“Help, I think I have a clogged duct. I have followed my doctor’s advice and everything I can find on Google: heat, massage, pumping, dangle feeding, vibration, nothing seems to work. In fact, it feels worse. What am I doing wrong?”
This is a frequent call or email we receive at the Growing with Baby Center home to lactation consultant and co-author of Suckle-Sleep-Thrive, Andrea Herron RN, MN, CPNP, IBCLC.
So why is the conventional treatment for what we previously called a plugged duct so often failing to treat the painful, recurring lumps on the breasts of these desperate women?
Basically, we misunderstood the cause of the debilitating symptoms many lactating persons were experiencing. Thanks to the contribution of the recently rising number of breastfeeding medicine physicians, we are seeing changes in the long-standing advice we give to treat this common problem. These dedicated physicians are applying their extensive knowledge of breast anatomy and physiology and disseminating their clinical expertise to change practice. The big game changer was the 2022 Breastfeeding Medicine Clinical Protocol on the Mastitis Spectrum. (1) Unfortunately, like all new findings, it takes a while for new treatments to become standard practice.
How did we explain a plugged duct?
In the past, it was thought that when a milk duct didn’t drain properly, the milk thickened and blocked the area. The area of the breast then became enlarged and painful. Sometimes thick stringy milk eventually would be expressed leading us to believe the area of the breast was blocked by the thickened milk. Suggested treatment was to apply heat, vigorously massage the area, and extra pumping or holding the baby in positions we thought would drain the breast while nursing. A plug diagnosis was differentiated from mastitis (infection) by symptoms. If a lactating parent feels well and it just hurts then it was called a plugged duct. If a woman had a fever and felt ill we suggested antibiotics, way too often. We now know that it is impossible for a single milk duct to become blocked because the ducts in the breast are numerous and interlacing.
What is really happening?
The working unit of the lactating breast is the alveoli where breast milk is produced, stored, and released. The alveoli are lined with lactocytes that secrete the milk. The lactocytes are tightly lined up around the alveoli (tight junctions) so that the milk components can only be transported to the alveoli where it is stored for the baby.
image from https://www.glowm.com/article/heading/vol-15–the-puerperium–global-aspects-of-breastfeeding/id/416233. A free and entirely CHARITABLE site to support women’s healthcare professionals.
It is hypothesized that when the ducts are overfilled by too much breast milk (more than the baby needs from an overproduction of milk or obstruction) it causes congestion and pressure it opens up the protective tight junctions between the lactocytes and allows fluids to leak into the surrounding tissue. This alerts the body’s immune system to think there is an infection. In response, antibodies and fighter cells are sent to the area to heal the area. The result is a swollen inflamed area. What causes this? It is believed that producing more milk than what your baby drinks or hyperlactation from overuse of a breast pump stresses the integrity of the cells and leads to inflammation and narrowing. Other causes are scheduling feeds or anything that causes pressure on the breast such as a tight bra, backpack straps, and always sleeping on the same side.
How do we treat this inflammation? What do we do?
First, it is important to be aware that full milk cells (alveolus) feel lumpy. Because of breast cancer awareness, of course, we get anxious when we feel a lump. A lumpy area is normal as long as after nursing, the area softens. If the area continues to feel lumpy and painful you are dealing with inflammation. To treat this condition the new breastfeeding protocol recommends the following:
- Apply cold compresses after every feed for ten minutes. Frozen vegetables are great for this, but first, cover your skin with a thin towel.
- Take ibuprofen 600 mg every 6 hours with food. Check with your doctor first for any contraindications.
- Do not massage or apply heat and vibration. The breast is very vascular and easily bruised.
- According to the work of Dr. Pamela Douglas, you may want to try more frequent, shorter feeds. Of course, don’t force your baby to eat.
- Don’t try to empty the breast by pumping and longer feeds, you are just worsening the problem.
When to see your medical professional?
- You start to feel ill.
- The breast becomes red and harder.
- You don’t feel better in 48 hours.
When should we worry?
If this problem seems to come up frequently, see your doctor. If the lump doesn’t go away in several days seek medical attention.
There are some criticisms of this new protocol. For my practice, it has been a game changer. In the past, I saw so many women that bruised themself and ended up with mastitis from overzealous pumping, and massage. Now most women seem to have quick resolution of the inflamed area.
