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Engorgement, Blocked Ducts & Mastitis - How do I manually clear a blockage? What does the research say?

The thought of mastitis and blockages is something that often fills us with dread when we are breastfeeding, and if it’s something that we’ve experienced before we’re often pretty afraid of it happening again.  So in this blog I want to explore a bit about this topic.  What is a blockage and why does it happen?  What’s the difference between a blocked duct and mastitis?  Crucially - how do we clear a blockage?  Are antibiotics always needed?

What’s a blocked duct?  Is it different from mastitis? What's engorgement?

 

The truth of it is that it’s a matter of degree.  Mastitis means inflammation of the breast.  Mast (to do with the breast) and itis (inflammation).  Inflammation can be on a spectrum from mild inflammation to very severe inflammation and in the same way inflammation of the breast is a spectrum from mild engorgement on the mild end, through blockages, through mastitis right up to abscesses on the extreme end.

Breastfeeding is all about flow of milk.  Creation of milk in the ducts, and removal of that milk by expressing or feeding keeps milk constantly moving.  It’s created, and it is removed.  It’s created and it’s removed.  Constant flow.  Think of it like a stream or a river flowing.  

The idea of the health of a flowing stream is a pretty good analogy for blockages actually.  As a child learning to camp outdoors I remember being taught only to drink from a flowing stream.  That’s because moving water is oxygenated.  When a stream stops moving and pools, the oxygen levels drop and the water becomes stagnant creating a perfect breeding ground for insects and for algae to grow.
Breastmilk doesn’t become “stagnant” as such, but when it is prevented from flowing, and so it sits static in the breast in the way that a pool doesn’t flow, we do get issues forming.  

Engorgement & How to Resolve

The first thing that happens when milk isn’t flowing effectively is that we get engorgement.  This in essence happens when the body is making milk faster than we are removing it so we get a building up of milk in the breast.  We start to feel uncomfortably full.  If we don’t get milk moving, we get more and more full and then we start to experience inflammation as well as fullness from the milk.  As this continues sometimes we can even find it hard to remove the milk at all.

So what are the techniques to resolve engorgement:


1.  Feed /express more frequently - this is the number 1 solution because the cause is that milk isn’t moving.  The solution is to get milk moving and to drain the breast.  If you are finding that you can’t latch your baby due to the engorgement and are having problems getting milk removed by expression, then massage may help.

2.  Breast massage - massage, and movement on the breast can help to get fluid drainage to resolve inflammation and also to get milk flowing.  A good set of movements can be the following:

-  Holding the breast with both hands, lift the breast up and down, then left and right, then move it clockwise and then anti-clockwise.  The breast may feel a bit softer after this.

- If still very full, try lying down on your back and massaging in long flowing movements from all around the breast towards your armpit.  The pressure should be similar to applying a moisturiser.  After this the pressure within the breast should have lessened a bit.

3.  Anti-inflammatories - anti-inflammatory medications can be helpful to reduce the inflammation as part of engorgement.

A number of therapies are often suggested for treating engorgement, such as hold or cold packs, cabbage leaves, ultrasound treatment etc, however it’s not clear if these are actually effective.  A meta-analysis of 8 studies looking at treatment for engorgement found that cabbage leaves, cold packs, gel packs, oxytocin treatment and ultrasound treatment were all ineffective (Snowden et al 2002).  Anti-inflammatories significantly improved symptoms however.  So although cabbage levels or cold packs might feel soothing (and soothing measures are helpful to how we manage the condition), they don’t resolve the engorgement itself, and perhaps that’s not surprising as they can’t actually remove the milk that is there.  With that in mind I’d also urge some caution around using heat - which I’ve also seen suggested.  Heat is generally not good to apply to an inflamed area, as it increases the inflammation.  It’s usually suggested in increase milk flow, but may in fact cause more issues on inflamed tissue as well as potentially increasing more production by increasing blood flow to the area.

