Physiological engorgement

When milk comes in between days two and six post-partum, normal breast filling occurs and the breasts become heavy and swollen without pain. When milk production increases rapidly during these first few days post-partum and more milk is made than the baby can remove, painful swelling known as engorgement may occur.

Initial physiological engorgement refers to the overfilling of the breasts, resulting in lymphatic and vascular congestion and oedema of the glandular breast tissue. Oedema results from a build-up of milk, blood and other fluids in the breasts. Swelling may occur in the areolae or the periphery of the breasts or both, and result in the breasts becoming very hard and tender, with the nipples becoming taut and flattened. Initial engorgement should not be confused with blocked ducts, despite ineffective milk removal being a common cause of both conditions. If left untreated, engorgement can lead to latching difficulties and mastitis.

Engorgement may also occur on a pathological basis throughout the breastfeeding period. Causes may include wearing a bra that is too tight or a baby sling that does not fit properly and presses on the milk ducts. Part of the breast then becomes tender to the touch. Untreated engorgement may lead to a decreased milk supply, mastitis and breast abscess.

Signs of physiological breast engorgement

Initial engorgement usually begins around the time of increased milk production after secretory activation from days two to six post-partum. The breasts usually become swollen, painful and tender, with redness, shiny skin and diffuse oedema present. The symptoms usually occur bilaterally and are generalised. A slight increase in temperature may be present (< 38.4C), but unlike with mastitis, systemic symptoms are absent. 

Evaluation of breast engorgement

Consultation with a lactation professional is required. Examination of the breasts, noting any redness, tenderness and asymmetry is important when diagnosing engorgement. 

Management

A management plan can be implemented and monitored with a lactation consultant or healthcare professional. The key to managing breast engorgement is promoting the frequent and effective removal of milk from the breast. In conjunction with a healthcare professional's advice, strategies that may be implemented include:

• Frequent and effective breastfeeding or pumping starting within the first hour after delivery. Mums should breastfeed at least 8-12 times a day, with no more than three hours between breastfeeds
• If breastfeeding is not possible, frequent expression with a pump 8-12 times a day is recommended
• Warming the breast with heat packs before feeding may help stimulate milk flow
• Cooling the engorged breast with cold packs or chilled cabbage leaves may help relieve pain
• Prior to attaching the baby to the breast, the reverse pressure softening technique can be applied. This technique uses gentle positive pressure/massage to soften the areola region, aiming to temporarily move some swelling slightly backwards and upwards into the breast to improve the latch of the baby during engorgement
• In the case of tender spots in the breast, mums may be able to position the baby during breastfeeding so that the baby’s chin is pointing towards the tender spot
• Following consultation with a medical professional, pain relief with an anti-inflammatory agent may be recommended to help with the milk ejection (let-down)
• If symptoms do not clear within 24-48 hours, or if flu-like symptoms develop or deterioration is present, the mum should consult a doctor, since engorgement can lead to mastitis 
• Other techniques, such as thermal ultrasound treatments for the breast and massage, have been reported to provide pain relief in some cases

Study abstracts

Reverse pressure softening: a simple tool to prepare areola for easier latching during engorgement

Successful breastfeeding requires efficient milk transfer through the nipple-areolar complex, which includes subareolar tissue. Subareolar tissue resistance increases during engorgement, when expanded circulation and excess ...

Cotterman KJ (2004)

J Hum Lact. 20(2):227-37

Maternal intravenous fluids and postpartum breast changes: a pilot observational study

The current breastfeeding initiation rate in Canada is approximately 87%. By one month, about 21% of women have stopped breastfeeding. Engorgement and edema in breast ...

Kujawa-Myles S, Noel-Weiss J, Dunn S, Peterson WE1, Cotterman KJ (2015)

Int Breastfeed J. 2;10:18