The Mastitis Spectrum & Physiotherapy

Previously, we have considered Mastitis to be a stand-alone condition. We now understand that mastitis is a spectrum of conditions ranging from inflammation to severe bacterial infections.

The information in this blog has been retrieved from Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum (Revised 2022). It provides updated guidelines for the diagnosis, management, and treatment of mastitis and related conditions in breastfeeding individuals.

NEW terminology

Mastitis is now classified as inflammatory OR infective

‘Blocked ducts’ are now referred to as ‘ductal narrowing’

Nipple bleb = ‘milk blister’ on the end of the nipple

Hyperlactation = oversupply of milk production

Dysbiosis = imbalance of microbiome in the breast tissue, bacteria impacting milk flow

The SIX Mastitis Spectrum presentations

1. Ductal Narrowing: Hard, tender breast tissue with or without redness. ‘Blocked ducts’.

2. Inflammatory Mastitis: Pink/ red breast tissue that is painful and swollen. Often alongside systemic signs like fever, chills and rapid heart rate.

3. Bacterial Mastitis: Spreading of painful areas and redness, including systemic symptoms for >24hrs.

4. Phlegmon: Created by excessive deep tissue massaging (causing more swelling). It can worsen into a firm, ‘lump’ that doesn't fluctuate.

5. Abscess: Progression from either bacterial mastitis or phlegmon. Infected fluid collection that requires drainage.

6. Galactocele & Infected Galactocele: Milk flow obstruction causing a collection of milk in a cyst-like cavity. Feels like a ‘firm lump’.

As you can see from this flowchart, this spectrum is not linear.

Figure 1:

It is important for healthcare providers to differentiate between the types of mastitis as it is critical for appropriate management for the mother and baby, and their breastfeeding success.

For accurate diagnosis, clinical assessment with an International Board Certified Lactation Consultant (IBCLC), breastfeeding physiotherapist, midwife or general practitioner with expertise in lactation is essential for optimal management. Laboratory tests (like milk culture) are usually reserved for recurrent or severe cases.

Breast engorgement is not part of the mastitis spectrum, but worth mentioning here. Engorgement happens due to a rapid increase in milk production. The sudden increase creates swelling and increased blood flow in the breast tissue. This can result in full, firm and often painfully swollen breasts. Engorgement usually occurs within the first 3-5 days after birth when milk ‘comes in’, or as late as day 10 if milk production is delayed. Lymphatic drainage (as outlined below) is the recommended management.

Now we know more about the Mastitis Spectrum…

Here’s some TIPS for management.

SO, WHAT CAN A PHYSIOTHERAPIST DO?!

1. Provide individualised education, advice and reassurance

2. Strategies and techniques to reduce breast pain and inflammation

3. Utilise therapeutic ultrasound, if available

4. Treat any contributing musculoskeletal pains

5. Protect mother’s mental health and wellbeing

6. Liaise with other lactation healthcare professionals, refer to an IBCLC and Women’s Health GP.

MEDICAL MANAGEMENT

Visiting a Women’s Health GP can assist with the pharmacological management of Mastitis disorders. This includes pain relief, NSAIDS, topical steroids and antibiotics. Antibiotics should only be prescribed for Infective mastitis conditions to target likely pathogens, primarily Staphylococcus aureus. If left untreated, mastitis may lead to abscess formation, requiring drainage. Continued breastfeeding and milk removal is still encouraged.

PREVENTATIVE STRATEGIES

1. Breastfeeding individuals deserve proper education on optimal breastfeeding techniques. Making contact with an IBCLC before commencing breastfeeding is valuable to early breastfeeding success. Learning the early signs of mastitis is crucial for prevention.

2. For those with a history of mastitis, proactive management is recommended, including regular follow-ups with IBCLC, GP and physiotherapist.

3. Individualised care, considering the mother’s and baby’s needs, preferences, and circumstances is imperative to a successful breastfeeding journey. A holistic approach is ideal, addressing physical and psychological factors.

Whilst this protocol is helping to shape mastitis care moving forward, it highlights the need for more research on the mastitis spectrum, particularly in understanding the role of the microbiome in these disorders and to assist with developing more effective treatment strategies.

It’s imperative that breastfeeding individuals seek out lactation qualified healthcare providers to help distinguish between different forms of the conditions for optimal management, personalised care and support to continue breastfeeding.

References:

1. Mitchell, K. B., Johnson, H. M., Rodríguez, J. M., Eglash, A., Scherzinger, C., Zakarija-Grkovic, I., Cash, K. W., Berens, P., Miller, B., & Academy of Breastfeeding Medicine (2022). Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine, 17(5), 360–376. https://doi.org/10.1089/bfm.2022.29207.kb

2. Academy of Breastfeeding Medicine: https://www.bfmed.org/protocols
   
   

About the author: 

Our senior physiotherapist Amber Hanrahan has a special interest in Women’s Health including pregnancy pain management, birth recovery and return to exercise postpartum. She is a breastfeeding mum of two and has shared online the highs and lows of her breastfeeding journeys to date. Having support and individualised advice has been paramount to her successful breastfeeding journey.

If you’d like to see more tips on these topics, follow Amber’s Instagram account. There you will find a mix of educational advice, exercise ideas and unfiltered, real-life mum-life! If you are in Perth, you can see Amber at our Cockburn Clinic Roar Physiotherapy. Otherwise, she will happily point you in the right direction to help you find a local physiotherapist to suit your needs. As always, these tips are general, and an individualised assessment and treatment plan is recommended for best outcomes.