Abstract
Dear Editor,
We are writing to highlight and correct factual errors in Douglas 1 paper, “Re-thinking Benign Inflammation of the Lactating Breast: Classification, Prevention, and Management,” published in Women’s Health in 2022 Jan–Dec. In her paper, Dr Douglas misreads and misstates the follow-up of our 2016 study on “Therapeutic Breast Massage in Lactation for the Management of Engorgement, Plugged Ducts, and Mastitis,” 2 leading her to dismiss our study’s findings on an erroneous basis. She furthermore misstates a summary of our study in Anderson et al.’s 3 systematic review of breast massage.
In her paper, Dr Douglas writes, Although Witt et al. conclude that their study demonstrates TBML “is helpful for the reduction of acute breast pain associated with milk stasis,” Anderson et al. state that the results of Witt et al.’s RCT are unreliable, because of an unusually high rate of drop-out from the intervention group. At 2 days post-intervention, 25 of 40 in the TBM group did not follow up, and at 12 weeks, 27 of 40 did not follow up. In contrast, the control group had a 90% retention rate.
1
These numbers are incorrect; our study was not a randomized controlled study (RCT), and Anderson et al.’s review is mischaracterized.
We want to reiterate the correct numbers. In our 2016 Therapeutic Breast Massage in Lactation (TBML) study, 2 42 patients were enrolled in a prospective cohort study describing the clinical response to TBML. This was not an RCT. Within the cohort, we used a nested case-control study of the 15 engorged women managed with TBML and compared to 73 control postpartum mothers to examine and better describe the engorgement severity of those receiving TBML.
Follow-up for the entire cohort of 42 is reported in the main text of the Results section: “Thirty-eight women completed the 2-day survey. Ninety-two percent reported pain improvement and 43% reported pain resolution. Forty-one women completed the final survey at 12 weeks.” This translates to 90% follow-up at 2 days and 98% at 12 weeks for the entire cohort.
Detailed follow-up for the nested case-control of engorged mothers (n = 15) is described in Table 3. For these cases, we had 87% (13/15) follow-up at 2 days and 100% (15/15) follow-up at 12 weeks. The control group had follow-up of 77% (56/73) at 2 days and 88% (64/73) at 12 weeks. Overall, our study reports excellent follow-up on patients receiving TBML.
In addition to inaccurately describing our patient follow-up, Dr Douglas states, “Anderson et al. state that the results of Witt et al.’s RCT are unreliable, because of an unusually high rate of drop-out.” However, Anderson does not describe a high rate of drop-out nor do they describe our study as an RCT but rather label it as “quasi-experimental.” Overall, the conclusion of Anderson’s systemic review of six massage studies states, the overall effect of breast massage on reported outcomes is uncertain. However, results suggest that breast massage, compared with no intervention, may help to reduce pain, increase breast milk supply and resolve symptoms for women with blocked ducts, engorgement and mastitis; further high-quality RCTs are warranted.
We agree with the conclusion of Anderson’s review.
In addition, we agree with Dr Douglas’ call to avoid mechanical forces that cause high intra-alveolar and intraductal pressures and the elimination of micro-vascular trauma from lump massage and to avoid focused deep pressure on the breast and lumps. However, we do not agree with her calling out therapeutic breast massage as not recommended. The principles of TBML do not involve prolonged external pressure nor does it employ direct mechanical compression of a lump. In our paper, we describe the technique of TBML as gentle and note the massage should be continually adjusted to the patient’s comfort level. TBML embraces two principles:
Focused gentle massage toward the axillae.
Alternating gentle massage and hand expression.
We provide further details on the massage technique in Appendix A of our paper. In particular, we note “To prevent tissue damage, avoid direct hard pressure on the plugged area.” And “Throughout the massage, frequently check the mother’s comfort level. If there is discomfort the massage pressure used should be lessened.” And “All massage techniques are gentle.”
We respect Dr Douglas’ efforts to offer a different theoretical framework for understanding management of benign lactation-related breast inflammation. We agree further understanding of the pathophysiology of these conditions and additional research are needed on all the topics she mentions in her paper, including massage. Given the wide range of massage practices in the world, we agree with highlighting the importance of avoiding high pressure, deep tissue massage that could result in tissue damage as described by Dr Douglas. However, we want to reiterate the importance of accurate discussions of the existing research.
