Why the massage styles of ‘Therapeutic Breast Massage’ and ‘Manual Lymphatic Drainage’ are no more helpful than milk ejections for lactating women with breast inflammation and may even make things worse

A breastfeeding woman needs to make time for many different ways of caring for her own physical and emotional needs. Breast massage has become very popular in recent years. But would you be better spending that money and precious time on another form of self-care, or even on whole-body therapeutic massage? In this article I look at breast massage during lactation from a researcher and clinician’s perspective.

Plain language summary of this article

Gentle movement of one’s own breasts with the palms of the hands, in a way that feels good but doesn’t cause any discomfort or pain, may have a role in the prevention or management of breast inflammation during lactation for some. This is more likely to be true for women with generous breasts. However, there is no evidence to show that Therapeutic Breast Massage (TBML) or Manual Lymphatic Drainage (MLD) are beneficial in lactation-related breast inflammation, and there are pathophysiological reasons to be concerned that they may worsen outcomes for some. Any perceived benefit is likely to be due to the milk ejections and milk removal that occur during these massages, which can be more cheaply and time efficiently achieved by putting the baby to the breast more often, or hand expression.

What the Witt et al study tells us about Therapeutic Breast Massage in Lactation

Erratum

My attention has been drawn to errors I have made in Appendix 1 of my research article Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management.¹ Appendix 1 is entitled: ‘Therapeutic breast massage or manual lymphatic drainage do not improve breast inflammation and may worsen outcomes’. I have wrongly represented:

1. The rates of follow-up in the Witt et al 2016 study,² and
2. The analysis of Witt et al in Anderson et al’s systematic review.³

I apologise unreservedly for these mistakes.

The Witt et al study is not an RCT, as I wrote in Appendix 1, but a nested case control study. It is referred to as “quasi-experimental’’ in the Anderson et al systematic review, not as an RCT. In Appendix 1 of my article, I also wrongly represent the numbers who responded to follow-up emails in the Witt et al study, falsely attributing these inaccurate numbers to Anderson et al.

Anderson et al did not state that that “results of Witt et al’s RCT are unreliable, because of an unusually high rate of drop-out from the intervention group.” Witt et al shows that 38 women of the intervention group of 42 completed the 2 day survey. Ninety-eight percent followed up at 12 weeks. For the nested case control of mothers with engorgement, there was 87% (13/15) follow-up at 2 days and 100% (15/15) follow-up at 12 weeks. The control group had a follow-up of 77% (56/73) at 2 days and 88% (64/73) at 12 weeks. Overall, Witt et al report excellent follow-up rates for patients receiving TBML, and also in the control group.

I wholeheartedly acknowledge the importance of accurate representation of research data. I am grateful for opportunity to amend my errors and apologise. I welcome respectful discussion and debate concerning interpretation of data, which is a different matter again.

Analysis of the Witt et al study of Therapeutic Breast Massage in Lactation

I continue to hold the view that Therapeutic Breast Massage in Lactation (TBML) should not be recommended to breastfeeding women as effective or evidence-based management of breast inflammation on the basis of Witt et al’s study, for five reasons:

1. TBML was delivered in this study as one element in a complex breastfeeding intervention. Its efficacy was evaluated in small numbers for mastitis (n=7) and plugged ducts (n=17), in the absence of a control group.

TBML was delivered in the context of full breastfeeding support provided by an International Board Certified Lactation Consultant/registered nurse and/or breastfeeding medicine physician, which included latch correction, feeding patterns, antibiotic prescription, milk removal, or analgesia as clinically indicated. The component of the study which investigates efficacy of TBML for mastitis and plugged ducts is a small, pre- and post-TBML assessment (mastitis n = 7, plugged ducts n = 17, see Supplement Appendix B of Witt et al), and lacks a comparison group. That is, pre- and post-intervention comparisons do not take into account the neurobiological effects of patient expectation (also known as the placebo effect), as Witt et al acknowledge.

2. TBML did not show improvement at 2 day and 12 week follow-up when the engorgement group was compared to the control group.

