New Perspectives on Engorgement
Mary Kay Smith, IBCLC
Romeoville IL USA
From: LEAVEN, Vol. 35 No. 6, December 1999-January 2000, pp. 134-36
We provide articles from our publications from previous years
for reference for our Leaders and members. Readers are cautioned to
remember that research and medical information change over time.
Engorgement is associated
with maternal discomfort, difficulty with latch-on (which can lead to
plugged ducts and mastitis), and the premature termination of breastfeeding.
Several studies cite engorgement and breast or nipple pain as primary
reasons for the cessation of breastfeeding. Engorgement is most common
during the first week of breastfeeding and occurs as a result of delayed,
infrequent or interrupted removal of milk from the breast.
While some breast fullness
is normal in the second to fourth day after birth, a mother should continue
to feel well and her nipple and areola should remain compressible. Occasionally
this fullness may last as long as seven days.
Mothers may describe their
breasts as feeling warm, full, and heavy; some have said they "woke
up with something heavy on their chest." This normal condition
is caused by congestion and swelling of breast tissue as blood and other
fluids begin to accumulate along with increased milk volume in the alveoli
as milk production begins.
According to Dr. Ruth Lawrence
in Breastfeeding: A Guide for the Medical Profession, engorgement
of the breast involves three elements: congestion and increased vascularity
(the physiologic response that follows removal of the placenta and does
not depend on suckling); accumulation of milk, also a physiologic response
to placental removal; and edema (swelling and fluid retention). Breasts
that are congested with milk are prone to swelling as circulation slows,
allowing fluid in the blood vessels to seep into the breast tissues.
When this sequence proceeds smoothly, no pain, discomfort or excessive
swelling occurs. However, when the edema is evident and the surface
of the skin pits with pressure, this process requires intervention.
Pathologic engorgement is the result of mismanagement of this normal
transitional period and is a condition of abnormal, exaggerated breast
fullness accompanied by heat, tenderness and low-grade fever. It can
also happen at any time during the breastfeeding relationship when the
breasts are not emptied and milk accumulation in the breast is prolonged.
The breasts can be hard and uncomfortable with tight, translucent skin;
there is frequently distention of tissue extending into the underarm
area. Severe engorgement can cause numbness and tingling of the mother's
hands from pressure on her nerves.
The nipple may be stretched
and flattened by the forward pressure of milk under the areola. Even
though the nipple may appear normal, it can be difficult for the infant
to grasp. Nipple damage can occur when the infant unsuccessfully tries
to grasp and draw the nipple and areola into his mouth.
Though there may be no evidence
of infection at this time, a low-grade fever or "fever of unknown
origin" may cause the health care provider to suspect an infection.
Occasionally treatment for the "infection" can interfere with
the resolution of the engorgement and the continuation of breastfeeding.
In a hospital setting, engorgement
is seen often in mothers who have had operative or cesarean births;
feedings are often delayed due to pain or reluctance to hold the baby
in a position near the incision. Sometimes breastfeeding is delayed
due to misinformation about medications the mother is receiving. In
situations when mothers are discharged from the hospital within 24 to
48 hours, engorgement sometimes does not begin until mother is at home.
New information shows that
mothers who received medications to suppress blood pressure or prevent
seizures in the labor and delivery period may also experience a delay
in milk production along with a related delay in engorgement.
There is evidence that unrelieved
engorgement can cause damage to the alveoli in the breast, thus impacting
potential for milk production. Whenever milk is allowed to accumulate
in the breast, a protein present in the whey fraction of the milk acts
to inhibit the production of more milk. In addition, the process of
engorgement creates pressure within the ducts which can lead to atrophy
of the secretory and myloepithelial cells (the cells responsible for
the manufacture of milk in and the removal of milk from the alveoli).
This situation, called pressure involution, can contribute to decreased
milk production and is a risk factor for lactation failure.
One recent study (Moon &
Humenick 1988) identified several factors that increase the risk of
engorgement. Short or restricted feedings are a contributing factor
as are the use of complementary and supplementary feedings. This study
also suggests several variations in patterns of breast engorgement occurrence.
Mothers with more than one child or pregnancy were more likely to report
more intense engorgement than were those having their first child. Obviously,
mothers' experiences may differ under similar circumstances, however,
this knowledge can help prepare a woman to cope with the experience.
During La Leche League meetings
mothers can be introduced to the idea that some breast fullness is normal
and they can learn management techniques for breast fullness. They may
be surprised to know that it is common and temporary, when babies breastfeed
early, often and effectively.
Frequent feedings with intervals
of one and one-half to two hours are essential. An effective latch is
vital to effective breast emptying. Mothers should hear audible swallowing
at this point of milk production. Mothers who are unable to feed the
baby due to separation or pain can be encouraged to use a breast pump
in combination with other treatments.
If normal breast fullness
is present, some manual expression of the breast prior to a feeding
may be sufficient to soften the areolar- nipple junction, enhancing
latch-on and effective breast emptying.
The Use of Thermal Treatments
Some currently recommended
treatment measures include the use of cold compresses on the breasts
between feedings to reduce swelling. In the not-so-distant past, the
use of heat prior to a feeding was encouraged "to help milk flow."
Although there is little research to prove the effectiveness of either
heat or cold treatments, the experience of many breastfeeding specialists
shows that the use of cold is more effective. Some theories to support
this new recommendation are that cold reduces vascular and lymphatic
congestion, reduces swelling and enhances milk flow. Although some cultures
avoid the use of cold during the postpartum period, an explanation may
make this treatment method more acceptable. When using cold compresses,
always use a layer of fabric between the skin and the cold source. There
are products available commercially for cold treatments but usually
crushed ice in a plastic bag or the ever-popular frozen vegetable ice
pack works just as well (bags of peas or corn mold well to the area
needing coverage). Be aware that cold on or near the nipple can impede
a let-down. The use of heat increases vascular congestion and swelling
and may impede milk flow. While it may feel soothing, if a mother chooses
to use warmth she should be cautioned to use it only immediately prior
to latch-on or pumping and for no longer than 3 to 5 minutes. Prolonged
application of heat has the potential for increasing swelling. A warm
shower with spray directed at the back, not on the tender, sensitive
breasts, may help relieve breast tension and improve milk flow as well.
