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Ep. 130- NEW Mastitis Protocol (Part 2): For Parents

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Ep. 130- NEW Mastitis Protocol (Part 2): For Parents

This is Maureen Farrell and Heather ONeal and this is The Milk Minute. We’re midwives and lactation professionals bringing you the most up-to-date evidence for all things lactation. So you can feel more confident about feeding your baby, body positivity, relationships, and mental health. Plus, we laugh a little or a lot along the way. So join us for another episode.

Welcome back to the Milk Minute everybody. We are in part two of our updated mastitis protocol that the Academy of Breastfeeding Medicine just put out, and now we’re gonna find out what to do about it. So if you haven’t heard part one yet from last week, and you’re interested in the physiology of what’s actually happening in your breast, please go back and listen to that because it’s not really that it’s plugged up with a fat clog from your milk. 

Okay, So if you are still thinking that you have a plug that looks like a chunk of fat, that’s not what’s happening. And today we’re gonna talk about how to fix what actually is happening when you have a hardened red area on your breast that may or may not have fever and malaise associated with it. And also we’re gonna speak directly to what you can do about it at home. 

Yeah. So we’re gonna make sure we go over four things that you need to stop doing immediately and the four things you can do instead. Yes. I love things that have numbers. I know you do. They make me happy and they make me feel organized.

But first, we would love to thank some of our wonderful patrons. And just so you know, we do batch record. So when we thank our patrons, sometimes you won’t hear your shout out for a couple of weeks because we record in advance. But they are coming and we do have a list to make sure no one is forgotten.

And today we are thanking Amanda from Waterville, Ohio, Nancy B and Mandy G from Morgantown, West Virginia. Thank you so much everybody for supporting the podcast. Really, they make this whole thing possible. It’s true. Let’s take a quick minute to thank a sponsor and then we’re gonna come back and answer a question.

You guys, Breastfeeding for Busy Moms, my little breastfeeding clinic isn’t so little anymore. I’m so excited that not only can people book with you in person here or virtually, but they can book with the other IBCLCs in your clinic. We also do accept some insurance directly. A lot of insurance will actually pre-approve you for a certain amount of visits, even prenatally.

So please head on over to and check out the services tab to see if your insurance is approved. Book with me or one of my IB CLCs, and we would love to work with you. You can do prenatal consults. What else can they do, Heather? Well, I often work with people who have supply issues.

We’ve got pumping troubleshooting. We’ve got preparing to go back to work, weaning, starting solids. We really cover the entire journey. So if you’re struggling, stop struggling and just schedule with me or somebody on my team at BreastfeedingForBusyMoms.Com. Dot com.

Okay, welcome back. Let’s answer a question. I think I’m gonna pull another from TikTok today. Do it. TikTok-ers have really good questions. They do, they do. So we got a comment from ADM3310 asking, Would it be bad to dry up my supply with Sudafed? And the answer is kind of like, no, but. It’s not bad to use Sudafed as part of weaning.

It just depends how much milk you’re actually making right now as to whether or not that’s like the only thing you have to do. It’s usually part of a larger process, right? So Sudafed can be like complimentary to, you know, cutting down a few minutes off your pumping or cutting short feeds or replacing feeds with, you know, it, it’s not the only answer is just part of it. 

I use Sudafed as a tool. Yeah. In the early days of maybe even bringing down a massive oversupply, I might use it to get like a little kickstart over the hill to get people moved in the right direction. And with weaning, you know, whenever you start cutting down pump times, especially when you’re eliminating pumps completely at work, but you can’t take Benadryl during the day because you know you have to work. 

I’ll use like a single Sudafed in the morning on the day that it’s like the hardest because your body down regulates pretty quickly. Mm-hmm. Usually within three days you’re kind of coming down, but that first 24 hours can be a real doozy and be very uncomfortable if you’re needing to wean quickly.

Yeah. And it shows that it really works in studies. I mean, in, in some studies just a single dose has been enough to reduce supply by 25%, and it’s safe to take Sudafed pretty often and for a number of days. You know, we all do it when we’re really sick. So you could take Sudafed like every day for a week while if you’re like, kind of aggressively trying to wean down, and that would be a really great compliment.

And as we’re moving into cold and flu season, we’re gonna link that episode in our show notes because I’ve had a lot of people that had covid that had to go to the emergency room, and the dumb ass residents don’t know anything about breastfeeding, and they load ’em up with all kinds of decongestants.

And I’ve had the breastfeeding parents be like, Uhuh, sorry, I can’t have that. And then the residents are like, Oh yeah, you’re right. Yeah. And then they’re like, Shoot, we don’t have anything else to do. So be sure to check out that episode if you’re looking for a quick, you know, refresher of what you can take when you’re breastfeeding to help cope with the uncomfortable symptoms of respiratory illness.

Absolutely. Okay. So if you tuned in last week, you know all about this, but I’m just gonna give a very small summary. Again. We now know mastitis is a spectrum of inflammation beginning with dysbiosis, so an imbalance of bacteria and or oversupply. And then it’s just like how the heck your body’s responding to it.

As you said earlier, there are no clogs in your ducts. Just swollen ducts. And when you pump out a clog, it’s actually a biofilm, folks. Cool and gross. Mm, biofilm. Yeah. It kinda looks like something I’d wanna take a Q-tip and like roll it up in it, like yeah. And then set it on fire and make it one of those tiny little fire sticks that bring into a cave.