For questions or concerns call Andrea Herron at 805-543-6988 or email aherron178@gmail.com. Follow Andrea on instagram @sucklesleepthrive
Sources
1. Academy of Breastfeeding Medicine: Academy of Breastfeeding Medicine Clinical Protocol #36: the Mastitis Spectrum, revised 2022. Breastfeed Med. 2022;17(5):360–75.
2. Douglas P. Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management. Womens Health (Lond). 2022 Jan-Dec;18:17455057221091349. doi:
10.1177/17455057221091349.
Thank you for this article!!! I had (thankfully) encountered the new guidelines when I had mastitis week 2 postpartum, but this fleshed some of them out more which was nice.
Now for a desperate question!
I am a new exclusive pumper (and first time mom). My little is recently a month old and going through a growth spurt! To try to keep supply up I have been power pumping every night for the past week. I’ve been dealing with clogged ducts for the better part of the week – I ice and do lymphatic drainage massage and they go away, and then come back in a new area of the breast the next day… it’s been that way for the last half of the week. He’s also eating more frequently which means more pumping on top of that and I’m BARELY keeping up supply. I have to pump for a full half hour every time to get the amount that he eats each feed and even then I sometimes come up a bit short (maybe why he’s eating more frequently). All this background info to set up my question:
The recommendations: “According to the work of Dr. Pamela Douglas, you may want to try more frequent, shorter feeds.
Don’t try to empty the breast by pumping and longer feeds, you are just worsening the problem.”
I can’t get enough to feed him unless I pump for at least 30 min. Is that a “longer” feed? If so, how do I get around that issue?
And secondly, the more frequently I pump, the less yield I have each pumping session. Even if I do a full half hour, let alone a shorter pump. What gives?
Today I have had to pump every 2 hours (I pump when or right after he eats) and I’m BARELY getting 3 oz at each 30 min. pump session. He wants to eat about 3.5-4oz. Meanwhile I feel like my clogs have been getting worse and worse today!
How do I follow protocol while keeping up with my voracious baby?
I would also like to know this! I have twins on formula for cmpi and planning to reintroduce via ebf currently have “clugged ducts” and need 30mins twice a day to empty or I get engorged, and I can’t do more often coz twins are very time consuming!
Hi Elle and Sandy,
First of all, I want to praise your amazing efforts to feed your baby breast milk. keeping up with a baby’s feeding needs by bottle is very hard. At the breast, babies are comforting as well as drinking. At the breast, there are many pauses and dry swallows. At one month of age, babies need 30-40 minutes of sucking per feed because of their strong sucking drive. they will overfeed when bottle feeding to meet that need. Be aware your baby has now entered the rashy, gassy, fussy stage. Fussiness will peak at 6 weeks and then abate at around 3 months. we often mistake this normal developmental crying for hunger. Learning the baby’s cues will help you keep up with his needs. In our book, Suckle, Sleep, Thrive we spend an entire chapter describing cues. Babies have different cues for hunger, fatigue, overstimulation, and pain. watching the baby and learning how to respond will help prevent overfeeding. Our Instagram page, @sucklesleepthrive has examples of these cues.
As far amount of milk babies drink, keep in mind the average baby drinks 3-4 ounces per feed the entire time they breastfeed. if you are pumping 3 ounces every 2 hours you are making more milk than your baby needs. You can calculate your baby’s 24-hour milk need by multiplying the baby’s weight in pounds by 2.5. A ten-pound baby needs 25 ounces. This decreases at 3 months., The baby’s weight now multiplies by 1.9, and in 6 months it multiplies by 1.6.
About the plugged ducts. First, I strongly suggest you see a lactation consultant to watch you pump and examine your breasts. Sometimes it is just about tweaking your technique. We also want to rule out any medical reasons for recurrent plugging. By the history you are giving us I suspect your breasts are overproducing and overwhelming the alveolus (milk ducts). Then if you skip a two-hour interval or go longer you feel those uncomfortable lumps.
Last, we are all different. if short frequent pumping sessions don’t work for your body then the 30-minute sessions are what you need.
As far as the twins. of course, their care is all time-consuming. Are you pumping more than twice a day? if not, your body may be telling you that your breasts are getting too full and then that causes inflammation and plugging.
Hopefully, this information will help you understand your baby better and start to heal the plugs.
best
Andrea Herron RN, MN, CPNP, IBCLC