Engorgement

July 27, 2011. Posted in: BF Concerns: Mother,Common Newborn Concerns

By Kelly Bonyata, BS, IBCLC

What is Normal?

It is normal for your breasts to become larger and feel heavy, warmer and uncomfortable when your milk increases in quantity (“comes in”) 2-6 days after birth. This rarely lasts more than 24 hours. With normal fullness, the breast and areola (the darker area around the nipple) remain soft and elastic, milk flow is normal and latch-on is not affected.

How to prevent or minimize engorgement

  • Nurse early and often – at least 10 times per 24 hours. Don’t skip feedings (even at night).
  • Nurse on baby’s cues (“on demand”). If baby is very sleepy: wake baby to nurse every 2-3 hours, allowing one longer stretch of 4-5 hours at night.
  • Allow baby to finish the first breast before offering the other side. Switch sides when baby pulls off or falls asleep. Don’t limit baby’s time at the breast.
  • Ensure correct latch and positioning so that baby is nursing well and sufficiently softening the breasts.
  • If baby is not nursing well, express your milk regularly and frequently to maintain milk supply and minimize engorgement.

Signs & Symptoms of Engorgement

When?   Engorgement typically begins on the 3rd to 5th day after birth, and subsides within 12-48 hours if properly treated (7-10 days without proper treatment).

How does the breast feel?    The breast will typically feel hard, with tightly stretched skin that may appear shiny, and you may experience warmth, tenderness, and/or throbbing. Engorgement may extend up into the armpit.

How does the areola feel?    The areola will typically feel hard (like the tip of your nose or your forehead) rather than soft (like your earlobe), with tight skin that may appear shiny. The nipple may increase in diameter and become flat and taut, making latch-on challenging.

You may also have a low-grade fever.

Moms’ experiences of engorgement differ. Engorgement:

  • May occur in the areola and/or body of the breast;
  • May occur in one or both breasts;
  • May build to a peak and then decrease, stay at the same level for a period of time (anywhere from minimal to intense), or peak several times.

Tips for treating engorgement

Before nursing

  • Gentle breast massage from the chest wall toward the nipple area before nursing.
  • Cool compresses for up to 20 minutes before nursing.
  • Moist warmth for a few minutes before nursing may help the milk begin to flow (but will not help with the edema/swelling of engorgement). Some suggest standing in a warm shower right before nursing (with shower hitting back rather than breasts) and hand expressing some milk, or immersing the breasts in a bowl or sink filled with warm water. Avoid using warmth for more than a few minutes as the warmth can increase swelling and inflammation.
  • If baby is having difficulty latching due to engorgement, the following things can soften the areola to aid latching:

While nursing

  • Gentle breast compressions and massage during the nursing session can reduce engorgement.
  • After nursing for a few minutes to soften the breast, it may be possible to obtain a better latch by removing baby from the breast and re-latching.

Between feedings

  • If your breast is uncomfortably full at the end of a feeding or between feedings, then express milk to comfort so that the breasts do not become overfull.
  • Hand expression may be most helpful (though obviously second to breastfeeding) as this drains the milk ducts better.
  • Mom might also use a hand pump or a quality electric pump on a low setting for no more than 10 minutes (engorged breast tissue is more susceptible to damage). A “juice-jar” pump may also be used.
  • Massaging the breast (from the chest wall toward the nipple area) is helpful prior to and during milk expression.
  • It’s not good to let the breasts get too full, but you also don’t want to overdo the pumping, as too much pumping will encourage overproduction. If you do need to express milk for comfort, your need to express will likely decrease gradually over time; if it does not, then try gradually decreasing the amount you express.
  • Use cold compresses (ice packs over a layer of cloth) between feedings; 20 minutes on, 20 minutes off; repeat as needed.
  • Cabbage leaf compresses can also be helpful.
  • Many moms are most comfortable wearing a well fitting, supportive bra. Avoid tight/ill-fitting bras, as they can lead to plugged ducts and mastitis.
  • Talk to your health care provider about using a non-steroidal anti-inflammatory such as ibuprofen (approved by the American Academy of Pediatrics for use in breastfeeding mothers) to relieve pain and inflammation.

AVOID:

  • Excess stimulation (for example, don’t direct a shower spray directly on the breasts).
  • Application of heat to the breasts between feedings. This can increase swelling and inflammation. If you must use heat to help with milk flow, limit to a few minutes only.
  • Restricting fluids. This does not reduce engorgement. Drink to thirst.

Contact your lactation consultant or health care provider if:

  • Engorgement is not relieved by these measures.
  • Baby is unable to latch or is not having enough wet/dirty diapers.
  • You have mastitis symptoms: red/painful breast, temperature greater
    than 100.6 degrees F, chills, body aches, flu-like symptoms.
  • You have any questions.

Other treatments for engorgement

Cabbage

Applying cabbage leaf compresses to the breast can be helpful for moderate to severe engorgement. There is little research on this treatment thus far, but there is some evidence that cabbage may work more quickly than ice packs or other treatments, and moms tend to prefer cabbage to ice packs.

