1. A Systematic Review of Breast Massage Techniques in PubMed and YouTube
Anna Sadovnikova, M.P.H., M.A., Ileisha Sanders, M.P.H., Samantha Koehler, M.P.H., M.S.W.
LiquidGoldConcept, LLC
ABSTRACT
Background: To date, no systematic review or categorization of breast massage techniques has been
completed; thus, it is unclear which technique mothers should use for a plugged duct, engorgement, or to
stimulate let-down.
Objectives:
1. To identify and match unique breast massage techniques to specific breastfeeding problems.
2. To compare breast massage techniques described in academic literature to breast massage techniques
used by and available to the general public.
Methods: Search terms such as “breastfeeding” AND “massage” and “breastfeeding” AND “engorgement”
were used to search for relevant literature in PubMed (from 1965 to April 2015) and in YouTube (first 15
videos per search term). Some articles were identified via reverse snowball and hand searches.
Results: Sixteen unique breast massage techniques from twenty-two articles were identified via the PubMed
search strategy. 51% of videos identified via the YouTube search strategy depicted a breast massage
technique that is different from the sixteen breast massage techniques described in academic literature.
Conclusion: Breast massage techniques are rarely described in academic literature. Few studies have
evaluated the efficacy of various breast massage techniques.A large discrepancy exists between techniques
described in academic literature and the techniques available to and practiced by the general public. Now
that many breast massage techniques have been identified and matched to specific breastfeeding problems,
well-designed studies are needed to understand the value and efficacy of each technique.
Conflict of Interest Disclosure: The authors of this abstract are all co-founders and primary shareholders of
LiquidGoldConcept, LLC, a for-profit breastfeeding education and technology company incorporated in the state of
Michigan. LiquidGoldConcept is currently funded by the authors themselves. Anna Sadovnikova received funding from
the University of California, Davis, School of Medicine to pay for the printing of this poster, and for conference travel,
registration, and transportation.
Please contact, liquidgoldconcept@gmail.com, for questions and comments about our research and projects.
Authors
• Anna Sadovnikova, MPH, MA, Chief Executive Officer and Co-Founder, M.D./Ph.D. Candidate at the University of
California, Davis.
• Samantha Koehler, MPH, MSW, Chief Financial Officer and Co-Founder
• Ileisha Sanders, MPH, Chief Operational Officer and Co-Founder
Special Thanks to Rachel Atwood, Chief Information Officer for designing the Breast Massage Knowledge Bank and to Jeff
Plott, MSE, Chief Technical Officer, for suggestions, edits, and support.
RESULTS
METHODOLOGY
PubMed Search Strategy
§ YouTube videos are constantly changing. Due to the subject matter (exposed breasts), many videos are
removed by YouTube or by the mother.
§ The YouTube videos were not screened based on who uploaded the video—some videos were uploaded by
mothers, others were uploaded by organizations or health professionals.
§ Only the PubMed search engine was used; thus, it is possible that some articles were not identified.
§ Many resources described in articles found through PubMed are cited as videos, brochures, websites and
other, non-academic materials. Many links were not functional, some brochures no longer exist, some articles
and books were not available through the University of Michigan Interlibrary Loan System.
§ Non-English articles were not included in this analysis.
Sixteen unique breast massage techniques from twenty-two articles were identified via the PubMed search
strategy. 51% of videos identified via the YouTube search strategy depicted a breast massage technique
that is different from the sixteen massage techniques described in academic literature.
1. The authors do not attempt to evaluate the efficacy of any breast massage technique.Very few studies have
attempted to determine whether or not a technique is efficacious (Foda et al. (2004),Yokoyama et al. (1994),
Morton et al. (2009, 2012, 2013), Kernerman et al. (2014)).Well-designed studies are needed to evaluate
the efficacy of each technique and the applicability of each technique to different breastfeeding problems.
2. More research is needed to determine whether or not one technique can be used for multiple breastfeeding
concerns. Many papers present outdated information (Applebaum (1970, 1975), Hoffman (1953)) and
discuss techniques that are no longer recommended (Bear 1993).
3. The authors are translating the non-English papers to get a more global picture of the variety of breast
massage techniques that exist. Until then, it is unreasonable to make any definitive statements about
techniques that originate from a non-English speaking country (example, Oketani).
4. The authors were surprised by the discrepancy between the YouTube techniques and the techniques
described by health professionals and researchers. Moreover, it was surprising that so few studies discussed
or referenced the Marmet technique, since the Marmet technique seems to be, at least anecdotally, the most
commonly taught technique in community groups, online forums, and the La Leche League.
We are inviting parents and providers to contribute to and learn from the Breast Massage Knowledge Bank.
We will use the data we collect to: 1) develop free breast massage tools for mothers, 2) create evidence-based guidelines
3) publish educational materials for health professionals, and 4) further breast massage research.
