Breast engorgement is the painful condition of breasts that occurs after 2-3 days of childbirth when the breasts start producing a larger quantity of milk. It occurs due to both increased production of milk and increased blood flow to the breasts. The breasts become hard, firmer, fuller and painful.
Physiology of Breast Milk Production
The breast tissue starts growing during pregnancy to prepare for breastfeeding. Synthesis of breast milk begins during the late stages of pregnancy. However, it is not secreted during pregnancy because the high levels of estrogen and progesterone present in the body prevent its secretion.
After delivery, when estrogen and progesterone levels fall, prolactin begins its milk secretory activity and synthesizes milk protein. The secretory activity is also influenced by other hormones like growth hormone, glucocorticoids, insulin, and thyroxine.
When a baby suckles, a reflex is set up. Impulses from the nipple and areola cause the release of hormone oxytocin from the posterior pituitary gland. Oxytocin causes the milk present in the breast tissue to move into the ducts from where it can be expressed by the mother or sucked by the baby. This is called ‘milk ejection’ or ‘milk let out reflex’.
Secretion of milk is a continuous process. The two hormones prolactin and oxytocin and a positive feedback loop provided by regular suckling ensure continued milk production as long as the infant continues to breastfeed.
Causes of Breast Engorgement
For the initial 2 to 3 days after delivery, the breasts produce a thick and yellowish fluid called colostrum. This is produced in low quantity, however, this little amount is sufficient for newborn’s requirements. Colostrum is rich in protein, low in sugar and contains essential nutrients.
After the first few days, as the digestive tract of the baby starts maturing and the needs of the baby increase, the quantity of milk produced by the breasts also increases.
Engorgement usually occurs when the breasts switch from colostrum to mature milk. It is also referred to as when the milk “comes in”. The breast tissue gets filled with milk, blood, and other fluids. This causes the breasts to feel full, firm, hard and painful.
This sequence of events is a normal phenomenon which occurs due to hormonal changes and increased milk production. Despite being painful, it is a temporary problem. If the baby is taking adequate feeds at regular intervals, the condition resolves on its own within 1 or 2 days in most of the cases.
In some cases, however, the breasts become very heavy and hard and the condition does not resolve on its own. Breast engorgement in such cases becomes problematic and needs to be treated. This occurs in the following conditions:
- Delayed initiation of breastfeeding
- The mother is producing more milk than what the baby is able to consume or the breasts can hold.
- The baby is not able to latch properly to the breast. So she is unable to feed resulting in accumulation of milk within the breast.
- Baby’s feeding pattern changes and she is consuming less.
- The mother has to miss several feeds because of separation from the baby due to work or other factors.
Signs and Symptoms of Breast Engorgement
One or both the breasts can be involved by engorgement.
There may be swelling and throbbing pain extending even up to the armpit.
The skin overlying the nipples may become stretched and shiny. It may feel hot to touch.
The nipples get flattened and become hard.
It may even lead to fever.
Effects and Complications of Breast Engorgement
It can lead to blocked ducts and mastitis (inflammation of breast tissue). In severe cases, it may even cause a breast abscess filled with pus.
It may lead to sore or cracked nipples, ulcers or bleeding from the nipples.
Difficulty in Feeding
Engorgement can cause problems during feeding. Because of the flattening of nipples, the baby is unable to latch on to the breast properly. This further leads to more retention of milk and worsening of the condition.
Forceful Flow of Breast Milk
The backup of milk present in the breasts can lead to an overactive let-down reflex. The milk comes out with high pressure and very fast flow. This may cause the baby to gag or choke. The baby may also swallow a large amount of air along with milk resulting in upset of the baby’s digestive system.
Early Weaning By Mother
Severe pain, frustration, and difficulty with proper latching force many new mothers to stop breastfeeding. It is one of the commonest cause of early weaning.
Reduced Milk Production
Severe engorgement may interfere with milk production. The excess milk stored in engorged breasts releases chemical signals that tell the body to reduce the production of milk. If not relieved, prolonged engorgement can lead to insufficient or no milk production after some time.
How to Prevent Breast Engorgement
- The baby should be breastfed right from birth.
- Feed the baby often and on-demand (not by the clock). At least 8 to 12 feeds should be given every day (including night time) especially in the initial days.
- Avoid giving the baby any fluids other than breast milk unless there is a specific medical reason. No water or formula milk should be given as they will reduce the baby’s thirst, hunger, and need for breast milk.
- Don’t limit the baby’s time at the breast.
- If due to any reason, the mother has to miss a feed, she should express the milk either manually or with the help of a breast pump.
Most of the mothers are discharged from the hospital and are at their home when engorgement occurs. Counseling should be given to mothers before they are discharged so that they are well informed about the causes and methods to be adopted to prevent engorgement.
Treatment And Self-Care Tips
Drain The Breasts Regularly
The best treatment of engorged breasts is to drain the breasts at regular intervals. This can be done by feeding the baby frequently and making sure that she empties one breast completely before moving to the other one. The baby should be fed for at least 8-12 times every day (including night time)
The baby should be latched properly to the breast. For learning proper technique, consult a lactation consultant or breastfeeding specialist.
Adopting Different Breastfeeding Positions
A different breastfeeding position can be tried so that minimum pressure is exerted on to the painful area of the breast.
Massaging the Breasts During Feeding
Gently massage the breasts in a downward motion from the chest wall till the nipple during feeding so that milk comes out easily.
Express Milk Before Feeding
Before feeding, express little milk by gently squeezing the breast so that the nipple becomes soft. A breast pump can also be used for this purpose.
Express Milk After Feeding
If after a feed, the breasts still feel firm, express more milk either manually or by breast pump till the breasts feel softer.
Reverse Pressure Softening
This technique is used to soften an area near the areola surrounding the base of the nipple. Gentle positive pressure is applied on the areola to move some swelling and edema backward and upward into the breast. This helps to improve the latch of the infant resulting in better drainage of the breast.
The following video demonstrates the technique of reverse pressure softening.
If the breasts show leaking milk, take a warm shower or apply a warm wet sterile piece of cloth on to the breast. This will help to relieve pain and promote the easy flow of milk.
If the breast is not leaking, a cold compress can be applied to the breast to reduce pain and swelling.
Adequate Support To Breasts
Wear a properly fitting bra to give adequate support to the breasts.
Application Of Cabbage Leaves
Clean cabbage leaves can be tucked inside the bra to reduce swelling and discomfort. Such a treatment may be soothing, inexpensive, and harmless although there is no conclusive evidence of its utility.
Never Miss Feeds
Do not miss feeds or abruptly stop feeding as it will worsen the engorgement.
Anti-Inflammatory Medicines and Painkillers
If the above remedies don’t help, anti-inflammatory medication and painkillers like paracetamol or ibuprofen can be taken.
Consult a healthcare professional
If nothing helps, there is fever, severe pain or the baby is not able to feed properly, consult a healthcare professional.
- Pang WW, Hartmann PE. Initiation of human lactation: secretory differentiation and secretory activation. J Mammary Gland Biol Neoplasia. 2007;12(4):211-221.
- Berens P, Brodribb W. ABM Clinical Protocol# 20: Engorgement, Revised 2016. Breastfeed Med. 2016;11(4):159-163.
- Witt A, Bolman M, Kredit S, et al. Therapeutic breast massage in lactation for the management of engorgement, plugged ducts, and mastitis. J Hum Lact 2016;32:123–131.
- Boi B et al. The effectiveness of cabbage leaf application (treatment) on pain and hardness in breast engorgement and its effect on the duration of breastfeeding. JBI Libr Syst Rev. 2012;10(20):1185-1213.