Mastering Mastitis

In the hormone-enhanced days of early motherhood, some mothers make huge amounts of milk and NEED to express off some of the excess for comfort AND to prevent other problems.  Unfortunately, I have seen too many women who were warned off the large milk volumes they should’ve expressed, who could’ve later written their own books on breast problems!  Certainly, if mothers express, say between fifty and a hundred ml before each feed for at least a few days, they might find they’ve been ‘blessed with a few buckets more’, but this is not normally what mothers need for relief.  In fact, ONE complete expressing session, where as much as possible is expressed from both breasts, is sometimes a very good idea, a bit like ‘starting again with a clean slate’.  

Otherwise, total volumes expressed for comfort are generally:

• only a few times a day
• for only a few days until the breasts’ over-enthusiasm abates
• between ten and fifty ml, but sometimes may need to be considerably more if breasts are really ‘backed up’ with milk 

If there is a persisting problem with rampant oversupply, other measures can be taken (discussed later in this chapter):

• cabbage leaves
• one dose of sage tea

One mother pumped off 200ml in 20 minutes, before she and I were both happy about her breast comfort!  She didn’t need to do any more expressing after this because her week old baby could breastfeed well from that point.  At this early stage of lactation, large milk volumes can be made regardless of what the baby’s actual needs are.  This is very handy if you have birthed twins, triplets or quads, but can be a bit overwhelming if you have only one baby! 

Other possible contributing factors to persisting oversupply:

• some maternal drugs
• some herbal treatments used by the mother
• mothers’ unique endocrine functions, possibly including underlying conditions such as underactive thyroid or pituitary tumour 
• infant feeding effectiveness may not be up to keeping breasts well enough drained. In this case, weight gains may not be good, and the baby’s nappy output obviously not very adequate
• a baby’s feeding pattern may be fine for the baby but too infrequent for his mother’s needs
• occasionally, babies who are frequently on the breast overstimulate milk secretion, especially if they just suck and nuzzle rather than drink
• sometimes babies with large weight gains are being put to the breast more often than strictly needed, and the extra breast stimulation keeps milk production at an uncomfortable level. Mothers may need to give these babies a dummy to satisfy their suck needs.  This is not common, and probably relates to these women’s individual endocrine responses.  In other words, hormones!!
• excessive fluid intake by the mother? It is very unusual for this to cause oversupply, but I have had a few cases in twenty years.  Usually, excessive fluid intake just means more urine output rather than more milk

Management of short-term acute oversupply, mastitis and breast infections

• the primary focus needs to be on good breast drainage, along with reducing the inflammatory response causing the symptoms. The baby’s attachment should not cause pain or nipple damage
• the baby should not be offered any breast substitutes, and should put to the breast as often as he is interested. If this is not possible, the milk needs to be expressed and fed to the baby in preference to using artificial baby milks.  An effectively feeding baby will generally do a far better job of draining breasts than any breast pump – and far more pleasantly  (140)
• the mother may need to express milk for breast comfort if the baby is not doing enough to help the mother out! ‘Expressing for comfort’ may mean taking off between ten and fifty ml of excess milk.  However, ONE ‘complete’ expression of the breasts may resolve an acute problem entirely because it relieves pressure on lymph return and milk production feedback mechanisms.  Note that ‘complete’ means ‘as much as a mother can express off at one time’ – there’s no such thing as an ‘empty’ breast!  
• anti-inflammatory drugs such as ibuprofen (Nurofen) or Voltarin should be taken three times daily after meals to relieve symptoms of acute oversupply, particularly the inflammatory response. Although aspirin is anti-inflammatory, it is not nearly so much so as Nurofen, Voltarin or other nonsteroidal anti-inflammatories.  Paracetamol can be taken as well if extra pain relief is needed  
• although pleasant massage for any ‘lumpy’ or engorged areas has been traditionally recommended, I don’t find it achieves much, other than it is comforting. Any massage should be done only by the mother – overfull breasts are easily bruised in the first two weeks after birth, resulting in further problems with pain and drainage
• in place of massage, I can strongly recommend the use of an electric massager-vibrator unit – but without the heat setting! I find this to be the quickest, most effective and pleasant way for the mother to resolve breast problems.  It is ideal for her to feed the baby (or express) from the affected breast/s soon afterwards
• vibration helps resolve ‘lumps’ and blocked ducts and is very comforting. It can also be used as often and for as long as the mother wishes, since it does not cause tissue damage. At least ten minutes per hour on ‘lumpy’ breasts or threatening mastitis is a good battle plan for resolving trouble!  The mother should persist with this until her symptoms disappear 

