Protocol #5 Engorgement Protocol #5: Engorgement

Engorgement may have one or more underlying causes that may be mother or baby related.

Observation and Assessment Breast fullness may sometimes be confused with engorgement. Breast fullness differs from engorgement in the following ways:

Breast Fullness (a normal condition) Breast Engorgement (an abnormal condition) Assess the mother for: Assess the mother for: • Breast fullness, heaviness, and some •Breasts and/or areolae that feel hard beginning tenderness that begins when the breast milk 3–6 days after birth or at other times when a volume increases 2–4 days after birth. mother’s breasts are not effectively emptied. • Breasts that feel soft when pressed •Breasts that are not compressible. (compressible). •Generalized breast tightness and pain. • Absence of breast pain or fever. •Breasts that appear flushed. •A low-grade fever. •Hands and arms that may be numb and tingling if engorgement is severe. Assess the baby for: •Breast refusal or difficulty achieving a latch (Protocol #9: Breast Refusal or Difficulty Achieving or Maintaining a Latch).

Possible Contributing Factors • Underlying abnormal breast pathology, e.g., non- or Causes patent breast milk ducts. Engorgement may have one or more underlying • Stress. causes that may be mother and/or baby related. • Fatigue. Assess the mother for: Assess the baby for: • Poor positioning and latching techniques (Protocol • Ineffective suck (Protocol #10: Ineffective Suck). #2: Positioning and Latching). • Medical conditions, e.g., jaundice. • Use of supplements and pacifiers. • Use of pacifiers (Protocol #1: The Initiation of • Restricting the frequency and length of Breastfeeding). breastfeedings. Temporarily stopping breastfeeding without expressing for the missed breastfeedings – Suggestions including separation of mother and baby. “The best management of engorgement is • Weaning abruptly. prevention.” (Lawrence, 2011)

Breastfeeding Protocols for Health Care Providers | Toronto Public Health 48 1. Determine the possible cause(s) of the • Express some breast milk (Protocol #19: engorgement (see previous section on “Possible Expressing and Storing Breast Milk). Causes”). • Apply heat to her back or shoulders for a few • Assess first for ine fective positioning and latching minutes before or during massage until letdown (Protocol #2: Positioning and Latching). occurs. Some mothers may wish to apply heat to • Assess for infrequent or delayed breastfeedings. their breasts – see discussion regarding application of heat for engorgement in General Principles. • For an ineffective suck, refer to Protocol #10: Moist or dry heat may be applied with a warm, wet Ineffective Suck. towel or disposable diaper, a warm bath or shower, 2. Provide the mother with suggestions for a bowl of warm water, a heating pad on low, or a breastfeeding with engorged breasts. water bottle wrapped in a cloth. Before breastfeeding, encourage the mother to: Or alternatively, some women prefer to: • Breastfeed early, frequently, and without restriction • Apply a cool cloth to their breasts for a few to promote optimal breast milk removal. minutes. Try cold compresses or diapers, gel packs, • Hold her baby skin-to-skin frequently. frozen wet towels or frozen vegetable packs, wrapped in a cloth. Limit direct exposure to cold to • Soften the areola and ensure that the letdown or prevent tissue trauma such as frostbite. breast milk ejection reflex is initiated. The baby’s rooting, sucking and hand movements on the During breastfeeding, encourage the mother to: mother’s breast are the natural stimuli for letdown • Assess that the baby is effectively positioned and when breastfeeding is initiated early and the baby latched (Protocol #2: Positioning and Latching). is calm, before the baby gets overly hungry and begins crying (Protocol #3: Signs of Effective • Assess that the baby is effectively sucking and Breastfeeding). swallowing (Protocol #3: Signs of Effective Breastfeeding). A mother can try the following ideas to initiate • Use breast compressions during breastfeeding if the letdown: baby is not effectively sucking and swallowing or if • Breastfeed in a quiet, relaxed place. her breast is not softening. Breast compressions will • Use relaxation strategies – such as a warm shower, increase the breast milk transfer and encourage the heat applied to the mother’s back and shoulders, baby to suck effectively. relaxation breathing, a warm drink, supportive To use breast compression, encourage the mother to: positions. • Support the base or middle of her breast using the • Manage pain to support comfort and relaxation and “C” or “U” hold (see diagram). facilitate breast milk letdown. • Compress her breast when the baby’s sucking • Initiate breastfeeding before the baby is stressed becomes less effective, e.g., no more “deep and and crying. slow” sucks (Protocol #3: Signs of Effective • Clothe the baby in a diaper only to promote skin-to- Breastfeeding). skin contact. • Hold the compression but do not press so hard that • Support the baby’s head higher than tummy in a it hurts. chest-to-chest position, with nose approaching the • Release the compression when the baby pauses and mother’s nipple to facilitate the normal neonatal swallows or is no longer effectively sucking, e.g., reflexes and self-attachment behaviours no more “deep and slow” sucks. Most babies will • Gently massage her breasts. stop sucking completely when the compression is • Stimulate her nipples. Gently roll her nipples released and will resume sucking again shortly. between the thumb and index finger for severa • If the baby does not resume effective sucking, wait minutes or until the letdown reflex occurs an a while before compressing again. breast milk leaks. • Rotate the position of her hand on all areas of her

