Some lucky mothers breastfeed successfully without ever noticing a problem with plugged ducts or mastitis. But for many of us, plugged ducts and mastitis are a painful problem that strikes again and again. The good news is, with just a little bit of know-how, you can put a stop to this problem without jeopardizing the nursing relationship you and your child share.

The key to breaking the cycle is knowledge. You must learn to prevent plugged ducts, recognize their symptoms early, and treat them effectively, before any other complications arise. More good news is that the longer you breastfeed, the less likely you are to experience plugged ducts and mastitis. Most veteran breastfeeding moms have learned what they have to do to keep trouble at bay. Here is what they know that you may not …

What is a plugged duct?

A plugged duct is a tender knot, usually found in just one breast. It may be the size and shape of a piece of chewed gum, or it may be larger, and it may stay in one spot or move around. The lump tends to become more painful during milk letdown. When milk doesn’t drain well from this duct, it becomes inflamed and creates a blockage, which causes buildup of milk behind it. If the duct is not allowed to drain, the inflammation spreads, and you may notice a hardened area in your breast shaped like a pie wedge, with the tip pointing at your nipple. The affected area may be warm and red, and you might start to run a low-grade fever.

What is mastitis?

Mastitis is an infection of the breast which occurs most often as a complication of a plugged duct not resolved quickly. Bacteria find an entrance into the breast, sometimes through broken skin in the nipple. They multiply in the stagnant, pooled milk, and an infection results. Mastitis presents not only with soreness of the affected breast, but flu-like systemic (whole body) symptoms as well, such as malaise, fatigue, headaches, and nausea. A fever of greater than 101 degrees is typical.

What causes plugged ducts?

In order to prevent plugged ducts you must understand their cause, which is simply anything that interrupts the normal flow of milk. Your breasts were designed to “know” exactly how much your baby needs. The more milk you take out (by nursing, pumping, or hand-expressing), the more your body will make. The less you take out, the less your body will make. Unfortunately, there is a limit to this magical flexibility of your mammary glands. If you nurse a lot every day and suddenly nurse very little one day due to a schedule change, you will find that your breasts probably did not get the memo. Especially if you have a large milk supply, the extra milk may pool and back up, resulting in problems for you. For this reason, it is usually recommended that you don’t wean any faster than dropping one feeding every three to four days or so.

If you know a schedule change is imminent because of an upcoming transition such as returning to work, it is important to drop feedings gradually. Though you may be planning to pump, be aware that a breast pump cannot empty a breast as fully as a baby can. Also, make sure you are well-versed in pumping before your first day at the office. Feeding the pump is an acquired skill, but a valuable one to possess in case of unexpected events.

Interruption of normal milk flow can also be caused by anything that compresses mammary tissue, such as an overly tight bra or constrictive shirt, pressure from carrying a heavy purse or bag, use of nipple shields, previous breast surgery or injury, wearing a baby carrier that presses heavily on your chest, sleeping on your stomach, or pressure from lying on a bunched-up shirt while breastfeeding. Some women believe erroneously that the breast tissue under their babies’ noses must be pressed down during breastfeeding to prevent suffocation. Actually, a baby’s nose is specially designed to breathe while at the breast, and this compression may just backfire and cause a plugged duct.

Mothers may be more prone to plugged ducts immediately postpartum due to problems with their baby’s latch (mouth position on the nipple). If the baby’s latch prevents him from nursing effectively, in addition to Mom getting a plugged duct, Baby might not be getting the milk he needs, so it is important to take up any problems with latch with a professional lactation consultant as soon as possible.

Some mothers find that other less obvious factors predispose them to plugged ducts, including exercise of the upper arms, and high levels of stress. Plugged ducts are also more likely to occur during winter months, perhaps because of holiday stresses and schedule alterations.

Some risk factors for plugged ducts are not within your control, but you can still take measures to prevent problems. For example, your baby might refuse to nurse. He might be overly sleepy, less hungry due to illness, less interested in the breast during certain phases of development, or on a “nursing strike” for some other reason. He may suddenly begin sleeping through the night instead of taking his 2 a.m. feeding, and you may find yourself awake and engorged. In these situations, you should pump or hand-express just enough milk to make you comfortable again. (If this doesn’t work, be aware that most babies will nurse during their sleep. You can wait until he is asleep, then offer the breast again.) If your baby no longer needs that feeding, your supply will gradually decrease with your baby’s decreased demand, and soon this extra effort on your part will not be necessary. On the other hand, if he later needs more milk, he will increase his consumption, and your supply will increase again.

How are plugged ducts treated?

