Ellie, mother of four-week-old Harry, has a mastitis which turns into an abscess

Ellie comes in to see me with a large painful lump in her breast

Ellie always intended to breastfeed her baby. She has an older sister with three school age children, and her nieces and nephews were breastfed until they were about twelve months old without any real problems. Ellie had always imagined she'd do the same.

When Ellie came in to see me, her baby Harry was a bit over three weeks old, and she'd had a lump of the inner half of her left breast for the past five days. It hurt a lot, especially when she was trying to sleep because of the way her breasts fell when she was on her side, and it was growing bigger. She was taking ibuprofen 400 mg four times in a 24 hour period, and sometimes paracetamol in between.

Ellie said the lump was hot and red at the beginning, less so now, and she'd also had sweats at night though whenever she took her temperature it was normal. Yesterday she saw her own GP, who started her on antibiotics.

When I examined Ellie, she didn't have a fever (but she was taking maximum dose analgesia, which suppresses fever). I was worried to find that the lump was ten by eight centimetres, hard and also perhaps somewhat fluctuant, I thought. The skin over the lump was normal and not at all red today, but she had cracks on the face of her left nipple which had painful-looking reddish scabs. She said the nipple pain and damage had flared up in the past 24 hours, after one particular feed went wrong.

I was glad Ellie's GP had prescribed the antibiotics the previous day, given the way the lump had been rapidly increasing in size day by day. Usually a lump like this develops quickly over a couple of days, but then after a few days with the correct treatment begins to resolve.

Ellie gave birth to little Harry vaginally a few days after his due date. When we weighed him, he was 260 gm above his birth weight, with normal amounts of poo and wee (you can find out what's normal here). Harry was a healthy, reasonably settled little thing, who slept through much of our consultation in the pram. He had fine delicate features and short downy blonde hair, and had been on the slow side to regain his birth weight, but did so at 14 days of age.

What aspects of Ellie's situation increased her risk of mastitis?

There's much in life that is outside our control, and this includes breast inflammation. We'll never be able to completely prevent it.

Ellie was diligently contacting her health professionals and researching online, just trying to follow the most reputable health professional advice that she could find. But our health system can give women advice which increases their risk of developing breast inflammation or mastitis, or which makes a mastitis more likely to get worse rather than quickly resolve when it first appears.

Ellie had nipple pain and damage, which results from nipple and breast tissue drag during breastfeeding

Ellie had seen an International Board Certified Lactation Consultant when Harry was seven days old because she had nipple pain and cracks on both sides. The nipple pain started with Harry's very first feed a couple of hours after he was born. Ellie was offering the breast every three or so hours, and was also pumping sometimes so that her husband James could feed him with the bottle, giving her nipples a break.

In desperation, Ellie and James had started a couple of bottles of formula on the sixth day of Harry's life, because Harry didn't seem settled after feeds and Ellie was beyond exhausted, and in excruciating nipple pain. Harry seemed to love the formula, drinking it down quickly, which really upset Ellie.

You can find out about formula use and baby safety in the first week of life here.

After seeing the lactation consultant, Ellie began to use nipple shields and the pain settled down. Breastfeeds still weren't entirely coomfortable but the cracks had healed up - until the day before she saw me, when cracks had opened up again on the face of the nipple on the side opposite to her mastitis.

Ellie and James had continued with bottles, sometimes expressed breast milk, sometimes formula. When I did a quick calculation the day she came in to see me, easily half of Harry's caloric intake was from formula.

You might often hear that women with nipple pain and damage are more likely to get a mastitis because bacteria travel back down from the nipple through the cracks into the breast tissue. Or sometimes the theory goes, from the surface of the nipple to the milk, because of the crack. This isn't the case, for a number of reasons.

• Bacteria found on the nipple and areolar skin are usually a part of the milk microbiome, anyway. The bacteria often labelled 'bad bugs' (like Staphylococcus aureus) are found everywhere, living ordinary harmless bacterial lives in both milk and on the nipple and areola skin, and in baby's mouth.

• The backflow idea doesn't make sense, because milk washes out from the breast in the opposite direction, in response to the baby's oral vacuum and the contraction of milk glands. Occasionally backflow from full ducts into empty ducts occurs during let-down in the breast the baby is not feeding from. But there's no reason to think that somehow bad bugs are being washed backwards from the baby's mouth into the ducts and glands.

• The saliva in baby's mouth is rich in anti-bacterial and immune factors, bathing a breastfeeding woman's nipples in protection (not to mention the powerful protection which comes from the milk itself washing in the baby's mouth and over the nipple).

