Breastfeeding and Engorgement
Marsha Walker, RN, IBCLC
from Breastfeeding Abstracts, November 2000, Volume 20, Number 2, pp. 11-12.
Engorgement is a well known but poorly researched aspect of lactation. The medical dictionary defines engorgement as congestion, distension with fluid. Lactation literature refers to engorgement as the physiologic condition characterized by the painful swelling of the breasts associated with the sudden increase in milk volume, lymphatic and vascular congestion, and interstitial edema during the first two weeks following birth. Engorgement is a normal physiologic process with a progression of events, not a result of trauma or injury to tissues.
When milk production increases rapidly, the volume of milk in the breast can exceed the capacity of the alveoli to store it. If the milk is not removed, over-distention of the alveoli can cause the milk-secreting cells to become flattened and drawn out, even to rupture. The distention can partly or completely occlude the capillary blood circulation surrounding the alveolar cells, further decreasing cellular activity.1 Congested blood vessels leak fluid into the surrounding tissue space contributing to edema. Pressure and congestion obstruct lymphatic drainage of the breasts, stagnating the system that rid the breasts of toxins, bacteria, and cast-off cell parts, thereby predisposing the breast to mastitis (both inflammation and infection). In addition, a protein called the feedback inhibitor of lactation (FIL) accumulates in the mammary gland during milk stasis further reducing milk production. Accumulation of milk and the resulting engorgement are a major trigger of apoptosis, or programmed cell death, that causes involution of the milk-secreting gland, milk resorption, collapse of the alveolar structures, and the cessation of milk production.3
Descriptions of exceptionally thick or stringy milk being expressed from an engorged breast may be a clinical sign of possible glandular involution.4 This may represent milk inspissation (increased thickness or decreased fluidity) secondary to fluid resorption and an accumulation of fat cells in the gland.5
Engorgement can also be classified as involving only the areola, only the body of the breast, or both. Areolar engorgement involves clinical observations of a swollen areola with tight, shiny skin, probably involving over-full lactiferous sinuses. A puffy areola is thought to be tissue edema caused by large amounts of intravenous fluids received by some mothers during labor.
Some degree of breast engorgement is normal. Minimal or no engorgement in the first week postpartum has been associated with insufficient milk,6, 7 early supplementation, and a higher percentage of breastfeeding decline in the early weeks.8 Women with mild to moderate hypoplastic breasts with a wide intramammary space (>1 inch) and a tubular shape are at particular risk for producing less than 50 percent of the milk necessary for the first week.9
Moderate to severe engorgement is of more concern. Methods of measuring engorgement have appeared in the literature and include: measurements of chest circumference changes,6 thermography,10 use of a pressure gauge to measure skin tension,11, 12, 13, 14 and mothers’ self- ratings.6, 15, 16 Rates of engorgement between 20 percent and 85 percent have been reported in the literature based on numerous definitions and are usually limited to the first few days postpartum. Such reports described engorgement as peaking between day 3 and day 6 and declining thereafter. However, data from two unpublished masters theses suggest that mothers actually experience more than one peak of engorgement17 and that engorgement may continue for as long as ten days or more.13
Four patterns of engorgement have been described: a single experience of firm, tender breasts followed by a resolution of symptoms; multiple peaks of engorgement followed by resolution; intense and painful engorgement lasting up to fourteen days; and minimal breast changes. These patterns demonstrate that the experience of engorgement is not the same for all mothers.8
Predicting an individual mother’s risk for and course of engorgement may not be possible, but application of some general principles may be of help in anticipating situations that predispose to a higher risk. The following factors may place a mother at a higher risk of engorgement:
- Failure to prevent or resolve milk stasis resulting from infrequent or inadequate drainage of the breasts. The higher the cumulative number of minutes of sucking during the early days postpartum, the less pain from engorgement mothers describe.15, 18
- Small breast size (other than hypoplastic and tubular) . While small breast size does not limit milk production, it can influence storage capacity and feeding patterns. Mothers with small breasts may need to experience a greater number of breastfeedings over 24 hours than women with a larger milk storage capacity.19 Robson20 observed that women who became engorged were more likely to wear a significantly smaller bra cup size (34 percent) than women who did not become engorged (12.5 percent).
- Previous breastfeeding experience, but not parity, influences engorgement. Second-time breastfeeding mothers experience greater levels of engorgement sooner with faster resolution than first-time breastfeeding mothers. Breast engorgement for multiparous mothers breastfeeding for the first time was similar to primiparous breastfeeding mothers.16 Robson20 found that mothers in a non-engorged group were more likely to have never experienced engorgement following previous births than mothers in the engorged group. McLachlan et al. found that 70 percent of multiparous mothers experiencing engorgement in a current lactation had also experienced engorgement with previous babies.21
- Mothers with high rates of milk synthesis (hyperlactation)22 or large amounts of milk such as mothers of multiples may see milk stasis magnified if infants consume less milk, if less milk is pumped, or whenever milk volume significantly exceeds milk removal.