Perhaps it is already too late for prevention. If you have a plugged duct, the next best thing is to treat it aggressively, as early as possible.

Your goal is to get the milk flowing through the affected duct again, and your greatest ally is your baby. The simplest cure is to let your baby nurse the breast empty, and his suction combined with your letdown reflex may open the duct. If his nursing doesn’t immediately provide relief of the pain and pressure, you can position his mouth over your breast to make sure that the area with the plug is getting the strongest force of suction. Point your baby’s nose at the plugged spot and allow him to nurse. Alternately, some women find it more effective to position their babies’ lower lip over the plug. Depending on the location of the plug, positioning yourself to do this may make you feel like a gymnast. An especially effective technique is to get down on your hands and knees with your breast dangling over your baby, so that gravity and suction can work together to eliminate the plug. Your baby may find this very silly, and so will anyone else who might see what you are doing, but the relief will be worth it!

Massage your breast with your hands as you breastfeed, pump, or express, trying to work the plug out. You should rub gently, but with pressure, working in a circular or straight motion, from base to nipple. Also, some women find that they need to support the bottom of their breast with one hand while nursing in order for the breast to drain completely.

If the plug does not release the first time, don’t give up. You may be able to release it using other methods. Try applying a heating pad or hot rice pack, taking a hot shower, or dunking your breast in a basin of hot water before the next feeding. Another effective method of applying heat is to fill a disposable diaper with warm water and press it to the breast. The heat may dissolve the clog. Make sure to offer the sore side first at each feeding, but don’t neglect the other breast. (The last thing you need is a plug on the other side, too.)

Nurse as often as possible, and don’t forget to take care of yourself. To prevent mastitis, you should get plenty of rest and drink a lot of fluids. Spending the day in bed, nursing your baby whenever you can, is a marvelous cure.

Use positioning, heat, and massage liberally until you get your reward: expulsion of the clog. Depending on whether you are nursing, pumping, or hand-expressing milk at the time, you may or may not see the plug come out. If you do see it, don’t be surprised if it looks like a piece of sand, a small strand of spaghetti, or a gelatinous substance. It is basically curdled milk. Rest assured that consuming this clog will not harm your baby. Nothing that comes from your breasts can possibly cause your baby to choke to death, nor are there any poisonous substances in a milk plug. It may pass from you to your baby without either of you realizing it, with a regular swallow of milk. After it passes, you will feel relief of built-up pressure as the milk behind it flows downward.

While waiting for the plug to release, be on the lookout for a white spot on your nipple. If you don’t see one, check again. It might be small. This white spot may be the plug itself, waiting to be expressed, with relief waiting behind it. You may be able to work it out with your fingers, like popping a very tiny pimple. Dissenting opinions exist on whether you should try and remove it yourself with a sterilized needle or let a doctor do it. If you decide to give it a try, you can sterilize a needle over a flame and very carefully remove the plug. Once it is released, don’t be surprised if the milk behind it squirts out with some force. You should feel better immediately afterward.

How is mastitis treated?

If you have a fever of greater than about 101 degrees and flu-like symptoms, or if you have red streaks on your breast and blood or pus in your milk, it is time to call the doctor. While not every case of mastitis may require them, antibiotics are the general standard for treatment. Dicloxacillin is most often prescribed for mastitis, but Keflex and erythromycin are also appropriate. Your doctor will select an antibiotic that will not harm your baby. Antibiotics are generally taken for 10-14 days, and it is important to finish the entire course to prevent your infection from recurring. Keep in mind, though, that antibiotics increase the risk of yeast infections, which can occur on your nipples and in your baby’s mouth (also known as thrush), so keep an eye out for white patches in his mouth that do not go away.

The same measures mentioned above to treat plugged ducts should be used when a plugged duct occurs with mastitis. There is no need to stop breastfeeding. Breast milk contains antibodies that will prevent any bacteria from harming your baby, so drinking milk from the infected breast will not hurt him. It is important to continue nursing so that your milk will flush the bacteria out, and your baby is better-designed than any pump for milk removal.

Occasionally, however, a baby will refuse to nurse on the affected side. When he discovers that milk is not flowing from that side as freely as he likes, he may cry in protest. (This may happen any time you have a plugged duct or mastitis.) Also, he may discover that milk from a recently infected breast has a slightly salty flavor. It may or may not bother him. If your baby refuses to nurse on your plugged or infected breast, it is important to continue to empty it as well as possible yourself, through pumping or hand-expression. (Again, you can also try waiting till he is asleep to offer the breast, since most babies will nurse during their sleep.) Failing to unplug an infected duct puts you at greater risk for a breast abscess, otherwise known here as the worst case scenario.