What happens, though, is that a woman with nipple pain and damage is more likely to develop an area of visible and painful inflammation because

• She may tend to space out breastfeeds as a way of managing the pain, which increases the risk of backpressure in the milk glands

• To have nipple pain and damage, there must be some breast tissue drag occuring when the baby breastfeeds. This same breast tissue drag will compress some ducts during breastfeeding, increasing the chance of backpressure in those ducts and glands from which the milk is unable to flow.

Ellie had been told not to change her pattern of breastfeeding during the day and to start ice applications, light massage, and probiotics

When Ellie first developed the lump, she phoned the lactation consultant she'd seen in the first week, who told her that the latest advice was not to change her pattern of breastfeeding, to start the probiotic Qiara and also lecithin, to apply ice packs, and to do some light massage. During the day, Ellie had been offering the affected breast perhaps six times, so she kept up the same three hourly routine. After offering the breast, she and James supplemented with formula.

Ellie was also trying the breast massage - fairly light, and towards the armpit - with cold pack applications, probiotics, lecithin, and hand expressing.

Ellie was sleeping through the night while James gave baby Harry a bottle

By the time Harry was ten days old, Ellie's nipple pain had settled down, but Ellie explained, with tears rising, that by this time Harry was wanting to breastfeed for hours each time he woke in the night. This had her seriously concerned that she couldn't continue with the breastfeeding. The sleep deprivation was beyond awful. Even during the day, she and James still worried that Harry was hungry, because he wouldn't settle into sleep after the breastfeeds - he just didn't seem satiated. Yet when they gave him a bottle of formula, he went straight to sleep.

You can find out what to do in a newborn sleep emergency in The Possums Sleep Program, starting here.

Finally, from about two and a half weeks after the birth, James took over and was ready to give Harry a bottle of formula each time he woke in the night, letting Ellie sleep through. James seemed to settle back to sleep well after the formula, and from the first night James did this, woke only a couple of times.

James was unable to come with Ellie and Harry to their consultation with me, but Ellie said James couldn't bear to see Ellie so distraught and sleep deprived, and he didn't think breastfeeding should continue on much longer. I could imagine that he was feeling very protective of his lovely wife, who was trying so hard to do things right for the baby, and that practically speaking, James's experience was that the formula really seemed to work to keep the baby settled and Ellie well slept. Ellie said that she wanted to continue breastfeeding, that she was determined to keep on going, at least for now.

"Breastfeeding, or at least pumping or hand expressing, as much as you can is best thing for your breast with the mastitis for now," I agreed, "because unfortunately weaning right now risks making the mastitis a lot worse. But this is difficult because of the nipple damage."

Ellie did confide that she too was wondering now that she had mastitis just how much longer she could carry on. In Ellie's experience, breastfeeding was associated with unbearable nipple pain and damage, severe sleep deprivation, and now, being unwell with a very large and painful mastitis.

"I get exactly why you feel as if you can continue on!" I said to her, and I didn't for a minute try to persuade her otherwise. My job isn't to persuade women to persist with breastfeeding. My job is to help unravel the multiple factors that are interacting to make breastfeeding this miserable, or unworkable.

My job is to help women experience breastfeeding as a tool for making the days and nights easier, and more enjoyable, rather than harder, just as quickly as we can.

Multiple problems interacted together to make breastfeeding very difficult for Ellie and baby Harry

In my own mind, there were a number of problems interacting together in this family's life to create a perfect storm of distress.

1. Nipple pain and damage at the very beginning of her breastfeeding experience had impacted on frequency of breastfeeds and therefore Ellie's milk supply and Harry's weight gain, so that formula supplementation became necessary, alongside expressing.

2. Misalignment between the newborn's body clock and his parents' body clock had occurred, so that the baby was wakeful (and therefore wanting to breastfeed) for very long periods in the night.

3. It's likely that Harry's hunger confused this situation, since Harry had weight gain challenges at first, and then woke substantially less in response to a bottle of formula at night. Usually, when everything has settled down and the baby is gaining weight well with exclusive breastfeeding, breastfeeding women sleep as well, if not better, than parents who are needing to use formula. You can find out about this here.

4. By sleeping for seven or eight hours at night, without breastfeeding or removing milk from her breasts, Ellie's breasts were at risk: the resultant backpressure in her milk glands put her at risk of breast inflammation. Some breastfeeding women might manage to go for a whole night without breastfeeding and not develop mastitis. But many other breastfeeding women will develop a mastitis in this situation.

Each element of this puzzle needed to be carefully addressed, in what was a complex consultation. There were two main problems underlying Ellie's mastitis.

• We needed to help Harry's circadian rhythm quickly get in sync with his parents' body clocks. I hoped this might help Ellie feel better able to offer at least one breastfeed in the night.

