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Abstract

Scenario: Elizabeth, a lactation consultant in private practice, is frustrated when a woman returns with persistent plugged ducts. She often sees women around 3 to 6 weeks and again around 4 months postpartum, with a combination of symptoms including white blebs at the tip of the nipple and abundant milk supplies. Often she works with them to clear up the plugged ducts, only to find them back under times of stress, when other children are sick or during the holidays, on the brink of mastitis. Elizabeth would like better indicators to help identify the risk factors for recurrent plugged ducts and suggestions for ways to work with women in their treatment to avoid other complications. She has heard about the use of alternative therapies, possibly even ultrasound, but is unsure of the scientific efficacy of these treatments. – [An invited response follows].
Faireld University
DigitalCommons@Faireld
Nursing Faculty Publications School of Nursing
1-1-2006
Consultant’s Corner: Recurrent Plugged Ducts
Suzanne Hetzel Campbell
Faireld University, scampbell@faireld.edu
Copyright 2006 Sage Publications.
is is the pre-peer reviewed version of the following article: “Recurrent Plugged Ducts” which has
been published in nal form in the Journal of Human Lactation ( 22, 340-343) DOI: 10.1177/
0890334406290362
Published Citation
Campbell, S.H. (2006). Consultant’s Corner: Recurrent Plugged Ducts, Journal of Human Lactation, 22, 340-343.
is Article is brought to you for free and open access by the School of Nursing at DigitalCommons@Faireld. It has been accepted for inclusion in
Nursing Faculty Publications by an authorized administrator of DigitalCommons@Faireld. For more information, please contact
digitalcommons@faireld.edu.
Repository Citation
Campbell, Suzanne Hetzel, "Consultant’s Corner: Recurrent Plugged Ducts" (2006). Nursing Faculty Publications. Paper 7.
hp://digitalcommons.faireld.edu/nursing-facultypubs/7
1
Scenario:
Elizabeth, a lactation consultant in private practice, is frustrated when a client returns
with persistent plugged ducts. She often sees mothers around three to six weeks and again
around four months postpartum, with a combination of symptoms including white blebs
at the tip of the nipple and abundant milk supplies. Often she works with them to clear up
the plugged ducts, only to find them back under times of stress, when other children are
sick or during the holidays, on the brink of mastitis. Elizabeth would like better
indicators to help identify the risk factors for recurrent plugged ducts and suggestions for
ways to work with mothers in their treatment to avoid other complications. She has heard
about the use of alternative therapies, possibly even ultrasound, but is unsure of the
scientific efficacy of these treatments.
Invited Response by Suzanne Hetzel Campbell Ph.D., APRN-C, IBCLC:
Recurrent or persistent plugged ducts are a significant problem for a large
percentage of lactating women. Without effective treatment, plugged ducts can lead to
infective mastitis,
1
breast abscess and ultimately breastfeeding cessation. There is a lack
of scientific research examining the incidence, risk factors, causes, and treatment for
recurrent plugged ducts. Although incidence has not been studied or documented,
anecdotally and experientially it appears that approximately two-thirds of women
experience plugged ducts at some point in their breastfeeding experience. Fetherston
found the most significant predictor of mastitis in both experienced and first-time
breastfeeding women was the presence of blocked ducts. Predictors in first-time
breastfeeding women included: engorgement, hurried feeds, and using a nipple shield,
2
while predictors in experienced breastfeeders were: restriction (e.g. tight bra), milk
described by mothers as “thicker”, misshapen nipple after the feed, and a past history of
mastitis.
2
Often circumstantial situations that interfere with infant led nursing combined
with physical risk factors such as poor latch, ineffective breast emptying and pumping or
restriction of the breast, cause persistent plugged ducts and the sequela that may follow.
Some of the physical symptoms that individuals with plugged ducts may describe
include: a tender lump in the breast, an area of blush color to the skin over the tender
area, and the breast itself may feel hot. Others will have a white bleb at the end of the
nipple on the breast with a plugged duct and some complain of pain in the nipple or brief
and shooting pains in the breast. The tender lump indicates an area where milk flow has
been impeded and is not moving freely. If left unattended, the area may become warm
and send shooting pains. The white bleb represents an actual blocked duct, similar to the
tip of white glue that has solidified with exposure to air. As the mother works on
removing the plugged duct, the bleb should also work its way out. In addition to physical
symptoms, the lactation consultant can be aware of risk factors for plugged ducts from
the client’s lactation history.
