BREASTFEEDING MEDICINE Volume 11, Number 4, 2016 ABM Protocol ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2016.29008.pjb ABM Clinical Protocol #20: Engorgement, Revised 2016 Pamela Berens,1 Wendy Brodribb,2 and the Academy of Breastfeeding Medicine A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. Purpose at least moderate symptoms of engorgement.9,11 (III) The he purpose of this incidence of engorgement may depend on breastfeeding protocol is to evaluate the state of management within the first few days following birth. En- Tevidence as to the prevention, recognition, and man- gorgement occurs less commonly when infants spend more agement of breast engorgement to encourage successful time breastfeeding in the first 48 hours12 (III) and when mother breastfeeding. and infant are rooming in. One difficulty when evaluating in- cidence and treatment options for this condition involves the Background spectrum of engorgement, from expected physiologic breast Engorgement has been defined as ‘‘the swelling and dis- fullness through to severely symptomatic engorgement. In tension of the breasts, usually in the early days of initiation of addition, more optimal lactation management and support that lactation, caused by vascular dilation as well as the arrival of are available in some healthcare facilities may reduce the the early milk.’’1 The concept put forward by Newton and frequency of significant symptoms compared to less support- Newton2 in 1951 suggested that alveolar distension from ive environments. milk then led to compression of surrounding ducts, which subsequently led to secondary vascular and lymphatic com- Assessment of Engorgement pression. Some degree of breast fullness in the second stage of lactogenesis (secretory activation)3 is considered physio- Tools logic and should be reassuring for the mother and healthcare No standardized reliable tool for assessing breast engorge- provider that milk is present. A recent study suggested con- ment has yet been established. Various methods of subjectively sidering distinguishing between ‘‘breast engorgement’’ and rating engorgement have been utilized, such as visual de- ‘‘breast edema’’ although both may cause significant issues scriptions, cup size, hardness or firmness scales, skin tension 4 for mothers and infants in the postpartum period. (II-2) measurements, and thermography, but none has become (Quality of evidence [Levels of evidence I, II-1, II-2, II-3, and clinically useful.2,9,13–16 III] is based on the U.S. Preventive Services5 Task Force Appendix A Task Force Ratings and is noted in parentheses.) Predictors Breast edema is fluid accumulation in the interstitial space caused by generalized fluid accumulation late in pregnancy 1. The onset of lactogenesis II (secretory activation) oc- or as a result of large amounts of intravenous fluids during curs sooner in multiparous compared to primiparous labor and may be responsible for edema around the areola and women17,18 (II-2, II-2) and tends to resolve more rap- nipple.6,7 (III, III). idly than in primiparous women.9,19 (II-2) Engorgement symptoms occur most commonly between 2. In one study, women who underwent cesarean section days 3 and 5 postpartum, with more than two-thirds of wo- typically experienced peak engorgement 24–48 hours men experiencing tenderness by day 5, but the onset may be later than those who gave birth vaginally.12 Women as late as days 9–10.4,8,9 (II-2, III) In the 2008 Infant Feeding in this study also initiated breastfeeding significantly Practices Survey, 36.6% of women reported overly full later than their vaginally delivered counterparts and breasts within the first 2 weeks postpartum,10 while other the impact of this delay has not been adequately explored. studies indicate that up to two-thirds of women experience This finding appears consistent with other research that 1Department of Obstetrics and Gynecology, University of Texas Health Sciences Center at Houston, Houston, Texas. 2Discipline of General Practice, University of Queensland, Brisbane, Australia. 