Blocked ducts, Mastitis, Abscess', Blebs and Galactoceles
By Jennifer Clark, IBCLC. Revised September 2022
Blocked ducts
Occur due to inflammation and narrowing of the milk ducts when milk sacs are overdistended (overfull) and/or mammary dysbiosis (imbalance of bacteria). These can start as a small hard lump or as a large area of swollen breast tissue. The skin covering the area can look pink but there are no systemic symptoms like fever. Feeding may relieve the congested area, but it is advised not to feed more frequently or pump as this will exacerbate the problem and increase milk production further. Avoid aggressive massage as this increases inflammation and can cause trauma to the tissue increasing the likelihood of getting more blockages.
Mastitis
Inflammation of the breast usually resulting from too much milk coupled with the disruption of the milk microbiome (imbalance of bacteria) results in swelling due to build-up of fluid and an increase in blood flow. This swelling causes narrowing of milk ducts and difficulty removing milk.
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Causes:
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Poor positioning and attachment
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Mum and baby being separated
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Missed feeds
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Exposure to antibiotics
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Regular use of breast pumps
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Restriction in an area for a long time - Tight clothing, babywearing, sleeping on your front etc.
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Inflammatory mastitis
This can occur when the blockage/ductal narrowing persists or worsens leading to the area in the breast becoming hot, swollen, and painful alongside flu-like symptoms. A fever does not necessarily mean an infection as it is a response to the inflammation.
Management of blocked ducts and inflammatory mastitis – General management as below.
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General Management
Most cases of blockages/mastitis will not need medical treatment and will resolve with conservative management. It is normal for lactating breasts to feel lumpy and even uncomfortable/painful at times, especially when milk is coming in and when there has been a long gap between feeds.
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Feed baby on demand – The above issues all result from a breast that is making more milk than has been removed, therefore, pumping or feeding more will increase this milk production further resulting in more swelling and inflammation.
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Ensure good positioning and attachment – seek support
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Minimise use of breast pumps – this increases milk production further and is not as effective as breastfeeding. Pumping does not allow for bacterial exchange between mum and baby so can predispose to dysbiosis (imbalance of bacteria). If the pump doesn’t fit the breast well or it is not used properly, for example, the setting is too high, or it is used for a long time it can cause trauma to the breast. If the baby is not able to go the breast, then mimic baby’s feeding and express the volumes that baby is taking at each feed.
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Avoid the use of nipple shields as this can interfere with milk transfer as well as exchange of bacteria and increase the risk of mammary dysbiosis (imbalance of bacteria).
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Wear a supportive, well-fitting bra.
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Avoid deep breast massage - this increases inflammation and swelling. Avoid using electric toothbrushes and other vibrating massage tools. Gently massage and breast compression during feeding and pumping can be used as well as manual lymphatic massage using light sweeping of the skin.
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Decrease inflammation and pain through the use of ibuprofen and ice packs. Paracetamol can also be used to reduce pain. Sunflower or soya lecithin 5-10mg daily can reduce inflammation and emulsify milk.
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Treat nipple blebs – these occur on the surface of the nipple and where milk blocks an opening. Taking lecithin as above as well as applying hydrocortisone 1% cream can help reduce inflammation. Avoid using a needle to open the bleb.
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Treat oversupply – consult with a breastfeeding specialist (BFC/IBCLC) for guidance on block feeding, herbs, and medication to lower supply.
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Antibiotics – only required in cases of bacterial mastitis as this can trigger worsening mastitis by disrupting the microbiome further. Overuse can lead to antibiotic resistance.
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Probiotics – may be helpful in the treatment and prevention of mastitis. Recommended strains are Limosilactobacillus fermentum (formerly classified as Lactobacillus fermentum) or, preferably, Ligilactobacillus salivarius (formerly classified as Lactobacillus salivarius) strains.
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Therapeutic ultrasound – uses thermal energy to reduce inflammation and swelling. This can be used by doctors or physiotherapists daily to reduce symptoms.
