All Things Breastfeeding Episode 89: ABM 2022 Mastitis Protocol

Barbara and Nancy discuss the ABM 2022 Mastitis Protocol.

Both Nancy and Barbara feel this Protocol is a step in the right direction! However, we don’t agree with everything and you can see others feel the same way. Listen and find out!
The ABM (Academy of Breastfeeding Medicine) Mastitis #36 Protoco replaces Protocols #4, #20, and Engorgement Protocol has been retired. From the Protocol: ”…Scientific evidence now demonstrates that mastitis encompasses a spectrum of conditions resulting from ductal inflammation and stromal edema. If ductal narrowing and alveolar congestion are worsened by overstimulation of milk production, then inflammatory mastitis can develop, and acute bacterial mastitis may follow. This can progress to phlegmon or abscess, particularly in the setting of tissue trauma from aggressive breast massage. Galactoceles, which can result from unresolved hyperlactation, can become infected. Subacute mastitis occurs in the setting of chronic mammary dysbiosis, with bacterial biofilms narrowing ductal lumens.”

The protocol claims, “Milk stasis has been postulated to be a potential instigating factor for mastitis, although scientific evidence has not proven a causation.” This is one of ideas that really challenges what we have seen in our private practice. A parent misses a feed or a pump, becomes engorged and then seems to have ductal narrowing (what we used to call a plug!) which can lead to mastitis. We will have to wait for more information and research on the subject.

Level of research- Not all are in agreement

Not everyone agrees with new Protocol.

This protocol was heavily influenced by Dr. Katrina Mitchell who is a breast surgeon. We love Dr. Mitchell so don’t get us know but she is a breast surgeon so instead of seeing our everyday horses or one off ductal narrowing or mastitis she sees zebras, folks who are in real trouble, all the time! Below are some reactions to the Protocol from others.

• • • (Douglas, 2023) https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-023-00588-8
      • “Clinical Protocol #36 offers some advances in the management of breast inflammation. However, Clinical Protocol #36 also exposes clinicians to two international trends in healthcare which undermine health system sustainability: overdiagnosis, including by over-definition, which increases risk of overtreatment; and antibiotic over-use, which worsens the crisis of global antimicrobial resistance. Clinical Protocol #36 also recommends unnecessary or ineffective interventions which may be accessed by affluent patients within advanced economies but are difficult to access for the global majority. The Academy of Breastfeeding Medicine may benefit from a review of processes for development of Clinical Protocols.”
    • (Baeza et al, 2022) Re: ‘‘Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022’’ by Mitchell et al.
      • “Authors state it is an entity necessitating antibiotics or probiotics to resolve—again, no evidence.”
      • “Changing the term ‘‘mastitis’’ to ‘‘mastitis spectrum’’ seems a step backward, as it implies losing scientific accuracy. It disperses the predisposing factors, the illness itself, and its complications under the term ‘‘spectrum.’’ More solid studies on mastitis are needed, but it is an entity that has a clear clinical definition, which we know how to diagnose and manage. Inserting it within a spectrum adds complicated nuances that are not scientifically justified.”
      • Subacute mastitis “This term is not defined in the literature, much less its cause. The articles cited by the authors (no. 19–22) give different clinical symptoms to define it. Reference no. 22 bases its conclusions once more on the mentioned article on candidosis (no. 5), so we have a circular citation wheel based on opinions and no facts. That subacute mastitis is an entity and that it is caused by biofilms in chronic mammary dysbiosis is supported by no evidence.”
      • Lecithin for blebs- Claim no evidence
      • Therapeutic ultrasound for pain- Claim no evidence
      • Probiotics for mastitis- Claim no evidence

Here are the main take homes from the Protocol. I like that they include the strength of evidence. Listen to the podcast to hear Nancy and Barbara discuss each one.
All treatments From Protocol #36: “Management of mastitis spectrum disorders includes general strategies that apply to the entire spectrum, as well as condition-specific interventions. Prompt and effective treatment will halt progression in the spectrum. Many of these measures provide not only treatment, but prevention as well.”

• • Treatment suggestions:
    • “Reassure mothers that many mastitis symptoms will resolve with conservative care and psychosocial support.”
      • Level of evidence: 3. Strength of recommendation: C
      • “Assist mothers in identifying ways to decrease stress, increase opportunities to rest, and help resolve early signs of inflammatory mastitis.”
      • “Fourth-trimester care programs represent a holistic approach to postpartum care, including mental health, psychosocial needs, and breastfeeding counseling.”
    • “Educate patients on normal breast anatomy and postpartum physiology in lactation”
      • Level of evidence: 3. Strength of recommendation: C
      • “Many patients experience breast fullness or palpate normal lactational glandular tissue and misinterpret this as ‘‘plugging.’’ They should be reassured that lactating breasts can feel ‘‘lumpy’’ and even painful at times. Although this is uncomfortable, it is not abnormal.
      • Patients should be reassured that infection does not develop in the period of several hours. The pain and redness they may experience in mornings after a long stretch of sleep represents alveolar distention, edema, and inflammation rather than infection.”
    • “Feed the infant on demand, and do not aim to ‘‘empty’’ breasts.”
      • Levels of evidence: 2–3. Strength of recommendation: C
      • “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.”
      • “In some instances, in which the retroareolar region is so edematous and inflamed that no milk is expressible by infant breastfeeding or hand expression, the mother should not continue to attempt feeding from the affected breast during the acute phase. She can feed from the contralateral breast and return to feeding from the affected breast when edema and inflammation subsides. Edema may resolve more quickly with ice and lymphatic drainage. She should be counseled that a decrease in milk production is expected, but can later be augmented.”
      • “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.”
    • “Minimize breast pump usage.”
      • Levels of evidence: 2–3. Strength of recommendation: C.
      • “Mechanical breast pumps stimulate breast milk production without physiologically extracting milk as an infant will.”
    • “Avoid the use of nipple shields.”
      • Level of evidence: 3. Strength of recommendation: C
      • “Available evidence does not support the use of nipple shields. Neither safety nor effectiveness has been demonstrated.”
    • “Wear an appropriately fitting supportive bra”
      • Level of evidence: 3. Strength of recommendation: C
    • “Avoid deep massage of the lactating breast.”
      • Levels of evidence: 1–2. Strength of recommendation: B.
      • “The most successful technique approximates manual lymphatic drainage with light sweeping of the skin rather than deep
      • tissue massage.”
      • “It should be noted that gentle compressions during breast pump usage, often termed ‘‘hands on pumping,’’ provide an effect similar to hand expression and is safe if excessive manual force is avoided.”
    • “Avoid saline soaks, castor oil, and other topical products.”
      • Level of evidence: 3. Strength of recommendation: C.
      • “Topical products such as castor oil will not treat this condition and may in fact cause tissue damage particularly if they are combined with massage.”
    • “Avoid routine sterilization of pumps and household items.”
      • Level of evidence: 3. Strength of recommendation: C.
      • “Mastitis is not contagious and does not result from unhygienic practices.”

Finally, below are their medical interventions.

• • • Medical interventions
      • Decrease inflammation and pain
      • Treat associated blebs and avoid “unroofing”
      • Decrease any hyperlactation
      • Utilize therapeutic ultrasound
      • Consider probiotics
      • Look for mood and anxiety disorders and address if needed

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