In taking the lactation history of an individual there are some indicators that
should alert the lactation consultant to the possibility of this person developing recurrent
plugged ducts. These indicators may include: early and/or extreme post-partum
engorgement, high milk supply, milk leaking in between feedings and/or one breast
spraying when the other lets down. In addition, some clients report having used an
ointment for sore nipples
3
, such as lanolin, or nipple shields
2
. The use of lanolin or
nipple shields does not indicate a woman will develop plugged ducts, nor is the ointment
3
or shield necessarily “causing” the problem. However, the presence of these factors
should alert the lactation consultant. A mother who has returned to work or school and is
pumping while separated from her infant is also at increased risk
3
. Although breast
pumps have become more efficient, they cannot match the infant’s ability to empty the
breast. Finally, clients may report a past history of recurrent plugged ducts and/or mastitis
with other children
3
. Physical symptoms in combination with the lactation history should
alert the lactation consultant to the client’s risk for recurrent
plugged ducts.
Factors that can lead to plugged ducts include: insufficiently emptied breasts
related to following arbitrary cultural rules about restricting or timing feeds, or side-
switching (neither determined by infant cue); infant behavior and positioning at the
breast; or environmental factors. Problems can occur in early postpartum if the mother
experiences engorgement and the infant is pre-term, near-term, or sleepy from jaundice.
Anything that interferes with latch and the adequate transfer of milk can lead to plugged
ducts. If the mother experiences cracked or bleeding nipples, or pain with nursing, it is
probable that the infant is not effectively emptying the breast. The lactation consultant
may notice that the nipple is misshapen, “lipstick shape” or compressed flat after a
nursing. Misshapen or sore nipples may be indicators of a shallow latch, insufficient
breast emptying, and increased risk for plugged ducts.
Infant behavior at the breast such as tugging, pulling, or twisting at the nipple may
be related to milk flow issues. These behaviors may reflect either the impatient infant
waiting for the flow to begin, or the infant struggling to control an abundant milk supply
and fast flowing milk.
4
Elizabeth complained of the increased occurrence of plugged
ducts in older infants, for example at four months. Older infants’ developmental changes,
4
including increased mobility and greater interest in their environment, lead to sudden
pulling at the nipple and less than optimal positioning. Infants with older siblings may be
exposed to more distractions, causing them to quit feeding early and/or to nurse less
often. In addition, at this age infants may start sleeping longer during the night, resulting
in decreased breast emptying.
Outside environmental factors that cause sustained pressure on the breast, such as:
infant carriers (especially front-holding), heavy purses or diaper bags, and restrictive
clothing (e.g. tight, under-wire, or sport bras, bathing suit), may also interrupt the milk
flow, resulting in plugged ducts
.5,6
Other factors that may affect the mother’s physical and
emotional health are fatigue and maternal stress. Busy, active, hectic days can lead to the
mother breastfeeding hurriedly and/or leaving the breast unemptied for longer periods of
time. Major holidays and/or family celebrations, family crises or illness, also increase
maternal stress and can result in infrequent feeds. Clients experiencing persistent plugged
ducts report a return to commitments outside the home (e.g. work or school), partners
who travel or work long hours, a lack of support systems, stress and fatigue.
7
Interventions:
In general, lactation consultants can educate mothers experiencing persistent
plugged ducts about the importance of baby-led breastfeeding and avoiding arbitrary
rules about breastfeeding. Baby-led breastfeeding refers to the mother understanding the
infant’s cues and behaviors (rooting, hands to mouth) and watching the infant rather than
the clock for timing, frequency, and duration of feeds. The lactation consultant’s role in
educating the mother to recognize when her infant is hungry, to determine whether the
5
latch is comfortable, and to recognize comfort and effective emptying in her own breasts
is crucial. In addition, demonstrating various positions for more effective emptying (e.g.
directing the infant’s chin toward the plugged duct)
5
and teaching breast massage can be
helpful as well. For easily distracted infants, suggesting that the mother nurse in a quiet
room or waiting until the infant is sleepy to nurse most effectively may be helpful.