a Reverse Pressure technique

can be used to soften the areolas of engorged breasts.  The mother uses her thumb and fingertips to press inwards around the base of her nipple and then to press them in towards each other under the nipple.  The pressure should be maintained for some seconds, using constant firm pressure, then the fingers removed before repeating it on another part of her areola until it has softened enough to let the baby attach well and feed.  If the areola tissue is very hard, the pressure may initially need to be less, but increased steadily as the tissue permits it.  She should do this firmly but gently enough to avoid any more pain than she is already in and certainly without causing bruising.  Nobody other than the mother should do this to her breasts because it is too easy for others to bruise them with more pressure than is safe.  She is attached to her nerve endings, which give pretty good warning of anything potentially damaging!  If no source of vibration is available, this technique may be the next best option

• warmth on breasts before expressing or feeding may assist the milk ejection reflex if it is inhibited by pain BUT I am not enthusiastic about warmth on oversupplied breasts because they are already overheated by the breasts’ feedback mechanisms! There is far too much advice still wrongly given about putting heat on sore breasts!  Too many people over-interpret such advice, thinking that if a little is good, then a lot more must be that much better!!  Heat applied to breasts helps increase milk production!  (145)

• if breastfeeding or expressing isn’t enough to relieve oversupply, cold cabbage leaves applied two hourly to breasts (for up to a total of six hours) after feeding or expressing helps to reduce inflammation and blood flow in the breasts, easing engorgement and decreasing oversupply. Longer than six hours may overly reduce milk production.  Cold cabbage leaves seem more effective and preferable to mothers than just cold compresses.  Cabbage leaf compresses have been used traditionally on various parts of the body that are sore and swollen  
• cold should not be applied to nipples, especially if they are damaged, because it increases the chance of nipple vasospasm and consequent deep burning radiating breast pain. Ravaged nerve endings in traumatised nipples seem prone to triggering otherwise unprompted disturbances of blood flow to the nipples (vasospasm).  It is a spontaneous constriction of blood vessels in the nipple.  Blood vessels normally contract on exposure to cold, so cold applied to damaged nipples can be expected to cause additional vasospasm episodes. 
• restricting the mother’s fluid intake will not usually have any impact on oversupply, but because of dehydration may increase the risks of blocked ducts, mastitis, breast infection and urinary tract infection for the mother

• rest helps a mother to conserve her physical resources and reduce the risk of breast infection. As much horizontal rest as possible helps the mother to fend off trouble.  Typically, women who have been pushing themselves too hard, not ‘tuning in’ to their own needs, are more at risk of mastitis and breast infection.  It is often a great surprise for first-time mothers to find that it takes far less activity than usual to make them feel quite drained.  A stress diagram (Figure 6.3) is useful to help women reassess how they expend precious personal resources like time and energy
• engorged breasts may be soaked in warm (not hot!) Epsom salts solution until the temperature of the solution returns to tepid levels, taking care to wash it off the breasts before feeding or expressing milk for the baby. About a quarter to a half a cup of Epsom salts (Magnesium Sulphate) is dissolved in about two litres of warm water – ice-cream containers work quite well.  The mother leans forward over the tubs, lowering her breasts into the solutions, resting her forearms on either side of the tubs for support while soaking her breasts.  The resulting osmotic flow greatly reduces the tissue oedema that often accompanies acute oversupply.  I don’t use this treatment now because I find vibration to be quicker, more effective and less messy   
• antibiotics are not indicated unless the mother has symptoms of breast infection – a sore breast and ‘flu’ symptoms.  Even then, only 20 percent actually have an infection and it is usually possible for her to ‘feed her way through’ early mastitis signs without antibiotics, as long as symptoms are not too severe – and the ongoing trend is obvious steady recovery