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6.1 Engorgement

Engorgement

In this topic I'd like you to understand the difference between the normal breast fullness associated with the milk "coming in" and the pathological and preventable event which is breast engorgement.

Breast fullness

It's because of the placenta!

When the placenta is delivered the progesterone it had been producing ends.

Progesterone blocks milk production.

  • progesterone levels fall when the placenta is delivered - no longer inhibiting milk secretion
  • prolactin, which is essential to 'make milk' was already in high concentration in the mother/lactating parent's blood stream
  • lactose secretion into the alveoli of the breast increases, osmotically drawing in water to increase milk volume

There is also a marked increase in blood flow and lymphatic activity in the breast. These changes will occur whether breastfeeding is initiated or not.


© Photo: Tracey Foster

Secretory activation (lactogenesis II) occurs biochemically at about 30 - 48 hours postpartum. The clinical onset experienced as 'the milk coming-in' is reported to occur around postpartum Day 2 - 3, with wide individual variation (1hr - 6 days).

Stage II lactogenesis (secretory activation) starts with copious milk production after delivery. With the removal of the placenta at delivery, the rapid drop in progesterone, as well as the presence of elevated levels of prolactin, cortisol, and insulin, are what stimulate this stage. Usually, at days 2 or 3 postpartum, most women experience swelling of the breast along with copious milk production. In primiparous women, the secretory activation stage is slightly delayed, and early milk volume is lower. Lower milk volume is also observed in women who had cesarean births compared with those who delivered vaginally. Late onset of milk production has also been seen in women who have had retained placental fragments, diabetes, and stressful vaginal deliveries.

Signs and Symptoms

Increasing milk volume is reported as:

  1. breast tingling
  2. breast fullness
  3. milk leakage
  4. physical appearance of milk
  5. change in infant swallowing pattern while feeding, and cues to feed.

These are all normal and manageable events. Frequent, effective milk removal will make this transition comfortable while meeting the changing needs of the infant.

Engorgement

Engorgement is ...

...the swelling and distension of the breast, usually in the early days of initiation of lactation, caused by vascular dilatation as well as the arrival of the early milk.

However, ...

Breast engorgement is not an inevitable part of early lactation. It is a distinct condition that can share some of the same clinical features as mastitis spectrum disorders.

Engorgement causes:

  • pain, discomfort, and sometimes misery for the mother/lactating parent

If not effectively treated it can result in a mastitis spectrum disorder:

  • blocked ducts
  • mastitis
  • low milk supply
  • premature weaning

This preventable condition should be rare in units that implement good breastfeeding standards.

Signs and Symptoms

If normal breast fullness progresses to engorgement the signs and symptoms include:

  • swollen breasts; tight, shiny skin
  • generalized pink or redness of both breasts
  • mild to severe pain
  • heat is increased in both breasts
  • difficulty latching baby effectively and achieving milk removal
  • mild pyrexia (fever)

Some of the early postpartum engorgement symptoms may appear similar to those of early inflammatory mastitis. However, postpartum engorgement results from the secretory activation (lactogenesis II) stage of lactation and is related to interstitial oedema and hyperemia (congestion).
It is bilateral in presentation and includes breast pain, firmness, and swelling occurring generally around 3 and 5 days postpartum. On rare occasions, it may be as late as day 9 or 10 (delayed lactogenesis II) and, therefore a delayed presentation.

Cause

  • Milk stasis in the breast
    • poorly latched infant, or ineffective suckling
    • reduced breastfeeding?
    • giving additional fluids to baby, that delay feeding cues
    • using pacifiers/dummies to delay feeds
    • 'skipping' feeds, particularly night feeds
    • not expressing when breastfeeding is ineffective
  • Overhydration of IV fluids during labor
  • Low serum albumin

Why does this happen?

When one or more of the changes that occur at secretory activation is abnormal it creates a spiral of events.

  • delayed, ineffective, or infrequent milk removal => blockage of capillaries and slowed venous return => breast swelling and tissue oedema => difficult milk removal ... and so on.
  • breast swelling and tissue oedema (from overhydration with IV fluids in labor) => difficult milk removal => blockage of capillaries and slowed venous return => tissue oedema ...

Engorgement can be prevented by implementing good breastfeeding practices.

      • Minimize use of intravenous fluids during labour
      • early initiation of breastfeeding - more breastfeeding in the first 48 hrs is associated with less engorgement?
      • baby well latched to the breast
      • frequent feeds day and night
      • finish feeding on one breast before offering the other side
      • if baby not feeding, hand express every few hours from the time of birth


      © Photo: UNICEF


      © Photo: Carole Dobrich


      © Photo: Tracey Foster


      © Photo: Tracey Foster

      Don't be fooled

      Breast fullness is normal. Engorgement is not.

      Engorged, painful breasts are not a sign of a good milk supply. It usually indicates that breastfeeding practices have been poorly initiated, and proactive management will be required to retrieve the situation.

      Breast engorgement is common, but preventable in most cases.

