by Anne Smith, IBCLC
Some mothers nurse several babies and never experience plugged ducts or mastitis (breast infection), while others have recurrent problems. There are many reasons for these problems to occur, but treatment is essentially the same: rest, apply heat, breastfeed often on the affected side, and use antibiotics when medically necessary.
A plugged duct is a sore, tender lump or knotty area in the breast. It occurs when a milk duct is not draining well, and inflammation builds up. The area may be warm to the touch and red, and if it is located in a duct close to the surface of the skin, you may be able to feel it distinctly with your fingers.
Generally a plugged duct is not accompanied by fever. If the plugged area is not drained, pressure can build up behind it and cause the surrounding tissue to become inflamed. If a large area of the breast is inflamed, hard, and tender, it is sometimes referred to as a "caked breast." Usually a plugged duct or caked breast occurs in only one breast at a time.
A plugged duct accompanied by flu-like symptoms (body aches, nausea, fatigue, headache) and fever is called mastitis, or breast infection. There will usually be a hot, tender, splotchy reddened area, most commonly on the outer and upper part of the breast, but it can occur anywhere. Like plugged ducts, mastitis usually occurs in only one breast. Mastitis is usually associated with Staph bacteria. When it occurs in both breasts, it is usually caused by Strep, and can be more difficult to treat.
Plugged ducts most often occur in women with abundant milk supplies, and occur more frequently during the early weeks of nursing, and during the winter months. Anything which contributes to inadequate drainage of the milk ducts can increase the incidence of plugged ducts. Contributing factors include:
• Missed, shortened, or scheduled feedings: This is one reason nursing mothers are more prone to get plugged ducts during the holidays or other periods of stress -- you tend to be busier, and your schedule is more hectic).
• Improper latch and positioning can put pressure on some ducts preventing complete emptying.
• Anything that puts consistent pressure on the ducts (including poorly fitted bras, a diaper bag strap after a day of shopping, or sleeping on your stomach).
• Changes in feeding schedule -- Sometimes the baby changes his schedule either because he is sleeping through the night, he has a cold and doesn't nurse as often, he is teething, or is beginning to wean. Eventually, your body will adjust to these changes, but abrupt changes can cause plugged ducts, which can develop into an infection if not treated.
Treating Plugged Ducts
Most plugged ducts will go away within a couple of days without developing into mastitis, if noticed promptly and treated aggressively. If the milk flows freely through the ducts, bacteria is flushed out and doesn't have a chance to multiply. However, milk that stagnates in the ducts allows bacteria to grow.
That's why the first step in treating a plugged duct is to empty your breasts frequently and completely.
Other helpful suggestions include:
• Apply moist heat before nursing (compresses, warm shower or bath, or leaning over a sink full of warm water). This will help increase circulation to the area and unclog the lump.
• Apply a heating pad on a low setting between feedings, especially during the night. This can also help dissolve the clog.
• Encourage the baby to nurse frequently (at least every two hours) and vary the nursing positions so pressure will be put on different ducts. One very strange but effective nursing position is "hands and knees." Try putting the baby down on the bed or on a blanket on the floor and lean over him on all fours. Let your breast hang straight down, falling freely from your ribcage. Try not to let anyone see you doing this because they will probably fall over laughing.
• Sleep on your back or side without putting pressure on the sore breast.
• Try to avoid under-wire bras. Wear a supportive bra, but make sure it isn't too tight.
• Offer the sore side first, but before you do, try to hand express a little to soften the areola and get the milk started flowing before baby starts nursing. Gently massaging the lumpy area in a circular motion, starting behind the lump and working toward the nipple, can help loosen the plug Sometimes when the clogged milk is released, you may see something strange coming out of your nipple. It may look like a strand of spaghetti or a grain of sand. Don't be surprised -- it's just the milk secretions working their way out. If the baby is nursing when this happens, you won't even be aware of it, and it won't hurt him if he swallows it. If you are pumping, however, it can be a little scary if you see this strange stuff coming out if you don't know what it is.
• Get rest, rest, and more rest. If possible, find someone to help with the housework and other kids for a day or two and take your baby to bed with you. If that's impossible, try at least to eliminate any extra activities and find time to put your feet up for an extra couple of hours while you nurse.
Usually, if you follow these guidelines after discovering a plugged duct, you will feel better and the lumpy area will go away within twenty-four hours. Even if you have a low-grade fever (less than 101°), you may want to try the measures mentioned above before calling your doctor.
Once a plugged, inflamed area has progressed into full-blown mastitis, it is important to contact your doctor immediately to begin antibiotic therapy. About one third of nursing mothers will develop mastitis at some point. This most often occurs during the first few weeks after birth (1/3 of the cases occur after baby is six months old, and 1/4 after baby is 12 months old), in mothers aged 30-34, and in women who work outside the home. Often mothers report unusual periods of stress, extreme fatigue, or a cracked nipple (any break in the tissue allows a route of entry for bacteria) before an episode of mastitis. The type of mastitis following a break in the nipple tissue usually occurs during the early weeks of nursing.