Breastfeeding Protocols for Health Care Providers | Toronto Public Health 49 breast to ensure that all of the breast milk ducts are who are immunocompromised (see notes below in compressed. General Principles). If cabbage leaves are being used: • Continue with breast compressions until the baby ◦ Wash hands well before and after handling is no longer sucking effectively when her breast is cabbage leaves. being compressed. ◦ Separate raw, green* cabbage leaves and rinse • Offer the other breast using breast compression well with running, drinkable water. as needed. ◦ Slice off any large veins and cut a hole for the mother’s nipple. ◦ Place the leaves directly on her breasts (not her nipples), and wear them inside a bra. ◦ When the leaves wilt, usually between 2–4 hours, replace them with fresh leaves. ◦ Discontinue using the leaves once the engorgement is relieved. Overuse may decrease the breast milk supply. Many mothers report some relief from engorgement within 8 hours of application. * Green cabbage is suggested because purple cabbage leaves can stain skin and clothing. Strategies to prevent engorgement: Breast Compression Using the “C” Hold • Observe the baby for early feeding cues to be able to breastfeed early and frequently: ◦ when the baby is showing early feeding cues, After breastfeeding, encourage the mother to: e.g., rapid eye movements under the eyelids as • Express some breast milk for comfort if her breasts the baby begins to wake, sucking/licking, hands are still hard and full, even if the baby has breastfed to mouth, increased body movements, and effectively and is satisfied. Both breasts should fee making small sounds. significantly softer after breastfeeding and/or breas ◦ before the baby is overly hungry or crying. milk expression (Protocol #19: Expressing and Storing Breast Milk). ◦ when the mother’s breasts become uncomfortable or full. • Apply cold to the softened breasts for a few minutes after breastfeeding to provide comfort and reduce ◦ at least 8 times in 24 hours, including overnight, swelling. Limit direct exposure to cold to avoid until her breasts are no longer engorged. tissue trauma such as frostbite. Try one of the • Wear a supportive and well-fitting bra.Avoid bras following methods: with underwires. ◦ A cool wet towel or cloth. •Use analgesics as needed, e.g., acetaminophen, ◦ A cold gel pack wrapped in a dry towel. ibuprofen. To inquire about the use of acetylsalicylic acid, i.e., aspirin, consult a Another practice sometimes suggested when optimal breastfeeding expert or breastfeeding clinic. breastfeeding management isn’t enough: • Feed the baby only breast milk. Avoid • Cabbage Leaves – Some mothers find the use o supplementation unless medically indicated green cabbage leaves to be helpful for increasing (Protocol #17: Indications for Supplementation or their comfort and reducing engorgement. Caution: This has not been scientifically proven. In addition due to the possible risk of listeriosis, this may not be an appropriate option for mothers or infants