Like weirdly satisfying. Very, yeah. I, I would just kind of wanna like smush it between my fingers. Mm-hmm. But don’t do it you guys. Yeah. Anyway. Okay. So we went on a big journey of new information and understanding, and honestly, it’s hard as healthcare providers to admit that you’ve been doing the wrong thing.

And that’s what we’re admitting now is that our other episodes are not the correct information. We’ve been giving what we thought was correct at the time treatment protocol to people. But now we have to change that. Well, and also I think we did some things right. Sure. You know, like when people had clogged ducts and they’d come to us, I’m always looking for oversupply.

Mm-hmm, because we did know that that was a precursor to plugged ducts, quote unquote, and mastitis, and also just correct fitting for flanges and breast pumping. So like how, making sure that we’re breast pumping okay. Yeah. And that’s going, so, you know, we’re trying to fix the root of the problem always, but it’s really, really good to know how we can tweak this and make it better so we don’t end up with chronic plugged ducts.

Yeah so in the protocol from the Academy of Breastfeeding Medicine, before they even talked about treatment, they gave broad recommendations that are kind of like, pre-condition things that we should be doing for everybody. And honestly, it’s like things that we do a lot, but as we’ve talked about in other episodes there’s not a lot of time for education when you see an obstetrician in a big practice.

So we’ll have to figure out how to implement this stuff. But let me just kind of go down the list a little bit and I feel like I would like to sing these from the top of the hills, please. Okay. Are these the four things? No. Oh, that’s next. This is more than four. Okay, so this is not even about treatment.

This is before you have mastitis. What we should be doing for everybody. Oh, okay. We should be telling everybody what to expect if they feel a clog or they have mastitis coming on and what the early symptoms mean. We should be educating everybody who’s going to breastfeed on that. We should tell them what educational resources are nearby like us.

Woohoo. We should educate all patients who have glands on their chest about normal breast anatomy and normal postpartum physiology of feeding. So like telling people that glandular tissue feels lumpy, you know? So it’s not alarming telling people that they’re gonna feel full and their breasts are going to feel warm after they have a baby.

Telling them what normal engorgement feels like. Preparing them. Childbirth education, breastfeeding education. This seems like I shouldn’t have to say this, but obviously I do if this is part of like a groundbreaking new protocol, we should be teaching infant feeding on demand and telling patients to try and avoid emptying their breasts every time.

Emptying the breast should not be the goal. Cuz they’re never really empty. Right? It’s a joke. And just like, as part of normal feeding, right? That’s not the goal. We should minimize breast pump usage because pumping may predispose you to dysbiosis because it interrupts the exchange from mother two baby, which is interesting.

If it’s necessary, which obviously it is, sometimes we need to make sure pumps are well fitted, they’re used correctly. We need to avoid nipple trauma. And your pumping schedule should reflect normal milk removal and not more, right? Because pumping often leads to oversupply. We should be avoiding nipple shields.

We’ve been saying over and over and over again. It’s nice to say one more time and we should be wearing bras that fit. We do have an episode on Nipple Shields and we are not anti-nipple shield. We will use them to get us back to the breast. Yeah. The goal is always to be direct breastfeeding. We think about nipple shields like epidurals.

If it’s gonna get you closer to a vaginal delivery, we’re gonna use it. If it gets you back to breastfeeding as opposed to exclusive pumping, we’re gonna use it. Yeah. And the thing about that is, you know, we’re, we’re advocating for judicious use because there are still places that you can have a baby that you just get handed one.

Oh yeah. And they’re like, Yep, use this. Okay. And you’re like, Oh, okay. Then I use this and no education about it. So we’re not doing that anymore, folks. Yeah. And all of those things you just listed definitely should have been happening already. Yeah. And they’re definitely not, and I think most people when they’re pregnant, they are so worried about the birth.

Mm-hmm. Preparing for breastfeeding in this way that’s so thorough in such a short amount of time is too overwhelming. Honestly I was like, it need to be like middle school. I was kind of exasperated about it, typing it out because I was like, Ugh, these aren’t happening? Oh, they’re definitely not happening.

But it, it really should be like in a special topics health class in high school, at the very least. Yeah. We can’t just learn this in 40 weeks while we’re also worrying about how we’re gonna get the baby out of our bodies. Absolutely. I mean, and you know, Ideally, right, we’ve got, we should be encouraging people to educate their friends and family and their kids, and to present normal infant feeding as like a public thing that we do, and we talk about ’em.

Okay? Okay. So I, I do have your four things now. I’m ready. I’m ready to receive them. Okay, everybody, Are you ready? I’m gonna blow your minds. You might feel defensive. Try not to feel defensive at home. If you’ve been doing these, like, there’s nothing wrong with you. This was the recommendation. Okay? Yeah. And, and if you see recommendations that are old on the internet, feel free to comment and send them directly to the new ABM protocol, which we will link in the show notes, okay?

Okay. Number one, avoid deep massage. Why? No more toothbrushes that vibrate. No more vibrators. No more digging into your boob. Not even gentle vibration? They say, No vibration, none. But I will get there because deep massage increases inflammation and basically damages tissue. Yeah. It’s not a muscle that we’re massaging here.

It’s a gland. So it might actually reduce pain in the short term. But it’s so easy to cause trauma. They mentioned in the protocol that like you can do massage with proper training technique, but that we should tell people not to do it. So I think that’s bs. So I’m gonna tell you how to do it. Lymphatic drainage massage is what they recommend.

So essentially the way that you do that is you make your hand flat and use the edge of your hand, so like your pinky and the outside of your hand, and you sweep down. Towards your armpit, you can sweep from the nipple to the arm. Cuz your glands, no, cuz you’re the lymphatic drainage they drain in your armpit. Right? 