Anderson et al state in their analysis of Witt et al: “Of the 15 participants with engorgement [in the TBML intervention group], measurements were taken from each breast, giving a total of 30 separate pain scores … These scores were treated independently (n = 30) in the pre-post analysis and combined (n= 15) for the comparison between the intervention and control groups, making interpretation quite difficult.” In the component of Witt et al which investigates efficacy of TBML for engorgement, the intervention group (n=15) was compared to a control group (n=73). 47% of the intervention group had severe engorgement compared to 7% of the control group. Comparison of the engorgement intervention and control groups showed no difference in pain, exclusive breastfeeding, or breastfeeding complications at day 2 or week 12 in email follow-up.

3. Pre- and post-TBML improvements can be explained by the ductal dilations (milk ejection) and milk removal components of TBML alone

TBML achieves milk removal in this study by alternating hand expression of milk or by direct breastfeeding of the infant during TBML (Supplement Appendix A of Witt et al). The reduction in breast pain and also in size of plugged ducts observed immediately after TBML are likely to be explained by the milk removal components of TBML alone, which are associated with milk ejections and ductal dilations.

4. There is no pathophysiological model which explains why light areola-to-axilla massage component of TBML might be beneficial

Is the proposed pathophysiological mechanism of light massage from the areola to the axillae increased lymphatic drainage in Witt et al? If so, this proposed mechanism isn’t supported by the latest research concerning the function of lymphatic vasculature (see below), and may risk increased intra-alveolar pressures.

What the Anderson et al systematic review tells us about breast massage in lactation

Various breast massage techniques are offered to breastfeeding women around the world. Anderson et al analyse the efficacy of a range of massage techniques in 3 RCTS and 3 quasi-experimental studies, including Witt et al’s study of TBML. Although the authors conclude: “Overall, different types of breast massage were reported as effective in reducing immediate pain for the participants”, I argue that neither Witt et al’s data nor Anderson et al’s data support Therapeutic Breast Massage as an evidence-based clinical intervention for presentations of lactation-related breast inflammation, as occurs in Academy of Breastfeeding Medicine Clinical Protocol #36 The mastitis spectrum (ABM CP#36).⁴ You can read more of my analysis of ABM CP#36 here.

Using the GRADE Working Group grades of evidence in their Summary of Findings, Anderson et al report Low Certainty of outcomes for reduction in pain, increase in breast milk supply, and reduction or resolution of symptoms of breast inflammation, noting that “the true effect may be substantially different from the estimate of the effect”. Anderson et al observe that ability to replicate or generalise results of the six studies are limited by:

1. Significant heterogeneity of study methods, interventions and outcome measures
2. Lack of detailed explanation of breast massage techniques
3. Use of invalidated tools
4. Small sample sizes

Anderson et al also note that requirement for extensive training for traditional Gua Sha⁵ and Oketani massage techniques⁶, in two of the studies, or the requirement in one of the other studies for seven consecutive days of massage combined with preparation of fresh topical cactus and aloe leaf lotion and pre- and post-massage application of aloe and cactus flesh, may not be practical in many settings.⁷

What the research investigating Manual Lymphatic Drainage tells us about its use in breastfeeding

Manual Lymphatic Drainage (MLD) is adapted for lactation from MLD interventions for patients suffering lymphedema after breast cancer treatment. Lymphedema is a non-reversible, fibrotic condition, secondary to permanent scarring, fibrosis, or surgical removal of lymph nodes and lymphatic vasculature. (Primary lymphedema is a very rare condition). MLD is typically applied as one aspect of Complex Decongestive Therapy, in combination with limb exercise and multilayered compression bandaging for up to a month.