      Clinical Management

      This painful condition can be resolved with diligent attention to:

      • Effective removal of milk
        • Use reverse pressure softening of the areola and if necessary hand expression or a manual pump to remove small volumes of milk before the infant latches as this can help facilitate physiological milk transfer.
        • Encourage the mother/lactating parent to breastfeed her baby often.
          • Encourage rooming in, breastfeeding/chestfeeding and avoid pumping where possible
          • Ensure the infant is well latched onto the breast.
          • Allow the baby to feed as long as he will on one side before offering the other side, optimizing drainage.
        • Hand express milk, if necessary.
          • If the baby is not transferring milk effectively or the dyad is separated
          • After feeding: If breasts are still uncomfortably tight, express enough to achieve comfort.
            If the baby does not breastfeed on the second side, hand express milk from that side until comfortable to prevent engorgement from getting worse.
        • When breasts are particularly full, stimulate a milk ejection by gentle massage/compression. Apply gentle compression anywhere on the breast with the palm of the hand. This gentle pressure may help the milk flow freely from the nipple without having to hand express when the mother/lactating parent is experiencing a lot of pain.
        • Try lymphatic drainage to alleviate oedema and consider using ice for symptomatic relief.

      There is some evidence to suggest that some treatments may be promising for the treatment of breast engorgement, such as cabbage leaves, cold gel packs, herbal compresses, and massage, but more studies are needed for the true effect of these interventions to be known.

      Will expressing increase milk production?

      Ideally, milk production will increase daily until peak milk volume is reached in the early weeks postpartum.

      Until engorgement is resolved:

      • breastfeed to meet the infant's needs (effectively and frequently)
      • if breasts are still uncomfortably full, hand express until comfortable (not empty!)
      • between feeds when breasts are uncomfortably full, hand express until comfortable (not empty!)

      Milk removal in addition to the immediate needs of the baby should only be enough to achieve breast comfort. Overdoing milk expression now will not make up for less milk removal later and may create unnecessary difficulties.

      As venous congestion reduces and the infant's needs increase, additional milk removal will not be required and the breast will tailor milk production to the infant's needs.

      Reassure the mother/lactating parent that this management will assist in faster resolution of her engorgement. Failure to diligently attend to these strategies will prolong the discomfort, initiate involution, and risk low breastmilk supply.

      • Reduce tissue swelling
        • A Cochrane Review of management of breast engorgement? found:
          • For breast hardness, cold gel packs may be more effective than routine care.
          • There is no difference between treatment with cold packs or cabbage leaves. Both were equally effective in relieving pain but there was no strong evidence that interventions resolved symptoms faster than with no treatment.
          • Acupuncture gave a greater improvement in symptoms in the days immediately after the treatment.
        • The underlying principle for the use of cold is to initiate vasoconstriction, decreasing venous congestion and reducing interstitial oedema.
          • Depending on the degree of engorgement, the cold compresses may need to be replaced frequently (e.g. 20 mins on, 20 mins off, and repeat several times)
          • Apply cold compresses to both breasts immediately after breastfeeding/expressing.
        • Certain non-steroidal anti-inflammatory drugs are very effective.

      Therapeutic ultrasound was found to be of no benefit in a randomized, controlled, double-blind trial.

      There is insufficient evidence from trials to support the widespread implementation of a particular treatment for breast engorgement. At the same time, treatments such as cold packs, massage, herbal compresses or cabbage leaves applied to the breast may be soothing, are unlikely to be harmful, are inexpensive and readily available.

      Heat or cold?

      Heat increases blood flow to the breast and the movement of fluid into the tissues to further exacerbate the engorgement. Avoid standing under a hot shower or soaking the breasts in warm water during this period of engorgement.

      Cold reduces the blood flow to the breast reducing swelling (interstitial fluid causing edema flows away from the breast via the lymphatic system).

      Mother/lactating parents usually prefer the feeling of cold, but it is important to individualize your management and be responsive if a mother/lactating parent finds this to be unpleasant.

      Areolar oedema/edema

      When breast engorgement is so severe that the areolar is edematous, latching the baby onto the breast for effective breastfeeding is impossible. Methods have been described to assist the movement of this interstitial fluid to make latching possible.

      Read this interesting article

      Click on the following link and read the 2021 study ExternalEffectiveness of Reverse Pressure Softening of Areola in Women with Postpartum Breast Engorgement.

      Print out the handout on ExternalReverse Pressure Softening by Jean Cotterman and file it in your Workbook.

      Share these papers with your colleagues who may be working with women experiencing this type of engorgement. Ask the mother/lactating parents about their feelings about the usefulness of this technique. When you are proficient at it you will be able to describe its application over the phone to mother/lactating parents with difficulty at home.

      Additional strategies include

      • lie mother/lactating parent on their back and using light stroking movements, very gently move the fingers along the breast away from the nipple, towards the axilla; aiding lymphatic drainage
      • baby has to be ready to feed immediately after this drainage because the fluid will return very quickly
      • hand express if the baby not available to suckle. DO NOT use a breast pump ... this increases the edema.

      PDFABM Clinical Protocol #20: Engorgement, Revised 2016

      The Basics of Breast Massage and Hand Expression from Maya Bolman

      What should I remember?

      • How secretory activation is initiated.
      • The difference between normal breast fullness and breast engorgement.
      • Breastfeeding practices which increase or decrease the likelihood of engorgement.
      • Management to assist the resolution of engorgement.
      • What will happen if engorgement is not quickly and effectively resolved.
      • Have an awareness of areola edema and overactive milk production.