Reverse Pressure Softening

If, after the measures above you are still finding it difficult to latch your baby on due to the firmness of your areolar area, then reverse pressure softening may help.  This is a method of using your hands to soften the area directly around the areola to help your baby latch.  This is how it is described in the original published paper (Cotterman 2004):

 

1. All that is really necessary are clean hands and fingernails
2. Choose one method described, depending on fingernail length,
3. to painlessly exert steady, gentle, but firm positive pressure,
4. on a 1- to 2-cm radius of the whole central areola, right at its junction
with the base of the nipple,
5. in an inward direction perpendicular to the mother’s chest wall,
6. for a period of 1 to 3 full minutes,
7. repeating once (or more), depending on severity of swelling,
8. immediately before each attempt to latch (or express or pump with
short trials of intermittent, minimum vacuum),
9. until engorgement has resolved well enough for easy latching

So basically, wash your hands.  Place your fingertips around the areola at the base of the nipple.  Press inward towards the chest wall for 1-3 mins.  This will push milk and fluids back from the areolar area, softening it and allowing your baby to latch.

 

Blocked Ducts / Mastitis & How To Resolve

If engorgement is not resolved it might become a blocked or plugged duct.  This might happen in a few ways.  Perhaps as milk sits some milk fat becomes clogged in the duct.   Perhaps some dead cells are shed into the milk which is sitting which becomes a clog or plug.  Perhaps some local inflammation in the duct (due to the engorgement) causes a narrowing of the duct making the clog more likely.  Then when we start either expressing or feeding this clog prevents milk behind it from moving - causing even more milk stasis in that area.  At this stage it is a blocked duct.  Symptoms are usually something like:

1.  Tenderness in that area of the breast, with some heat and possible redness.

2.  If the blockage is close to the skin you may feel a lump

3.  Often it's possible to see a little white spot on the nipple (this is a clog right at the nipple opening) causing a back up of milk behind it.

At this stage it's usually relatively easy to move the blockage with careful expressing and massage (I will describe a particularly effective technique below).  If the blockage isn't cleared then it may develop into mastitis.  Mastitis occurs when the local inflammation from the blockage becomes systemic (whole body) symptoms, which make us feel like we have the flu.  Symptoms are usually:

1.  Fever

2.  Tiredness

3.  Breast tenderness (usually localised to the area of the blockage), with redness and heat

4.  Headache and flu like muscle aches

It can be surprising just how quickly this stage develops and it is this experience of speed that makes most people fearful of it happening again.  Indeed having a history of mastitis unfortunately makes it more likely to experience it again, however keeping the milk flowing with regular drainage will reduce the risk.

The treatment for mastitis is firstly to drain the breast and clear the blockage.  If we can clear the blockage the inflammation response will end and the symptoms will go.  This is why the NICE guidance is self care for 24 hours before considering antibiotics.  Usually 24 hours of self care will clear the blockage!


So what is self care?  How do we clear a blocked duct or mastitis.  The technique I am going to describe is known as SSRMT (Six Step Recanalization Manual Therapy) which has been shown in a clinical study to be highly effective.  You may even want to try the massage for engorgement mentioned above before the SSRMT (lifting and moving the breast to help with drainage).

 

SSRMT Technique

In a study of almost 3500 women this technique was found to be highly effective (Zhao et al 2014).  After just one treatment 91.3% of the women had complete resolution of symptoms.  A further 4.9% had marked improvement, 2.4% had some improvement and only 1.5% had no improvement.  The 8.8% of the women who had not had a complete resolution had a further treatment 3 days later, and 7.6% had complete resolution, 0.8% had marked improvement and 0.4% had some improvement.  NONE had no improvement after the 2nd treatment.

The technique comprises the following 6 steps:

1.  Wash hands and get a clean towel /flannel

2.  Stretch out the nipple with one hand.  With the other, take the towel and wipe any bits of dried milk, dead skin cells etc from the nipple to clear the duct openings

3.  Now the duct endings are clear we move back to clear the nipple of clogs.  Hold, stretch, roll and extend the nipple in different directions.  You may find that as well as flowing milk, clogs of milk or milky strings may emerge from the duct endings when doing this.  What it also does is stimulate the nipple well in order to trigger the milk ejection reflex (the letdown).

4.  Now that we have worked on the nipple we move back to the areola.  Press and push the areola from lots of different directions while expressing.

5.  Then move back again to the breast area.  Knead and push the breast towards the nipple - this is what we usually do when we are hand expressing with our hands a bit further back from the nipple.

6.  Finally, having worked backwards and expressed using our hands from nipple back through the breast area use the flat of 3 fingers to press over the breast looking for any areas where you can still feel any palpable lumps.