A 2021 systematic review concluded it is “difficult to draw clear conclusions regarding the effect of MLD on breast cancer related lymphedema” of the upper limbs,⁸ and another 2021 systematic review shows that MLD has not been proven effective for breast cancer related lymphedema of the breast.⁹ A 2020 systematic review and meta-analysis of randomized controlled trials of MLD came to the same conclusion: that MLD cannot significantly reduce or prevent breast cancer related lymphedema of the upper limbs.10 A 2020 systematic review of Complex Decongestive Therapy for lower limb lymphedema concludes that pressure application is effective in reducing limb volume, but positive effects on patient function or quality of life are not demonstrated, concluding that prolonged tissue compression alone may be the active ingredient in Complex Decongestive Therapy.¹¹ A 2015 Cochrane review found MLD offered no benefits for the limb pain and heaviness of lymphedema, with contradictory or inconclusive evidence concerning improved function and quality of life.¹²

Why Therapeutic Breast Massage and Manual Lymphatic Drainage may even place breastfeeding women at risk

The lactating breast has intact and healthily functioning lymph nodes and vessels, and the stroma is not only highly vascular, but dense with functioning alveolar glands and ducts. The functional anatomy of the lymphatic vasculature in the lactating breast is described in detail in my publication Re-thinking benign inflammation of the lactating breast: a mechanobiological model page 12, under the heading ‘Intra-lobular stroma is exposed to frequent and irregular alterations in pressure gradients due to alveolar contractions and ductal dilations’.¹³

Firstly, the contribution of increased interstitial fluid and dilated, active lymphatic capillaries to increased stromal tension is not clear but is likely to be much less significant than the stromal tension effects of high intra-alveolar and intraductal milk pressures and hyperaemia. Secondly, an increase in interstitial fluid, lymphatic vessel dilation, and lymphangiogenesis are a normal and necessary response to endogenous tissue damage and hyperaemia. Fifty percent of lymphatic capillaries are collapsed and quiescent in the non-inflamed lactating breast. These lymphatic capillaries are activated (not ‘blocked’) by stromal tension, dilating as they take up immune cell and metabolic waste and fluid. Thirdly, any external pressure upon lactating tissues, no matter how light, compresses lactiferous ducts;¹⁴ if applied in a direction from nipple to the axilla, even light pressure risks exacerbating alveolar backpressure and inflammation.¹³ Fourthly, lymphatic capillaries which operate by fluid diffusion and cell translocation are deeper in the stroma, wrapped around the alveoli; superficial lymphatics are collecting vessels which have a myoepithelial layer, valves, and intrinsic contractility.¹³

Attempts to manually ‘move’ lymph into lymphatic vessels and towards lymph nodes are unphysiological. The latest evidence concerning functional anatomy, mechanical dynamics, fluid dynamics, and the role of inflammation in the immune system of the lactating breast, detailed in Re-thinking benign inflammation of the lactating breast: a mechanobiological model, suggests that like lump massage, TBML and MLD risk at best, ineffectual health system expense, and at worst, ductal compression and exacerbated backpressure of milk, micro-trauma, and haemorrhage in already highly sensitive, densely glandular, hyperaemic tissues.

Any perceived relief is likely to relate to ductal dilations associated with nipple and breast stimulation, or in the case of TBML also by the effects of hand expression, the infant suckling from the breast during the massage session. This is more safely and much more cheaply achieved by vacuum milk removal.

There are possible benefits to gentle manual movement of one’s own breasts with the palm of the hand

Neuroprotective Developmental Care applies an evolutionary lens to propose that in Homo sapiens’ environment of evolutionary adaptedness, the mammary gland was subject to constant and irregular movement, occurring in the context of frequent and flexible breastfeeds. Breast position and conformation shifted in relation to gravity repeatedly throughout the day, including with tissue vibration in response to rapid fall or movements of the breast in space. Bras limit breast movement and tissue vibration and create areas of the breast, depending on breast shape and bra fit, which are exposed to minimal or no movement in response to gravity.

The breast massage popularly referred to as ‘breast gymnastics’ requires lifting and gently moving the breasts in various directions, often with circular movements using the whole of the hand or palm laid gently over the breast. This form of breast massage may have a role, either preventatively in very early lactation or in the context of benign lactation-related breast infammation.3 It is detailed in Re-thinking benign inflammation of the lactating breast: classification, prevention, and management as Principle 5 in the NDC principles of prevention and management of breast inflammation.

