In July last year there was some discussion of the new ABM protocol on
Mastitis written by Dr Katrina Mitchell.  Lacnetters may be interested to
learn that another article on the topic appears in the latest JAMA, again
recommending conservative treatment of mastitis:



Louis-Jacques, Berwick & Mitchell, Risk factors, symptoms & treatment of
lactational mastitis, JAMA 2023;329(7):588-589. doi:10.1001/jama.2023.0004

January 26, 2023 at
https://jamanetwork.com/journals/jama/fullarticle/2800977



Once again, I find it troubling that this article implies that mastitis
does not require more frequent breast drainage to avoid a worsening
situation.  Dr Mitchell and colleagues contend, “Conservative treatment
consists of rest, continuing physiologic breastfeeding/milk expression,
over-the-counter nonsteroidal and analgesic medications, and monitoring for
symptom progression. Physiologic breastfeeding consists of feeding infants
on cue or expressing the volume of milk that the child needs. In contrast,
attempts to keep the breast continually drained may lead to hyperlactation,
pain, and further complications such as recurrent mastitis and abscess”



There is no reference provided for this claim.  If there is no research to
demonstrate whether  keeping the breast well drained leads to
“hyperlactation” or whether good drainage in fact resolves mastitis more
effectively, then this statement is speculative.



My experience is that frequent and thorough drainage of a breast that is
showing inflammation, pain and induration can head off mastitis.
Unfortunately you only hear retrospectively from mothers whether treating
potential mastitis conservatively allowed it to get worse, and then if
treating full-blown mastitis conservatively led to development of an
abscess.  I have worked with hundreds of such scenarios and all my
experience is that doing nothing allows a small (and avoidable) problem to
become much worse, eg



unresolved overfullness/engorgement à induration+inflammation+pain à
mastitis à abscess,



There is no information in this article about the consequences for the milk
producing cells of allowing the breasts to remain inadequately drained, of
increased permeability with breakdown of the tight junctions, exchange of
milk and blood components which occurs when the alveoli become so full that
there is breakdown of the tight junctions, and that it can actually be
measured by tracking lactose in the mother’s urine, that it is most likely
to occur during Lactogenesis II and during and after mastitis. (Fetherston
CM, Lai CT, Mitoulas LR and Hartmann PE,  Excretion of lactose in urine as
a measure of increased permeability of the lactating breast during
inflammation.  Acta Obstetricia et Gynecologica 2006;85:20-25 and
Fetherston CM, Lai CT and Hartmann PE, Relationship between symptoms and
changes in breast physiology during lactation mastitis, Breastfeeding
Medicine 2006; 1(3)136-145).



All this can be avoided by teaching new mothers good breast self-care
techniques to keep the breasts frequently and thoroughly drained (to
comfort), and stressing the need to drain more often at the very first
symptoms of possible mastitis (inflammation, induration, pain).



Furthermore, we work in an environment where a disappointingly low
percentage of mothers fulfil the WHO recommendation for 6 months exclusive
breastfeeding.  So many mothers begin supplementing or give up
breastfeeding altogether due to “not enough milk”.  Low milk production is
directly due to poor lactation management and the domino effect of
lactation failure identified by Desmarais et al in 1990 (Desmarais L &
Browne S.  Inadequate weight gain in breastfeeding infants; assessments and
resolutions, Lactation consultant Series Unit 8, 1990 La Leche League
International)    Mothers need information about the importance of good
breast drainage not only so that they can reduce the risk of milk stasis
and mastitis but also so that they can maximize their milk-producing
potential, facilitating development of prolactin receptors within the
breast and conserving the milk-producing alveoli.



Pamela Morrison

Retired IBCLC, Rustington, England

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