The breast drains into the armpit. It’s light sweeping. You can sweep in any direction because we just have a million lymph nodes. And while some of them drain up into your auxiliary, into your armpit, others drain like down to the side. And really what we want more than anything is just some movement there.

So we’re gonna do gentle sweeping. No deep tissue massage. And you can have your partner do this if you have a supportive partner. Mm-hmm with some coconut oil, just to make it real slicky and make sure they’re doing it very gently. You control the pressure by telling them what’s too much. Yeah. We need it super light and they’re just gonna have a better angle than you will.

Yeah. I actually think of this more on, on the spectrum of massage. We’re looking more at like the sensual pressure, effleurage, versus like you know, you, you had like a hard workout. Now you need a massage. Like mm-hmm more and more like the sensual side. And then they did note that breast compression during milk expression is actually still recommended.

But it needs to be pretty gentle. It shouldn’t, you shouldn’t be like squashing your breast like you’re getting a mammogram. 

Okay. Number two. Are you ready? I’m ready. No more saline soaks, castor oil, or any other topical treatments. Can I be honest? I never bought into the saline soaks anyway. I didn’t understand it. 

Honestly I kind of feel conflicted about this one a little bit. I do understand that like sometimes the Epsom salt haakaa thing can macerate the skin, but their reasoning was basically that like it’s inside your tissue and not topical. So anything you do topically like doesn’t work. But our skin also like absorbs things and circulates it like as a semipermeable barrier.

So I could see possibly some things being helpful, but things like castor oil are only going to increase circulation and you don’t want more fluids there. Things like Epsom salts yeah, they might actually damage your skin. Again, it’s gonna like increase circulation and we wanna kind of have the opposite happening.

We’re like, No thanks. And I think people really like the Epsom salt haakaa situation because they’ve seen videos of the biofilm clog getting sucked out into the haakaa. Sure. And they want that relief so badly. And I think the haakaa being placed on creating that negative pressure is a manual pump. Yeah.

And so that’s just potentially, you know, wreaking havoc on oversupply, which might already be the reason that we have this inflammation in the first place. Or it’s just basically poking the inflammation by sucking, you know, creating the vacuum suction right on it unnecessarily. Although, a baby’s mouth.

Yeah, it’s, it’s an interesting one. I guess with all of these, the way I look at it is, okay, this is not our first go to anymore. Yeah. And if we use these things, we’re gonna be very careful and we’re gonna use them differently. Right. 

Number three is to avoid routine sterilization of pumps and household items. So especially with things like thrush, but even often with bacterial mastitis, especially with nipple wounds, people tell you to like, make sure you sterilize your bras. I mean, like clean everything because that bacteria’s gonna get in there. Sterilize your pump parts. That doesn’t do anything. And it also might just contribute to the dysbiosis.

I have questions. Yeah. So current recommendation by the CDC is sanitizing pump parts every 24 hours. Yeah. ABM says no. So what about if you do have a yeast infection, which I know they’re saying that it’s very unlikely that it is actually yeast. Mm-hmm. But if you’ve seen thrush in your baby’s mouth and they actually have the white patches and you’ve got the red shiny bits on your skin, the white vinegar, the cup of white vinegar in your washer with your breast pads is supposed to kill the yeast spores. 

Are we not supposed to be? The yeast spores are sons of bitches! Like there’s so hard to get rid of. I think what they’re saying now though is that the nipple and breast pain associated is not because of candida, it’s because of staph.

So even if your baby has candida. So are they saying like, sanitize your pump parts as usual, but don’t over sanitize them to fix the staph? No routine sterilization because it doesn’t decrease the incidence of mastitis. But does it help anything else like preventing your baby from getting ill? I mean, as we went over in the storage and pump parts protocol and everything, the milk storage protocol, no. Unless you have a preemie or like a medically complex baby, it doesn’t make a difference.

It’s not better than just washing your parts in hot water and soap. Hmm. You know, the only time they do recommend that is if regular washing is not possible, right? Like say you’re on the road and you have to do like steam sterilization. Great. But also I don’t think, you know, maybe sanitizing your pump parts is not making it, it’s not decreasing the incidence of mastitis, but mm-hmm it’s also not increasing mastitis, right? 

Yeah. But it’s just another thing to do that you don’t have to. Well, I know, I’m just trying to speak to the people that are out there currently sanitizing every 24 hours. You’re not giving yourself mastitis. No, I, but they do mention that it might be contributing to dysbiosis to have just this routine sterilization of everything.

But that’s not like the definitive reason why. I’m pretty sure. But aren’t they also saying that what, sorry to play devil’s advocate, I’m just, it’s a very complicated protocol. It is. So, but they’re also saying, topical stuff on the nipple is not traveling back in the ducts to create mastitis either, but our microbiome also exists on our skin.

Right, right. So I don’t know. It’s interesting. That I need closure on eventually, but that’s good to know. Well, you know, I didn’t have time to read every single study cited, cuz there were about like 85 of them. Usually, I tried to go through a bunch of them, but there was a very long list of studies cited because this is a very long protocol.

So unfortunately, like usually I like to really dig in deeper on these. I just didn’t have the time, this time. Well, and it also says avoid routine sterilization of pumps and household items. So that might just be like, stop scrubbing your house top to bottom with Clorox. You know, that is creating dysbiosis in every tract of your body, I’m sure.

