Mastitis, engorgement, blocked duct: how to recognise and relieve them

On day three, your breasts have doubled in size, they are as hard as stone and baby can no longer latch. Or, six weeks later, a red, burning patch appears on one breast, and by evening you are shivering. Engorgement, a blocked duct, mastitis: these three breastfeeding problems look alike, sometimes follow one another, and are now treated better than they used to be.

They almost always resolve without stopping breastfeeding. But the guidelines changed in 2022, and some reflexes handed down from mother to daughter, like heat or firm massage, can make things worse. Telling them apart lets you choose the right care, and know when to see a doctor.

Engorgement, blocked duct or mastitis: how to tell them apart

Engorgement affects both breasts. A blocked duct and mastitis most often involve one area of one breast, and a fever points to mastitis.

On brown or black skin, redness is harder to see, warns the NHS: rely on heat and pain too. A nipple discharge, white or streaked with blood, is possible with mastitis.

These situations are linked: too much milk or an engorgement that lasts can lead to mastitis, Naître et grandir reminds us. The Academy of Breastfeeding Medicine (ABM), a medical society devoted to breastfeeding, has spoken since 2022 of a "mastitis spectrum", from simple narrowing of inflamed ducts to infection and, rarely, an abscess.

Why do these problems happen?

Almost always because milk builds up, or because the breast makes more than baby drinks. Situations that put you at risk:

• feeds that are spaced out, cut short or skipped: a long night, a day of visitors, going back to work without expressing;
• an ineffective latch;
• an oversupply of milk, sometimes kept going by too many pumping sessions;
• a bra or clothing that compresses the breast;
• a cracked nipple, which can let bacteria in;
• stopping breastfeeding abruptly.

When problems keep coming back, the NHS advises reviewing the latch first: see our breastfeeding positions and our tips for treating cracked nipples before they get infected.

What changed in 2022: cold, gentleness, no "emptying"

For a long time the advice was to warm the breast, massage the lump hard and empty the breast completely. Some general-public leaflets, UNICEF's included, still say so. The ABM protocol, revised in 2022, explains that the pain comes mostly from inflammation and oedema, the swelling of the tissue around the ducts. There is no milk "plug" to dislodge.

Three changes follow, echoed by the NHS, Naître et grandir and Quebec's INSPQ:

1. Cold rather than heat. Ice reduces oedema and inflammation. Heat widens the vessels and can worsen symptoms.
2. A feather-light massage, never firm. Deep massage increases inflammation and can damage tissue. The right movement is a very light stroke on the skin, with no vibrating device.
3. Breastfeed on demand, without trying to empty. "Emptying" the breast with feeds or a pump stimulates production even more, and the inflammation with it. You only express a little milk if you are uncomfortable.

Engorgement: what relieves it

Engorgement in the first days often goes with the milk coming in: the breasts fill and the tissue swells. This discomfort generally lasts 24 to 48 hours, according to INSPQ.

1. Offer the breast often, at least 8 times in 24 hours, day and night.
2. Soften the areola if it is too hard for baby to latch: press gently with your fingertips all around the nipple for about a minute. This counter-pressure should not hurt.
3. Hand-express a few drops before the feed, just enough to soften the breast.
4. Apply cold between feeds, 10 to 15 minutes every 1 to 2 hours: an ice pack or a bag of frozen peas, wrapped in a thin cloth.
5. Take a painkiller if needed, asking the pharmacist which one suits you while breastfeeding.

If baby feeds too little, a breast pump can bring relief, explains Naître et grandir, as long as you stop as soon as the breast is softer. Our article on your milk coming in covers this stage in detail.

Blocked duct: a tender lump, no fever

A small painful mass, sometimes a little red, while you feel well otherwise. The care is similar:

• keep breastfeeding according to baby's needs, varying the positions;
• apply cold between feeds and stroke the area lightly during the feed, without pressing;
• loosen your bra and clothing, day and night;
• ibuprofen can reduce redness, swelling and pain, according to INSPQ, if your pharmacist thinks it suitable.

Feeding on all fours, leaning over baby, is not a technique endorsed by the ABM. A small white dot on the nipple should not be pierced. And a lump that lasts more than a few days must be examined by a doctor, Naître et grandir insists, even if it no longer hurts.

Mastitis: keep breastfeeding and watch the fever

Mastitis is an inflammation of the breast, sometimes complicated by a bacterial infection. What should you do?

• Keep breastfeeding, at least 8 times a day, including on the affected side if possible: the milk is still good for baby. If feeding is too painful or baby refuses that breast, hand-express enough to feed baby. If the breast is too swollen to let milk flow, the ABM suggests offering the other breast until the oedema goes down.
• Apply cold for about ten minutes every hour.
• Ease pain and fever with a medicine compatible with breastfeeding, chosen with your pharmacist. No aspirin, the NHS specifies.
• Rest. During the nfissa, the forty days after childbirth, family is often around: hand over the house, the meals and the visitors.
• Wear a comfortable bra that supports without squeezing, and apply no oil, cream or bath to the breast.

Many cases of mastitis heal without antibiotics: the ABM cites a Swedish study in which most inflammatory mastitis resolved this way. But if nothing improves after 12 to 24 hours of this care, or if the fever lasts more than 24 hours, get medical help. The doctor will judge whether an antibiotic is needed and choose one compatible with breastfeeding. If there is no improvement 48 hours after starting treatment, the NHS advises going back.

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Breast abscess: the complication not to leave

Rarely, mastitis develops into an abscess, a pocket of pus in the breast. It is suspected when an area hardens and reddens over several days, with a well-defined mass that feels full of fluid. The fever may drop or persist. An ultrasound confirms the diagnosis, and the abscess is drained with a needle or a small drain. According to the ABM, you can keep breastfeeding, including on that side after drainage.

Heat, cabbage, massage: sorting through what relatives suggest

When a breast hurts, everyone has a remedy. Sorting them out:

• Scalding towels, hot-water bottle, very hot hammam: heat risks keeping the inflammation going. A warm shower that relaxes you is fine, but it does not treat anything.
• "Melting the lump" with hard massage: avoid. Firm massage worsens oedema and, according to the ABM, can lead to an abscess.
• Cabbage leaves: no more effective than ice (see the FAQ).
• Oils, poultices, salt baths: not recommended; castor oil can even cause lesions when used for massage.
• Stopping breastfeeding "to rest the breast": the opposite is what you need, because stopping abruptly exposes you to new engorgement. If you wish to stop, see how to manage gentle weaning.

The breast pump keeps its place when baby cannot feed: see our tips for expressing your milk at the right pace, without feeding an oversupply.