What is engorgement?
On the whole, breast engorgement is a great reassurance for mothers and lovely feedback to tell her breasts are responding to their newborn’s demands, but equally, engorgement is uncomfortable and, if not resolved or if in the presence of feeding issues, can lead to blocked milk ducts or mastitis.
Usually, an engorgement is caused due to increased blood flow in the breasts after delivery. A mother with a baby who feeds efficiently, frequently or for long periods of time and without restrictions/supplements in the first few days after birth is least likely to encounter painful engorgement.
You are more likely to experience engorgement if your baby has been missing feeding, you’re skipping pumping sessions, your baby is having difficulty latching and sucking or weaning too quickly.
Sometimes, a sleepy baby may need waking to prevent discomfort associated with engorgement. Therefore, early support and realistic expectations for the mother are the best prevention for associated problems.
Signs of engorgement
Below is a list of common symptoms of breast engorgement:
- Breasts feel uncomfortably full.
- Skin on breast is tight.
- Areola is hard.
- Nipple has possibly been pulled flat.
- Engorgement usually affects the whole breast.
Prevention of breast engorgement
Breast engorgement can be prevented by:
- Positive, timely breastfeeding initiation.
- Helpful assistance with latch and positioning.
- Frequent and unrestricted nursing.
- Waking sleepy newborns every 3 hours with some 4-5 hours stretches for longer sleeps.
- Wearing a well-fitting bra may be helpful.
Breast engorgement treatment
You can relieve engorgement by:
- Increasing feeds with particular attention to good attachment and positioning.
- Letting the baby finish one breast before offering the other one.
- Using a cool compress such as the TheraPearl breast therapy pads to provide relief.
- Using a moist heat (compress/shower/heat pack) and gently massage the area right before a feed.
- Draining the breast with an efficient breast pump can potentially decrease severe engorgement by mimicking an efficiently feeding baby. It can also decrease venous and lymphatic congestion in the breast in general and therefore relieve swelling.
- Hand expressing a small amount of milk to soften the nipple may ease difficulties in latching a newborn, who may then effectively drain the breast.
- Using the reverse pressure softening technique, which works well for some mothers (Cotterman 2003)
Blocked milk Ducts
A blocked milk duct is a common complaint in breastfeeding mothers. It has multiple potential causes such as pressure on the breast, infrequent feedings and cracked skin on the nipples. All these causes need to be explored and dealt with in order to help avoid a pattern of recurring plugged ducts and subsequent mastitis.
What does a blocked milk duct feel like?
A blocked milk duct has gradual onset of symptoms such as:
- Hard lump or wedge within the breast which may or may not move location.
- Mild to moderate pain, possibly increased before feed and reduced after.
- Lumpy area may become smaller after feed but not disappear.
- Generally no warmth or redness in the affected area.
- Mother is generally well apart from the localised breast discomfort.
- Potentially decreased yield from the affected breast if pumping.
- Stringy or fatty looking lumps in expressed milk.
How to prevent a blocked duct
You can prevent a blocked milk duct by following the below advice.
- Make sure latch and positioning are good to enable good milk transfer.
- Air out nipples after nursing.
- Ensure unlimited access to breast/feeding on cue.
- Be mindful of restrictive clothing/sling/bags and adjust if necessary.
- Feeding position may contribute to uneven pressure on the breast and lead to a blocked milk duct.
- Take a lecithin supplement (Scott 2005)
Blocked milk duct treatment
Most of the preventative and relieving measures for engorgement are likely to be helpful in relieving and preventing further episodes of painful blocked ducts.
- Rest with your baby.
- Always feed from the affected side first.
- Moist heat and massage before a feed either with a compress, Therapearl, immersion or shower.
- Massage can be done manually or with a wide toothed comb - use oil, HPA Lanolin or soap to make the comb glide smoothly.
- Moist heat and massage during a feed to facilitate draining the blockage within the ducts (baby’s position may have to be adjusted to allow this – Baby’s chin over the affected part may also help).
- Pumping sessions in between feeds may be necessary.
- Breast compressions may help.
- Cold compresses (Therapearl) after feeds to reduce swelling and pain can be used.
- Anti-inflammatory/analgesic treatment with ibuprofen can be very effective.