- Limited mother/infant contact in the early days. Shiau23 demonstrated significantly less engorgement on day three in mothers who participated in skin-to-skin care of their full-term babies rather than standard nursery care.
Numerous preventive strategies have been seen over the years including: restricting fluids, prenatal expression of colostrum, prenatal breast massage, postnatal breast massage, binding the breasts, or wearing a tight bra. Mothers experience less severe forms of engorgement with early frequent feedings,6 self-demand feedings,24 unlimited sucking times,25 and with babies who demonstrate correct suckling techniques.26 Short frequent feeds were shown to increase engorgement in one study,15 probably because abbreviated feeds (as short as two minutes) did not allow sufficient drainage of the breasts to prevent milk accumulation.
A technique called alternate breast massage has been shown to significantly reduce the incidence and severity of engorgement while simultaneously increasing milk intake, the fat content of the milk, and infant weight gain.27, 28, 29 Alternate massage involves massaging and compressing the breast when the baby pauses between sucking bursts. Massage alternates with the baby's sucking and is continued throughout the feeding on both breasts.
A plethora of treatment modalities for engorgement have been put forward, both anecdotally and in the literature, such as hot compresses, hot showers, soaking the breasts in a bowl of hot water, cold compresses after feedings, cold packs before feedings, ice packs, frozen bags of vegetables, both hot and cold therapy, oxytocin, proteolytic enzymes, stilbestrol, binding the breasts, manual expression, mechanical expression, no expression, lymphatic breast massage, ultrasound, frequent feedings, alternate massage, chilled cabbage leaves, room temperature cabbage leaves, and cabbage leaf extract.
- Heat application in the form of hot compresses, hot showers, or hot soaks is poorly researched and has usually been more of a comfort measure to activate the milk ejection reflex, rather than a treatment for edema. Some mothers complain that heat exacerbates the engorgement, causes throbbing and an increased feeling of fullness.20
- Cold therapy, including cold applications in the form of ice packs, gel packs, frozen bags of vegetables, frozen wet towels, etc. , has been studied under various conditions. Cold application triggers a cycle of vasoconstriction during the first 9 to 16 minutes where blood flow is reduced, local edema decreases, and lymphatic drainage is enhanced.30 This is followed by a deep tissue vasodilation phase lasting 4 to 6 minutes that prevents thermal injury.31 Robson20 discusses that application of cold for 20 minutes would have a minimal vasoconstriction effect in the deeper breast tissue and that venous and lymphatic drainage would be enhanced in the deeper tissues due to the accelerated circulation to and from the superficial tissues. Sandberg32 reports on the application of cold packs for 20 minutes before each feeding on a small sample of women. Mothers reported increased comfort compared to heat, decreased chest circumference, and no adverse affect on milk ejection or milk transfer.
- Thermal (continuous) ultrasound treatment of engorged breasts has not been shown to improve pain or edema.21
- Lymphatic breast drainage therapy is a gentle massage of the lymphatic drainage channels in the breast. Lymphatic drainage is thought to improve the movement of the stagnated fluid, reduce edema, and improve cellular function.33, 34 Wilson-Clay35 reports the relief of discomfort and better subsequent milk yields during pumping following manual lymphatic drainage therapy in three women with unrelieved severe engorgement.
- Chilled cabbage leaves. Rosier36 anecdotally describes the use of chilled cabbage leaves applied to engorged breasts and changed every two hours in a small sample of women as having a rapid effect on reducing edema and increasing milk flow. Nikodem et al.37 showed a non-significant trend in reduced engorgement in mothers using cabbage leaves. Roberts38 compared chilled cabbage leaves and gelpaks and found similar significant reduction in pain with both methods, with two-thirds of the mothers preferring the cabbage due to a stronger, more immediate effect. Roberts et al.39 studied the use of cabbage extract cream applied to the breasts which had no more effect than the placebo cream.
- Expressing milk. Refraining from expressing milk because the mother will "just make more milk "cannot be justified. Hand expressing or pumping to comfort reduces the buildup of FIL, decreases the mechanical stress on the alveoli preventing the cell death process, prevents blood circulation changes, alleviates the impedence to lymph and fluid drainage, decreases the risk of mastitis and compromised milk production, and gives relief to the mother. It is not known what degree of engorgement or duration of milk stasis presents a situation from which milk production may not recover. The milk production in the alveoli not experiencing engorgement continues normally. The breast is capable of compensating to a point. Future research would delineate this further.
Marsha Walker, RN, IBCLC, is Executive Director of the National Alliance for Breastfeeding Advocacy (NABA). She is owner of Lactation Associates in Weston, MA, USA and is a former President of the International Lactation Consultant Association.
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