Yeah. So be dirtier. I’m fine with that. Okay. Number four, you ready? I’m ready. No more heat. We’re done with heat. Ever? Pretty much. Yeah. They say avoid hot compresses because heat increases inflammation. We used to be like hot showers, hot compresses. So now they’re saying no hot compresses and even just like standing under the hot shower is not necessarily going to help.

No. It may provide immediate pain relief. Mm-hmm. Like something like a hot shower isn’t gonna make it worse, but the repeated application of hot compresses definitely can make it worse. Hmm. Even for engorgement? Yeah. Hmm. Because that is like part of that inflammatory mastitis, but there is a difference between the primary engorgement and inflammatory mastitis.

Oh, sure. Yeah. But either way, the tissue is probably more friable. Mm-hmm and more delicate because it’s being stretched. Same thing with hyper lactation. Those tissues are just working extra hard at those times and we have to treat them more like injured tissue. But you know, that’s funny because if we have injured tissue and we’re a physical therapist, we’re gonna do, depending on what it is, we’re gonna do, heat or cold, or maybe both.

Right. True. But this isn’t like with, say, a physical therapist, where we’re talking about injured muscle or tendons or whatever. But this is a gland. Okay? But if I had, for example, a, you know, my Bartholin’s gland on my honeymoon and my vagina that swelled up, they’re gonna tell me to do an Epsom salt hot bath.

And maybe they shouldn’t. Not anymore. I don’t know. They probably will still tell you to do that. And what they noted in this is that often that hot compress provides immediate pain relief, but it doesn’t help with the root cause. It doesn’t release anything. Yeah. Okay. Okay. I do actually have more than four things that we’re doing.

Sorry. It’s like seven. God, I thought it was four. God. Okay, so now we told you what you’re not allowed to do anymore. No, just kidding. You do whatever you want. But here’s the real up to date recommendations. Now what? Okay. Our aim, now that we have all this knowledge in our brains is to decrease inflammation.

So what do you think we should do? Well, this part I feel like I’m actually doing well with my patients. Yeah. It’s the other ones that I need to stop doing. We’re gonna do ICE and NSAIDs. Yep. So lots of ibuprofen. And they, they’re actually giving recommendations for big doses. People do not go hard enough on this, like we’re treating an acute inflammatory issue, so they want us taking 800 milligrams of ibuprofen every eight hours.

And possibly in addition, 1000 milligrams of acetaminophen every eight hours if there’s a lot of pain. Mm-hmm. And this is kind of shocking. Ice hourly or more often as needed. Yeah. That I can see for people that have an oversupply, but I can’t imagine that ice is gonna be good for a milk ejection reflex in someone who’s just dysbiotic but doesn’t have an oversupply.

Yeah. And I think we’re gonna, you know, and, and what they said, basically as needed, like what I read into that is this is a case by case basis, but they’re saying ice is preferable over heat in most cases. And they are still saying, this is interesting to me. Mm-hmm. They’re still saying sunflower or soy lecithin 5 to 10 grams daily by mouth.

I know why. Yeah. I looked this part up. Mm-hmm. Yeah, so it’s actually, we’re trying to pinpoint what it is about the lecithin that makes it anti-inflammatory and it’s the choline in it. Right. And so actually a lot of lactation consultants are like, can we skip the soy? Yeah. And can we just get the choline and we can actually get choline from a lot of foods like egg yolks and kale.

Organ meats, peanuts, things like that, right? Which a lot of people are eating anyway. But like you can also just get a choline supplement. And you can get a choline supplement. I’ve also found recently there’s a lot of like B complex vitamins that have a hefty dose of choline in it, and B is not bad for anything, right.

You know, so it’s, and it’s water soluble. It’s gonna make you pee a funny color. It’s gonna make your pee a little bit neon. So I’ve had some good luck with that. And just kind of skipping the soy bit all together and there’s been a lot of noise recently from lactation professionals and like holistically minded practitioners being like the soy and sunflower lecithin is so pro-inflammatory.

Why are we using it then with this new protocol? And they’re pushing just for the isolated choline. I don’t know how strong the evidence is that this lecithin is a pro-inflammatory food. You know, like I think there’s maybe like one study or something. It’s, it’s not something we have like 10 studies on though, so.

Well this makes sense to me also to have a little bit of an emulsifier on board. Sure. Because you know, if you have that inflammation and the ductal narrowing and you’ve got a biofilm, clunking everything up, then our milk will get there. Then our milk is gonna thicken up around there too. It’s not, cuz your milk is high in fat, but it’s gonna, it is gonna congeal around that biofilm.

Yeah, I guess, and if the opening is smaller, it makes more sense than to have like slightly thin milk. But that’s an interesting one. And I know they said like they, for all this stuff, they provided like a level of evidence, you know, the level for that wasn’t like as high as, you know, ibuprofen. And 5 to 10 grams is a lot.

So that’s a lot. Yeah. I did not say milligrams. Yeah. So I’ve actually, I’ll have to change what I’m doing, because I tell people if they have an active area that’s, you know of concern. We’re doing 1200 milligrams three times a day’s. Not enough, I guess. Like three to four grams a day. So I’ll have to change that too.

Yeah. Okay. Well, we’re changing people. It’s okay to change. Yeah. Okay. So we’re also making sure that we pay attention to nipple blebs. We don’t tell people that they’ll just go away. We still are avoiding un roofing or picking at them or poking them with a needle. However we’re treating them like we treat everything else because they are part of the same inflammatory process.