Once plugged ducts have formed, traditional treatments such as hot compresses to
the site (wet or dry) work well. Hot showers and baths, with or without some form of
massage, are often used. Many lactation consultants recommend analgesics and massage,
using firm pressure behind the lump of milk, pressing the mass of milk towards the plug
in an effort to move the blockage towards the nipple. Frequent attention to the site and
eliminating plugged ducts is of the utmost importance, to avoid the other more severe
complications of mastitis and breast abscess. Some mothers experience relief from pain
and discomfort with ibuprofen, an analgesic and anti-inflammatory. To accomplish the
traditional treatments’ goals, mothers need relief from day-to-day duties of household
management and the care of other children. Finding support from family members,
friends, and/or doula’s can save the breastfeeding relationship and avoid future
complications and problems at this critical point in time. Emphasis on baby-led feeding,
effective latch and positioning, and early recognition and management of plugged ducts
is the foremost goal for the lactation consultant working with all clients with persistent
plugged ducts.
In another venue, physicians and physiotherapists have recommended trying
therapeutic ultrasound for the treatment of plugged ducts. Newman states that if blocked
ducts are not resolved in 48 hours “therapeutic ultrasound often works”. He goes on to
6
suggest that ultrasound also appears to prevent recurrent plugged ducts that occur in the
same part of the breast.
8,9
The only known blind randomized clinical trial using
ultrasound showed that overall the treatment (i.e. ultrasound and heat or massage therapy)
was successful for early postpartum engorgement, but the ultrasound portion alone did
not make a significant difference.
10
In a Cochrane review of treatments for breast
engorgement, the placebo effect, ultrasound treatment without the ultra-wave emitting
crystal, was equally effective to that with the ultra-wave emitting crystal. This raises the
possibility that the effect on breast engorgement was due to the radiant heat or massage
therapy provided as part of the ultrasound treatment, not the ultrasound therapy itself.
11
Although efficacy of ultrasound therapy has not been shown to be effective as a sole
intervention for postpartum engorgement, many popular breastfeeding guides include it
as a viable option for the treatment of plugged ducts.
9,12
In the United States, physical therapists may provide ultrasound treatments for
plugged ducts. In a pilot study
7
utilizing clients from Breastfeeding Resources, a specialty
medical practice in the northeast United States, Dr Christina Smillie and I looked at
women referred for ultrasound for the management of their plugged ducts and compared
them to those managed without ultrasound. No significant difference in outcome was
noted between these groups.
The use of ultrasound, while perceived as effective by the mothers, was viewed
nevertheless as stressful and not empowering. As a result of their study, the clinical staff
at Breastfeeding Resources decreased their referrals for ultrasound. An unexpected result
was their altered approach to plugged duct massage. Based on techniques learned from
the physical therapists, the clinicians stopped recommending massage from behind the
7
plug, but instead suggested massaging in front of the lump of milk towards the nipple, as
if "trying to clear a pathway."
13
The mother begins her kneading close to the nipple,
pushing towards it. She then changes the starting point, so that she begins her kneading a
little further back, starting her massage movements successively closer to the lump of
milk, but always pushing towards the nipple. Dr. Smillie notes this is “less painful and
more effective than using the lump of milk as a battering ram against a long stringy dried
plug.” Ramsay’s ultrasound investigations of breast anatomy
14
indicate that the milk
ducts are convoluted and mothers may come to recognize the areas in their breasts where
they are more likely to experience persistent plugged ducts. These mothers may be
predisposed to tender, inadequately emptied areas in their breast/s and can be educated
about the benefits of massage while breastfeeding, and the positive effects of altering
positioning to best empty areas where they most likely experience plugged ducts
repeatedly. Encouraging the infant to nurse before and after heat therapy and massage
increases the likelihood of eliminating plugged ducts. If a breast feels uncomfortably
full, removing milk by hand expression or with a pump “to comfort” can avoid the
development of plugged ducts. In addition, encouraging clients to trust the infant’s cues
related to feeding, allowing them to “empty the breast” and switch sides when they are
ready, will help to avoid plugged ducts.
Conclusions:
Persistent and recurrent plugged ducts can be a frustrating and overwhelming
condition that puts
a mother at risk for other complications and early cessation of
breastfeeding. Traditional treatment in the early stages, including recognition of risk
factors – physical, emotional, and lifestyle factors – can lead to early treatment and relief.