159 160 ABM PROTOCOL has found that a cesarean birth may correlate with a management option has not been studied in detail.33 One re- higher likelihood of delayed onset of lactogenesis.17,18 cent study found a reduction in engorgement in women who 3. Large amounts of intravenous fluids given during labor expressed colostrum once or twice for 25–30 minutes in the appear to be associated with an earlier and more pro- first 1–2 days (vaginal birth) or 2–3 days (cesarean birth) longed maternal perception of breast fullness and postpartum. Infants of the women in this study did not have tenderness as well as increased levels of breast edema free access to the breast and were limited to six to eight extending beyond day 9 postpartum.4 breastfeeds per day.20 However, these findings do suggest that 4. One study suggests that women who experience pre- early and frequent breast emptying in this population may menstrual breast tenderness and engorgement may be prevent engorgement. more likely to develop more severe engorgement 20 postpartum. (II-2) Treatment 5. It is not uncommon for women who have undergone any breast surgery or lumpectomy to experience en- While one study found an increase in milk production on gorgement, and so, they should be given anticipatory day 4 for primiparous women with marked engorgement,19 guidance regarding these potential complications.21,22 adequate management of engorgement is important for suc- (III, III) cessful long-term lactation.35,36 (III, III) Experiencing en- 6. The influence of length of labor, premature delivery, gorgement is temporarily uncomfortable for mothers and and anesthetic options remain unclear.23–25 (III, III, III) appearstobeassociatedwithanincreaseinthelikelihood of early weaning.37 (III) Failure to effectively resolve pro- longed symptomatic engorgement may also have a negative Differential diagnosis impact on continued production of an adequate milk sup- Differentiating engorgement from these other causes of ply. Suckling problems in the infant should be considered breast swelling is key. at the same time. Moreover, pain control is an impor- tant consideration in managing a woman with symptomatic 1. Mastitis. Engorgement may be associated with a engorgement. slight elevation of maternal temperature, but signifi- Both pharmacologic and nonpharmacologic therapies have cant fever, especially when associated with breast er- been considered to be beneficial for the treatment of en- ythema and systemic symptoms such as myalgias, gorgement. A Cochrane Systematic Review of both ran- suggests the diagnosis of mastitis. Typically, mastitis domized and quasirandomized controlled studies assessing affects only one breast with a segmental pattern of 26 the effectiveness of treatments for breast engorgement was redness. Engorgement is usually diffuse, bilateral, 38 1 done by Mangesi and Dowswell in 2010. (I) This analysis and not associated with breast erythema. identified eight studies, including 744 women who evaluated 2. Gigantomastia. Gigantomastia is a diffuse bilateral acupuncture, cabbage leaves, protease complex, therapeutic process that occurs very rarely and does not typically ultrasound, oxytocin (subcutaneous), and cold packs. Meta- present in the postpartum period. The reported inci- analyses could not be performed because of the differences in dence is *1:100,000, but some feel that it is more 27 the study designs. Overall, the authors concluded that there common with a rate as high as 1:8,000. It is usually was insufficient evidence to recommend any particular regarded as bilateral, benign but progressive massive treatment regimen.38 However, they did find the following. breast enlargement to an extent that respiratory de- pression or tissue necrosis may occur. Infection and 1. Acupuncture resulted in significantly fewer women sepsis may result. Histologic findings suggest marked having engorgement symptoms on day 4 and 5, but not lobular hypertrophy and ductal proliferation. No clear day 6 postpartum. etiology for this condition has been elicited, although 2. Although the study investigating cold packs found a hormonal changes may be involved.27–30 reduction in pain intensity in the intervention group, problems with the study design make results difficult to interpret. Prevention and Treatment 3. Enzyme therapy using a protease complex enteric-coated Prevention tablet containing 20,000 U of bromelain and 2,500 U of crystalline trypsin, another anti-inflammatory agent tak- There has been a great deal of research into medical ther- ing orally, was compared to a placebo. However, this apies to suppress lactation, but limited research into preven- study is now 50 years old and it is not certain that the tion and treatment strategies for lactating women who may 39 preparation is in general use. (I) develop engorgement. Focused education given to mothers 4. Treatments such as cabbage leaves may be soothing, regarding breastfeeding positioning and attachment has shown are inexpensive, and are unlikely to be harmful al- no difference in subsequent incidence of engorgement.31,32 though evidence for their use is not conclusive.