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8.1 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

Secretory activation (lactogenesis II) occurs biochemically at about 30 - 48 hours postpartum. 1 2 3 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) . 4

It's because of the placenta!

When the placenta is delivered the progesterone it had been producing is stopped.
Progesterone blocks milk production.5
  • 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's blood stream
  • lactose secretion into the alveoli of the breast increases, osmotically drawing in water to increase milk volume 6
There is also a marked increase in blood flow to the breast. These changes will occur whether breastfeeding is initiated or not.

Review this in Topic 4.0

Signs and Symptoms

Women report knowing their milk is 'in' by the following signs and symptoms:

  1. breast tingling
  2. breast fullness
  3. milk leakage
  4. physical appearance of the 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 for the mother, while meeting the changing needs of the infant.

Engorgement

Engorgement causes:
  • pain and misery for the mother
If not effectively treated results in:
  • blocked ducts
  • mastitis
  • low milk supply
  • premature weaning
This preventable condition should be rare in units that implement good breastfeeding standards.
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. 7
However, ...
Breast engorgement is not an inevitable part of early lactation.

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 ...
  • I'm sure you 'get the picture' now.

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
  • increased heat of both breasts
  • difficulty latching baby effectively and achieving milk removal
  • mild pyrexia (fever)

Cause

  • Milk stasis in the breast
    • poorly latched infant, or ineffective suckling
    • reduced breastfeeding8
    • 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 9,10
  • Low serum albumin11

Prevention

Engorgement can be prevented by implementing good breastfeeding practices.
  • early initiation of breastfeeding - more breastfeeding in the first 48 hrs is associated with less engorgement 12,13
  • baby well latched to the breast
  • frequent feeds day and night
  • fully draining of one breast before offering other side14
  • if baby not feeding, express every few hours from time of birth

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 preventable in most cases.

Did you know?

Allowing breasts to become engorged is the physiological way to suppress lactation.

That's NOT what you want to happen with your new mothers.

Workbook Activity 8.1

Complete Activity 8.1 in your workbook.

Clinical Management

This painful condition can be resolved with diligent attention to:
  • Frequent, effective removal of milk
    • Encourage the mother to breastfeed her baby often.
      • Ensure baby is latched on to breast well.
      • Allow the baby to feed as long as he will on one side before offering the other side, optimizing drainage.

    • Firm, but gentle massage of lumpy areas while baby feeds helps milk flow. Allow the other breast to drip freely.

    • Hand express breastmilk, if necessary.
      • Before feeding: to help baby latch to a very full, firm breast.
        A few minutes of expressing milk from around the nipple/areola can make a big difference. Also, after baby has suckled for a minute unlatch him from the breast and relatch - frequently achieving an even deeper, more effective and more comfortable latch.
      • After feeding: If breasts still uncomfortably tight, express enough to achieve comfort.
        This should be done after and between feeds as often as necessary.
        If baby does not breastfeed on the second side, hand express milk from that side until comfortable to prevent engorgement getting worse.

    • When breasts are particularly full stimulate a milk ejection by gentle massage or a warm compress. 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 is experiencing a lot of pain.

Will expressing increase milk production?

Ideally, milk production will increase daily until peak milk volume is reached around 2-3 weeks postpartum.

Until engorgement is resolved:
  • breastfeed to meet the infant's needs (effectively and frequently)
  • if breast/s still uncomfortably full, hand express until comfortable (not empty!)
  • between feeds when breasts uncomfortably full, hand express until comfortable (not empty!)
Milk removal additional to the immediate needs of the baby should only be enough to achieve breast comfort.
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 that this management will assist 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 15 found:
      • 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 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 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. 15
Therapeutic ultrasound was found to be of no benefit in a randomized, controlled, double-blind trial. 16

Heat or cold?

Heat increases blood flow to the breast and movement of fluid into the tissues to further exacerbate the engorgement. 17 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 breast via lymphatic system).
Mothers usually prefer the feeling of cold on their hot breasts, but it is important to individualise your management and be responsive if a mother finds this to be unpleasant.

Workbook Activity 8.2

Complete Activity 8.2 in your workbook.

Unit Activity

Revise your unit's policy on the management of engorgement. Develop a teaching plan for a 15-minute educational session you could lead on the prevention and management of engorgement for your colleagues.

Advanced care

Generally speaking engorgement can be prevented in most mothers by implementing the breastfeeding standards described. If engorgement should develop, prompt intervention will manage the signs and symptoms and normal breastfeeding will be able to continue.

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. 11,9

Read this practical article

Click on the link to be taken to a description of Reverse Pressure Softening for the treatment of areolar edema. Print the paper for filing in your Workbook.

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

Additional strategies include

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

Overactive milk production

Mothers with overproduction are usually very uncomfortable with large, swollen breasts, leaking milk and an abundant supply. The baby may appear to gulp milk during feeding, or develop poor breastfeeding technique, slipping off the nipple in an attempt to not have to consume so much.
Full drainage and block feeding may be the solution.18

Read this article

Click on the title of this box to open the article: "Overabundant milk supply: an alternative way to intervene by full drainage and block feeding".
Print the article, read it and file it in your workbook for future reference.

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.

Self-test quiz

Notes

  1. # Cox DB et al. (1999) Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships
  2. # Hurst NM (2007) Recognizing and treating delayed or failed lactogenesis II.
  3. # Henderson JJ et al. (2008) Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women.
  4. # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
  5. # Pang WW et al. (2007) Initiation of human lactation: secretory differentiation and secretory activation.
  6. # Neville MC et al. (1991) Studies in human lactation: Milk volume and nutrient composition during weaning and lactogenesis
  7. # Lawrence R (2010) A Breastfeeding guide for the Medical Profession
  8. # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
  9. # Miller V et al. (2004) Treating Postpartum Breast Edema With Areolar Compression
  10. # Hunter D (2004) Oedema and its impact on breastfeeding outcome: Assessment and management of the mother and her breastfeeding baby during the postpartum period.
  11. # Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement
  12. # Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention
  13. # Academy of Breastfeeding Medicine (2009) Clinical Protocol #20: Engorgement
  14. # Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic
  15. # Mangesi L et al. (2010) Treatments for breast engorgement during lactation.
  16. # McLachlan Z et al. (1993) Ultrasound treatment for breast engorgement: A randomised, double-blind trial
  17. # Robson BA (1990) Breast engorgement in breastfeeding women
  18. # van Veldhuizen-Staas CG (2007) Overabundant milk supply: an alternative way to intervene by full drainage and block feeding.