8
The use of hot compresses, including water therapy (hot showers or baths), and directed
massage are key, as well as finding ways to minimize stress and allow for adequate
opportunities for breastfeeding that allow sufficient removal of milk so the breast/s are
usually comfortable. The mother of young children needs support, encouragement, and
realistic goal setting when a new infant is added to the family. Recognizing triggers for
plugged ducts with individual clients may help them to prevent the recurrence of plugged
ducts. Information about how to differentiate plugged ducts, mastitis, and other
infections and when to contact their primary care provider is critically important as well.
Referral for ultrasound therapy specifically for plugged ducts needs more scientific study.
Until randomized clinical trials have been completed, we cannot be sure of the efficacy of
these treatments. A lactation consultant who takes the time to consider all the aspects of
her client’s life to provide holistic care and who helps her client trust her baby’s cues and
her own instincts will do much for the prevention and treatment of recurrent or persistent
plugged ducts.
9
References
1
Kinlay J. Risk factors for mastitis in breastfeeding women: results of a prospective
cohort study. Aust NZ J Publ Health. 2001;2:115-20.
2
Fetherston C. Risk factors for lactation mastitis. J of Hum Lact. 1998;14(2):101-09.
3
Foxman B, D'Arcy H, Gillispie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence
and medical management among 946 breastfeeding women in the United States. Amer J
of Epidemio. 2002;155(2):103-14.
4
Smillie CM, Campbell SH, Iwinski S. Hyperlactation: How left-brained 'rules' for
breastfeeding can wreak havoc with a natural process. Newborn Inf Nurs Rev.
2005;5(1):49-58.
5
The Womanly Art of Breastfeeding. 7th ed. Schaumburg, IL: La Leche League
International; 2004.
6
Mohrbacher NS, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League
International; 2003.
7
Campbell SH & Smillie CM.Recurrent Plugged Ducts: The effect of traditional therapy
versus ultrasound therapy”, Printed in the Proceedings for the Conference and Annual
Meeting of the International Lactation Consultant Association, “Milk, Mammals, &
Marsupials: An International Perspective”, Sydney, Australia. 2003.
8
Newman J. Blocked ducts and mastitis. 2000.
http://www.bflrc.com/newman/breastfeeding/mastitis.htm
9
Newman J, Pitman T. The Ultimate Breastfeeding Book of Answers. Roseville, CA:
Prima Publishing; 2000.
10
McLachlan Z, Milne E, Lumley J, Walker B. Ultrasound treatment for breast
engorgement: A randomised double blind trial. Austr J of Physi. 1991;37(1):23-29.
11
Snowden HM, Renfrew MJ, Woolridge MW. Treatments for breast engorgement
during lactation. Cochrane Database Syst Rev. 2001;(2);CD000046.
12
Humphrey S. The Nursing Mother's Herbal. Minneapolis: Fairview Press; 2003.
13
Smillie CM, The prevention and treatment of plugged ducts, clinical handout from
Breastfeeding Resources, a specialty breastfeeding medical practice in Stratford, CT.
January 2004.
14
Ramsay D, Kent J, Hartmann R, Hartmann P. Anatomy of the lactating human breast
redefined with ultrasound imaging. J of Anatomy 2005;206(6):525-34.
Suzanne Hetzel Campbell is an assistant professor of nursing at Fairfield University
School of Nursing. She has been a La Leche League leader since 1991, working with
10
low-income and employed women, and is on the Board of Directors of the Connecticut
Breastfeeding Coalition. She studied plugged ducts as part of an ILCA grant with co-
investigator Christina Smillie, MD, FAAP, IBCLC while employed as a lactation
consultant/nurse practitioner at Breastfeeding Resources in Stratford, CT. She would like
to acknowledge Sue Iwinski and Dr. Smillie for their helpful suggestions in the writing of
this response. Address correspondence to Suzanne Campbell, Fairfield University School
of Nursing, 1073 North Benson Road, Fairfield CT, 06824, USA; email:
scampbell@mail.fairfield.edu.
... Unfortunately there is a dearth of data regarding the pathophysiology of plugging. Anecdotally, women who report "fatty appearing milk" may be more likely to experience plugging and nipple blebs [10], and it is possible that individual variability in milk composition [11] may impact the viscosity of milk and likelihood of plugging. In other individuals, plugging may result from hyperlactation and/or an imbalance between milk production and extraction [6,10]. ...