We’re doing the oral lecithin and this recommends topical steroid cream, which in the last episode we mentioned that the blebs are essentially an overgrowth of skin in response to the inflammation and steroid cream thins out your skin. Over time if you use it long enough. Yes, over time. So it might be something where that is another kind of like perk to using that in this case is that it’s gonna possibly thin out those epithelial cells. 

And reduce inflammation, so, mm-hmm, you know, something to think about. They didn’t really explain in detail why they recommended all of this. Well, what’s going through my head as a provider is like, okay, well can I skip the compounded cream, the all-purpose nipple ointment, and can I just order betamethasone at 0.2%?

Yeah. They gave a specific recommendation for the kind of steroid and the percentage. I just didn’t write it right here because. Okay. Well I will go dig out. Sorry. I was trying to keep this brief and accessible. I’ll stop asking questions. Okay, next we’re treating oversupply. Come on people. This happens all the time where people go from mastitis, they get antibiotics, and then that’s it.

End of story. It’s usually caused by oversupply. We need to treat the oversupply if it’s causing a pathological problem. Yeah. Please don’t be pathological.

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This next one, I’m so excited to see. It says, utilize therapeutic ultrasound. How was that different from vibration ? I don’t know. It’s different. TUS uses thermal energy to reduce inflammation and relieve edema. It can be effective for all conditions on the mastitis spectrum. Can be used on a daily basis until symptoms are relieved.

So we’re not going once a week. You’re gonna go every single day, you know, to whomever is providing this to you. And they said they wanted like one megahertz intensity of. I don’t know. I don’t know what this measurement is. Certain intensity for five minutes at a time. So short little bursts of this therapeutic ultrasound.

And if you provide therapeutic ultrasound services or you think you can, or you want to, check out this protocol and it gives you exactly what you need to use for that. I want one of those little ultrasound machines for my office. Mm-hmm, like one of those little handheld ones. Like the butterfly? The butterfly.

Can you do therapeutic ultrasound with those? I don’t know, but I will find out. Like you would have, I like, I know with my like doppler, you have to change the probe if you wanna change the megahertz. So like some of those fancy ultrasound machines, just like the probe is the whole thing. I don’t know if you can adjust or not, but I will look into it.

Yeah, look into it. Because that would be awesome to have in your office. Yes, it would. I wonder how you go billing for that as a lactation professional? I don’t know. I have so many questions about how to do anything. Maybe you could bill for that as a cnm. Yes. Well, there’s, that’s very complicated actually.

It’s more complicated. I’m sure it is. Insurance companies barely know what to do with midwives anyway. And then if you’re like, No, I’m a midwife, lactation consultant, and I could do ultrasound. You like, I used an ultrasound on a boob, and they’re like, weird. You don’t fit in a box. $5. Yeah, I maybe that would have to be cash pay only for that. Flat rejection. 

You figure it out. Yeah, No doubt. Yeah. I promise you guys we do not ever want to be cash pay only providers. It is only out of necessity when that happens. Like for the most part because working with insurance companies is soul sucking. Yeah, it’s a lot. But we’re willing to figure it out and like these new protocols are helpful to have on hand so we can be like, Alright, well who is able to use it?

Yeah. I think they specifically mentioned that it’s common at like physiotherapy offices. Mm-hmm. But it’s not the only place. A lot of chiropractors have them. Mm hmm. Stay tuned everyone. Okay. So what else are we doing? Okay. We are not prescribing antibiotics as often. Basically we have known for a really long time that we should stop overprescribing antibiotics.

Prophylactic antibiotics have not shown to be effective to prevent mastitis, but we have to note that some antibiotics and antifungals are also anti-inflammatory. So that’s often why they seem to work, even if we’ve been dealing with inflammatory mastitis and not bacterial mastitis. Yeah. But when I read this protocol, they did make a good point.

Mm-hmm, the minute you give antibiotics, you’re putting them into dysbiosis. Yes. Which sets them up for future mastitis episodes. Yeah. And you’re possibly setting them up to then have you know, if they had a very small bacterial infection or something to have a resistant strain crop up later. Now we have an abscess.

Yeah, with a gravity drain. Well, the next one I’m really excited. So the next one is consider probiotics. Yes. And they actually gave us strains for once. I feel like usually I look at these and they’re like, try probiotics. Maybe they’ll work. End of story. They told us which ones. Yeah, so they told us the strains and the goal is always to find a probiotic that has the strain in it with the highest number of CFUs that you can afford. 

Yeah. For your budget. And you know, refrigerated is also going to be the best way to go because it’ll preserve the most bacteria, the most live bacteria. Yeah. So probiotics, do you wanna give these names?

So you want me to read ’em? These used to both be Lactobacillus Genus named, but now they’ve changed it much longer words. You try one. I’ll try the other. All right, so we’ve got Limosilactobacillus fermentum, formerly lactobacillus or, and then preferably they want you to use Ligilactobacillus salivarus. Whew.

Yeah. So probably still labeled as lactobacillus. Yeah. Which is also good for your vagina. Yeah. Which is great. Absolutely. So, hopefully not too hard to find, but I have to say, I did not troll Amazon last night to see if I can find. So I have looked so Klaire Labs is usually what I like. I like Klaire.

Yeah. But they’ve been out of it. Oh. And so I’ve seen some on Amazon there’s one called Elactia. Okay. And of course, I can’t promote any of these brands, really. Yeah. Because I don’t, we don’t have one that’s best, better than the others, which is part of the hard thing about probiotics. Yeah. 

And I think one of the big thing is you don’t wanna just get one that has like every lactobacillus strain in it. You wanna really target it. Yeah. With just one or two. And that is harder to find, right? Because a lot of these probiotics kind of sell like what you might think of as like broad spectrum to deal with a number of different issues.

