Engorgement

Brand new baby?  Tight, full breast?  Baby having trouble latching on?  You probably have “first week engorgement.”  And there may be some simple solutions.

Mothers have come to see engorgement as the natural follow-up to birth.  But it’s more often a natural follow-up to modern expectations of age-old biology.  In a nutshell, babies and breasts expect a lot more cuddling and nursing than many new mothers expect.

You’ve been making milk since your first trimester.  Maybe you leaked, maybe you didn’t.  But that first milk – colostrum – was there.    Colostrum is thick and yellowish and sluggish and more salty than sweet, but it’s full of antibodies and protein.  Call it “practice milk” for your newborn.  It coats your baby’s stomach and intestines with antibodies. It fuels but it doesn’t flood.

Now wait a couple days.  Your hormones shift.  The blood supply to your breasts increases to start up the milk factory, causing fullness.  (If you’ve had IV fluids, that fullness may be more than normal.)  Sugar enters your early milk, which pulls water into it.  It turns white.* From now on, your milk will be sweet and sloshy, and there will be a lot more of it… provided your body gets the message it’s looking for. (*sometimes human milk isn’t white – see our post on the Color of Milk for more info).

Your colostrum happened automatically.  Sugar and water ramped up automatically.  But now your breasts wants to know how much milk to make.  Is milk removed?  Then milk will be made.  Is milk not removed?  Then the flood gradually subsides, the breasts soften, and the factory shuts down.  It’s a kind of conversation between breast and baby that they both expect will go like this:

Breast:  MILK!  MILK!  TIME TO MAKE MILK!

Baby:  Why thank you!  Yum!  Ah.  That’s enough for now.

Breast:  I CAN MAKE LOTS MORE!  HOW MUCH DO YOU WANT?

Baby:  Actually, I could use another sip.

Breast: READY!  GO FOR IT!

Baby: Hey, you know, this stuff is good and getting better.  Let me just hang out here for the next few days.  I’ll nurse and nap, nurse and nap, and learn your territory.  I like this never overfull, never over-hungry, never hot or cold or scared, relaxed, sleepy, snacking sweet spot.  Mama is my universe, and for now, you wonderful breast, you’re at the center.

Breast:  Okay, I’m ready and willing whenever you need me.

Later:

Breast: It’s been a few days and we’re hitting our stride.  I know you better, you know me better.  I can settle down now and not overdo it.  And we can both rely on Mama to listen in on our conversation.  So if you ever need more, just ask.  Take more, and I’ll make more.

But here’s how the first-week conversation goes too often:

Breast:  MILK!  MILK!  TIME TO MAKE MILK!

Baby:  I’d love to!  But we’ll have to wait until after (pick one) Mama checks her social media, I’ve had my diaper changed, Auntie comes and Mama covers up for an hour, or someone – or some book – says it’s too soon to nurse again.

Breast:  NO, REALLY, I CAN MAKE LOTS MORE!  HOW MUCH DO YOU WANT?

Baby:  Sorry.  We waited too long and I’m too frazzled or too tired to sort out this new technique.

Breast: BUT I’M READY!

Baby: Yeah, too ready.  You’re so full of swelling and milk that now there’s nothing soft enough to latch onto!  I give up!  We’ll have to try again later.

Breast: NO, REALLY!  I HAVE LOTS, AND IT’S BACKING UP!

Repeat any of the above scenarios multiple times.

 Later:

Breast:  Hmm… I don’t get a customer very often, not even a pump.  I just have to assume there’s less milk needed.  I can do that.

Baby: Will someone feed me something?  This thing’s broken.

