In the previous blog article, we reviewed the differences in the definition of mastitis between the new ABM protocol on mastitis (protocol #36: The Mastitis Spectrum) and the old protocol (#4: Mastitis). In this article, we summarise the changes or updates from the new protocol on the recommendations for the management of mastitis and its different related disorders.

It should be noted that the new protocol provides general and specific recommendations for all possible conditions within the mastitis spectrum. This article only focuses on the general recommendations without going into detail about each specific situation.

The general recommendations for mastitis treatment from the previous protocol, such as antibiotic treatment, the use of first-line pain relief and anti-inflammatory drugs to relieve pain and reduce inflammation, as well as comfort measures, remain the same in the new protocol. However, the new protocol introduces some modifications to manage mastitis, and the most important differences from the previous protocol are:

• The new protocol does not recommend emptying the affected breast and recommends simply continuing to breastfeed on demand as breastmilk volume depends on a feedback mechanism. Therefore, more milk expression increases milk production. Instead, it recommends that mothers hand express small volumes of breastmilk to feel comfortable.
• The use of breast pumps should be minimized, as they do not allow bacterial exchange between the baby’s mouth and the mother’s breast and so may contribute to dysbiosis. In addition, breast pumps can cause trauma to the breast parenchyma and the nipple-areola complex.
• The use of nipple shields should be avoided, as they promote suboptimal milk extraction, and infants tend to passively draw milk from the nipple shield reservoir without latching onto the breast parenchyma.
• The new protocol also recommends avoiding deep massage of the affected breast as this increases inflammation and oedema and causes microvascular damage. Therefore, it recommends avoiding any massage devices.
• Consider the use of probiotics. Scientific evidence suggests that probiotics based on strains of Lactobacillus fermentum or Lactobacillus salivarius may treat and prevent mastitis.
• Evaluate mood and anxiety disorders in the mother. It has been observed that in women with a history of depression or anxiety, the rates of mastitis symptoms are higher, and the level of anxiety is increased in patients who experience breastfeeding complications.

Please note that the level of evidence and the level of recommendation of most of these recommendations is low according to the SORT taxonomy (3), and most have a level 3 evidence and level of recommendation C. Therefore, these recommendations are based on agreed guidelines, extrapolations of basic research, standard practice and opinion and are not based on clinical studies or meta-analyses.

References:

1. Amir LH. ABM clinical protocol #4: Mastitis, revised March 2014. Breastfeed Med [Internet]. 2014;9(5):239–43.

2. Mitchell KB, Johnson HM, Rodríguez JM, Eglash A, Scherzinger C, Zakarija-grkovic I, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med [Internet]. 2022;17(5):360–76.

3. Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, et al. Strength of Recommendation Taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract [Internet]. 2004;17(1):59–67.