Leading Lactation Insights - September 2022

A New Look at Mastitis – ABM Clinical Protocol #36

Maria Lennon, MSN, CNM, IBCLC

With the publication of “Clinical Protocol #36: The Mastitis Spectrum”, the Academy of Breastfeeding Medicine has caused a paradigm shift in how we view the cause, prevention, diagnosis, and treatment of mastitis. Instead of looking at mastitis as a single entity, an infection of the breast, scientific evidence demonstrates that mastitis “encompasses a spectrum of conditions” resulting from inflammation of the ducts and edema of breast tissues.

Mastitis is an inflammation of the mammary gland, and usually presents in a segment of the breast. The lumens of the mammary ducts can be narrowed by edema and increased congestion of blood associated with milk oversupply (hyperlactation) and mammary dysbiosis (a disruption of the milk microbiome). Ductal inflammation can result in narrowed lumens, stromal edema, dysbiosis, the formation of nipple blebs, and mastitis. Many factors contribute to the development of mastitis, but milk stasis has not been shown by scientific evidence to be the cause.

Clinical Protocol #36 should be required reading for all healthcare professionals who care for breastfeeding women because many of the prevention and treatment strategies for mastitis currently in use have been proven not only to be unhelpful, but can also cause damage to breast tissue. Firm massage and breastfeeding or pumping frequently to keep the affected breast “empty” can lead to tissue trauma and hyperlactation, conditions that can lead to ductal narrowing and phlegmon (fluid collection) formation. Instead of helping to prevent or treat mastitis, these recommendations can lead to further progression along the mastitis spectrum.

The protocol recommends prompt and effective treatment regimens that may not only halt progression of the spectrum but may also prevent problems as well. Some of the general recommendations include:

• Reassure mothers that many mastitis symptoms will resolve with conservative care, such as rest and decreasing stress.
• Feed the baby on demand, and don’t try to “empty” or “drain” the breasts. Milk expression by breast pumping should be limited to the amount that baby consumes when mother and baby are separated.
• Avoid deep massage of the breast, as it can cause inflammation, tissue edema, and microvascular injury. Gentle compressions when breastfeeding or using a pump are considered safe.
• Use of ice and anti-inflammatory medications can reduce swelling and inflammation and provide some relief from pain.
• Treat hyperlactation or milk “oversupply” as it causes congestion of ductal lumens and inflammation, which leads to mammary dysbiosis.
• Reserve the use of antibiotics for bacterial mastitis. If used for inflammatory mastitis, the breast microbiome is disrupted which increases the risk of progressing to bacterial mastitis.

There are other recommendations in the protocol for medical interventions and for specific conditions, such as postpartum engorgement, inflammatory mastitis, bacterial mastitis, phlegmon, abscess, recurrent and subacute mastitis.

The ABM’s Clinical Protocol #36 presents evidence that changes the prevention and management strategies of mastitis. This new protocol replaces ABM Protocols #4, Mastitis, and #20, Engorgement. Useful adjuncts to the Mastitis protocol, are ABM Protocol #32 (Management of Hyperlactation) and #35 (Supporting Breastfeeding During Maternal or Child Hospitalization). These protocols can be found at: www.bfmed.org.

Reference:
Mitchell KB, Johnson HM, Rodríguez JM, Eglash A, Scherzinger C, Zakarija-Grkovic I, Cash KW, Berens P, Miller B; Academy of Breastfeeding Medicine. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med. 2022 May;17(5):360-376. doi: 10.1089/bfm.2022.29207.kbm. PMID: 35576513.

This month we are spotlighting Lisa Breen, RN, MS, IBCLC

Megan Quinn

Lisa Breen, RN, MS, IBCLC is a full-time lactation consultant in the NICU for Capital Health, a baby-friendly hospital in New Jersey. While she is originally from Buffalo, New York, her husband’s career has allowed them to live in many different areas of the United States, though they’ve called Pennsylvania home for the last 14 years. 

Lisa says that she knew from a very young age that she wanted to be a “baby nurse” and received her BSN from SUNY Buffalo and then her MSN from the University of Pennsylvania. She shares that her first job out of college was on the infant floor and preemie step-down unit at Children’s Hospital of Buffalo and, from there, she became a pediatric nurse practitioner providing primary care in their outpatient clinic. Lisa has always had a passion for new moms and babies and, while living in Denver, worked on a postpartum unit through Kaiser Permanente and also did home visits after the moms and babies were discharged from the hospital. There, the bulk of her work involved providing education and support to breastfeeding families, which inspired Lisa to become an IBCLC after moving back to Pennsylvania. 

Lisa shares that she seized the opportunity for her current role after it became available through a March of Dimes grant about 10 years ago. She was thrilled to become Capital Health’s dedicated NICU lactation consultant and says, “immediately I knew I had found my place and have been there since!” Her goals are to educate and support new families with premature newborns, which involves everything from helping moms initiate their breast milk through hand expression and/or pumping to assistance with breastfeeding and helping develop individualized feeding plans upon discharge to help these families meet their lactation goals. As a result, she is excited to note that “our data exceeds the national average of preemies <1500 grams receiving some EBM upon discharge!”

In 2019, Lisa wrote a grant to provide a Medela hands-free pumping bra to each NICU mom in her care in an effort to help establish pumping as soon as possible after delivery. Additionally, she regularly provides education to staff, including a session for all new maternal child health RNs, and manages the donor milk program. She says that, “the ultimate reward is a visit from a proud family with their thriving infant to developmental follow-up appointments, knowing the infant had a healthy nutritional and immunologic start.” Additionally, Lisa also briefly worked as an adjunct faculty member at the Sunyab School of Nursing in Buffalo years ago. 

Outside of work, Lisa says that she enjoys kickboxing classes and spending time with her family, which includes her husband and three kids – two of whom recently completed their first year of college in Madison, Wisconsin and New York City, which she notes are two fun places to visit and explore. Thank you, Lisa, for all that you do for the most vulnerable babies and NICU families!

Thank you to this issue's contributors!

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