Thanks to Lydia for creating an opportunity for further discussion of the
new ABM mastitis protocol. And thanks too to Kika for first alerting us to
it a few weeks ago.



Having carefully read the protocol, and watched the video, I have to say
that I am very troubled by the recommendations being made not to drain an
overfull or mastitic breast.  The suggestion that we would advise leaving
engorgement or mastitis to sort itself out goes against everything I’ve
learned and seen for the last thirty-something years.  The possibility that
there may be industry involvement in these suggestions make them even more
suspect.



While much of the new advice makes sense (plugs, knowing the difference
between inflammatory and infective mastitis, not damaging overfull breast
tissue by too-firm/deep massage) I have  concerns about whether the
recommendations to resolve mastitis and to preserve ongoing breastmilk
synthesis are sound. My observations is that the induration which happens
with engorgement or mastitis causes milk to back up, making drainage
difficult and often in itself resulting in reduced intake by the baby.
Induration and compromised drainage can happen when one lobe of breast
tissue becomes so full (is inadequately drained) that it prevents another
lobe from draining. If this is not resolved quickly, the subsequent back-up
of milk (stasis) can lead to opening of the tight junctions, higher levels
of FIL, elevated breastmilk sodium and ultimately down-regulation of
supply.



While frequent drainage of a breast does drive up milk production if a
mother is under-producing after the first few weeks, in the early
postpartum milk production is on autocrine control and nothing bar
cabergoline will suppress lactation, so you are off-setting an inevitable
phenomenon of high breastmilk synthesis and in fact *protecting* the breast
tissue by frequently draining (by baby, or if the baby cannot/will not
breastfeed, then by manual expression or by pumping).



I actively promote exclusive breastfeeding for a full six months, and in my
experience, managing lactation very well in the early postpartum,
especially Days 4 - 9 after birth, when the quantity of milk produced often
exceeds the baby's appetite, preserves the milk producing cells and acts as
a preventive measure against mastitis round about 3 weeks postpartum.



If there is a lumpy painful area forming in the breast, or if there is
inflammation and/or pain, it seems illogical to hear that mothers shouldn’t
pump because it would create a blockage upstream. The reasoning seems
faulty, and when there is no concern expressed about what happens when an
overfull, inflamed breast is _not_ drained well, it bothers me.  I can see
a reverse causality in fact – the induration that accompanies mastitis also
compromises drainage, and if you can keep the unaffected remainder of the
breast well drained, then it facilitates resolution.  So In my experience,
draining an overfull breast doesn’t _create_ blockages, it clears them.



My mastitis protocol has always been to increase/maximize drainage of the
milk from the breast by breastfeeding if the baby will and/or by gentle
manual expression or by a pump every 2 hours in the day and every 3 hours
at night, and to seek medical advice (does the mother need an antibiotic?)
if fever, inflammation and induration are not obviously on the way to being
resolved within 24 hours.  I also recommend _gentle_ massage, and cool
cabbage leaves in between attempts to breastfeed and to drain the breast.
Often these measures are enough - increased drainage often fixes the
problem.



I would love to hear from colleagues on Lactnet. I would also love to hear
from the wonderful researchers from the Hartmann Lab in W Australia whose
work has greatly informed my understanding of breastmilk synthesis.



It’s difficult to talk about this because care needs to be tailored to each
mother’s individual circumstances (this mother, this baby, today) and the
protocol seems to cover scenarios that we might meet in the early
postpartum, or in the later weeks, ie either preventive or therapeutic care
for breast engorgement following Lactogenesis II, for blocked ducts, for
mastitis, for abscess.  Our best-case recommendations would be different
for each scenario.



Pamela Morrison

Retired IBCLC, Rustington, England

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