Breastfeeding Protocols for Health Care Providers | Toronto Public Health 50 Cessation of Breastfeeding). • Avoid the use of pacifiers and bottles General Principles If the baby is unable to breastfeed effectively, Prevention is key to managing engorgement. encourage the mother to: Fundamental to preventing engorgement is: • Gently express each breast, until her breasts • Early initiation of breastfeeding. are soft, each time the baby has been unable to breastfeed effectively. Hand expression is suggested • Frequent and unrestricted breastfeeding. as the mother is less likely to remove enough breast • Effective removal of breast milk from the mother’s milk to trigger increased breast milk production. If breasts. breastfeeding is stopped for any length of time the • Effective positioning and latching practices. mother will need to express each breast 8 times or more in 24 hours, including overnight, as long as • Not supplementing unless medically indicated. her breasts are engorged. Breast Fullness – Breast fullness is part of the The mother should also express if her breasts become normal physiological process of breast milk uncomfortable or full (Protocol #19: Expressing and production. The mother’s breasts usually become Storing Breast Milk). fuller between the second to fourth day after birth. A normal full breast will feel heavier and warmer, • Soften the areolae before breastfeeding and and may be uncomfortable. For most women this is a initiate the letdown reflex by using one of th reassuring sign that their “milk has come in”. Breast following techniques: fullness does not interfere with breastfeeding. ◦ Gently massage her breasts while applying wet Breast fullness normally occurs during the initial or dry heat to the back or shoulders until the period of rapid breast milk production. It is due to letdown reflex occurs. Some mothers may wis increased vascular supply and postpartum hormonal to apply heat to their breasts. shifts following the removal of the placenta (see How - Wet or dry heat includes a warm, wet the Breast Works regarding Lactogenesis II). It will towel or disposable diaper, a warm bath or gradually decrease within 2–3 weeks when the baby shower, a bowl of warm water, a heating is breastfeeding well. When breast fullness subsides, pad, or a hot water bottle. Then, gently the mother’s breasts will continue to produce plenty express some breast milk until the areolae of breast milk despite feeling much softer and are soft (Protocol #19: Expressing and flatte . If the mother’s breasts are not adequately Storing Breast Milk). and regularly emptied, breast fullness can lead to ◦Gently roll her nipples between her index finge engorgement at any time during lactation. and thumb for a few minutes or until the letdown Breast Engorgement – Breast engorgement is reflex occurs. Then gently express some breast considered to be abnormal in this resource; the milk until the areolae are soft (Protocol #19: mother’s breasts become overfull due to failure Expressing and Storing Breast Milk). to remove breast milk effectively or frequently • If necessary, feed the baby with the expressed breast enough (Lauwers et al., 2011). There may be a range milk using an alternative feeding method, e.g., of difficulties or pathology in the physiological cup, spoon, syringe, finger feeding Protocol #18: process. Giuliani identifies three basic components Alternative Feeding Methods). If expressed breast of breast engorgement: accumulation of breast milk, milk is not available then an appropriate supplement congestion caused by increased vascularization, should be offered (Protocol #17: Indications for and edema caused by congestion and obstruction Supplementation or Cessation of Breastfeeding). of lymphatic drainage (Giuliani, 2004). The engorged breast feels hot, tender, swollen, and • Referral to a breastfeeding expert or breastfeeding painful. Engorgement may be the result of the clinic for further assessment as soon as possible is mismanagement of breastfeeding and may be a recommended. reason for early weaning (Riordan, 2010) (Protocol #1: The Initiation of Breastfeeding).