What is a breast abscess?

A breast abscess, the worst case scenario, is a very rare occurrence, but can result as the sequela of mastitis. It usually does not happen unless a mother completely ignores her plugged ducts and mastitis, and it occurred more commonly a generation ago, when women were told that having mastitis meant they had to wean their babies completely. In an abscess, the hardened knot in your breast fills with fluid or pus, like a boil, and must be opened and drained by a doctor.

Even a breast abscess does not mean you have to give up breastfeeding. When the doctor drains the abscess, make certain that he does not make his incision in the areola, which might make nursing difficult afterward. You should be able to nurse again 12-24 hours after the surgery, if you choose to.

How can plugged ducts and mastitis be prevented?

Knowing the causes of plugged ducts and mastitis, mentioned above, will help you prevent them. Avoid abrupt changes in your nursing schedule. If you are trying to eliminate feedings or pumping sessions, try not to drop them more quickly than one about every three to four days. This might require a little bit of advanced planning, especially if you are making a major change such as a transition back to work. Understand that since a pump cannot empty a breast as effectively as a baby can, abruptly substituting several feedings with pumping sessions can lead to a buildup of milk that may cause a clog.

Anything that compresses your breast tissue can predispose you to a plugged duct, so you should avoid wearing overly tight bras or constrictive clothing, and be careful when wearing baby carriers or carrying heavy bags that press heavily against your chest and upper arms. Some women find that they can reduce their risk of plugged ducts by sleeping on their sides or backs instead of on their stomachs. Nipple shields used inappropriately or unnecessarily can contribute to your risk. Also, be aware that it is not necessary to press down on the breast underneath your baby’s nose to help him breathe, and this misguided practice may lead to a plugged duct. Be careful not to nurse while lying on a bunched-up shirt, as this too can cause compression.

If you experience problems with your baby’s latch postpartum, it is important to remedy them as soon as possible by seeing a professional lactation consultant, preferably someone who has undergone the rigorous training of an IBCLC (International Board Certified Lactation Consultant) program, as these consultants have a wealth of practical breastfeeding knowledge. Poor latch can lead to plugged ducts and engorgement for you and inadequate nutrition for your baby, so improving it is key to successful breastfeeding.

Be aware that plugged ducts may result from excessive repetitive upper arm exercises, and that holidays and stress are also risk factors. The importance of taking care of yourself, drinking adequate fluids, and getting enough rest cannot be overemphasized for preventing plugged ducts, and for staving off mastitis when plugged ducts do occur.

If your nursing schedule is thrown off because of your baby’s refusal to nurse, leaving you engorged and uncomfortable, pump or hand-express just enough milk to make you comfortable. Alternately, you can wait until your baby is asleep and offer the breast again. He may take it while he is sleeping. Though you needn’t empty your breasts completely if your baby isn’t interested, avoiding an uncomfortable level of fullness can prevent plugs.

What can I do about recurrent plugged ducts and mastitis?

Some women are prone to plugged ducts because of anatomical differences. Perhaps you have had a breast injury or surgery, or maybe you are unlucky enough to have narrow or tortuous (twisting, turning) milk passageways. You may notice that plugs always occur in the same problem area with an unseen anatomical irregularity. Or you may just be more prone to problems because of a hectic lifestyle. You should try all the prevention and treatment strategies mentioned above, plus a few more.

A lactation consultant can meet with you and discuss your problems. She might be able to pinpoint a risk factor you haven’t thought of yet. Some consultants recommend that you take additional vitamin C or use a supplement called lecithin, a common food additive. Some women find that increasing their water consumption and decreasing dietary saturated fat protects against plugged ducts. In addition, if your milk supply is greatly depleted after your problem resolves, a lactation consultant may recommend herbs to increase milk production.

Milk plugs tend to lead to more plugs, so if you don’t feel complete initial relief after releasing a clog, keep in mind that more than one may be present at one time. Keep up the treatments, and the problem will soon clear up. Be patient. The swelling might take a little time to resolve.

If mastitis keeps stubbornly recurring, the problem may actually be the same unresolved infection that keeps coming back. You should talk to your doctor, and he may suggest switching antibiotics or going on long-term, low-dose antibiotic therapy.

Plugged ducts and mastitis are a definite annoyance and can be very painful. You should take all precautions to prevent them and treat them quickly and aggressively if they do occur. Happily, you can make a difference with the power of knowledge, and even in the worst cases, you can and should continue to share a close breastfeeding relationship with your baby.