The World’s First Collection of Evidence-Based Breast Massage Techniques
The Breast Massage Knowledge Bank
Technique Description Citation Indication Images
Foda et al. (2004)
Improve milk quality (increased lipids,
casein, total solids)
Yes
Kabir et al. (2000)
Poor nipple pliability; mastitis
prevention; alleviate engorgement; low
milk volume
Yes
Yokoyama et al.
(1994)
Facilitate let down; oxytocin release No
With the mother reclined, both hands can be placed together around the areola and then slide toward
the base of the breast with or without a gentle rotation of the breasts: to the right and back, and then
repeated to the left and back. Gentle stroking hand motions across the breast are performed, starting at
the areola and directed toward the axillae.
Bolman et al.
(2013)
Facilitate lymph drainage and improve
blood circulation during engorgement
or mastitis.
Video
Gently roll the knuckles downward over the breast, beginning at the ribs and working towards the
areola.
Jones et al.
(2001)
For preterm if low milk volume No
Starting at the base of the breast, place a hand on each side of the breast with thumbs and fingers of
both hands together. With moderate, evenly distributed pressure slide both hands toward the breast,
encompassing the breast in a circle between the hands. Continue sliding hands toward each other until
you reach areola; at all times keep pressure even and moderate. Repeat this procedure four to five
times, being sure to start well back on the side chest wall and maintain even pressure throughout.
Storr et al. (1987) Engorgement No
Applebaum
(1975)
Applebaum
(1970)
Morton et al.
(2009, 2012,
2013)
Before and during pumping to facilitate
let down and milk ejection, respectively
Videos
Bowles (2011) Facilitate let down No
La Leche League
Brochure (2003)
Facilitate let down Yes
Ayers (2000)
Storr (1988)
Atkinson (1979)
Brown (1975)
5. Dancing Fingers
Place fingertips over the affected area and move them quickly (high frequency) in repetitive, up and
down motions.
Bolman et al.
(2013)
To improve circulation of blood and
facilitation of lymph drainage to reduce
swelling
Video
6. Gentle Vibration
Another fingertip approach is gentle vibration with the fingers placed over the affected area and
oscillated back and forth. A similar effect is achieved by using the whole palm in the same vibrating
motion.
Bolman et al.
(2013)
To improve circulation of blood and
facilitation of lymph drainage to reduce
swelling
Video
7. Gua-Sha
Scrape accupoints in the direction of the nipple as well as between the breasts using the index and
middle fingers in a spiral motion toward the nipples. Each position is lightly scraped seven times in two
cycles.
Chiu et al. (2010) Engorgement Yes
8. Chest Massage
The mother uses her left hand to support her breast and her right hand to firmly massage the upper
pectoralis muscle with a flat hand. The mother uses her left hand to support her breast and her right
hand to firmly massage the anterior serratus muscle with her fingertips.
Kernerman et al.
(2014)
To alleviate breast pain and thoracic
tightness
Yes
Bolman et al.
(2013)
Use during engorgement in
combination with other techniques
Yes
Jevitt et al.
(2007)
If obese, can use to alleviate
engorgement, improve latch, and
facilitate let down
No
Cotterman (2004) Improve latch when engorged Yes
10. Point Pressure
While taking a hot shower or bath, use firm pressure behind the lump of milk, pressing the mass of
milk toward the plug in an effort to move the blockage toward the nipple
Cambpell (2006) Alleviate plugged ducts No
Morton (2009,
2012, 2013)
Use while pumping to stimulate milk
ejection
Videos
Bowles (2011)
Use while breastfeeding to increase milk
ejection
No
Jevitt et al.
(2007)
If obese, to promote milk ejection while
breastfeeding
No
Dr. Jack
Newman's
Website
Use while breastfeeding to increase milk
ejection
Videos
Iffrig (1968)
Use while breastfeeding to increase
milk ejection
No
12. Hands on Pumping Combination: Marmet + Alternate/Compression
Morton et al.
(2009, 2012,
2013)
To Increase milk volume, especially for
preterm or after delivery
Videos
13. 6 Step Recanalization
Technique
Clear the plugged duct outlets: stretch the nipple with 1 hand and deep clean the nipple with a dry
towel to remove all milk stains, milk clogs, and flakes of epidermis at the opening of the milk
ducts.Nipple manipulation: hold and lift the nipple from different directions to mimic the suckling
stimulation for the milk ejection reflex. Push and press the areola: push and press the areola from
different directions. Push and knead the breast: push and knead the breast from the base toward the
nipple.
Zhao et al. (2014) Alleviate plugged ducts Yes
14. Side-to-Side
Rolling/Kneading
Roll the breast between both hands or use the backs of fists as if gently kneading.
Bolman et al.
(2013)
To improve circulation of blood and
facilitation of lymph drainiage to reduce
swelling
Video
15. Third Finger
This technique uses fingers from the hand not performing hand expression. The finger provides gentle
but firm pressure moving around the edges of the plug to assist in its release.
Bolman et al.
