What is the treatment for a lactating woman with a swollen breast due to milk obstruction?

Treatment of Swollen Breast Due to Milk Obstruction in Lactating Women

The primary treatment for milk obstruction (blocked duct) in lactating women is frequent and flexible milk removal through continued breastfeeding or expression, combined with elimination of external breast pressure—this prevents progression to mastitis or abscess while maintaining lactation. 1, 2

Initial Management Approach

First-Line Treatment: Optimize Milk Removal

• Continue breastfeeding frequently and flexibly to prevent excessive intra-alveolar and intra-ductal pressures that cause lactocyte tight junction rupture 1
• Ensure complete breast emptying at each feeding session, as regular and complete drainage is essential for both treatment and prevention 3
• Active emptying of the breasts can prevent mastitis development in most cases of early obstruction 4

Critical: Eliminate Mechanical Forces

• Avoid massage or vibration of breast lumps, as these worsen micro-vascular trauma and inflammation 1
• Eliminate focused external pressure on the breast, including tight bras or clothing 1
• Correct any conflicting vectors of force during milk removal by optimizing infant positioning and latch 2

Diagnostic Considerations

When to Obtain Imaging

• Ultrasound is the first-line imaging modality for lactating women with palpable masses, showing nearly 100% sensitivity 3
• Imaging is indicated if a discrete mass persists despite conservative management or if clinical concern for abscess develops 5, 3
• Mammography has limited utility due to increased breast density during lactation 5

Differential Diagnosis

• Blocked duct is the most common cause of breast pain in lactating mothers (35/69 cases in one series) 2
• Without prompt relief, blocked ducts may progress to mastitis (13/69 cases) or breast abscess (6/69 cases) 2
• Engorgement (physiologic overfilling) differs from obstruction but may coexist 6

Escalation of Treatment

When Conservative Management Fails

• If pain persists beyond 7 days despite optimal milk removal, consider infectious mastitis 2
• Antibiotics should be administered for 10-14 days if mastitis develops, with continued breastfeeding 4
• Bacteriological culture of milk sample is needed to guide antibiotic selection in suspected infectious mastitis 7

Abscess Management

• Drainage (needle aspiration or catheter) plus antibiotics is the standard treatment for breast abscess 3, 7
• Breastfeeding can continue on the affected side as long as the infant's mouth does not contact purulent drainage 3
• Incision and drainage may be required for abscesses that cannot be drained percutaneously 2, 7

Adjunctive Therapies (Limited Evidence)

Symptomatic Relief Options

• Cold cabbage leaves may reduce breast pain compared to routine care (MD -1.03 points on 0-10 VAS scale), though evidence certainty is very low 6
• Cold gel packs may reduce breast hardness (MD -0.34 points), with low-certainty evidence 6
• Herbal compresses may reduce pain (MD -1.80 VAS points) compared to hot compress, with low-certainty evidence 6

Common Pitfalls to Avoid

• Do not recommend lump massage or vibration, as this is a key error that worsens inflammation and delays resolution 1
• Do not delay treatment—blocked ducts require prompt intervention to prevent progression to mastitis or abscess 2
• Do not discontinue breastfeeding unless there is purulent drainage contacting the infant's mouth 3
• Avoid confusing physiologic engorgement (bilateral, generalized) with pathologic obstruction (localized, unilateral) 1

Red Flags Requiring Urgent Evaluation

• Persistent pain beyond 7 days despite conservative management 2
• Development of fever, systemic symptoms, or signs of sepsis 1
• Palpable fluctuant mass suggesting abscess formation 3, 2
• Inability to achieve adequate milk removal despite positioning correction 4