I call it ‘the breastfeeding tax’ for a reason: mastitis (along with thrush and plugged ducts) feels like the price you pay for breastfeeding. And it’s a painful one. Mastitis is an inflammation of breast tissue that, if left untreated, could lead to a bacterial infection. But updated 2022 clinical guidelines from the Academy of Breastfeeding Medicine (ABM) published in May now assert that mastitis should be considered “a spectrum of conditions”, ranging from oversupply (hyperlactation) to inflammation, bacterial infection and abscess.

The new clinical protocol from ABM outlines several key changes that significantly shift what we thought we knew about the condition, namely that plugged ducts are more accurately described as “ductal narrowing,” that ice and other anti-inflammatory treatments should be used to manage mastitis instead of heat, and that extra pumping and other measures used to increase drain the breast will only hurt, not help.

Here’s what else has changed per the new 2022 mastitis guidelines

Feed on demand

Oversupply is now considered to be the first marker on the mastitis spectrum. An overproduction of breast milk, known as ‘hyperlactation’, can lead to inflammation, causing a narrowing of the milk ducts, (previously called a ‘plugged duct’), and could progress to inflammatory mastitis.

Mastitis Spectrum ABM 2022 Guidelines — Breastfeeding Medicine, ABM Protocol 2022

According to the protocol, the best thing to do for oversupply is to continue to feed your baby only on demand or to pump on your normal schedule. They warn against attempting to fully drain the breast and suggest breastfeeding parents should minimize extra pumping, because increased pumping could signal the body to continue to produce more milk.

“Overfeeding from the affected breast or ‘pumping to empty’ perpetuates a cycle of hyperlactation and is a major risk factor for worsening tissue edema and inflammation,” states ABM. The authors also mention that some may need medication to correct an oversupply when other methods don’t work.

Stop dangle feeding and other forms of clog removal

Because plugged ducts are now understood to be the result of inflammation rather than a blockage that stops up milk supply, there’s no need to ask your partner to suck out a clog or to hover on all fours above your infant while nursing (better known as ‘dangle feeding’.)

“No evidence exists to support ‘dangle feeding’ (i.e., feeding an infant on the floor with the mother hovering above) or other unsafe infant positions. Patients may consider safe variations on standard feeding positions, with the understanding that this may improve comfort. However, this does not address underlying inflammation.” You might also try feeding first from the unaffected breast and then switching to the affected breast to avoid overstimulation.

Use ice instead of heat for plugged ducts and inflammatory mastitis

Save your warm compresses for another use, because heat doesn’t actually help reduce inflammation when you have a painful plugged duct (narrrowing). To tackle that swelling, instead use a combination of ice packs or a cold compress and NSAIDs such as acetaminophen or ibuprofen. Cold reduces the blood flow to cut down on swelling, as opposed to heat, which increases blood flow.

Ice for mastitis ABM 2022 Guidelines — Breastfeeding Medicine, ABM Protocol 2022

Heat might help some feel more comfortable, however, the authors note. “Although heat will vasodilate and may worsen symptoms, it also may provide comfort for some patients. The use of warm showers and antipyretics did not improve mastitis outcomes in a randomized controlled trial.”

Stick to gentle massage, not aggressive squeezing

Gone are the days when you head to the shower armed with an electric toothbrush (or a vibrator?) and a jar of coconut oil to forcefully massage out your clogged duct. That might just make things worse, according to the updated guidelines.

“Attempts to extrude a ‘plug’ or milk precipitate by squeezing or aggressively massaging the breast are ineffective and result in tissue trauma,” note the authors.

Instead, aim for a gentle, lymphatic draining massage, which involves “a light sweeping of the skin rather than deep tissue massage.” You’ll want to sweep up from the nipple toward the armpit to help drain any extra fluid and quell inflammation.

Antibiotics may not always be necessary

Antibiotics should be reserved for bacterial mastitis, but not inflammatory mastitis, the authors note. “Use of antibiotics for inflammatory mastitis disrupts the breast microbiome and increases the risk of progression to bacterial mastitis.” Antibiotics also shouldn’t be used for mastitis prevention. Many antibiotics also boast anti-inflammatory properties, “and this may explain why women experience relief when taking these,” state the protocol authors.

Instead, consider taking probiotics for mastitis prevention. “A systematic review suggested that probiotics may be effective for both treatment and prevention of mastitis, but a strong recommendation could not be made due to limitations of the studied trials.” Specific strains that have clinical research supporting their use with mastitis include: Limosilactobacillus fermentum (formerly classified as Lactobacillus fermentum) or, preferably, Ligilactobacillus salivarius (formerly classified as Lactobacillus salivarius) strains.

Signs of bacterial mastitis

You may be experiencing a bacterial mastitis infection if you notice the following symptoms:

Abnormal swelling and/or a wedge of redness on the breast
A painful lump on the breast or general breast tenderness
Pain or burning while breastfeeding
A breast that feels unusually warm or hot to the touch
General malaise or flu-like symptoms
Chills
Fatigue
Fever

Bacterial mastitis may require antibiotics. Be sure to reach out to a physician for treatment recommendations.

Reach out to a lactation consultant

Breastfeeding shouldn’t be painful. If you’re dealing with any pain during breastfeeding or notice symptoms of an infection, don’t hesitate to reach out to a lactation professional or your OB/GYN or primary care doctor for a consultation. Managing an oversupply, poor latch, recurring inflammation or infection can be difficult on your own, especially if it’s early in your breastfeeding journey. A lactation consultant can help identify issues and offer support and suggestions to make breastfeeding easier for you and your baby. Your child’s pediatrician should be able to refer you to a lactation consultant, or reach out to friends and family for recommendations.