Contact your doctor immediately if:
• Both breasts are affected
• The nipple looks infected, and pus or blood appear in the milk
• Your fever shoots up to over 101°, especially if symptoms came on suddenly
• There are angry looking red streaks near the sore area
• You have tried the suggestions above for treating plugged ducts for 24 hours, and symptoms worsen instead of improve
If testing determines that you have a bacterial breast infection, your doctor will probably prescribe an antibiotic and possibly a pain relieving medication. The antibiotic will probably be a broad spectrum antibiotic (these are effective against Staph and Streph) such as penicillin, cephalosporin, or erythromycin. These medications, like most antibiotics, are compatible with breastfeeding. Remember, babies are given antibiotics when they get sick, and your baby will get much less of the drug via your milk than if he were to take it directly.
You will need to take the medication for 7-10 days. Be sure to take the complete course as prescribed. Even though you should feel much better within 24-48 hours of taking it, it is important to take it all. Otherwise you may kill off the weaker bacteria, but some will stick around and might make the infection recur later. Most of the time when a breast infection recurs within a few weeks, it means the original infection was not completely cured.
If you do have chronic mastitis, and you have ruled out problems such as latch-on, breast compression, scheduling feedings, etc., you may need to take a small daily dose of an antibiotic for longer periods of time. Discuss this with your doctor. Some research has found that changing your diet by reducing saturated fats and adding a tablespoon of lecithin each day may help avoid chronic plugged ducts.
In very rare cases, a breast infection may develop into a breast abscess. This is an infection which comes to a head and collects pus, like a boil. It may open by itself and drain, or may require a doctor's incision and drainage. Let me emphasize how unlikely this is to happen -- in over twenty years of experience, I've only encountered four or five cases. These cases were either woman with particularly nasty hospital acquired Strep infections, or women who had ignored the symptoms and not sought treatment until the infection was too far progressed.
Our mother's generation used to experience breast abscesses a lot, not because they were anatomically different, but because mothers then were encouraged to put babies on a rigid schedule (leading to plugged ducts), and were then told NOT to nurse their babies because the milk was infected and would make them sick. Nowadays, every doctor knows that the milk from an infected breast will not harm the baby in any way, because antibodies in the milk protect him from infection.
If a breast abscess does develop, and surgical drainage is necessary, there is usually no reason to stop breastfeeding. If the incision isn't on the nipple, and his mouth doesn't come in contact with it, he can continue nursing on that breast. If the incision is on or near the nipple, you can nurse on the other side and express milk from the affected breast while the abscess is draining. Usually within a few days, once the drain or stitches are removed, you can resume nursing on the affected breast.
After a bout of mastitis, several things may occur. Sodium and chloride levels in the breast can rise, making the milk temporarily taste salty. The baby may or may not be bothered by this difference in taste. The affected breast may produce less milk temporarily as it goes through a resting phase. Again, this may or my not be a problem, but some babies become fussy at the affected breast due to the difference in taste and amount. These problems are only temporary.
Anytime you have taken an antibiotic, you are at risk for a yeast infection -- not just a vaginal infection, but one on your breasts, your baby's mouth or diaper area as well. It is a good idea to begin taking Acidophilus as soon as you begin the antibiotic, and to familiarize yourself with the symptoms of yeast overgrowth in you and your baby as well, so that if symptoms occur you can treat them early. (see article on "Yeast Infections" for more information).
Plugged ducts are a fairly common occurrence during the course of lactation. Once you have one, you will know to watch that "trouble spot" because it probably means that you have a duct that tends to not drain efficiently, and if the problem recurs, it will most likely be in that same spot. This allows you to promptly begin treatment, and hopefully prevent the occurrence of a breast infection. Remember that the likelihood of getting plugged ducts or mastitis decreases the longer you breastfeed, and if they do develop, the best thing you can do for you and your baby is to keep nursing.
Anne Smith, IBCLC has breastfed a total of six children (three boys, three girls). She feels that her first hand experience plus her more than twenty years experience of counseling nursing mothers are among her most important credentials. Anne has been a La Leche Leader since 1978 and IBCLC since 1990. As a nursing mother, LLL Leader, and IBCLC, Anne has worked in many areas over the years. She has led support group meetings, taught breastfeeding classes, trained breastfeeding peer counselors to work with low income mothers, worked one-on-one with mothers to solve breastfeeding problems, helped thousands of mothers with breastfeeding questions over the phone, held workshops for health professionals on various breastfeeding topics, taught OB, Pediatric, and Family Practice Residents breastfeeding at Bowman Gray School of Medicine, and run a breast pump rental station with over 100 pumps, scales, and nursing bras for the past eleven years. We invite you to visit Anne's website.