Breastfeeding Protocols for Health Care Providers | Toronto Public Health 51 For some women, the production of breast milk may As a result of short hospital stays, most women will initially exceed the infant’s requirements. Engorgement experience breast fullness or engorgement after is a result of increased breast milk stasis together they have left the hospital. Anticipatory guidance with increased blood flow to the mothe ’s breasts. If is essential and should include education about the the excess breast milk is not removed, the alveolar physiology and the patterns of engorgement as well space may become over-distended, exerting pressure as information about how to access breastfeeding on the surrounding tissues, impeding lymph flui support after they leave the hospital. drainage and leading to edema. Engorgement may be Women who have had birth interventions, including areolar engorgement, involving only the areola, and/ a caesarean delivery, may have a delay in initiation or peripheral engorgement, involving the surrounding of breastfeeding (TPH, 2010). As a result, they may breast tissue, possibly including the ducts located in the experience engorgement one to two days later than axilla. Mothers with smaller breasts have less storage for a vaginal birth, particularly if there has been a capacity (Daly & Hartmann, 1995) and have been observed delay in initiation of breastfeeding. to experience greater frequency of engorgement (Robson, 1990). This does not impede their ability to breastfeed Research Challenges – It is difficult to conduct successfully when managed effectively. conclusive scientific research related to engo gement because engorgement will spontaneously resolve Engorgement can make it difficult for the baby to as women continue to breastfeed no matter what latch on the mother’s breast, especially if the areola is treatment, if any, is tried (Mangesi et al., 2010). hard and non-compressible. Unrelieved engorgement A Cochrane systematic review in 2010 found may cause mother’s breast milk supply to decrease. insufficient evidence to recommend widespread Poorly managed engorgement may lead to implementation of interventions to treat engorgement. complications such as: In addition, methodological limitations in the existing • difficulty with latchin research have led to a high risk of bias in the results (Mangesi et al., 2010). The limited number of studies not • sore nipples only meant that the Cochrane review was unable to • decreased breast milk intake by baby carry out a meta-analysis, it also meant that several • decreased breast milk supply of the studies frequently cited were dated, including some doctoral theses that have not been published in • breast milk-producing cells (alveoli) being peer review journals (Robson, 1990; Sandberg, 1998). destroyed When Optimal Breastfeeding Management Isn’t • breast milk stasis Enough – In addition to optimal breastfeeding • plugged ducts management – frequent breastfeeding and breast milk removal, effective positioning and latching, as well • mastitis, and as gentle breast massage – breastfeeding mothers • decreased maternal motivation to continue may try and/or breastfeeding experts may suggest breastfeeding related to pain. a variety of other strategies. The 2010 Cochrane Patterns of Engorgement – The experience of breast systematic review found that in interventions such engorgement is not the same for every breastfeeding as ultrasound, cabbage leaves, and oxytocin, there woman (Humeniuk et al., 1994). It may be mild, or it was no statistically significant evidence that the may be severe. It may peak early or as late as Day interventions were associated with more rapid 14 postpartum; it may also occur at a later time due resolution of symptoms; symptoms tended to to missed breastfeedings or weaning too abruptly. improve with or without the intervention. In addition, There may be a single peak or multiple peaks. the review did not find evidence strong enough to Humeniuk et al. (1994) identified four patterns of recommend the use of acupuncture, although some early engorgement, the most common being a gradual women’s symptoms improved after acupuncture. intense peak followed by a gradual cessation of Heat vs. Cold engorgement. For multiparas it may occur earlier, for shorter periods, and with less intensity because their • Heat applied to engorged breasts has long been used by breastfeeding women to promote letdown “milk comes in” earlier (Lawrence, 2011). and comfort, although concerns have arisen that