• It seemed to me that Ellie might benefit from more help with fit and hold during breastfeeding, because of the fresh nipple pain and damage. It was quite likely that the milk transfer wasn't terribly efficient when she was breastfeeding, due to breast tissue drag. Her milk production was certainly much less now than Harry needed.

But today, before all else, we needed to address the direct risk to Ellie's health and wellbeing - the mastitis. I was worried that she might have developed an abscess.

Things to do which help heal mastitis

I ordered an ultrasound scan to check that an abscess hadn't developed. Then I explained the steps for healing a mastitis, here.

Ellie and I spent time discussing

• What was meant by frequent flexible breastfeeds, and why this mattered. We talked about the challenge of this, given the fresh cracks which had developed in Ellie's breast. Although I offered, Ellie did not want fit and hold help today, as she felt she knew what had happened in Harry's positioning when this latest damage happened. I explained that frequent flexible breastfeeds in her situation would require experimenting with what's workable - just doing what she can. I explained how she did not need to offer the breast for long. Ellie had also used a nipple shield previously and she said she would use it again if she felt she needed to. I explained that 60% of the milk is transferred in the first two let-downs (which women mostly can't feel). What matters is frequent, if short, opportunities to breastfeed or remove the milk, to dilate up her ducts and relieve the inflammatory pressures in her breast.

• Analgesics and antipyretics. I explained that ibuprofen or paracetamol didn't actually help heal the breast inflammation, which was the impression Ellie had from her online research.

  "They are for symptom relief," I said. "The research shows that antipyretics, which suppress the fever, actually also suppress our immune response. So you can find your own balance. Take them to help you feel better, expecially at bed-time, but you don't have to take them, and only take them when you feel you need them."

• How she and James might get Harry's body clock settings better aligned with their own, as quickly as possible. This included a chat about his sensory motor needs, and also not burping or holding upright, which can make babies unsettled after feeds (but might be misinterpreted as due to hunger and lack of satiation from the breast). I talked to her about the The Possums Sleep Program.

• Why it would be best to stop all other interventions, including the massage. Anything that irritates that highly sensitive, inflamed tissue in her breast is best avoided. I talked about how when we have a pimple or zit on our face, the more we touch with it with our fingertips, even just lightly touching it to check out how it is going, the more we are likely to irritate the inflammation and worsen it. It's best to completely avoid touching an inflamed area - and just concentrate on activating the fluid pump from the inside, by removing milk frequently, and triggering let-downs.

Ellie didn't have an abscess when I first saw her but was admitted to hospital one week later for intravenous antibiotics and abscess drainage

Fortunately, Ellie's ultrasound didn't show an abscess, and by phone the next day I recommended that she continue the antibiotics and continue with the steps that we'd discussed. She was also in close contact with her own GP.

My heart dropped when Ellie told me down the phone that she'd had a great night's sleep and was feeling better, that James had got up to Harry and she had slept for eight hours. I knew that this was dangerous for her breast, but then, Ellie was feeling unwell and had weighed things up for herself and decided that sleep was more important.

She was also not removing milk from the affected breast more often during the day, because of the cracks and nipple pain.

In a confusing health system environment, parents simply make their own path through as best they can, and my role is to offer information and support Ellie's own carefully weighed-up decisions.

Five days after the first clear ultrasound, Ellie's GP sent her up to the hospital for intravenous antibiotics. Ellie had woken that morning feeling awful, with painfully swollen lymph glands in the armpit on the affected side of her body. A second ultrasound in hospital now showed an abscess.

Ellie was admitted for intravenous antibiotics, drainage of the abscess, and for therapeutic ultrasound. When I spoke with her by phone, Ellie wanted to know if this might have been prevented if she had started antibiotics earlier, and if she'd had therapeutic ultrasound from the start, too.

"Ellie, I know this is very confusing," I responded, cautiously. "But there is no reason to think that starting antibiotics earlier, say 12 or 24 hours after your fever started - which is what you often hear - would have prevented the abscess forming. The research tells us that regardless of when we start antibiotics, about the same percentage of women with mastitis go on to develop abscess."

"Ok," Ellie said. "It's just hard, because I did wait five days or so."

"I know, but waiting for a number of days, even when you were feverish, was the right thing to do. Our job as health professionals is to make sure you know about the things that you can be doing which might help."

Ellie was happy to accept that. Then she continued: "My next question is about the therapeutic ultrasound. It kind of felt good, as if it was helping, especially when the milk started flowing, and I was wondering why no-one had told me about it sooner?"

