It is not uncommon for a breastfeeding mother, especially with copious milk supply, to have minor blocked ducts when her few-months-old baby begins to sleep through the night. Excessive milk, not removed from the breast, triggers the autocrine feedback mechanism to down-regulate the milk supply. In the meantime, milk stasis increases the likelihood of blockage of ducts, which often presents as mildly painful small lump(s). These usually resolve within a few days if milk removal is effective. One or two days of simple analgesic are often helpful. However, further assessments would be needed when the blocked ducts do not improve within 2 days.

In this case, Mrs. Chan had appropriately continued demand feeding during the day while encouraging suckling on the affected side. In the first couple of nights, she had woken up to relieve the breast fullness by pumping. These had helped to gradually adjust her milk supply to fit the baby’s new feeding schedule while resolving the blockage through effective milk removal by the baby.

Sudden changes in feeding schedule
For Mrs. Chan, both major episodes of blocked ducts had occurred on the first working day after the long holidays. It was notable that she had switched to more frequent direct BF during the long holidays and returned to the usual schedule upon returning to work. It is conceivable that more frequent suckling during the long holidays had stimulated an increase in milk supply. When she returned to work, a less frequent schedule of milk removal had resulted in fullness of her breasts and milk stasis. Besides, work stress might have further impeded the production of oxytocin. Both had contributed to the occurrence of blocked ducts. Therefore, to prevent future attacks, on the first few days of returning to work from long holidays, Mrs. Chan should pump or express breastmilk more frequently during the day to prevent her breasts from being too full.

What is the most effective way to relieve blocked milk ducts?

Many mothers with blocked ducts have tried resolving the problem by breast massage: in form of compressing +/- squeezing the breast / lumps either by themselves or with the help of “lactation specialists”. As the milk ducts are located beneath the skin, compression with considerable force is needed to push the milk plugs through. Although this may help in some mothers, such manipulation can potentially traumatize the breast tissues, in addition to causing intense pain.

There are pain-free and more effective strategies in resolving the blocked ducts. Let us revisit the physiology of milk ejection (let-down) reflex: When the nipple is stimulated by the baby’s suckling or pumping, oxytocin is released in a pulsatile manner into the blood stream from the posterior pituitary gland. Oxytocin causes the myoepithelial cells around the alveoli to contract and squeeze the milk down the ducts. It also shortens and widens the milk ducts, facilitating the milk to flow down easily. Therefore, amplifying the milk ejection reflex, analogous to a natural “internal pump”, is the physiological and effective way in resolving blocked ducts. Apart from tactile stimulation of the nipple, seeing, hearing or simply thinking about the baby can also induce oxytocin secretion, while anxiety, stress, tiredness or pain would diminish its release.

 To maximize this physiological pump, we may advise the mother to:
Reduce the pain: Adequate pain relief is important because pain inhibits the milk ejection reflex. The mother may take simple analgesics +/- cold compress.
Relax: The mother should breastfeed or express her breastmilk in a comfortable position and relaxing environment. Listening to music, breathing slowly and deeply, keeping warm and/or drinking something warm are often helpful. Some mothers may prefer a warm shower or placing a warm face-steamer on her breast before breastfeeding.
Gently perform breast massage and nipple stimulation: Before milk removal, gentle breast massage and rolling the nipple between fingers can stimulate the milk ejection reflex. During milk removal, the affected breast can be massaged gently by stroking from behind the lump towards the nipple with the palm or shaft of fingers to further improve the milk flow.
Think about the baby: During breastfeeding or pumping, the mother may keep her baby close to her through skin-to-skin contact. When pumping in the workplace, thinking about her baby or looking at her baby’s photo can be very helpful.
Get the support of her spouse: Last but not least, inviting the husband (or other suitable persons) to perform gentle back massage can be very useful in soothing and relaxing a stressful and tiring mother.

In sum, GENTLE massage with amplified milk ejection reflex is a powerful tool to resolve blocked ducts. Breast massage with forceful compression should be avoided.