... Anecdotally, women who report "fatty appearing milk" may be more likely to experience plugging and nipple blebs [10], and it is possible that individual variability in milk composition [11] may impact the viscosity of milk and likelihood of plugging. In other individuals, plugging may result from hyperlactation and/or an imbalance between milk production and extraction [6,10]. Hyperlactation most often presents with both breasts producing more milk in excess of infant's needs. ...
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Anti-inflammatory drugs help ease the symptoms of breast engorgement Painful breasts are a common reason for women giving up breastfeeding. Engorgement can occur when excess milk is not removed from the breast during breastfeeding. The cells that excrete the milk become swollen, hot and painful. The review of trials found that the drugs Danzen and Kimotab are effective but oxytocin, ultrasound and cold packs are not effective in improving the symptoms of engorgement. The review also found that there was no difference between using cabbage leaves or a cold gel pack.
Article
The aim of this study was to use ultrasound imaging to re-investigate the anatomy of the lactating breast. The breasts of 21 fully lactating women (1-6 months post partum) were scanned using an ACUSON XP10 (5-10 MHz linear array probe). The number of main ducts was measured, ductal morphology was determined, and the distribution of glandular and adipose tissue was recorded. Milk ducts appeared as hypoechoic tubular structures with echogenic walls that often contained echoes. Ducts were easily compressed and did not display typical sinuses. All ducts branched within the areolar radius, the first branch occurring 8.0 +/- 5.5 mm from the nipple. Duct diameter was 1.9 +/- 0.6 mm, 2.0 +/- 90.7 mm and the number of main ducts was 9.6 +/- 2.9, 9.2 +/- 2.9, for left and right breast, respectively. Milk ducts are superficial, easily compressible and echoes within the duct represent fat globules in breastmilk. The low number and size of the ducts, the rapid branching under the areola and the absence of sinuses suggest that ducts transport breastmilk, rather than store it. The distribution of adipose and glandular tissue showed wide variation between women but not between breasts within women. The proportion of glandular and fat tissue and the number and size of ducts were not related to milk production. This study highlights inconsistencies in anatomical literature that impact on breast physiology, breastfeeding management and ultrasound assessment.
Article
National surveys have shown that painful breasts are the second most common reason for giving up breastfeeding in the first two weeks after birth in the UK. One factor contributing to such pain can be breast engorgement. Views differ as to how engorgement arises, although restrictive feeding patterns in hospital are likely to have contributed in the past. These differing views are reflected in the range of solutions offered to treat engorgement in breastfeeding mothers and these treatments are assessed in this review. To determine the effects of any proposed intervention to relieve symptoms of breast engorgement among breastfeeding women. The register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group. CINAHL and MEDLINE were also searched. Date of last search: December 2000. All randomised and 'quasi-randomised' controlled trials, with or without blinding, that assess the effectiveness of treatments for the alleviation of symptoms in breastfeeding women experiencing engorgement . Data were extracted by one reviewer and verified by a second reviewer. Eight trials, involving 424 women, were included. Three different studies were identified which used cabbage leaves or cabbage leaf extracts;. no overall benefit was found. Ultrasound treatment and placebo were equally effective. Use of Danzen (an anti-inflammatory agent) significantly improved the total symptoms of engorgement when compared to placebo (odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3 - 10.3) as did bromelain/trypsin complex (OR 8.02, 95% CI 2.8-23.3). Oxytocin and cold packs had no demonstrable effect on engorgement symptoms. Cabbage leaves and gel packs were equally effective in the treatment of engorgement. Since both cabbage extract and placebo cream were equally effective, the alleviation in symptoms may be brought about by other factors, such as breast massage. Ultrasound treatment is equally effective with or without the ultra-wave emitting crystal, therefore its effectiveness is more likely to be due to the effect of radiant heat or massage. Pharmacologically, oxytocin was not an effective engorgement treatment while Danzen and bromelain/trypsin complex significantly improved the symptoms of engorgement. Initial prevention of breast engorgement should remain the key priority.
The prevention and treatment of plugged ducts, clinical handout from Breastfeeding Resources, a specialty breastfeeding medical practice in
  • C M Smillie
Smillie CM, The prevention and treatment of plugged ducts, clinical handout from Breastfeeding Resources, a specialty breastfeeding medical practice in Stratford, CT. January 2004.