"Yes it does feel right and healing when the milk is flowing, doesn't it!" I replied. "That's the best part of the ultrasound - when the probe is covered with the warmed up lubricant and the gentle movement of it over the breast triggers a let-down!"

"I know, it just felt right," Ellie said, again.

"But the problem is that the best way to get a let-down is to have your baby breastfeeding. The second best way to get a let-down is gentle hand expressing of your breast, if your baby doesn't want to breastfeed or there's nipple damage, like you had. The evidence doesn't show benefit to therapeutic ultrasound and also there's no convincing scientific rationale to explain why ultrasound of your breast tissue might actually heal up the inflammation." I took a deep breath. I knew Ellie wanted to know the facts and my perspectives, so I decided to go on.

"This is why physiotherapists have largely stopped using therapeutic ultrasound for tissue strain and injury. Once, they were using it all the time! I can tell you from my own experience with my son, who was sporty, that the physios 20 years ago were right into ultrasound, but then the evidence started to show it wasn't effective. Now, it's being used on women's inflamed breast during lactation - and the concern is that if used too vigorously it might even apply pressure over the very sensitive inflamed tissues which makes inflammation worse. At best, it is not likely to help beyond the benefits of having let-downs."

"Right," Ellie said, rather doubtfully. "It's really upsetting that there's so much conflicting advice! How can you know what to do when everyone claims that what they are doing is evidence-based?"

"I know," I said quietly. I had no answer to this. "It is really hard."

Will Ellie continue breastfeeding? At this point in Ellie's story, I couldn't know. Our health system has quite accidentally conspired to make breastfeeding much harder for Ellie than many parents would consider acceptable. These parents most definitely want the very best for their baby's health and wellbeing, but they weigh up the costs against the benefits, and decide it's just not worth the suffering and distress which they have been experiencing around the clock.

The decision to stop breastfeeding is not due to a woman's lack of persistence. It's also not due to lack of knowledge about the downsides of formula use. It's a pragmatic decision about how to navigate a very rocky patch in their family's life, in a way that feels responsible and manageable.

Our health system blind spots made it very hard or impossible for breastfeeding to work for Ellie and her baby

When I saw Ellie next, two weeks after she'd been admitted for intravenous antibiotics and drainage of the abscess, the baby was taking 800 mls of formula in a 24-hour period - that is, was receiving all of his necessary calories from formula.

Ellie was gamely putting Harry to the breast as often as he would take it. He usually suckled away for a while and drowsed off into sleep. The lump in her left breast was still there, but smaller and soft, not at all tender, and gradually disappearing.

"It's too stressful trying to increase the amount of breastmilk he is getting," she said. "It's affecting my mental health and James is very worried about me. I keep worrying that Harry is getting nothing but I can't tell. I keep feeling like I should try to re-lactate. I feel incredibly guilty that I'm not giving him more of my breastmilk, but I just can't bear the stress. I stopped pumping a week ago because I just couldn't keep it up."

I nodded quietly. I completely understood. By the end of our consultation, I believe Ellie had a number of things clear in her own mind.

1. Ellie didn't want to try to drive up her milk supply either through pumping or trying to make breastfeeding work.

2. Ellie wanted to keep using her breast as a 'tool' for dialling little Harry down whenever she felt like it, and she might still offer the breast before the bottle to see what happens.

3. Ellie had done her very best to make breastfeeding work, and she would practice a deep self-compassion, knowing this. She also knew that much has been out of her control. For instance, she had received lots of conflicting advice from the health professionals and 'evidence-based' sources that she turned to.

Although I didn't say this to Ellie, hers is a story about how the advice she received from kind and caring health professionals when she struck problems to do with breastfeeding and sleep made things worse for Ellie than they needed to be. The advice she received made it very difficult or impossible for her to continue breastfeeding, and resulted in her needing to predominantly formula feed her little one.

This is the way our health system fails women and their families. In advanced economies, we can no longer blame the formula companies. Our health system in advanced economies fails women and their families because of a historic lack of investment into research exploring how best help with breastfeeding challenges and how best to help parents and their babies in sync. We focus a lot more now on the mental health fallouts, without considering how effective help for breastfeeding and resultant unsettled baby behaviour helps prevent family distress and postpartum anxiety or depression.

This is no-one's fault - it is a health system problem. Advice that is definitely not evidence-based is taught to, or written into guidelines for, health professionals as if it is research-based. This includes advice to not change your breastfeeding patterns if you have mastitis, or to use therapeutic ultrasound, or massage, or probiotics, or lecithin, as if these approaches, which are costly, will help heal mastitis. But they don't. Many businesses have sprung up specialising in the treatment of mastitis, using approaches recommended by scientifically flawed guidelines.