(2013)
Alleviate plugged ducts Yes & Video
Bear (1993)
Mentions Hoffman's as an ineffective
method
No
Applebaum
(1975)
Applebaum
(1970)
Hoffman (1953) Yes
Yes
In order to separate the adhesions, breast is to be pushed forward manually by inserting a hooked
finger into the basal portion to a depth of about 0.8 cm lifting the breasts forward. After that the
adhesions are gently pushed back towards the pectoral muscle depending on the reaction of the
mother. As a result, the operator feels a gap between breast base and the pectoralis major. Short
rhythmical pulls separate the basal portion of the breast from the pectoral muscle by distance of 1-2 cm.
1. Oketani
2. Sliding
With the thumbs together and the fingers or both hands cupped well under the breast, gentle traction is
exerted from the back downward to the nipple. While one hand holds the breast firmly, the other is
released. The thumb and forefinger of the free hand are placed on the areolar margin and turned
through all points of the compass, pushing inward and back toward the chest wall until secretion is
obtained.
Sixteen Unique Breast Massage Techniques Identified via the PubMed Search Strategy
To prevent inverted nipples if used
prenatally, as early as 5th month of
pregnancy
Done prenatally to prevent nipple
tenderness and pain
No
16. Hoffman's
The procedure is one of placing the thumb or the forefingers, close to the inverted nipple, then pressing
into the breast tissue quite firmly and gradually pushing the fingers away from the areola. An imaginary
cross is drawn on the breast, that is, a vertical line and a horizontal line, and the patient is instructed to
put her two thumbs close to the nipple, press in firmly against the breast tissue, and then pull the
thumb and finger laterally in the horizontal position or upward and downward in the vertical position.
After the nipple has been brought out to this projected position, it is easier to grasp as a whole unit, and
by graspoint it at its base, she can gently tease it out a bit further.
Yes
Start at the top of the breast. Press firmly into the chest wall. Move fingers slowly, pressing firmly in a
small circular motion on one spot on the skin. After a few seconds, pick fingers up and move to the next
area on the breast. Do not slide on breast tissue. Spiral around the breast toward the areola using this
massage. The pressure and motion are similar to that used in a breast examination. Stroke the breast
from the chest wall to the nipple with a light tickle-like stroke. Continue this stroking motion from the
chest wall to the nipple around the whole breast. Shake the breast gently while leaning forward so that
gravity will help the milk eject.
Roll the nipple for 30 seconds with the hand and then rub the nipple for 15 seconds with a towel.
9. Reverse Pressure
Softening
One-Step Method for Applying RPS (Short Nails Needed)
The “flower hold": Instruct the mother to curve her fingers and grasp her nipple at the base, right where
it joins the areola, positioning her fingers near the place for the baby’s tongue and lower jaw. Thumb
compresses a place for upper jaw. Press inward for 1 to 3 minutes, firmly enough to form 6 to 8 dimples
or pits at the base of the nipple This should not cause any pain or discomfort.If really needed, she may
rotate the hand and reapply RPS to the unpitted area. Can be done with one or two hands. (Refer to
Cotterman (2004) for more details and for the two-step method)
11. Alternate or
Compression
During Breastfeeding: With the baby latched on, the mother gently massages and compresses the
breast until the baby again sucks and swallows. She then suspends the massage until the baby
resumes the non-nutritive sucking pattern. Thus the breast massage is alternated with the bursts of the
baby’s sucking. When one area softens she moves her fingers to a new position and continues
alternating the massage the baby’s nursing until the entire breast has softened. During Pumping: With
the pump attached and turned on, the mother feels for hard lumps in the breasts and compresses them
while observing milk ejection in the flange. When one area softens, she can move to a new position.
3. Marmet
4. Nipple Rolling
Prenatally for nipple protractility; low
milk volume; facilitate let down;
prevent engorgement; alleviate
plugged ducts and engorgement
LIMITATIONS
DISCUSSION
NEXT STEP
ABOUT LIQUIDGOLDCONCEPT
YouTube Search Strategy
Number of articles identified in PubMed
based on search terms
1.Identification
22 articles, 1 website, 1 brochure used to
determine 16 unique techniques
3.Determination2.Assessment
1054
-15Non-English excluded
-1000
Articles excluded based on
title and abstract, and if
duplicates
+21
21 new articles identified
from reverse snowball and
hand searching
Full text articles (read and assessed by AS, IS,
SK) that mentioned breast massage in
relation to breastfeeding
39
-38
Excluded, no description of a
breast massage technique
60
22
Full text articles (read and assessed by AS, IS,
SK) that mentioned breast massage in
relation to breastfeeding
First 15 videos per search term assessed
based on title and screenshot (IS, SK)
Excluded based on title and
screenshot, or if duplicate
51% (n=33) of breast massage techniques
depicted/described are different from
Techniques 1-16 identified through PubMed.
Each video watched by IS and SK
>500,000 videos identified in YouTube
based on the search terms
64
Excluded, if not related to
breastfeeding, if not available, if
breast massage not discussed or
shown
295
33
Excluded, (but categorized in
separate database) if describe/
depict Techniques 1-16
1.Identification3.Determination2.Assessment
-231
-31