There is no evidence or physiological rationale to support the use of lecithin, therapeutic ultrasound, cold compresses, cabbage leaves or epsom salts for breast inflammation

Lecithin

Powdered organic sunflower lecithin is often recommended for lactating women who have breast inflammation. The recommended dose may be

• 1200 mg 3-4 times daily

• 5-10 gms daily

• 10 gm daily for severe white spots (Mitchell & Johnson 2020)

Proposed mechanism

The Academy of Breastfeeding Medicine Clinical Protocol #36 'The mastitis spectrum' advises clinicians that: “Sunflower or soy lecithin 5-10 gm daily by mouth may be taken to reduce inflammation in ducts and emulsify milk.” (no citation). Although this protocol does not offer mechanisms, elsewhere lecithin is said to emulsify the fats in breast milk, which are proposed to cause sticky milk and blocked ducts.

Evidence

There is no evidence or physiological rationale to support the use of lecithin for breast inflammation.

Ingestion of oral lecithin does not affect distribution of fat globules in human milk or reduces inflammation in the lactiferous ducts.

• In a 2003 study by Chan et al, lecithin was directly added to a test tube of milk from mothers of prematurely born infants, resulting in less loss of fat, because the milk fats were less likely to adhere to the collecting device. This study is not equivalent to in vivo physiology, and does not support ingestion of lecithin as a ‘thinner’ of breast milk or as a treatment that improves outcomes for breastfeeding women.

Therapeutic ultrasound (TUS)

Physiotherapists commonly use TUS as an intervention for breast inflammation. For many years, therapeutic ultrasound was used by physiotherapists for musculoskeletal soft tissue injury. However, evaluations have not supported its use. For example, a 2020 systematic review of TUS for musculoskeletal soft tissue injury by Papadopolous et al found that "no specific positive recommendations [for its use] can be made", and TUS has fallen out of favour with physiotherapists for this reason.

Proposed mechanisms

The Academy of Breastfeeding Medicine Clinical Protocol #36 'The mastitis spectrum' advises clinicians that: “Therapeutic ultrasound (TUS) uses thermal energy to reduce inflammation and relieve edema. TUS may be an effective treatment for conditions arising in the mastitis spectrum.[Mogenson et al 2020]”

Acoustic waves transport mechanical energy via vibration of particles. TUS is claimed to

• Induce in vivo mechanical and thermal changes in the breast stroma, such as oscillation of gas bubbles and molecules within tissue and fluid movement, in response to acoustic waves

• Disrupt bacterial biofilms, making antibiotics more effective

• Vibrate stromal tissue resulting in an anti-inflammatory effect

• Soothe sensory nerves

• Improve local circulation through improved lymphatics and blood supply which reduces swelling.

It is generally acknowledged that the motion of the transducer may also help facilitate mild drainage.

Evidence

The ABM CP #36 recommendation cites an article by Mogenson et al which is a narrative review of “non-pharmacological approaches to pain, engorgement and plugging in lactation”, not data in an evaluative study supporting the use of TUS. There is no evidence to support the use of TUS in breast inflammation.

• In 1991, McLachlan et al reported that TUS was no more effective than placebo for engorgement.

• In 2012, in a retrospective study of 25 mothers, Lavigne and Glebezen found that 23 had resolution of plugged duct following TUS, but this study had serious methodological weaknesses. The mechanisms by which TUS is proposed to ‘[use] thermal energy to reduce inflammation’ are not clarified.

• In 2019 Diepeveen et al noted that there is little empirical evidence to support the use of TUS in lactation-related breast inflammation though it is commonly applied by Australian physiotherapists.

• In 2023, Moura et al conducted a trial that compared the use of TUS, TUS + lymphatic drainage, and lymphatic drainage only in 99 lactating women with breast engorgement. The women were not blinded. Although Moura et al found that TUS + lymphatic drainage was most effective in reducing swelling and pain, this trial does not control for the neurobiological effects of an intervention (that is, the power of expectation) nor for the effects of milk ejection in reducing swelling and pain.