Other women have reported good results from immersing the breasts in
a basin of warm water while doing some gentle massage prior to a feeding.
Others have reported that using a few drops of olive oil applied to
the skin of the breast (not on the nipple) helps avoid skin discomfort
when doing breast massage.
The use of raw green cabbage
leaves has been anecdotally reported to reduce engorgement. Mothers
who have used this treatment report the use of chilled or room temperature
cabbage leaves to be soothing. The advantages of this treatment are
its low cost and convenience. One study reported the group using cabbage
leaves experienced a slight reduction in perception of engorgement and
exclusively breastfed longer (Roberts 1995b). A study comparing the
use of chilled cabbage leaves to chilled gel packs found that pain was
relieved within 1-2 hours with both treatments, but mothers preferred
the cabbage treatment (Roberts et al. 1995a).
The clean, inner leaves of
a head of green cabbage can be applied between feedings for several
feedings. The leaves should be changed at least every two hours or when
they wilt. Mothers should know that there may be some smell of cooked
cabbage if they choose this treatment method. They should also know
that overuse of cabbage leaves can lead to a reduction in milk supply
according to some reports. Cabbage leaves should be used only until
the swelling goes down and should be discontinued if a skin rash or
other signs of allergy appear.
Other Treatment Measures
The goals of treatment for
engorgement are to reduce vascular and lymphatic congestion and remove
milk from the breasts. Use of a breast pump is sometimes discouraged
due to a fear of engorgement reoccurring, but it can be part of an effective
treatment plan. For a breast pump to assist in the treatment of engorgement,
it must effectively and gently remove milk. An automatic cycling breast
pump with adjustable suction levels is most effective. Breast tissue
is fragile when engorged and can bruise easily. For this reason, gentleness
should also be emphasized when recommending massage of the breast during
this time.
The mother may find that
the use of pain medication is helpful. She can ask her health care provider
to recommend an over the counter anti-inflammatory medication. Most
are approved by the American Academy of Pediatrics for use in breastfeeding
mothers; specific drugs can be researched by a Professional Liaison
Leader. Binding the breasts is not recommended although a supportive
bra may be worn if mother is comfortable. Some women prefer a "sports
bra" for support during engorgement. Mothers should NOT limit fluid
intake to reduce engorgement as adequate fluid intake is needed in the
postpartum period to avoid urinary tract infections and constipation.
Occasionally, wearing breast
shells for about 30 minutes prior to a feeding will help reduce the
pressure and help the nipple to evert. This does encourage the breast
to leak which can help relieve the tightness of an overfull breast.
Other Circumstances That
May Be of Concern
A mother who has had breast
augmentation surgery with implants should avoid severe engorgement.
She is at risk for pressure involution and a reduction in milk supply
in addition to the possibility of a breast infection. If the baby is
sleepy or not nursing well, an automatic cycling breast pump may be
helpful during this time if the mother feels uncomfortable using hand
expression.
When physiologic engorgement
is treated promptly and consistently, resolution should occur within
24-48 hours. Resolution of severe engorgement may take anywhere from
one week to longer. Mothers may need some assurance that they have an
adequate milk supply when engorgement is resolved.
Suggested Care Plan for
Engorgement
- Frequent feedings: at
least every 1.5 to 2 hours around the clock; let baby nurse as long
as possible, no time restrictions at the breast.
- Warm compresses can be
used for a few minutes prior to a feeding if the mother desires. Use
a warm, wet towel to cover the entire breast. It may facilitate milk
let-down in the early stages of engorgement.
- Gentle areolar expression
can help soften the areola to assist with latch-on.
- An electric breast pump
can be used at low settings, if necessary to empty the breast enough
to facilitate a latch-on.
- Vary nursing positions
to help promote drainage of the breast; use gentle massage during
a feeding if it is comfortable.
- Apply ice or cold compresses
to the breasts between feedings or pumping sessions for approximately
15-20 minutes.
- Raw green cabbage leaves
can be used as a compress instead of ice, if desired. The leaves should
be changed when wilted or after 2 hours. The breasts should be assessed
for reduced swelling and enhanced milk flow with each change of cabbage
leaves until the desired result is obtained.
- A supportive bra may be
helpful; avoid underwire styles at this time.
- The mother may ask her
doctor to suggest an anti-inflammatory drug compatible with breastfeeding
for pain and swelling.
- The mother should contact
a health care professional if any of the following symptoms are present:
temperature of more than 100.6 degrees F (38.1 degrees C), chills,
body aches, localized pain or flu-like symptoms. Breastfeeding is
not contraindicated in the case of an elevated temperature.
References
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Evans, K., Evans, R., Simmer,
K. Effect of the method of breast feeding on breast engorgement, mastitis
and infantile colic. Acta Paediatr 1995; 84:849-52.
Foxman, B. Schwartz, K.,
Looman, S.J. Breastfeeding Practices and lactation mastitis. Soc
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Hill, P.D., Humenick, S.S.
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Humenick, S.S., Hill, P.,
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Lawrence, R.A. and Lawrence
R.M. Breastfeeding. A Guide for the Medical Profession. Fifth
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J Hum Lact 1995a; 11:17-20.
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Page last edited Sun Oct 14 09:31:53 UTC 2007.
