Current mastitis management guidelines from both the World Health Organization
4 and the Academy of Breastfeeding Medicine
2 recommend conservative methods before antibiotics, including effective milk removal, dietary changes, heat or ice, and oral analgesics. However, Foxman et al
3 concluded that conservative managements for mastitis were minimally effective on their own, and most cases of mastitis are eventually treated with antibiotics.
2,4 Antibiotics are often effective at eradicating the infection, but recurrence is not uncommon. The actual recurrence rate is not clearly defined in the literature.
The osteopathic approach to patient care attempts to address as many contributing factors in a patient's illness as possible, taking a health-focused view of the patient. The causes of a patient's presentation can be viewed through 5 models: biomechanical, respiratory-circulatory, neurologic, metabolic, and biopsychosocial.
6 These 5 models were developed by the Educational Council of Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine (AACOM)
7 as a framework to ensure a well-rounded plan of care. The biomechanical model addresses factors to do with posture and body movement, including but not limited to joints, muscle tonicity, and fascia. For this case of mastitis, with this model in mind, we treated the fascia and soft tissues of the breast and related lymphatic structures. The respiratory-circulatory model addresses fluid flow throughout the body, including arterial flow, venous return, lymph, and oxygen. This case required management via this model to improve lymphatic drainage of the breast, along with pump treatments to the thoracic region to increase lymphatic return to the heart. The neurologic model addresses the autonomic system, pain perception, and viscerosomatic and somatovisceral reflexes. The reduction of pain in this patient from the manual treatment addresses the neurologic model, whereby reducing nociception seems to reduce sympathetic activity, thereby promoting an effective immune response. The metabolic model was addressed in this case by discussing an improved diet, heat or ice locally applied, and the addition of oral analgesics when indicated. Finally, the biopsychosocial model addresses the psychological impact of a diagnosis or condition on the patient.
In this case, we provided reassurance regarding the self-limiting nature of the presentation, suggested behavioral changes such as increased feeding on the affected breast, and promoted continued breastfeeding, as re-establishment of successful breastfeeding can be a coping mechanism to improve stress and anxiety in patients.
8 Lastly, we also taught the patient some self-treatment techniques for her breast, consisting of taking the breast tissue in the cardinal directions as a stretch. This last step was done to empower the patient in light of what had been a long and emotionally draining condition, further supporting the patient from the biopsychosocial model perspective.
Breast massage has been documented in the literature for a variety of conditions, including plugged ducts, mammary gland hyperplasia, milk stasis, engorgement, and mastitis. Most studies show improvement in patient presentations.
9-12 Many of the manual techniques studied in the previous literature overlap with the techniques used in this case, such as myofascial release, soft tissue, and articulatory techniques. No studies have documented the use of OMT specifically. The mastitis protocol from the Academy of Breastfeeding Medicine
2 specifically calls for research on breast massage. As the incidence of mastitis with MRSA and other serious infections such as breast abscess increases, effective managements that do not require antibiotics are urgently needed.
13 Additionally, there is a paucity of research on recurrent mastitis in the literature. One study
5 proposed recurrent mastitis as resulting from shortened courses of antibiotics, or the presence of
Staphylococcus carriers. Another study
14 found that the presence of infectious bacterial strains are not correlated with infectious lactational mastitis. This lack of definition highlights the difficulty of adequately assessing and managing mastitis and recurrent mastitis. We agree that in many cases, including ours, the etiology is unclear. Taking a patient-centered approach such as the framework offered by osteopathic medicine, including investigating somatic causes for mastitis, increases the chance of an appropriate management plan being formulated. Further research into defining mastitis and the causes of these cases would aid in management.