Breast: ———–

Maybe your own breast-baby conversation went off-course at first.  Here’s how you can help get it back on track:
  • Keep your baby touching you most of the time, lying on your chest, in your arms, at your side. (If you think you’re going to fall sleep, make sure your baby is in a safe place.  You’ll find more tips in our sleep posts: Sleep: Bedshare and Safe Sleep for Breastfeeding Babies).  Sure, you can shower, eat, let your loved ones do some holding.  But as a wise person said years ago, “There’s no such thing as a baby.  There is a baby and someone.”  Right now, almost all the time, that someone needs to be you.  And a calmer baby is a calmer, less grabby nurser, so your nipples may be grateful for this gentler start.
  • Try “relaxed nursing”. Get comfortable in the “couch slouch” you’d watch television with.  Not flat, not straight up (hospital beds can be especially good for leaning back).  Lay your baby chest-down on your own chest, between your breasts.  He may curl up and go to sleep, which is fine.  Just being on your chest helps keep his blood sugar, temperature, breathing, and heart rate normal, and being there on his chest makes him more competent.  If he starts rummaging around looking for your breast, or seems restless, or just makes movements with his mouth, make the offer.  Help him as much as you like, but don’t assume you know how he wants to do this.  Follow his lead rather than leading him.  Shift your breast and your baby in any way that feels right to you, but fit it to what he’s trying to do.  He knows what he’s looking for, and it’s probably not one of the holds the books show.  He may even nurse in his sleep, if you put his face near your nipple.  If you find yourself playing with his feet, or find his feet pressing against something, he’s grounding himself, just as you would.  And you’re using your mothering instincts.  Good for both of you!
  • If your breasts or nipples are sore, ask for help. Nothing about breastfeeding should hurt.  Pain is a sign to all mammals that something’s not right.  Some fullness and a little nipple discomfort for a few days, okay.  But bruising, broken skin, or outright pain?  It’s not good for you, and it probably means your baby is having some trouble taking milk out easily.
  • If you’re uneasy about any advice you get, try someone else. Almost all breastfeeding problems now have known reasons and remedies, but no one person knows them all.  Maybe you have a nursing friend who can visit.  Look over the Womanly Art of Breastfeeding, 8th edition, Chapter 4.  Or call your LLL Leader – find your local Leader here.  Super-sore nipples or breasts usually mean the baby’s not getting milk as effectively as he could.
What if I’m already badly engorged?
  • Keep your baby with you – on your chest, in your arms, at your side. Body contact can actually help, and it makes frequent nursing more likely.
  • Nurse or express your milk at least every 2 hours, and at least twice during the night. The more milk that collects in your breasts, the stuffier they get and the harder it is for fluids to move.  By taking milk out often, you make it easier for all the fluids in your breast – not just the milk – to move around.
  • Move your breasts around gently and massage them in any way that feels good. It may help shift excess fluids.
  • Lie back, which keeps your breasts higher than usual. Fluids follow gravity.
  • A bag of frozen vegetables can be a cold compress. Wrap it in a towel and put it on your breast(s) for about 20 minutes, then take it off for about 20 minutes.  The breaks “wake up” your breasts and are more effective than steady cold.
  • Use cabbage leaves to help bring down swelling – an old remedy in the “can’t hurt, might help” category. Discard the outer, possibly sprayed, leaves of a head of green cabbage.  (Red cabbage could stain.)  Now peel off one or more leaves, tear out the hard vein if you like, crumple each leaf gently in your hand, and put the leaves on your breast (not over your nipple).  They should feel nice and cool, and can be held in place with a bra or shirt.  Leave them on until you get tired of them, and repeat as often as you like.  Maybe there’s a reason cabbage leaves are shaped the way they are!
  • Stand in a shower and let the hot water land between your shoulder blades. You may find yourself leaking in the shower.  If not, it’s still relaxing.
What if my baby can’t nurse well enough or often enough to get my milk production going and keep it going?
  • In the first couple hours post-birth, you’re likely to have the most colostrum. If your baby can’t nurse soon after birth, you can hand express and give your baby her “starter dose” of colostrum with a spoon.  (See our post for information on hand expression.)
  • In the first couple days, colostrum is too thick to pump easily, but you can hand express into a spoon (plastic works really well). While you express into one spoon, a helper can give another spoonful to the baby.  Do it as often as you like, but at least every couple hours during the day and at least twice at night if you can.
  • Once your milk starts to increase quickly (a couple days after birth), you can try a good electric pump. Do a bit of gentle breast massage and hand expression before you start, in the middle, and at the end.
  • Don’t worry about making too much milk. Set your “milk thermostat” high in these early days and you can always back it down.  If you set it too low it can be tough to bring it back up.
What if I’m too full for my baby to latch on?
  • Hand express before you try to nurse. You don’t have to soften your whole breast, just the area around your nipple where his mouth – especially his lower jaw – needs to go.  (It’s hard to latch onto a soccer ball, a lot easier on a soft water balloon.)
  • Press fluid gently out of the way. It’s another way to soften the breast around your nipple to give your baby more softness to latch onto. You might try using your fingertips or the sides of your index fingers to make slight dents in the area around your nipple.  Do any pressing gently and for a short time; nothing you do to your breasts should hurt.
What if I become engorged and my baby isn’t a newborn?

Sometimes an older baby gets sick and doesn’t eat as much for a few days.  Or maybe it’s a growth spurt that boosted your production but ended quickly, temporarily leaving you with more milk than either of you wants.  You’ll find tips on dialing back overproduction at XX.

Engorgement in just one part of your breast could be from a plugged milk duct in that area.  Anything that reduces or stops milk flow can cause a milk “log jam” in all or part of your breast.  If the backup continues too long, you could end up with a breast inflammation or infection called mastitis.  But odds are that just nursing more often, hand expressing, or pumping – all with some gentle massage – will break up the “log jam”.  You’ll find more low-tech tips on getting your milk moving again in our post on plugged ducts and mastitis.

Remind me why I’m bothering?

If your baby is three or four days old, you may be feeling especially overwhelmed.  But just keeping your baby in body contact with you, nursing freely, and following the baby’s lead can keep most early problems, including engorgement, from happening, (and certainly helps you fall in love).

Mild engorgement doesn’t need more than the comfort measures above.  But if milk builds up in your breasts too much for too long, milk production can shut down partially or completely for this baby.  Too-much-too-long engorgement can also lead to a breast infection.  (See our post for information on mastitis.)  So even for your own health, it’s worth dealing with engorgement.

It takes most mothers a few weeks to feel fairly comfortable with motherhood, and first-week problems can loom especially large.  Once you get past any early hurdles like engorgement, you and your baby can have months or years of one of the simplest, most absent-minded and delicious, free-est and most health-giving relationships of your life.  Many, many bottle-feeding mothers wish they had breastfed.  You’re not likely to meet a breastfeeding mother who wishes she hadn’t.

It’s worth getting the help you and your baby deserve, and La Leche League is here to help you.

Further Reading

The Womanly Art of Breastfeeding

Amount of Milk – how to tell if your baby is getting enough milk

Frequency of Feeding FAQs

Positioning and Latch