And then they don’t really work well for any of them. Mm-hmm. So if you can find that, that’s what we should be recommending to people, that’s what you should be doing as part of your at home treatment. So I also, when I give people the recommendation to do these probiotics, I also say pick up some of that, like Kavita probiotic drink like kombucha.

You know, drink lots of kombucha, lots of fermented foods. You can really think about your diet in this case, like if you can get six servings of a fermented food in every day. Yeah, lots of good yogurt. If you can find like lactose fermented pickles, sauerkraut. Lots of stuff like that is gonna be very good for the situation.

And what these do is really help with that biofilm. So it helps break down that biofilm and get everything moving again and flowing. And then additionally, I will tell people if they can tolerate it to make a ginger turmeric honey lemon tea and make it really strong and take a few shots of it every day.

Just throw it in the fridge and take a few shots of it. Cuz turmeric is very anti-inflammatory and so is ginger. Yeah. And ginger is good for your tummy in general, just kinda makes it easier. Yeah and with, with those things, like you could take pretty massive doses without harming yourself. Exactly. And usually things are a lot more bio available to us when we eat them and digest them.

Yeah. As opposed to what am I trying to say? Like taking pills and capsules and stuff. Yeah. Right. Cause you know, Okay. So love that the probiotics are in there and we’re actually like a big organization is giving a nod to the fact that they might work. Yeah. So this last one is, a note for healthcare providers who are seeing people who need to have their mastitis treated is that we need to be evaluating all mastitis patients for perinatal mood and anxiety disorders because people with those PMADs have much higher rates of mastitis.

Oh, weird. How the gut and the brain are connected and, and it’s just, it makes sense. If you’re having some issues with oversupply and feeding and your stress and you probably have something disrupting like normal physiological feeding of your infant, maybe your baby is in the nicu, like shocker, you’re probably gonna have some issues.

So, this mentioned that many patients are going to feel defeated by breastfeeding, afraid of mastitis and supply issues, and might be unable to stop pumping despite your recommendations because of anxiety. And how many times have we seen that? A thousand. A thousand times. And this is possibly the first time I’ve ever seen it mentioned in a scientific paper.

Yep. I’m really excited about it. Yeah. If someone is exclusively pumping, and they have an oversupply, but they won’t stop, I’m like, Listen man, we gotta talk about this. Yeah. Wait for having a problem. You are creating a pathological problem, or at least preventing your body from healing itself. You know, like we gotta intervene at some point.

Yeah. They also mentioned that if they’re coming in for an exam folks with a PMAD might show an extreme pain response that is out of proportion to the exam. Hmm. That also makes me think Big T trauma. Yeah, which of course we’re gonna have higher rates of postpartum, like mood and anxiety disorders if we’ve experienced that in the past, maybe are currently experiencing it.

It also mentioned to consider D-MER as a possibility, not really explaining why they linked it, but I think they’re just throwing it in there, being like, We need to talk about this more. So good. Good. Yeah. We do need to talk about it more. Thanks ABM. Yeah, absolutely. So the further details that I just wanna mention, first of all, if you are a healthcare provider who can prescribe and treat mastitis, you have to go check this out.

They provide very clear protocols for new antibiotic dosing, all of that. What we’re telling folks now is all that stuff that we mentioned above with the ice and the gentle massage and normal feeding and anti-inflammatory. If you have mastitis forming, do all of that for 24 hours. If nothing improves, that’s when you need an exam and possibly antibiotics. 

Providers then, if you have someone who has been on those antibiotics for mastitis for 48 hours and nothing is improving, you should consider doing a milk culture. You might not be using the right antibiotics. You might have a resistant strain. So that’s really important to do soon and not make people suffer. Okay, so we have some new recommendations for draining galactoceles, abscesses and phlegmon.

And I don’t wanna bog you down in the details, but I just have to mention them cuz they all kind of relate. The phlegmons may or may not need to be drained, but just think about them while I’m talking about this. Okay, So for abscesses and galactoceles, If they need to be drained with a needle aspiration, if you’re already doing that, please do a fluid culture.

Okay, you already have the fluid. Do a culture. Repeated aspirations of those significantly increase the rates of early weaning. Shocker, if we’re stabbing you with a needle over and over because you’re breastfeeding, you’re gonna wean. So what’s recommended is that drain placement should be done as part of the initial intervention often and, and that should be part of your consideration for the definitive management, right?

When you do that first aspiration with a gravity drain rather than suction. No vacuum assisted devices. Probably if we’re doing that we need an antibiotic as well. We’re feeding normally. And we’re gonna have intermittent exams as well as part of that ongoing treatment. And we’re gonna do imaging at the end to ensure resolution.

And then you take the drain out. Yes. So that is not what the recommendation was before. Before, we were doing lots of repeated needle aspirations and really needlessly putting people in pain. So well, and also they were un roofing blebs with needles, which was also uncool. And also I think the recommendation to do aggressive massage and lots of vibration and lots of heat was creating more phlegmon and abscesses that had to be drained.

Yeah, and you know, this protocol is really encouraging the use of radiology as a guide for how to treat and when to stop treating, and I definitely appreciate that. It’s also mentioned it now as part of the treatment for recurrent mastitis is to use imaging to evaluate what’s going on under there.

Is there an underlying mass? Is there some kind of anatomical anomaly? Like do we have like some kind of granulomas or something, you know, like, what’s going on? Is there something there structurally? Yeah. I’m glad they put that in there. Yeah. Cause can I just tell you that I have sent people to breast centers before and they refuse to ultrasound them, so they’re like, Well, if they’re lactating, there’s so much going on in the breast, we won’t be able to see anything anyway.