There remains wide variation and no clarity around high dose continuous or low dose pulsed ultrasound, and similarly with frequency choice. The most appropriate frequency to use is unknown. Research has only examined penetration depth in non-breast tissue.8

Warm or cool compresses

Proposed mechanisms

Warmth is said to help with milk flow by opening up ducts. Cool applications are believed to decrease interstial fluid volumes and pressures.

Evidence

The Academy of Breastfeeding Medicine Clinical Protocol #36 'The mastitis spectrum' advises clinicians to: “Consider ice for symptomatic relief”. But there is no evidence to support the application of compresses, either hot or cold.

• Ductal dilation is not influenced by warmth, unless warmth is used as part of nipple stimulation, which releases oxytocin. Warmth may increase stromal tension and duct compression by increasing blood flow.

• Cold applications are known to decrease ductal diameters in the nipple, risking decreased milk transfer (Geddes et al 2016) This has potential impact on initial flow of milk during breastfeeding, though this is unlikely to be clinically signficant, since the baby's mouth rapidly warms the nipple and intra-oral breast tissue.

Patients need to be careful with cold applications that direct ice application doesn't damage tissues.

When clinicians recommend the use of cold applications, patients assume that the cold application

• Is an evidence-based intervention

• Acts to heal the breast inflammation.

Neither are true.

Putting time into regular application of ice may be yet another task that an exhausted, unwell woman needs to fit into her day. It may be easier for her to simply offer the breast to the infant for a few minutes, stimulating another episode of milk ejection, to open up her milk ducts.

Cold cabbage leaves

A 2020 Cochrane review by Zakarija-Grkovic et al showed very low certainty evidence for efficacy of cold cabbage leaves in helping breast inflammation. There is no rationale for their use. (It was not recommended by ABM Clinical Protocol #36.)

Epsom salt bath of breasts

Leaning the nipple or breast into a hakaa pump or a container of warm water in which Epsom salts have been dissolved draws milk blockage out of the breast No rationale for treatment of breast inflammation. (It was not recommended by ABM Clinical Protocol #36.)

Selected references

1. Chan MM, Nohara M, Chan BR, Curtis J, Chan GM. Lecithin decreaes human milk fat loss during enteral pumping. Journal of Pediatric Gastroenterology and Nutrition. 2003;36(5):613-615.

2. Diepeveen LC, Fraser E, Croft AJ. Regional and facility differences in interventions for mastitis by Australian physiotherapists. Journal of Human Lactation. 2019;35(4):695-705.

3. Geddes DT, Sakalidis VS. Ultrasound imaging of breastfeeding - a window to the inside: methodology, normal appearances, and application. Journal of Human Lactation. 2016;32(2):340-349.

4. Lavigne V, Glebezon BJ. Ultrasound as a treatment of mammary blocked duct among 25 postpartum lactating women: a restrospective case series. Journal of Chiropractic Medicine. 2012;11(3):170-178.

5. Mitchell K, Johnson HM. Breast pathology that contributes to dysfunction of human lactation: a spotlight on nipple blebs. Journal of Mammary Gland Biology. 2020:http://doi.org/10.1007/s10911-10020-09450-10917.

6. McLachlan Z, Milne EF, Lumley J, Walker BL. Ultrasound treatment for breast engorgement: a randomised double blind trial. Australian Journal of Physiotherapy. 1991;37(1):23-28.

7. Moura SO, Borges LCdC, Carneiro TMdA. Therapeutic ultrasound alone and associated with lymphatic drainage. Breastfeeding Medicine. 2023;18(11):881-887.

8. Papadopoulos E, Mani R. The role of ultrasound therapy in the management of musculoskeletal soft tissue pain. International Journal of Lower Extremity Wounds. 2020;19(4):350-358.

9. Zakarija-Grkovic I, Stewart F. Treatments for breast engorgement during lactation (review). Cochrane Database of Systematic Reviews. 2020(9):doi:10.1002/14651858.CD14006946.pub14651854.