Mastitis: what it is and what actually helps.

Mastitis is defined as inflammation of the breast. That's it. Not infection, not a blocked pipe, not a plug of milk wedged in a duct. Inflammation. That distinction matters more than it sounds, because almost everything people are told to do about mastitis comes from the plug theory. Massage it out. Heat it up. Pump it dry. Buy the vibrating gadget. These things can make an inflamed, swollen breast angrier.

The Academy of Breastfeeding Medicine rewrote its mastitis guidance in 2022, and the change was significant enough that it retired two of its previous protocols. Clinical Protocol #36: The Mastitis Spectrum is now the reference point, and it turns a lot of the standard advice on its head.

Here's what's actually going on, and what to do about it.

What is actually happening in the breast?

So why does it hurt so much?

Inflammation is a chemical response to stress, trauma or infection. The features are the ones you'd recognise from any injury - pain, redness, swelling, heat, sometimes fever and fatigue. In the breast, that inflammation causes the tissue to swell. The milk ducts run through that tissue, so when the surrounding tissue swells, the ducts get compressed from the outside. Narrower ducts, slower flow, more pressure building behind them.

Which brings us to the lump.

The lump you can feel is swelling. It is not stuck milk. The milk that isn't moving sits behind the lumpy region, not inside it. This is why trying to rub, squeeze or push the lump out doesn't work. There's nothing solid in there to move, and the pressure you apply can add more trauma to tissue that is already inflamed.

Let's hear that again, because it's the single most useful thing on this page. please don't try to rub the lump out.

It's also worth knowing that ducts in the breast are a complex branching network rather than a few straight pipes. Anatomically it isn't possible for one duct to become blocked by a macroscopic ‘plug’ of milk.

Does mastitis mean infection?

Not always, and this is where the treatment path changes.

Mastitis sits on a spectrum. It can start as ductal narrowing (what most people call a blocked duct), progress to inflammatory mastitis, and only then progress to bacterial mastitis if it isn't settled. Antibiotics are the treatment for the bacterial end of that spectrum.

So when are antibiotics indicated? 

If you're very unwell with fever, or you're not responding to conservative measures within about 24-48 hours. The usual choice in Australia is flucloxacillin, or keflex if you have a penicillin allergy. That's a conversation with your GP or emergency doctor.

Also note that bacterial mastitis is not contagious, and it poses no risk to your baby. Your milk is safe. You do not need to stop feeding, sterilise your pump parts, or scrub your nipples.

What makes mastitis worse?

These are the things to stop doing, and the reasoning behind each.

Deep massage. Firm massage of an inflamed lactating breast can increase tissue swelling and cause microvascular injury.The technique that helps is closer to manual lymphatic drainage, which is feather-light sweeping of the skin.

Vibration. Electric toothbrushes, massage guns and the various vibrating gadgets marketed for ‘clearing blockages’ are not recommended. There's no plug of milk to dislodge. The aim is to reduce inflammation and swelling. Vibration is either unhelpful or problematic if too firmly applied.

Heat. Heat causes vasodilation and can encourage inflammation. If gentle warmth helps your milk flow just before a feed, a warm cloth is fine. Otherwise use ice or cool packs after feeds and in between, as often as you like.

Pumping to empty. This is the one that surprises people most. Milk volume runs on a feedback mechanism - the more milk you remove, the more your body makes. Overfeeding or pumping from the affected breast to ‘keep it empty’ drives production up, which means more congestion in a breast that is already swollen. It is a genuine cycle, and it's one of the most common reasons mastitis keeps coming back.

Feed as normal, on demand. Express for comfort only, and only enough to take the edge off. If the milk won't flow, don't force it. Deal with the swelling first. Your supply may dip while the breast settles, and that's temporary.

Topical products. Castor oil, saline soaks and Epsom salt soaking in a silicone pump don't treat inflammation in a deep organ space, and some of them can macerate the skin of the nipple and areola, making things worse.

What helps at home?

Ice and anti-inflammatories. Ibuprofen taken regularly with food is safe while breastfeeding and is doing real work here, not just masking pain - it's reducing the inflammation that's causing the swelling. Paracetamol can be taken alongside it, or instead of it if you can't take anti-inflammatories. Ice can be applied every hour or more often if you want it.

The whole breast mobilisation sequence. 

This is the one you actually want to do, and it's gentle:

• Elevate your arm and gently roll your knuckles in your armpit for a minute to stimulate the lymph glands.

• Hold the whole breast gently in two hands and rock it up and down, side to side, and around, for one to two minutes.