Guess what? It’s your job, time to get good at it. Like I’m, I’m done with that. I’m so done with it, and I’ve, I’ve definitely had people refused for ultrasounds before because they, and because they were lactating or they come in and they’re like, Oh, I drained my breast. And they’re like, No, you were supposed to come in full.

We’re like, well, you should tell people. Yeah. Like, oh God, I’m sorry. Okay. Be clear. We should be doing ultrasounds on breasts when we have issues with abscesses, galactoceles, et cetera. Okay. Yeah. Thank you. Okay, so you ready for the summary? I’m ready. 

Ice, NSAIDs, physiologically normal breastfeeding are ideal for broad spectrum treatment. Do not ignore oversupply. Refer to a lactation specialist if you don’t know how to deal with oversupply. Do not underestimate the importance of the microbiome and supporting that. Avoid deep tissue massage and too much heat and avoid overstimulation of the breasts, extra pumping, extra milk removal. Okay. Okay.

Well, everyone take a deep breath. Understand that change is hard. You know, we’re not losing our practice, okay? We’re gaining a new way to practice. True. And we are always gonna try to get better. In 50 years, this will be different also. 

But you know what I did lose? What? My bathroom birds. They’re gone. My God.

Susan. Susan has gone. Do you guys remember, I don’t know how many episodes of ago. I was like, Heather, I have a bird living in my bathroom and she’s raising babies while I poop. Yeah. So if you haven’t heard that one, I was like silently blinking at her from across our recording space, just like, of course you have a freaking bird in your bathroom.

Yes. So anyway, summary, I left the window open, a bird made a nest and laid eggs in my bathroom, and there were federally protected species, so we just left her there. They hatched; they grew up. And then one day I came into the bathroom and like the day before I was like, they’re gonna fledge so soon.

They look like adult birds basically. And I came in and you know how when you open a double hung window, there’s like the gap between them. Oh boy. So I came in and one bird was stuck in the tub. One, thank God, was not in the toilet. It was just near it. And then the other was stuck between the windows. Why are babies always trying to unalive themselves?

No, they’re really, they were just like toddlers, I swear. So I scooped up the two that were easy to access and threw them out the window and they flew. You just throw ’em? Yes. You just throw them? Well, I mean, I like gently like, you know, like just, Oh God, I didn’t like throw them like a ball. I just kinda like underhand. Like she just over, I just kinda like boost this House Wren out the window. And I could hear the parents out. 

Like the parents are part of the fledging process. So they were out in the popular tree by the window, like yelling for them. So I just kinda like boosted them out. But then that one between the windows there, it was so stuck and when I pushed the windows like open to try and grab it, it got like wedged and then it was like, it was a process.

But I do, I did put a video on my personal TikTok account cuz Griffin was there, so he was videoing. Oh God. But I got it out safely, which is hard to do because they’re so delicate. They’re like, their bones are like toothpicks. So I was like, Oh my God, I don’t wanna break you. And I got it out and I just like gently extended my hand out the window and that one flew away.

Cause I wanted to be a little more gentle with that one. Oh. And it successfully flew out into the yard and their parents fed them all and it was fine. Why does that give me so much anxiety? It was a hectic moment to walk into my bathroom and have birds flying around. I just, that’s one of those things I just don’t need to deal with in my life.

You know what I mean? You know. It was exciting though. Oh god. So much pressure. If I had killed a baby bird by accident, broke its little wing and then softball pitched it out the window, I would’ve been so sad. Well there were only three birds in my bathroom and I know four had hatched, but it was really hard to tell if four reached fledging because the nest like was so small. 

I could never tell if all four were in there after a certain point, you know, cuz they’re just like in a little bundle of snuggle birds. So I don’t know if they all made it, but I know three did. And 75% is pretty good. Yeah. You know? I feel successful.

I’m going for a hundred percent with my kids. Yeah. Speaking of leaving the nest. Well, I think like, you know, fledgling mortality rates are generally higher, so I would hope so. Yeah. Speaking of leaving the nest, Heidi started pre pre-K cuz she’s three and a half and she’s going to the big girl school and she keeps talking about how she, I, I growed up.

Oh, and I’m like, Heidi, did you? She told me she’s gonna start driving soon. I was like, You’re, you’re not gonna start driving soon. And she’s like, I’m gonna drive myself. And she goes, But I don’t know how to turn around. And I was like, Well, turning around is a really big part of driving, so maybe we’ll just wait.

And she’s like, Yeah, maybe we’ll wait. And so I said, Are you nervous about your first day? And she was like, No. And I said, Are you gonna make friends? And she goes, Yeah. And so when I picked her up, of course she’s covered in dirt head toe. Sure. And I love the school that she goes to. Their playground is twice as big as the building, which shows where their priorities are.

And she literally was filthy and I, and she was exhausted. And I said, Hi, did you have a good day? She goes, Yes, I made 50 friends. Aww. So I’m really proud of her. She has fledged all the way to the Early Learning Facility called ELF. That’s so sweet. Yes. And she’s having a great time. She’s there right now. Aw.

Yep. Yeah. Oh, they’re so sweet. It’s really hard to believe. Do you know, I just yesterday witnessed like possibly the first instance of actual like, cooperative play between my children. Oh. You know, like they’ve done some parallel play, which you know, like occasional things you see in like, you know, year and a half, two year old range.