Keep in mind a plugged milk duct may also be caused by a nipple bleb, a thin membrane of skin covering one of the milk ducts exiting the nipple. It often presents as painful nipple when latching. Attempting to hand express often shows up the bleb, looking similar to a whitehead on the nipple.
Softening the skin covering the bleb with some olive oil on a cotton wool ball may be enough for the skin to be lifted off it during the next feed. Sometimes lifting the skin off the bleb with a sterile needle can bring forth an immediate spray of milk and relief for the mother.
What is mastitis?
Mastitis means inflammation/infection within the breast. It’s a result of bacteria found on the skin and saliva making its way to the breast tissue through a milk duct or crack in the skin. The most likely organism causing mastitis is staphylococcus aureus.
It is sometimes difficult to differentiate between a severe blocked milk duct and mastitis and one can turn into the other fairly quickly if treatment is not prompt and effective. Previous history of mastitis makes diagnosis more likely.
Antibiotic treatment is frequently not necessary, if the right treatment is given promptly. As with engorgement and blocked duct, the key to providing relief is to facilitate effective emptying of the breast, meaning that a review of positioning and attachment, and an oral exam to rule out any unusual anatomy in the baby’s mouth will always form part of your assessment.
The signs and symptoms of mastitis are often very similar to the ones accompanying a blocked milk duct. It only affects one breast where you may develop a wedge-shaped red mark.
- Pain and redness are usually more severe than with a blocked duct. There may be red streaking radiating from the affected part of the breast.
- Mothers tend to feel unwell and have a temperature. They may also have body aches, nipple discharge, nausea, fatigue, headaches and chills.
- Mastitis often comes on suddenly unlike a blocked milk duct which may develop more gradually.
- Mastitis is more likely if nipple trauma is present or has been recently, presenting an entry point for pathogens.
- Exposure to hospital pathogens may make infective mastitis more likely.
- A stressed mother is more likely to get mastitis.
- A mother with low iron count or history of poor diet generally is more prone to infection.
How to prevent mastitis
Mastitis can be prevented using the same advice given for preventing a blocked milk duct.
The treatments for a blocked milk duct are also applicable to mastitis treatment and need to be commenced promptly. Here are the common mastitis treatments:
- Bedrest with your baby (Mohrbacher 2008); discuss safe co-sleeping and advise responding to early feeding cues.
- Possible antibiotic therapy for 10-14 days (a shorter course makes relapse more likely), indicated if fever/symptoms do not decrease after 24 hours or the fever suddenly increases.
- Consider a probiotic in case of antibiotic therapy to avert an increased risk of breast thrush (Gyte 2014)
- If mastitis does not seem to respond to treatment, consider culturing the milk to pinpoint pathogen.
Keep in mind that re-occurring blocked milk ducts and mastitis originating in the same (quadrant of) breast may[SS1] , in rare cases, be a sign of a breast tumour. Referral to a doctor may be indicated.
Bilateral mastitis, though rare, may be a sign of hospital acquired infection and streptococcal in nature. Always advise women not to cease breastfeeds during an episode of engorgement, blocked ducts or mastitis. Milk removal is of utmost importance to avoid problematic recovery.
Be vigilant to the formation of breast abscesses and refer to an appropriate clinician.
Bibliography / References
Conner A (1979) “Elevated levels of sodium and chloride from mastitic breast.” Pediatrics 63:910
Cotterman (2003) “Too Swollen to latch on? Try Reverse Pressure Softening first”, Leaven, Vol. 39 No. 2, April-May 2003, pp. 38-40
Fetherston C (1998) “Risk Factors for lactation mastitis.” J Hum Lact; 14(2):101-09
Gyte, Dou and Vazquez (2014) “Different classes of antibiotics given to women routinely for preventing infection at caesarean section” Cochrane review. Wiley and Sons. Accessed April 2015 at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008726.pub2/full
Moon J. and Humenick S (1989) “Breast Engorgement: contributing variables and variables amenable to nursing intervention.” JOGNN; 18:309-15
Minchin M (1998) “Breastfeeding Matters.” 4th ed. Armadale, Australia: Alma Publications
Mohrbacher, N., Stock J. (2008) “La Leche League International: The Breastfeeding Answer Book, 3rd revised edition, LLLI
Scott CR. Lecithin (2005) “It isn’t just for plugged milk ducts and mastitis anymore. Midwifery Today Int Midwife. 26-7