Breast engorgement is a situation that can complicate lactation at the time of its establishment. It appears during the onset of lactogenesis II and can endanger the continuation of lactation.

What is lactogenesis II?

Lactogenesis is the physiological process in which the ability to secrete milk is developed, which is divided into 3 phases:

• Lactogenesis I, secretory initiation. This occurs during gestation.
• Lactogenesis II, secretory activation. This begins immediately after delivery, reaching its maximum peak at 48-72 hours, and is established in the following 24-48 hours. The woman may experience a feeling of fullness and hyperthermia in the breast and, sometimes, mammary tension. This stage begins with the delivery of the placenta, which occurs in any delivery method. It is hormone-dependent, so the process can still occur even if the mother does not want to initiate breastfeeding with her baby. Socially, this stage is known as milk coming in.
• Lactogenesis III, or lactopoiesis: is the continuous secretion of milk from the breast.

Breast engorgement as a complication

Breast engorgement consists of generalized, usually bilateral edema of the breast due to extracellular fluid accumulation. This compresses the mammary ducts, preventing milk from flowing out of the nipple and producing pain, swelling, and tension in the breast, making it difficult for the newborn to latch on properly. This situation is considered pathological. Appropriate support is the key to improving maternal satisfaction and the breastfeeding experience at the beginning of breastfeeding.

How to manage breast engorgement

Engorgement needs to be addressed as soon as possible to alleviate pain, reduce breast tension and improve breastfeeding initiation.

Although the evidence is lacking, since it is a situation of edema, local heat should be avoided, because it can facilitate vasodilatation and worsen the condition. The application of local cold should be recommended instead: if ice is used, it should not come into direct contact with the skin of the breast. Some studies show that the application of cabbage leaves can alleviate the discomfort of engorgement. It is advisable to wash the cabbage leaf to be applied, break the leaf stems by pressing them with a rolling pin and apply it directly to the breast. Avoid the nipple area if they are sore from tears or nipple damage.

In case of significant breast tension, the Reverse Pressure Softening Technique massage can be used to soften the nipple and areola area and facilitate the latch to the newborn: After washing hands, place the fingertips around the nipple and maintain pressure towards the ribs, keeping it for 2-3 minutes or until the area is soft. Then put the newborn immediately onto the breast to latch. This massage improves the engorgement of the areola area of the breast, and the baby’s suction can improve the overall tension of the breast and the sensation of fullness perceived by the mother.

In this link, you can find an explanatory video of the Reverse Pressure Softening Technique.

If necessary, appropriate anti-inflammatory medication compatible with breastfeeding, such as ibuprofen, can be prescribed by medical practitioners.

Once the Reverse Pressure Softening Technique has been performed, the breast can be offered to the newborn, or a breast pump can be used. It is important that pumping and directly breastfeeding the newborn are not painful. Therefore, the breast pump funnel size and the pump’s suction force should be assessed.

There is a widespread myth that a breast pump cannot be used in case of breast engorgement. But engorgement is not a sign of an inadequate milk supply, but the swelling is the cause of discomfort. For this reason, expressing the accumulated milk does not increase the risk of overproduction. On the other hand, if there is an excessive increase in hyperproduction, it can be improved by gradually reducing the use of a breast pump.

Prevention of engorgement and situations to be taken into account

Usually, breast engorgement appears in mothers who have had a long labor and/or who have been administered high-dose fluids during birth, in separations of the mother-newborn dyad, or in case of a complicated initiation of lactation in the first hours after birth. When accompanying women during labor, it is recommended to adjust the serotherapy and that women keep hydrated via mouth freely on their own.

The care that will be proposed to the dyad in case of having experienced a similar situation:

• The mother should be encouraged to initiate breastfeeding immediately after delivery and always within the first two hours. In case there has not been a spontaneous latch within that period, the mother needs to be taught the technique of stimulation and manual expression of milk and needs to be encouraged to initiate this early and at a frequent rhythm, not allowing more than 3 hours to pass between stimulation.
• Encourage skin-to-skin contact.
• Avoid mother-newborn separations.
• Be aware of the newborn’s hunger signals to anticipate and to be able to offer the breast before the newborn cries.
• Avoid unnecessary interference, such as bottle teats and/or pacifiers.

References:

Zakarija-Grkovic, I., & Stewart, F. (2020). Treatments for breast engorgement during lactation. The Cochrane database of systematic reviews, 9(9), CD006946. https://doi.org/10.1002/14651858.CD006946.pub4