• Stroke the breast very lightly, directing feather-like fingertip strokes towards the breastbone, collarbone and especially the armpit, for one to two minutes.

• Do it before feeding or expressing if you can, but any time is better than not at all.

• Do it as often as is practical, and keep doing it daily once you've recovered.

  
  

Rest, properly. Your body is under stress in the same way it would be with a heavy cold or an injury. Call in family and friends. Go to bed. Lie down or recline, which elevates the breast and helps the swelling drain. Drink plenty of fluids. Take your bra off when you're resting, because breast movement can help.

A well-fitting supportive bra for the rest of the time. Lactating breasts are heavy and highly vascular, and without support you get dependent swelling plus back and neck pain.

Supplements that have evidence behind them. 

A probiotic containing Limosilactobacillus fermentum or Ligilactobacillus salivarius. Qiara is the readily available Australian option. Two sachets daily with acute symptoms, then one daily until the box is finished. If you've had mastitis more than once, half a sachet daily ongoing may help prevent recurrence. Lecithin helps keep milk flowing and less sticky, and is useful for recurrent episodes or nipple blebs. Vitamin C can be helpful if you're run down. Qiara and sunflower lecithin are available at Balance health.

Chest and upper back exercises. It's common to get stiff through the chest, neck and upper back while feeding and carrying a baby, and that stiffness doesn't help lymphatic drainage. Roll your shoulder blades up, back and down. Pinch them together, then pull them apart. Stretch both arms out to the sides to open the chest. Lie on a rolled towel or foam roller placed lengthways between the shoulder blades for five to ten minutes. Pump your fists in and out during the exercises to encourage circulation.

What we do in clinic

Therapeutic ultrasound uses soundwave energy to reduce inflammation and relieve swelling in the breast tissue. ABM Protocol #36 specifically names it as a treatment that can be performed by a trained physiotherapist. It's painless and takes 10-15 minutes.

Lymphatic drainage massage does what the home sequence does, but with trained hands and an understanding of where the congestion actually sits.

Working out why it happened. This is the part that changes your next six months. Understanding the cause is how you avoid the next episode.

In the experience of the author, most mums need one to two sessions in rooms, usually across two to three days, and results are best when in-clinic treatment is combined with the home sequence, resting, continuing to feed and taking the supplements.

If your symptoms are getting worse, or they're bothersome and not improving within 24-48 hours of starting self-management and treatment, see your GP about antibiotics.

Why did this happen to me?

There is usually a reason, often multiple, and it's rarely something you did wrong.

Irregular or incomplete milk removal. This is the most common one. A longer stretch between feeds because you had visitors, or you were away, or baby slept through for the first time. Or attachment that isn't quite right, so feeds are incomplete. Or an abundant supply that leaves you feeling very full and firm.

Trauma or compression to the breast. Sleeping on your tummy. A bra, baby carrier, or a seatbelt that's too tight. A knock from a toddler's elbow.

Nipple damage. A shallow latch with a newborn, or a bite from an older baby. Note that the current evidence is more nuanced here than we used to think. Mastitis is not caused by bacteria travelling backwards from visible nipple damage, and the organisms found on a sore nipple are regularly found in healthy milk too. But nipple damage is still associated with mastitis, and it usually points to something worth assessing about the latch.

Dysbiosis. An imbalance in the breast microbiome. This is influenced by your general health, gut health, antibiotic exposure, regular pump use, and iron status. Low iron increases infection risk, high iron can drive inflammation.

Where to get help on Phillip Island?

We treat mastitis as urgent at Balance Health. Ring reception and we will aim to see you within 24 hours, and on the same day wherever we can fit you in. Mastitis moves quickly and early treatment makes a real difference to how long it takes to settle.

Kristine Miles is a Senior Physiotherapist and IBCLC Lactation Consultant. She treats mastitis and also sees mums and babies together for a full breastfeeding assessment, which is worth doing if there is nipple damage, concerns about supply, difficulty with positioning and attachment, or if mastitis keeps coming back.

Casey Cleeland is a Physiotherapist with a Post Graduate Certificate in Women's Health and also treats mastitis, which means there are more appointment times available when you need one quickly.

The Australian Breastfeeding Association Breastfeeding Helpline is free, available 24 hours a day on 1800 686 268, and staffed by trained breastfeeding counsellors. Worth saving in your phone before you need it.

Balance Health Phillip Island, 14 Warley Avenue, Cowes. Call 5952 2244 

This article is for general education only and is not a substitute for personalised medical advice.

References:

Mitchell KB, Johnson HM, Rodríguez JM, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med. 2022;17(5):360–376.

Australian Breastfeeding Association, breastfeeding.asn.au.