Revised mastitis spectrum treatment protocol – a paradigm shift

Mastitis is a common lactation complication, affecting ~25% of women in the first 26 weeks postpartum.1

Historically, mastitis has been considered as pathology presenting in the lactating breast alone2, but newer scientific evidence shows that it encompasses a range of conditions resulting from ductal inflammation and stromal oedema.3

Papers published by Dr Douglas on breast inflammation have resulted in a shift in our understanding of the causes of mastitis, and therefore a need to change the assessment and management moving forward.4,5  

Douglas’ analysis proposed a mechanobiological model of breast inflammation in which very high intra-alveolar and intra-ductal pressures are hypothesised. It is proposed that this pressure puts strain on, or ruptures the tight junctions between lactocytes and ductal epithelial cells, triggering inflammatory cascades and capillary dilation. The increase in stromal tension leads to pressure on lactiferous ducts, resulting in a worsening of intraluminal backpressure. Rising leucocyte and epithelial cell counts in the milk and alterations in the milk microbiome are signs that the mammary immune system is recruiting mechanisms to downregulate inflammatory feedback loops leading to potential pain and oedema which can then worsen the ductal pressure.4,5  

The key for prevention and treatment of breast inflammation is to avoid excessively high intra-alveolar and intra-ductal pressures, which prevents a critical mass of mechanical strain and rupture of the tight junctions between lactocytes and ductal epithelial cells.

Pressure in the ductal system may occur for a number of reasons:

  • Engorgement/oedema
  • Hyperlactation
  • Milk stasis
  • Underlying anatomical features e.g. dead-end ducts, previous surgery
  • External compression from clothing or massage  

ABM protocol

ABM protocol

The revised ABM protocol has created change in how we need to think about and manage mastitis. It is now important to disseminate the new information to women needing this information through adequate support and education.’ Kate Barry, Registered Nurse and International Board-Certified Lactation Consultant.  

Prevention and management  

The revised ABM protocol looks at general strategies for the management of mastitis spectrum disorders, as well as condition-specific interventions.3

Overall principles are categorised as follows:

Guidance for mastitis

Medical interventions for mastitis

For condition-specific recommendations, please refer to the full protocol.

We know the benefits of therapeutic breast massage, and there is much research available to support its use in many breastfeeding conditions. However, without adequate training/direction/instructions, the techniques used can often cause more harm than good. The use of gentle massage, using the right combination of three critical components - temperature, movement and compression – has shown to have benefits in many conditions including mastitis.’ Kate Barry, Registered Nurse and International Board-Certified Lactation Consultant.

Prompt and effective treatment will halt progression in the [mastitis] spectrum.3


  • Wilson E, Woodd S and Benova L. J Hum Lact 2020; 36(4):673-686.
  • Kvist LJ. J Hum Lact 2010; 26:53-59.
  • Mitchell K, et al. Breastfeeding Med 2022; 17(5):360-376.
  • Douglas P. Women’s Health 2022; 18: 17455065221075907.
  • Douglas P. Women’s Health 2022; 18: 17455057221091349.

Kate Barry

Kate is a Registered Nurse and International Board-Certified Lactation Consultant. Kate is an experienced neonatal intensive care nurse and the founder of Little Bird Lactation, a lactation support service and online breastfeeding store.