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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

Auerbach, K.G. and Riordan, J. Breastfeeding and Human Lactation. Sudbury, Massachusetts: Jones and Bartlett, 1998; 283, 294-95,431.

Biancuzzo, M. Breastfeeding the Newborn: Clinical Strategies for Nurses. St. Louis: Mosby, 1999.

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 Sci Med 1994; 38:755-61.

Hill, P.D., Humenick, S.S. The occurrence of breast engorgement. J Hum Lact 1994; 10:79-86.

Humenick, S.S., Hill, P., Anderson, M. Breast engorgement: patterns and selected outcomes. J Hum Lact 1994; 10:87-93.

Lawrence, R.A. and Lawrence R.M. Breastfeeding. A Guide for the Medical Profession. Fifth Edition. St. Louis: Mosby, 1999; 255-58.

Moon, J.L. and Humenick, S.S. Breast Engorgement: Contributing Variables and Variables Amenable to Nursing Intervention. JOGNN 1988; 17:309-15.

Mohrbacher, N. and Stock, J. BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: LLLI, 1997; 414-18.

Nikodem, V.C., Danziger, D., Gebka, N., et al. Do cabbage leaves prevent engorgement? A randomized controlled study. Birth 1993; 20:61-64.

Newton, M. & Newton, N. Postpartum engorgement of the breast. Am J Obst Gyn 1951; 61:664-67.

Roberts, K.L. A comparison of chilled cabbage leaves and chilled gel paks in reducing breast engorgement J Hum Lact 1995a; 11:17-20.

Roberts, K.L., Reirter, M, Schuster, D. A comparison of chilled and room temperature cabbage leaves in treating breast engorgement. J Hum Lact 1995b; 11:191-94.

Rosier, W. Cool cabbage compresses. Breastfeeding Review 1987; 11:28-31.

Shrago, L. Engorgement reconsidered. BREASTFEEDING ABSTRACTS 1991; 11 (1):1-2.

THE WOMANLY ART OF BREASTFEEDING. Schaumburg, Illinois: LLLI, 1997; 54-56, 76.

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