of the cells and leads to inflammation and narrowing. Other causes are scheduling feeds or anything that causes pressure on the breast such as a tight bra, backpack straps, and always sleeping on the same side.
How do we treat this inflammation? What do we do?
First, it is important to be aware that full milk cells (alveolus) feel lumpy. Because of breast cancer awareness, of course, we get anxious when we feel a lump. A lumpy area is normal as long as after nursing, the area softens. If the area continues to feel lumpy and painful you are dealing with inflammation. To treat this condition the new breastfeeding protocol recommends the following:
Apply cold compresses after every feed for ten minutes. Frozen vegetables are great for this, but first, cover your skin with a thin towel.
Take ibuprofen 600 mg every 6 hours with food. Check with your doctor first for any contraindications.
Do not massage or apply heat and vibration. The breast is very vascular and easily bruised.
According to the work of Dr. Pamela Douglas, you may want to try more frequent, shorter feeds. Of course, don’t force your baby to eat.
Don’t try to empty the breast by pumping and longer feeds, you are just worsening the problem.
When to see your medical professional?
You start to feel ill.
The breast becomes red and harder.
You don’t feel better in 48 hours.
When should we worry?
If this problem seems to come up frequently, see your doctor. If the lump doesn’t go away in several days seek medical attention. There are some criticisms of this new protocol. For my practice, it has been a game changer. In the past, I saw so many women that bruised themself and ended up with mastitis from overzealous pumping, and massage. Now most women seem to have quick resolution of the inflamed area.
For questions or concerns call Andrea Herron at 805-543-6988 or email aherron178@gmail.com. Follow Andrea on Instagram @sucklesleepthrive
Sources
1. Academy of Breastfeeding Medicine: Academy of Breastfeeding Medicine Clinical Protocol #36: the Mastitis Spectrum, revised 2022. Breastfeed Med. 2022;17(5):360–75. 2. Douglas P. Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management. Womens Health (Lond). 2022 Jan-Dec;18:17455057221091349. doi: 10.1177/17455057221091349.
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