There is no reason to routinise this kind of breast care or to outsource it to a masseuse, since a woman herself can gently move her own breasts as often as she wishes, which may stimulate milk ejections, being careful not to cause deep microvascular bruising by avoiding any discomfort or pain. Upper limb stretching movements which engage the pectoral muscles may similarly help move the breast tissue, and also do not require exercise prescriptions or outsourcing. 

Conclusion

Because clinical breastfeeding support remains a research frontier,¹⁵ breastfeeding women are commonly referred to multiple providers for unproven interventions when problems emerge. Many popular treatments such as TBML and MLD lack both a convincing evidence-base and a robust underlying pathophysiological model. Such treatments may increase the financial burden for families and health systems, and raise the spectre of discriminatory breastfeeding support globally, with ease of access limited to affluent families in advanced economies.

References

1.            Douglas PS. Re-thinking benign inflammation of the lactating breast: classification, prevention, and management. Women's Health. 2022;18:doi: 10.1177/17455057221091349.

2.            Witt AM, Bolman M, Kredit S, Vanic A. Therapeutic breast massage in lactation for the management of engorgement, plugged ducts, and mastitis. Journal of Human Lactation. 2016;32(1):123-131.

3.            Anderson L, Kynoch K, Kildea S, N L. Effectiveness of breast massage for the treatment of women with breastfeeding problems: a systematic review. JBI Database Systematic Reviews Implement Rep. 2019;17(8):1668-1694.

4.            Mitchell KB, Johnson HM, Rodriguez JM, Eglash A, Scherzinger C, Zakrija-Grkovic I, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeeding Medicine. 2022;17(5):360-375.

5.            Chiu JY, Gau ML, Kuo SY. Effects of Gua-Sha therapy on breast engorgement: a randomized controlled trial. J Nurs Res. 2010;18(1):1-10.

6.            Cho J, Ahn HY, Ahn S, S LM, M-H H. Effects of Oketani breast massage on breast pain, the breast milk ph of mothers, and the sucking speed of neonates. Korean Journa of Women's Health and Nursing. 2012;18(2):149-158.

7.            Meng S, Deng Q, Feng C, Pan Y, Chang Q. Effects of massage tratment combined with topical cactus and aloe on puerperal milk stasis. Breast Disease. 2015;35(3):173-178.

8.            Thompson B, Gaitatzis K, De Jonge XJ, Blackwell R, Koelmeyer LA. Manual lymphatic drainage treatment for lympedema: a systematic review of the literature. Journal of Cancer Survivorship. 2021;15:244-258.

9.            Abouelazayem M, Elkorety M, Monib S. Breast lymphedema after conservative breast surgery: an up-to-date systematic review. Clinical Breast Cancer. 2021;21(3):156-161.

10.          Liang M, Chen Q, Peng K. Manual lymphatic drainage for lymphedema in patients after breast cancer surgery. Medicine. 2020;99(49):e23192.

11.          Brandao ML, Soares HPS, A AM. Efficacy of complex decongestive therapy for lymphedema of the lower limbs: a systematic review. Jornal Vascular Brasileiro. 2020;19:e20190074.

12.          Ezzo J, Manheimer E, McNeely ML. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database of Systematic Reviews. 2015;5:DOI:10.1002/14651858.CD14003475.pub14651852.

13.          Douglas PS. Re-thinking benign inflammation of the lactating breast: a mechanobiological model. Women's Health. 2022;18:https://doi.org/10.1177/17455065221075907.

14.          Geddes DT. The use of ultrasound to identify milk ejection in women - tips and pitfalls. International Breastfeeding Journal. 2009;4(5):doi:10.1186/1746-4385-1184-1185.

15.          Stuebe AM. We need patient-centred research in breastfeeding medicine. Breastfeeding Medicine. 2021;16(4):349-350.