Breast engorgement typically occurs in early lactation, after then onset of Lactogenesis II, when copius milk production begins, but it can also occur later in the breastfeeding journey. It is caused by incomplete drainage of the breast so any separation of the mother and infant or change in expressing pattern could lead to engorgement.
It is a preventable condition and if managed at an early stage then progression to severe engorgement can be avoided. Severe engorgement can lead to complications such as mastitis and is the beginning of the process of breast involution which can lead to a decreased milk supply. Also engorgement of the breast can make it more difficult to latch the baby, which can lead to suboptimal latching and consequent painful feeding and nipple damage.
Risk Factors For Engorgement
Anything that causes milk stasis is a risk factor for engorgement
- Suboptimal latch or suckling- will lead to incomplete drainage of the breast
- Infrequent feeding from the breast in the early days and weeks or a sudden reduction in typical feeding frequency later in the journey, e.g. in case of illness
- If mother and baby are separated, not expressing milk to maintain the typical feeding frequency
- Delayed initiation of breastfeeding after delivery
- Some studies suggest that over hydration with IV fluids during parturition can predispose to breast engorgement but more research is needed into this
The most effective way to prevent engorgement in early lactation is to ensure to carry out breastfeeding best practice such as:
- Initiating breastfeeding as soon as possible after delivery
- If mother and baby are separated or direct breastfeeding is not possible, encourage regular expression to empty the breasts and maintain regular feeding frequency
- Ensure optimum latch
- Regular feeding or expressing throughout the day and at nighttime
Later in the journey, good breastfeeding education should prepare mothers to prevent engorgement themselves by ensuring adequate milk removal and regular feeding. When it comes to weaning, ideally this should be done gradually to prevent engorgement.
Management of Engorgement
The primary principle of managing engorgement is to frequently remove milk from the breasts until they feel comfortable. A common concern is that expressing milk from engorged breasts in the early days will lead to oversupply as the supply is establishing but this is a myth. The reason the breasts are engorged in early lactation to begin with is typically due to inadequate milk removal before and during Lactogenesis II so removing enough milk to ensure comfort and to correct this inadequate milk removal should not cause issues with oversupply in the long term.
- Regular breastfeeding is key to managing engorgement. Encourage breastfeeding on demand and avoid scheduling feeds or any other practices that restrict the infant’s access to the breast.
- Identify the cause of the engorgement e.g. suboptimal latch and correct it if possible.
- When the baby is feeding on a particular side, allow her to drain that side fully before switching to the next side. Firm massage from a gentle hand on any lumpy areas while the baby is feeding from that side can help to drain those areas. While the baby feeds on one side, do not inhibit the other from dripping. If the baby wants to feed on the other side when she has drained the first, proceed with this, however if she does not want the second side, express enough milk from that side to ensure comfort.
- Even if baby is feeding well from both sides, if the breasts remain uncomfortable after feeding, it is important to remove enough milk to relieve the discomfort to prevent involution of over distended lactocytes which could have a detrimental effect on supply.
- If expressing milk for comfort, the ideal way is to stimulate a milk ejection reflex, then use the palm of the hand to compress the breast which is enough to allow milk to flow out without needing to express either by hand or via a pump, both of which can exacerbate areolar oedema.
- If there is no areolar oedema, hand expressing a small amount of milk before latching can assist in achieving a deeper and more effective latch.
- Gentle massage of the breast can also help. Bear in mind when massaging what your goal is. Interstitial fluid drains via the venous and lymphatic systems towards the upper outer quadrants and the axilla, while milk drains via the nipple. Is your goal with massage to move milk out via the nipple or interstitial fluid towards the axilla? This may inform your technique. Do not use excessive stimulation, e.g. massage under a warm shower.
- If the mother wears a bra, it is key that it be well fitting.
- Simple analgesia such as paracetamol may be helpful.
- There is not adequate evidence for the use of chilled cabbage leaves or warm/cold compresses, however many mothers find them soothing in the setting of engorgement and they have not been shown to cause harm. Warm compresses applied before feeding can assist with milk flow whereas cold compresses or chilled cabbage leaves applied after feeding can be soothing and ease discomfort. The use of cabbage leaves could affect milk supply so it should be limited.
- Click the link below to a Cochrane review of treatments for breast engorgement for further information.
If engorgement has progressed to involve areolar oedema, it is extremely difficult to effectively latch the baby to the breast. The primary technique for reducing areolar oedema in order to latch the baby is Reverse Pressure Softening, the link below from the HSE describes the technique in detail.
Key points to remember when areolar oedema is present are:
- Position the mother supine- this will assist drainage
- When massaging the goal is to move interstitial fluid towards the axilla- massage away from the nipple.
- Fluid will return rapidly after massage so latch the baby on as soon as possible
- Avoid using breast pumps as these will exacerbate the oedema, feeding baby directly is the optimum way to remove milk in this setting but hand expressing is also acceptable.