Blebs/blocked ducts/mastitis and then abscess usually occur when the breastfeeding parent has an abundant milk supply but the baby does not have a good latch. A poor latch, and thus, poor emptying of the breast sets the breastfeeding parent up for blocked ducts and mastitis. And why does the baby not latch on well?
A blocked duct is a clog or blockage of milk inside a milk duct that results in a tender or painful lump or firm area in the breast. The skin around the lump may be red and warm. Generally, there is no fever. Sometimes a low fever may occur (usually less than 38.4°C/101°F). Generally, you feel well.
Blocked ducts will almost always resolve without special treatment within 24 to 48 hours after starting. During the time the block is present, the baby may be fussy when breastfeeding on that side because the milk flow will be slower than usual. This is probably due to pressure from the lump collapsing other ducts. A blocked duct can be made to resolve more quickly if you:
Continue breastfeeding on that side and draining the breast better. This can be done by:
Other treatments for persistent or recurrent blocked ducts:
Most blocked ducts will be gone within about 48 hours. If your blocked duct has not gone by 48 hours or so, therapeutic ultrasound often works. Most local physiotherapy or sports medicine clinics can do this for you. However, very few are aware of this use of ultrasound to treat blocked ducts. An ultrasound therapist with experience in this technique has more successful results.
If two treatments on two consecutive days have not helped resolve the blocked duct, there is no point in getting more treatments. Your blocked duct should be re-evaluated by your doctor or at our clinic. Usually, however, one treatment is all that is necessary. Ultrasound may also prevent recurrent blocked ducts that occur always in the same part of the breast. The dose of ultrasound is 2 watts/cm² continuous for five minutes to the affected area, once daily for up to two treatments.
Some have used the flat end of an electric toothbrush to give themselves “ultrasound” treatment. And apparently have had good results.
Lecithin is a food supplement that seems to help prevent blocked ducts. It may do this by decreasing the viscosity (stickiness) of the milk by increasing the percentage of polyunsaturated fatty acids in the milk. It is safe to take, relatively inexpensive, and seems to work in at least some breastfeeding parents. The dose is 1200 mg four times a day.
Sometimes, but not always by any means, a blocked duct is associated with a bleb or blister on the end of the nipple. A flat patch of white on the nipple is not a bleb or blister. If there is no painful lump in the breast, it is confusing to call a bleb or blister on the nipple a blocked duct. A bleb or blister is, usually, painful and is one cause of nipple pain that comes on later than the first few days. Some get blisters in the first few days due to a poor latch.
A blister is often present without having a blocked duct.
If the blister is quite painful (it usually is), it is helpful to open it, as this should give you some relief from the pain. You can open it yourself, but do this one time only. However, if you need to repeat the process, or if you cannot bring yourself to do it yourself, it is best to go to see your doctor or come to our clinic.
Once you have punctured the bleb or blister, start applying the “all purpose nipple ointment” after each feed for a week or so. The reason for this is to prevent infection and also to decrease the risk of the bleb or blister returning. See the information sheet “All Purpose Nipple Ointment”. You need a prescription for the ointment
Mastitis is due to an infection (almost always due to bacteria rather than other types of germs) that usually occurs in breastfeeding parents. However it can occur in any woman, even if she is not breastfeeding and can even occur in newborn babies of either sex. Bacteria may enter the breast through a crack or sore in the nipple but those without sore nipples also get mastitis and most who have cracks or sores do not.
Mastitis is different from a blocked duct because a blocked duct is not thought to be an infection and thus does not need to be treated with antibiotics. With a blocked duct, there is a painful, swollen, firm mass in the breast. The skin overlying the blocked duct is often red, but less intensely red than the redness of mastitis. Unlike mastitis, a blocked duct is not usually associated with fever, though it can be. Mastitis is usually more painful than a blocked duct, but both can be quite painful. Thus seeing the difference between a “mild” mastitis and a “severe” blocked duct may not be easy – in fact, there may be no difference. It is also possible that a blocked duct goes on to become mastitis, so things become even more complicated. However, without a lump in the breast, there is no mastitis or blocked duct for that matter. In France, physicians recognize something they call lymphangite when the breastfeeding parent has a painful, hot redness of the skin of the breast, associated with fever, but there is no painful lump in the breast. Apparently, most do not believe this lymphangite requires treatment with antibiotics. I have seen a few cases that fit this description and yes, in fact, the problem goes away without the breastfeeding parent taking antibiotics. But then, often a full-blown mastitis also goes away without antibiotics.
If you start getting symptoms of mastitis (painful lump in the breast, redness and pain of the breast, fever), follow the recommendations for blocked ducts (above).
Generally, it is better to avoid antibiotics if possible since mastitis may improve all on its own and antibiotics may result in your getting a Candida (yeast, thrush) infection of the nipples and/or breast. Our approach is as follows:
If you have had symptoms consistent with mastitis for less than 24 hours, we would give you a prescription for an antibiotic, but suggest you wait before starting to take the medication.
If you are going to take an antibiotic, you need to take the right one. Amoxicillin, plain penicillin and some other antibiotics used frequently for mastitis do not kill the bacterium that almost always causes mastitis (Staphylococcus aureus). Some antibiotics which kill Staphylococcus aureus include: cephalexin (our usual choice), cloxacillin, dicloxacillin, flucloxacillin, amoxicillin combined with clavulinic acid, clindamycin and ciprofloxacin. Antibiotics that can be used for methicillin-resistant Staphylococcus aureus (MRSA): cotrimoxazole and tetracycline.
All these antibiotics can be used by breastfeeding parents and do not require interruption of breastfeeding.You should not interrupt breastfeeding if you are infected with MRSA! Indeed, breastfeeding decreases the risk of the baby getting the infection.
A breast abscess may form when there is a long delay in treatment for mastitis, or if mastitis is not treated/ineffectively treated. An abscess is a pocket of pus formed in an infected area because the body cannot completely fight off the infection on its own. It is the body’s way of preventing infection from spreading.
Symptoms often include a swollen lump usually just under the skin (usually painful to touch or squeeze) and swelling or redness in the surrounding area. You may have a fever.
If you have mastitis that has not completely resolved, or at least significantly improved, within 5 to 7 days of starting antibiotics, you should be assessed for an abscess.
The treatment of choice now for breast abscess is no longer surgery. We have had much better results with ultrasound to locate the abscess and a catheter inserted into the abscess to drain it. Breastfeeding parents going through this procedure do not stop breastfeeding even on the affected side, and complete healing occurs often within a week. This procedure is done by an intervention radiologist, not a surgeon. Ask your doctor to check out this study: Dieter Ulitzsch, MD, Margareta K. G. Nyman,MD, Richard A. Carlson, MD. Breast Abscess in Lactating Women: US-guided Treatment. Radiology 2004; 232:904–909
For small abscesses, aspiration with a needle and syringe plus antibiotics often is all that is necessary, though it may be necessary to repeat the aspiration more than once.
If you have a lump that is not going away or not getting smaller over more than a couple of weeks, you should be seen by a breastfeeding-friendly physician or surgeon. You don’t have to interrupt or stop breastfeeding to get a breast lump investigated (ultrasound, mammogram and even biopsy do not require you to stop breastfeeding even on the affected side). A breastfeeding friendly surgeon will not tell you that you have to stop breastfeeding before s/he can do tests to investigate a breast lump.
The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.
This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!
©IBC, updated July 2009, 2016
Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).
Make an appointment at the Newman Breastfeeding Clinic.