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A Systematic Review of Breast Massage Techniques in PubMed and YouTube
Anna Sadovnikova, M.P.H., M.A., Ileisha Sanders, M....
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ABM.2015 Poster


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ABM.2015 Poster

  1. 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,, 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