What are cabbage compresses used for?

  • Engorgement.
  • Extreme cases of oversupply, when the usual measures for decreasing supply (adjusting nursing pattern, nursing “uphill,” etc.) are not working
  • During weaning, to reduce mom’s discomfort and decrease milk supply.
  • Sprains or broken bones, to reduce swelling.

To use cabbage leaves:

  • Green cabbage leaves may be used chilled or at room temperature.
  • Wash cabbage leaves and apply to breasts between feedings.
  • For engorgement or oversupply: Limit use as cabbage can decrease milk supply. Leave on for 20 minutes, no more than 3 times per day; discontinue use as soon as engorgement/oversupply begins to subside.
  • During the weaning process: Leave the leaves on the breast until they wilt, then apply new leaves as often as needed for comfort.

For further information on how to use cabbage leaves:

“Juice Jar” breast pump

This simple pump can be useful to help with engorgement, and to draw the nipple out when baby is having a difficult time latching on.

  • Find an empty glass jar or bottle at least 1 liter in size with a 5 cm or larger opening. The type of bottle that cranberry juice comes in is often a good size.
  • Fill the jar nearly full with very hot water. The glass will get very hot and you will need to hold it with a towel.
  • Pour all the water out of the jar.
  • Use a cool washcloth to cool down the rim and upper part of the jar so you can touch it without burning yourself (test it with your inner arm).
  • Place your breast gently into the mouth of the jar so that it makes an airtight seal. Some moms lean over a table to do this, others put the jar in their lap on a pillow and lean forward. Expect this to take a few minutes, so make yourself comfortable.
  • As the air slowly cools inside the jar, it creates a vacuum inside the jar and this gentle suction expresses milk from the breast. Break the suction immediately if you feel discomfort – if the jar cools too quickly it may create excessive suction which can damage breast tissue.
  • Repeat for the other breast.
  • Some moms need to repeat this, others find it works sufficiently with only one try.

Fenugreek seed poultice

This is a traditional treatment for engorgement or mastitis. Steep several ounces of fenugreek seeds in a cup or so of water. Let seeds cool, then mash them. Place on a clean cloth, warm, and use as a poultice or plaster on engorged or mastitic breasts to help with let-down and sore spots. For more information, see Fenugreek.

 

Additional Resources

@

Reverse Pressure Softening… aids latching when mom is engorged

@ other websites

Prevention and Treatment of Engorgement by Becky Flora, BS, IBCLC

Treating engorgement by Kathy Kuhn, IBCLC

New Perspectives on Engorgement by Mary Kay Smith, IBCLC, from Leaven, Vol. 35 No. 6, December 1999-January 2000, pp. 134-36.

Animation of baby nursing when mom is engorged showing how engorgement can lead to nipple trauma, from the Breastfeeding Management Series software by Sallie Page-Goertz, MN, CPNP, IBCLC and Sarah McCamman, MS, RD, LD

References:

Cotterman KJ. Too Swollen to Latch On? Try Reverse Pressure Softening First. Leaven, April-May 2003;39(2):38-40.

Hill PD, Humenick SS. The occurrence of breast engorgement. J Hum Lact. 1994 Jun;10(2):79-86.

Humenick SS, Hill PD, Anderson MA. Breast engorgement: patterns and selected outcomes. J Hum Lact. 1994 Jun;10(2):87-93.

Lawrence R and Lawrence R. Breastfeeding: A Guide for the Medical Profession, 6th ed. St. Louis: Mosby, 2005, p. 278-281.

Mohrbacher N, Stock J. The Breastfeeding Answer Book, Third Revised Edition. Schaumburg, Illinois: La Leche League International, 2003, p. 492-496.

Moon JL, Humenick SS. Breast engorgement: contributing variables and variables amenable to nursing intervention. J Obstet Gynecol Neonatal Nurs. 1989 Jul-Aug;18(4):309-15.

Riordan J and Auerbach K. Breastfeeding and Human Lactation, 3rd ed. Boston and London: Jones and Bartlett, 2004, p. 205-207, 228.

Roberts KL, Reiter M, Schuster D. A comparison of chilled and room temperature cabbage leaves in treating breast engorgement. J Hum Lact. 1995 Sep;11(3):191-4.

Roberts KL. A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast engorgement. J Hum Lact. 1995 Mar;11(1):17-20.

Smith A, Heads J. Breast Pathology. In: Walker M, ed. Core Curriculum for Lactation Consultant Practice. Boston: Jones and Bartlett, 2002, p. 175-180.

Snowden HM, Renfrew MJ, Woolridge MW. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2001;(2):CD000046.

Walker M. Breastfeeding and Engorgement. Breastfeeding Abstracts, November 2000;20(2):11-12.

Wilson-Clay B, Hoover K. The Breastfeeding Atlas, Third Edition. Austin, Texas: LactNews Press, 2005, p. 109-111.

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