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Note: antibiotics can cause loose stools in baby, this is temporary and usually resolves after the course has been completed.
Bacterial mastitis
If flu-like symptoms (fever, aches, chills) persist for more than 24 hours alongside congestion, redness, and heat in one or more segments of the breast then antibiotics are usually required. Bacterial mastitis is not contagious, and breastfeeding does not need to stop. If there is nipple damage there is an increased risk of mastitis, however, new evidence shows that mastitis is not caused by the entry of bacteria via the wound on the nipple.
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Management:
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General management as above.
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Antibiotics.
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Drink plenty of fluids.
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If symptoms do not settle after 48 hours of antibiotics talk to your doctor about doing milk cultures.
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Subacute mastitis
Occurs when there is a disruption in the mammary microbiome. Symptoms include burning breast pain, nipple blebs, blockages/congestion and unresolved over supply but no flu like symptoms. This occurs when there has been previous treatment for bacterial mastitis.
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Management – Milk cultures maybe negative but antibiotics maybe required. Taking a probiotic maybe helpful.
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Causes of recurrent mastitis:
Hyperlactation (oversupply), dysbiosis (imbalance of bacteria in the breast), inadequate treatment of previous mastitis, not addressing underlying issues.
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Management of recurrent mastitis:
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Breastmilk cultures to find the causative bacteria so appropriate antibiotics can be given.
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Review breastfeeding with an IBCLC to see if there is another reason for recurrent mastitis.
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Taking a probiotic maybe helpful - Lactanza Hereditum.
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If there is recurrent mastitis or any changes to the breast such as skin puckering or and “orange peel” effect, then referral to a breast clinic maybe advised for further investigation.
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Abscess
Abscesses occur when bacterial mastitis isn’t treated correctly and requires surgical drainage. Flu-like symptoms may start to ease as the body walls off the infection into a well-defined area and often the infected fluid can be felt under the skin. Diagnosis is usually made by clinical examination and ultrasound scan.
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Management:
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Referral for ultrasound for this to be confirmed.
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Antibiotics, usually for 10-14 days.
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Drainage of the abscess by needle with fluid sent to laboratory for cultures to ensure correct antibiotic treatment.
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A drain maybe inserted to ensure continuous drainage of fluid while the abscess heals.
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Continue to breastfeed on the affected breast.
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Galactocele/infected galactoceles
Galactoceles occur when ductal narrowing obstructs milk flow leading to a cyst like cavity, these can be anything from 1-10cm and size can fluctuate depending on how full the breasts are. They are not usually painful, red, or hot but can become infected. Ultrasound scan is required for diagnosis.
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Management:
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Referral for ultrasound to confirm this.
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The recommendation is that these are drained with a drain and not needle aspiration as with needle aspiration they are likely to reoccur.
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Antibiotics maybe needed if the galactocele is infected.
Blebs
Blebs or milk blisters are a blocked duct on the nipple. They present as a small white spot on the nipple or may look like a blister which fills with milk during a feed or expressing session. While they are tiny they are very painful and can make you feel like your nipple and breast are being stabbed with a hot needle during feeds. There can sometimes be a blocked duct further back in the breast linked to a bleb. To treat a bleb
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Some may burst while feeding, especially if you are feeding an older baby or toddler and beyond.
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Some may scrape gently clear with a fingernail after a shower or bath
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Softening the blister pre feed with a warm compress can help them burst during a feed. You could also use olive oil pre feed.
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Soaking with a saline solution several times a day can also help to soften a milk bleb to burst during a feed. Use 2 teaspoons of Epsom salts to 1 cup of water and soak 4 times a day.
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Stubborn ones may need a medical professional and a sterile needle to burst them.
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Once they have burst remember to keep an eye on the open wound and use a nipple cream or Vaseline to aid healing.
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Nipple bleb
Mastitis shown on 3 women. The final picture shows mastitis on a woman with a darker skin tone.