But this one, Griffin, he was doing something really annoying. He was pretending to be a cat, so he was like crawling around on all fours going like, meow, you know, it’s like the most annoying thing. But Lyra looked at him and got on all fours and started crawling around and going, meow, meow. And like interacting with him though, not just like paralleling, you know, she’d like crawl over to him and like touch him and meow at him and I was like, Oh my God, this is the most annoying, adorable thing I’ve ever seen.

Amazing. Just wait. They’ll start fighting soon. It’s really funny to watch my nine year old fight with my three and a half year old. I’m like, buddy, you’re nine and you are full on arguing with a little terror. Well, you should check yourself. He’s like, I know, but good. I’ll hear Heidi. And I’m like, Griffin already is just like Lyra, ah! 

Yeah. She. So she understands potty humor now. Oh yes. That’s the first kind of humor. Yeah, it is. So now when she farts, she waves her hand in front of her nose and wrinkles it, you know, and laughs. And then she farts on purpose. You’ll see her go like, Oh, and like squeeze another out and then do it.

Yes. And she’ll go over to Griffin and stick her butt on him and squeeze outta fart. And then laugh about it. No. Ah, she’s like one year old. I’m shocked at her like literally pushing farts out because everybody laughs. Like I, I, I know they get that humor at that age, but like, she’ll look at you and her whole face will turn red, you know?

And she’ll like squeeze one out and then laugh about it. Oh my gosh. That’s hilarious. Yeah, we, Heidi, just every, she slips she calls penises peanuts and vaginas poo vaginas. And she sneaks those two words into every one of her jokes. And you know, and if she really gets you laughing with, you know, something separate, then she’ll just start randomly say, Yeah, and peanuts and poo vaginas peanuts and poos just to like, keep you laughing cuz she’s enjoyed it so much.

Oh yeah. Oh that girl. Huh. I know. It’s wonderful too. They’re growing up so fast. They are. All right. Well, much like our children, the mastitis protocol has grown up and we’re releasing it. We’re fledging it out into the world. Please spread the word. This would be very helpful if you shared it with all of your people.

As you can tell, it’s very, very important that we get this new information out there for everybody so we can prevent antibiotic resistance and chronic mastitis. And breast surgery basically is what we’re preventing here and early weaning, because nobody likes any of that.

I tell all my patients who are brand new parents to put a list of soothing techniques on the refrigerators so they can both remember what they’ve already tried for soothing baby. I like to put a Happi Tummi on that list. It’s a natural herbal wrap that soothes and relieves pain instantly, and it’s so fuzzy.

It’s so great. It helps baby sleep at night, resolves colic, gas, or constipation, and it’s great because it has a cute animal on the front for when they’re doing tummy time, which provides gentle pressure to help them get their toots out. And you know what? They’re not just for babies. They have them for teens and adults too.

Mm. So if you’re struggling with those period pains, get your herbal warm, Happi Tummi wrap today by going to And if you love us, enter promo code MILKMINUTE10 for 10%. That’s MILKMINUTE10 for 10% off your Happi Tummi. Thank you so much for supporting the show.

All right, well, before we get outta here, we’re gonna give an award in the alcove and can I give this one cuz? Yeah. She’s my buddy. So this award goes to Jamie from West Virginia. Well, she said I could use her full name. This goes to Jamie Williams from West Virginia. Everybody knows her and loves her cuz she’s on our local radio station.

Jamie says, I’m still on my breastfeeding journey with my four and a half month old son. Since I work full time, I’m mostly pumping. Over a weekend there was a fundraiser that involved me camping in a tent in a business parking lot until I could raise $10,000 for the local no-kill animal shelter. My biggest concern was where can I pump?

The business was generous in offering me their only bathroom. They don’t have a private office or break room. I found an alternative. The giant mobile boom box for our radio station. It is often used in parades or for sporting events, and it’s basically the size of a parade float and plays music. So every four hours, there I was on a camping chair inside a giant boom box so I could feed my kid.

What an experience. You think that vibration of the boom box was helping ? I hope so. Jamie, we’re gonna give you the Boomin’ Boobs Award. I love that because obviously pumping in a boombox is incredible and you deserve all of that. And also congrats on raising $10,000 for a local no-kill animal shelter.

That’s really great. I mean, there’s just so much good happening in that one award. I mean, this is part of why I love the awards, cuz I feel like we get to see these like little personal moments from such amazing dynamic people that listen to this podcast. Yeah. There’s good people out there, guys.

Yeah, really good people like this one who wrote us an Apple Review. Libbyluv1269. Binge watching. I found y’all on TikTok and started listening to a recent episode while I was cleaning the house. I loved it so much I started from episode one and I listen all day long. My baby is so used to it now that he sleeps through the podcast playing

Thank you both so much for all the answered questions. Aw, thank you so much, Libby. We’re so happy to help. Thank you Jamie. And thank you to everybody else listening out there. Yes. That’s been another episode of the Milk Minute podcast. Yeah, and thank you for helping us change the way we do things here with this new mastitis protocol because we need to change this big system that’s just not really helping us.

If you found value in what we produce for you today, you can become one of our V I P patrons. So head on over to, and you can get early in ad free episodes, merch. You can message us. You can do live video with us. You can see all of our personal behind the scenes stories, and you get to support a really cool project and help more people just like you access this information for free.

Sounds good to me. It does. Okay, guys. We’ll see you next week with another amazing episode. All right. Bye-bye.


Academy of Breastfeeding Medicine Clinical Protocol #36:
The Mastitis Spectrum, Revised 2022


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