If you've heard that the Academy of Breastfeeding Medicine released new mastitis guidance and found yourself wondering how to actually apply it, you're not alone.
ABM Protocol #36 (2022) introduced a spectrum-based model for understanding breast inflammation. And while the core principles aren't entirely new, they do challenge some long-standing clinical habits.
Here's a practical breakdown of what's changed, what to do, and what to stop doing.
What Changed, And Why
The biggest conceptual shift is this: mastitis is an inflammation-first condition, not an infection-first one. As Dr. Melody Jackson explains in her LER course on this topic, "Inflammation is at the heart of mastitis, and infection, while possible, is not always present or even necessary to explain the symptoms."
ABM #36 describes mastitis as a spectrum, from physiological engorgement on one end, through inflammatory mastitis and bacterial mastitis, to abscess on the other. This framing matters clinically because where someone falls on that spectrum should drive your management decisions. Not every red, sore breast needs antibiotics. Many presentations are inflammatory in nature and will resolve with supportive care.
The other key update is how we think about antibiotic decisions. Duration of symptoms is no longer the recommended framework. A parent can have bacterial mastitis at 12 hours or inflammatory mastitis at 48 hours. What matters are systemic symptoms: fever, chills, spreading redness, and malaise. Those are your signals for antibiotics, not the clock.
Finally, there's the matter of skin presentation. The classic "red breast" description fails patients with melanated skin. Dr. Jackson is direct on this: "In more melanated skin, there might be dusky areas or areas of swelling." She recommends using the back of your hand to compare warmth across both breasts, and looking for skin that appears darker brown, purplish, or violet compared to surrounding tissue, or skin that looks shiny and taut rather than red. Palpation is essential.
What To Do
- Suggest anti-inflammatories first. Ibuprofen and diclofenac are safe in lactation, effective, and should be your first-line treatment for breast inflammation. For inflammatory mastitis without systemic symptoms, this is often sufficient.
- Support responsive milk removal. This means removing enough milk to relieve pressure and maintain flow. It does not mean aggressive emptying. A short, comfortable feed or a few minutes of gentle hand expression is the goal. As Dr. Jackson puts it: "More isn't always better, and in the case of mastitis, it's usually not."
- Use cool compresses to relieve heat and pain in an inflamed breast.
- Reserve recommending antibiotics for bacterial mastitis. Systemic symptoms are the threshold, and should prompt you to refer. When antibiotics are indicated, flucloxacillin or dicloxacillin are first-line, with cephalexin for penicillin allergy.
- Assess pump fit and suction settings in anyone using a pump, especially with recurrent mastitis. Poor flange fit is a hidden and common cause of microtrauma and recurring inflammation.
- Continue breastfeeding. It is both safe and protective. It helps resolve inflammation and is one of the most important tools for preventing abscess formation.
- In cases of hyperlactation, reduce stimulation (don't add more). Block feeding, reclined positioning, and paced removal are the right tools here. The worst thing you can do is tell these parents to drain more.
What To Stop Doing
- Stop assuming antibiotics are needed for every red, sore breast without systemic symptoms. Most early mastitis is inflammatory. Unnecessary antibiotic use disrupts the gut microbiome in both parent and baby and contributes to resistance.
- Stop recommending "empty the breast." As Dr. Jackson notes, "There is no such thing really as an empty breast." Chasing full drainage drives oversupply, increases milk stasis, and can worsen the very problem you're trying to solve.
- Stop recommending heat. Prolonged heat can worsen edema and engorgement. Cool compresses are now preferred.
- Stop recommending deep tissue or firm massage. This is one of the most harmful things we've continued to do out of habit. It can damage breast tissue, increase inflammation, and worsen pain. If you're recommending any massage, it should be gentle lymphatic drainage, with light strokes toward the axilla only.
- Stop recommending frequent pumping at the first sign of inflammation. For parents with normal or high supply, this worsens the problem. "Pumping really is a double-edged sword," Dr. Jackson says.
- Be cautious about routinely recommending therapeutic ultrasound, lecithin, or probiotics. These appear in ABM #36, but the evidence base is limited. If you discuss them, include that context and let families make informed decisions.
Ready to Learn More?
This blog draws Dr. Melody Jackson's LER course, Navigating Breast Inflammation: Engorgement, Mastitis, and the Evolving Science of Care. For a thorough, critically-engaged review of the evidence, Dr. Jackson's course is an excellent next step.
View the course
See the Full Series
We've covered the whole spectrum. Explore the other two posts:
It's Not Just Milk: Understanding Engorgement
Wait ... Do Plugged Ducts Still Exist?