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3.1 Early problems

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.
Joanne is discharged early on day three and comes to see you for follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Secretory activation

Breast fullness is a physiological response to the initiation of copious milk production (secretory activation), and is a function of increased vascularity, increased milk production and increased oedema due to increased vascularity and milk production.1 Breast fullness is associated with some tenderness and pain beginning around day two and peaking by day five.2

Breast engorgement is an exaggeration of the physiological process, with breasts becoming swollen, hard and very painful, and the nipple being flattened by underlying breast fullness. The skin of the breast is often red and shiny and the mother may be slightly febrile (38C). The baby is often unable to latch well, resulting in painful, cracked nipples and poor milk drainage. With severe engorgement, the breasts may extend from the clavicle to the lower rib cage and from the midaxillary to the midsternal line.1

Prevention of engorgement

Early, frequent and effective breastfeeding, or breast expression if infant not feeding, will prevent normal breast fullness from developing into breast engorgement.

Predisposing factors

Restricted breastfeeding increases the incidence of engorgement, 3 while other predisposing factors for engorgement include:

  • delay with the first breastfeed
  • infrequent feeding
  • time-limited feeds
  • late maturation of milk, and
  • supplementary feeds 4

Management

A recent Cochrane Systematic Review found there was insufficient evidence to recommend a particular treatment. However, managing engorgement focuses on ensuring good breast drainage and maternal comfort. 5 6 It may include the following points:

  • Encourage frequent feeding - most neonates require between eight and 12 feeds a day.
  • Soften the areola by expressing a small amount of milk before a feed so that the infant is able to latch more easily. The amount of milk expressed will depend on the individual woman and degree of engorgement.
  • Position the infant at the breast to ensure effective latch and breast drainage.
  • Allow the infant to drain the first breast well before offering the second side. Some studies suggest feeding from one beast at each feed, while expressing small amounts of milk from the other breast for comfort. 7
  • Express by hand or pump until the breasts are soft if the infant is not feeding well at the breast. When the infant has fed well but the breast is still full and painful, only express until the breasts feel more comfortable.
  • Complete drainage of both breasts followed by using one breast at each feed may be helpful in some situations.8
  • Warm compresses and massage before a feed encourage milk flow.
  • Cool/cold compresses after a feed result in vasoconstriction, reduction of edema and a degree of pain relief. Cold cabbage leaves are as effective as cold packs. 9
  • Breast support from a well-fitting bra or firm t-shirt assists some women. Breast binding is not recommended. 10
  • Anti-inflammatory medications and other analgesics provide some pain relief.

Reverse pressure softening for areolar oedema

Some women, especially those who receive large amounts of IV fluids during labour, have oxytocin augmentation of labour, or use high suction electric breast pump early postpartum, develop pitting oedema of the breast and areola. In these situations, a technique of reverse pressure softening reduces the oedema surrounding the nipple so that the infant can attach/latch more easily.11

(Click on the icon to read an article on this technique.)

Case Study Activity

Notes

  1. # Lawrence RA et al. (2011) Breastfeeding: A guide for the medical profession.
  2. # Hill P et al. (1994) The occurrence of breast engorgement
  3. # Slaven S et al. (1981) Unlimited suckling time improves breast feeding.
  4. # Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention
  5. # Mass S (2004) Breast pain: engorgement, nipple pain and mastitis
  6. # Brodribb W (ed) (2012) Engorgement, oversupply and fast flow. IN: Breastfeeding Management in Australia
  7. # Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic
  8. # van Veldhuizen-Staas CG (2007) Overabundant milk supply: an alternative way to intervene by full drainage and block feeding.
  9. # Roberts KL (1995) A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast engorgement
  10. # Swift K et al. (2003) Breast binding... is it all that it's wrapped up to be?
  11. # Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement