Plugged Duct

Mastitis
Breast Abscess

Katlyn Carter 11/25/17

Evaluation and management of Plugged Ducts, Mastitis, & Breast Abscesses

1. Definition or Key Clinical Information:

Plugged ducts are a condition in which the blockage of milk results in the milk duct not
adequately draining. This results in an increase in pressure in the lactiferous duct leads
to local discomfort in the breast and a small lump in the breast, without detriment to
the mother’s general state of health. If plugged ducts are not resolved they can lead to
Mastitis.

Mastitis is an infection of the breast tissue that results in breast pain, inflammation,
warmth and redness, as well as flu like symptoms. Mastitis most commonly affects
women who are breast-feeding (lactation mastitis), although sometimes this condition
can occur in women who aren't breast-feeding. In most cases, lactation mastitis occurs
within the first 6-12 weeks postpartum, but it can happen later during breast-feeding. It
occurs most commonly in women who have cracked or blistered nipples or who are
undergoing a period of increased stress, such as returning to work.

Unresolved Mastitis can lead to a breast abscess. A breast abscess is a painful infection
brought on by bacteria. Bacteria, most often Staphylococcus aureus can enter through a
crack in the skin on the breast or on the nipple. Only a small percentage (5-10%) of
breast infections develop into abscesses.

2. Assessment
i. Risk Factors
Plugged Ducts
 Usually found in mothers who have an abundant milk supply and who do not
adequately drain each breast
 Anything that causes consistent pressure on the breast (ex: constrictive clothing,
underwire in a bra, sleeping on one side, etc.)
 Oversupply or frequent engorgement
 Stress & fatigue
 Possible risk of increase in the winter season (possibly the effects of restrictive
winter clothing, or simply the cold)
  Previous breast surgery
 An anatomical problem or variation in a particular duct, breast lump/cyst,
previous injury
Mastitis
 All of the above, as plugged ducts can lead to mastitis
 Poor nutrition
 Risk is higher among women who have breastfed previously, especially with a
history of mastitis
 Cracked or fissured nipples
 Engorgement and stasis
 Use of a manual pump
 Vigorous exercise

Breast Abscess
 All of the above-unresolved plugged ducts and/or mastitis can lead to a breast
abscess
 Previous history of breast abscess

ii. Subjective Symptoms

Plugged ducts
 Small, hard lump that is sore to the touch
 Redness around that lump
 Hot/burning sensations that may improve with nursing
Mastitis
 Tender to the touch
 General feeling of malaise and/or flu-like symptoms
o Fatigue
o Rapid pulse
o Headache
o Flu-like muscle aches
 Pain and/or burning with feedings or continuously
 Breast swelling and/or redness
 Fever greater than 101 F
 Clumpy, lumpy, stringy milk
 Baby may refuse/resist nursing
 Blood and/or pus possibly present in milk

Breast Abscess
 All of the above
 Enlarged axillary lymph nodes
 Well-defined lump in the affected breast

iii. Objective Signs

 Plugged Ducts
 Indicated by either of these two sets of symptoms
o Complaints of tenderness, heat, and possible redness in one area of the
breast
o If the plug is located in a duct close to the skin, a palpable lump of well-
defined margins without a generalized fever
 Sometimes a tiny white milk plug can be seen at the opening of the duct on the
nipple
Mastitis
 Same as above
 Breast swelling
 Area of redness on the breast that is often wedge-shaped
 Fever greater that 101F
 Tender to the touch
Breast Abscess
 Same as above
 Well-defined fluctuant lump in the affected breast

iv. Clinical Test Considerations

Mastitis and Plugged ducts can be diagnosed by taking symptoms into account, along with a
physical examination of the breast. Inflammatory Breast Cancer (IBC) can initially be confused with
mastitis. An MD may suggest a diagnostic mammogram to rule out suspected IBC. If symptoms persist
after antibiotic treatment, an MD may recommend a biopsy to check for breast cancer. Abscesses can be
diagnosed examination in conjunction with aspiration or ultrasound.

3. Management plan
i. Therapeutic measures to consider
Plugged ducts
 Rest
 Seek assistance of lactation professional to adjust breastfeeding technique that
may have caused the issue
Mastitis
 Same as above
 Pain relievers
 Antibiotics (typically penicillin or a cephalosporin that covers S. aureus for 10-14
days
Breast Abscess
 Aspiration of small abscesses (3 cms or less) (lanced and drained by MD with
differing needle techniques)
 Surgically drained for larger abscesses (>3 cms)
o A percutaneous suction catheter can be placed for 3-7 days with drain
 Antibiotics, ideally prescribed based on the results of a culture
 ii. Complementary measures to consider

Plugged Ducts

● Rest
● Apply moist heat before nursing (compresses, warm shower or bath, or leaning over a sink full
of warm water).
● Apply a heating pad on a low setting between feedings, especially during the night. This can help
dissolve the clog.
● Increase fluids
● Frequent nursing (every 2 hours)
● Change nursing position frequently
● Hands and knees nursing. Place baby on the bed or on a blanket on the floor and lean over him
on all fours. Let breast hang straight down, falling freely from rib cage. This helps drain the milk
ducts more efficiently than other positions.
● Sleep on back or side to avoid pressure on the affected breast
● Use of a properly fitting, supportive bra
● hand express a little to soften the areola and get the milk started flowing before baby begins
feeding. Gently massaging the lumpy area in a circular motion, starting behind the lump and
working toward the nipple. This can help loosen the plug.
● Offer the sore side first
● Position your baby at your breast with his chin pointed toward the sore spot, and then have him
latch on and begin nursing. This directs suction at the clogged duct.
● Cold packs as needed for discomfort
● In a reclining position have mother gently stroke the skin surface from the areola to the axilla, to
promote fluid drainage toward the axillary lymph nodes.

Mastitis
 Same as above for plugged duct

Breast Abscesses
 Refer to MD

iii. Considerations for pregnancy, delivery and breastfeeding

With all 3 conditions, it is important to continue breastfeeding/expressing milk as a
sudden weaning may worsen the conditions.

iv. Client and family education

Provide client and family with information on all 3 conditions (as one can lead to
another). Ensure family understands the importance of rest and support while dealing with and
recovering from these conditions.
 v. Follow-up
Frequent follow-up to ensure the condition(s) are improving and/or resolved. No
mandatory reporting necessary. No peer review necessary.

4. Indications for Consult, Collaboration or Referral

If appropriate measures fail to resolve the mastitis, or it continues to worsen, client should be
referred to an MD for possible treatment with antibiotics. If it is not resolved after several days of
management that includes antibiotics, a wider differential diagnosis should be considered. Resistant
bacteria, abscess formation, an underlying mass, or inflammatory or ductal carcinoma should be ruled
out. More than two or three recurrences in the same location also warrant evaluation to rule out an
underlying mass or other abnormality. Breast abscess should be referred to MD.

5.References

Wambach, K., & Riordan, J. (Eds.). (2014). Breastfeeding and human lactation. Jones & Bartlett
Publishers.