Breastfeeding Protocols for Health Care Providers | Toronto Public Health 52 the application of heat to the mother’s breasts may some breastfeeding women but for which the evidence increase vasocongestion. Robson reported that of effectiveness is inconclusive due to methodological mothers complained that heat worsened symptoms, limitations. The Cochrane review found no statistically causing throbbing and a greater feeling of fullness significant evidence that the use of cabbage leaves wa (Robson, 1990). The Cochrane review does suggest associated with a more rapid resolution of engorgement that warm compresses be applied to the engorged symptoms (Mangesi et al., 2010). breast (Mangesi et al., 2010). Heat may also be applied Despite this, many women find the application of to the mother’s back or shoulders to promote cabbage leaves to be soothing. It is not necessary relaxation, comfort, and letdown. to chill cabbage leaves (Roberts et al., 1995). Mothers •Cold may be applied to engorged breasts to decrease should be informed that their breasts might smell or local edema and enhance venous and lymphatic taste like cooked cabbage. drainage, as well as provide comfort. Although the Caution: Safety is an issue. Bacteria such as listeria current evidence is not definitive, the Cochran have been identified on many vegetables ncluding review suggested that cold packs may be soothing raw cabbage (Heisick et al., 1989). Listeriosis can be a very for some women, and that application of cold does serious disease for pregnant women, newborns, and not cause harm and may be associated with symptom immunocompromised individuals. Although application improvement (Mangesi et al., 2010). Despite a lack of to the skin does not have the same risk as ingestion, it is statistical significance, the evidence continues t reasonable to suggest that cabbage leaves should not be suggest clinical benefits. Mothers should protec applied to nipples or breasts with lesions, nor used by their skin from direct exposure to extreme cold. mothers with immunocompromised infants, including As many women report comfort after applying premature babies. cold and/or warmth for engorgement, these can be For all applications, it is essential to: reasonable strategies to suggest provided that they are used conservatively and safely. It is important • Thoroughly wash cabbage leaves in cold, running, to prevent tissue trauma or negative physiological drinkable water. effects, such as increased congestion and swelling • Wash hands before and after handling cabbage from too much heat, or possible tissue trauma such as leaves. frostbite, or impeding letdown with application of too • Clean all utensils, cutting boards, and work surfaces much cold. with a 10% bleach solution before and after use. To avoid direct exposure to hot and cold, use a layer (Source: Adapted from Health Canada, 2008 and of fabric between the skin and the source of cold or 2009) heat. To prevent tissue trauma, limit the application time so that the skin does not redden. Some Saline Soaks – Some practitioners may suggest that practitioners continue to suggest the application a mother soak her breasts in a mild saline solution, of heat before breastfeeding and cold immediately or soak in an Epsom salt bath. Although no specific afterward for relief (Riordan, 2010). research could be found to support the effectiveness Expression/Pumping – If a mother is expressing of this practice, it is unlikely to be harmful as long as breast milk from her breasts (by hand or pump) the baby is not swallowing the solution. Magnesium because she is uncomfortable or the baby has sulphate treatments are rated as L1 by Hale (2010). not removed enough breast milk, it is important Promoting Areolar Grasp “Reverse Pressure that she understands that she should remove only Softening” – For most women, the gentle massage enough breast milk to feel comfortable. The mother and expression described above in “Suggestions” are should not drain her breasts, because it may further enough to soften an engorged areola. If these do not stimulate the production of breast milk and possibly reduce the areolar edema, it may help to try “reverse increase the engorgement symptoms (Protocol #19: pressure softening”, as described by Cotterman Expressing and Storing Breast Milk). (2004). Gentle positive pressure is applied by placing Cabbage Leaves – The application of cabbage leaves the fingertips around the base of the mothe ’s nipple to the mother’s breasts between breastfeedings to reduce to create a ring of “dimples”. This can temporarily engorgement is another strategy that has been used by reduce edema by moving some swelling slightly

Breastfeeding Protocols for Health Care Providers | Toronto Public Health 53 backward and upward into the breast, softening the her can facilitate an informed decision. It creates an areola enough to permit effective latching. It is best opportunity to offer accurate information about how done with fingernails trimmed short and immediately the possible benefits and risks of traditional practices before breastfeeding. may impact her breastfeeding success. Some women Cultural Practices – It is important to acknowledge may feel that certain practices are not an option, and that some cultures traditionally avoid practices such for others an explanation of the rationale may lead to as “cold” during the postpartum period. Having a the possibility of trying a different treatment. conversation with the mother about traditional and Prevention – All findings emphasize th t prevention cultural practices and exploring their significance for of engorgement should remain the key priority. References Cotterman, K.J. (2004). Reverse pressure softening: A simple tool to prepare areola for easier latching during engorgement. Journal of Human Lactation, 20(2), 227–237.

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