 

In the study the treatment lasted about 5 mins per breast.

Some notes of caution here...often on breastfeeding support groups online I hear suggestions to massage really hard, or really "get in there and work out the clog".  Breast tissue is delicate, and when you have a blockage / mastitis you are dealing with already inflamed tissue.  It's very easy to damage it further.  The study above states that "special attention must be paid to avoid intolerable pain".  It also says that a maximum of 2 SSRMTs were given in a single session to avoid injury.  Another thing which is often mentioned in groups is using heat on the breasts to help flow.  Again heat is helpful to get milk flowing, but should be used just before a feed / expression, not frequently as it may make inflammation worse.  What can be helpful I have found however is using heat and water while using the expression steps of the SSRMT.  Steps 3-6 can be done in the bath with the breasts submerged in water and that has certainly been very helpful for many women I have worked with.

I'd also say - get used to handling your breasts.  Often we aren't terribly familiar with our breasts and just what breasts full of milk feel like.  You may be able to feel areas full of milk before a feed which aren't clogs - they are just full areas that empty during the feed.  

This technique can be very helpful, as well as effective feeding and expressing to get milk regularly flowing again and to reduce inflammation.  Anti-inflammatories are also helpful.  

 

Do I need antibiotics?

If you don't see any improvement after 24 hours of self care then the guidance is to see a GP to be evaluated for antibiotics.  The vast majority of cases of mastitis are caused by milk stasis as described above and will clear with effective management and drainage of the breast, however some cases of mastitis will be bacterial in nature and are caused by infection.  This will be a more likely cause if you have trauma to your nipple (allowing bacteria to easily enter).  Within 2-3 days of taking an antibiotic you should feel much better, but even though the antibiotic will kill infection it will not drain the breast.  You will still need to feed / express frequently and regularly in order to get milk flowing again and to prevent milk stasis, engorgement and further inflammation.

 

Breast Abscess

A small number of cases of mastitis may develop into a breast abscess ( at the other end of the spectrum from engorgement).  In an abscess the body attempts to isolate an infection by walling it off from the rest of the ductal system.  This leads to a sealed off area of milk and pus which by design cannot drain through the nipple no matter what techniques you use or how much you express or feed.  Often in fact it just continues to get bigger and bigger despite all your efforts to clear it.  This is a clear sign that the breast needs to be scanned for the presence of an abscess.  This would be done by ultrasound at your local breast clinic and if an abscess is confirmed then it will need to be drained by needle, as it is unable to drain through the nipple.  90% of abscesses appear to be caused by bacterial infection (Efrem 1995).

 

 

Summary
 

The key to avoiding blockages is all about flow.  Production -> removal -> production -> removal with no sudden changes in the system like a very long gap between feeds for example.  If you are getting good effective drainage and don't have damage to your nipple then chances of getting blockages are low, and if they do happen they are likely to clear quickly with the effective drainage.  If you do get a blockage which is a little more stubborn however, the SSRMT has been shown to be a very effective manual technique to remove them and get you back into the production -> removal process again.

 

Further Reading

1.  Snowden HM, Renfrew MJ, Woolridge MW. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev 2001;(2):CD000046.

2.  Cotterman,Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement Journal of Human Lactation 2004 20:2227-237 https://journals.sagepub.com/doi/pdf/10.1177/0890334404264224

3.  Zhao, C., Tang, R., Wang, J., Guan, X., Zheng, J., Hu, J., … Song, C. (2014). Six-Step Recanalization Manual Therapy: A Novel Method for Treating Plugged Ducts in Lactating Women. Journal of Human Lactation30(3), 324–330. https://doi.org/10.1177/0890334414532314

4.  Efrem SEE. Breast Abscesses in Nigeria:  Lactational versus non-lactational.  J R Coll Surg Edinb. 1995;4-:25-27

About the author

Carol Smyth

I am an IBCLC (International Board Certified Lactation Consultant) in private practice in Northern Ireland and a La Leche League Leader with La Leche League of Ireland

Important Information

All material on this website is provided for educational purposes only. Online information cannot replace an in-person consultation with a qualified, independent International Board Certified Lactation Consultant (IBCLC) or your health care provider. If you are concerned about your health, or that of your child, consult with your health care provider regarding the advisability of any opinions or recommendations with respect to your individual situation.