Engorgement is a common cause of breast pain and breastfeeding difficulties in the first week after birth. Engorgement predictably occurs at 3-4 days postpartum when the breasts become swollen, firm, and tender. Unfortunately, engorgement often starts right after parents get discharged home from the hospital with their newborn. This leaves sleep-deprived new parents at home when the swelling causes latching difficulties, nipple pain, and a vicious cycle of breastfeeding problems and worries about the baby’s intake.

Despite the predictability of this common issue, few lactating parents are prepared for engorgement ahead of time. Even fewer are given truly effective, safe advice on preventing and treating it. Many are even given advice that actually worsens the situation. It is high time we set the record straight on lactation related breast engorgement.

The Myth:

Let’s first address a common misconception. Many believe that the breast swelling of engorgement occurs due to the breasts filling with far too much milk, making it hard to fully drain the breasts. Many fear that if the supposed large volume of milk is not drained, it will lead to ‘milk stasis’ and cause plugged ducts and mastitis. There is no actual physiologic evidence that this process occurs as presumed. Yet this widespread misunderstanding leads to common advice for mothers to frequently pump the excess milk and use firm massage and vibration to get any stuck milk areas, often called plugs, out.

Then often a firm or chunky ‘plug’ comes out of the nipple, followed by a rush of milk and temporary decrease in an area of swelling. This further reinforces the incorrect idea that the stuck areas of milk harden, plug and clog the milk ducts, and cause all this swelling, pain, and difficulty.

This may initiate a vicious cycle, leading to more pumping, more swelling and breast trauma, more ‘plugs’ being expressed, then more pumping…and on and on. Unfortunately, this common mismanagement leads to a worsening of the very problem it is meant to fix.

The Reality:

Breast engorgement is actually better described as an inflammatory reaction in the breasts due to increased blood flow. The breasts are a highly vascular organ, comprised of delicate connective tissue interlaced with innumerable and largely microscopic milk ducts, blood vessels, lymphatic vessels, and nerves.

Predictable postpartum hormone shifts cause a significant increase in blood flow to the breast tissue. This often leads to vascular congestion in the breasts, causing areas of swelling and firmness, severe breast pain, breast warmth, overlying skin redness, and even a feeling of fever or chills.

Mismanagement:

The standard advice for breast engorgement and supposed plugged ducts is to apply heat, massage and unnecessarily pump more milk to ’empty’ the breasts. This leads to further up-regulation of milk production, increased vascular congestion, and breast tissue trauma and inflammation. The inflammation leads to even more breast swelling and pain. This in turn causes the mother to massage and pump more, thereby increasing swelling and inflammation. And so the cycle  continues.

In the best case scenario, the swelling of the nipple, areola, and underlying breast tissue frequently causes new or worsening latch difficulties several days after birth. If the mother is lucky and the engorgement is mild, the swelling, latch issues, and nipple and breast pain may resolve over a few days.

“Breast engorgement is actually better described as an inflammatory reaction in the breasts due to increased blood flow.”

In the worst case scenario, pumping and firm massage cause more trauma, swelling, and excess milk production. Severe swelling puts pressure on the surrounding tiny milk ducts, making it impossible for the milk to be expressed from the breasts. This can even lead to recurrent ‘plugged ducts’ in the first weeks postpartum. The underlying vascular congestion can cause overlying redness, warmth, and systemic chills – this is often misdiagnosed as infectious mastitis when it is really due to inflamed breast tissue. Continued massage and pumping may eventually lead to actual infectious mastitis, a breast tissue phlegmon, and even a breast abscess. Of note, the highest risk of these worst outcomes is in women who are predisposed to hyperlactation and those with perinatal mood and anxiety disorders (PMAD).

Patient Friendly Explanation:

Several days after your baby is born, your hormones shift and cause more blood to flow to your breasts. This helps with bringing in your mature milk. Unfortunately, this also often causes inflammation and painful breast swelling called engorgement.

This swelling can make it hard for your baby to latch deeply enough. This can lead to nipple pain, trauma, and even wounds. If you had a rocky start, the latch and nipple pain may worsen further at this point. Or if things went well the first few days, then this may cause new issues with latch and nipple pain when you least expected it.

Engorgement does not occur due to having too much milk in your breasts, so pumping more and more milk to empty your breasts won’t fix the problem. In fact, following common advice to pump more and firmly massage the breasts can make the situation worse.

Proper Care:

Luckily there are simple measures lactating parents can take to prevent and easily treat engorgement during the first week postpartum.

1. Feed your baby! 

If your baby is nursing well, then nurse them at LEAST every 3 hours during the first few weeks after birth.

If you have a lot of discomfort with engorgement, then it is ok to occasionally hand express a tiny bit of milk to ease the pain. This should be done cautiously. You are not trying to ‘empty’ the breasts fully. A hand-operated pump can also be used the same way. I am very cautious with electric pumps and silicone milk collectors used for these purposes, a topic I will be sure to discuss in the future

You do NOT need to start pumping more than your baby needs to drink unless you are directed to do so by a physician with expertise in managing lactation.

Of course, if your baby won’t or can’t nurse well directly (for example due to being separated from you or due to problems with latch and suck), then you will need to express milk every 2-3 hours to get the normal amount your baby needs to drink.

2. Take your anti-inflammatory. 

If your physician or healthcare provider says it is ok for you to take a medicine like ibuprofen, then use it regularly during the first weeks postpartum. This helps pain and also decreases the inflammation in the breast that comes with engorgement.

Acetaminophen can also be used to relieve any pain (if your physician says this is ok for you to take).

3. Therapeutic lactation massage

By barely stroking and tapping the breast or chest, you help move out the fluid that causes the swelling to build up. Beware – this is NOT a massage like you would do on your muscles – that type of vigorous massage can actually WORSEN the swelling! This is a gentle, barely touching the skin technique.

This video by Maya Bolman, RN, IBCLC shows how to do the lymphatic drainage type breast massage that I recommend.

Do this at least every couple of hours as soon as the feeling of fullness and swelling begins. This can help to decrease the swelling, making it easier for the baby to latch and get milk out.

This gentle technique is amazing. It is NOT a firm massage of the breast tissue. It is the lightest touch, much like stroking a cat. Avoid any pressure that causes pain. Do not firmly push or massage the breasts. Do not apply deep vibration to the area of discomfort.

4. Use gravity to help

Laying back at a 45 degree angle can help drain the fluid away from the breasts and chest while you do the gentle lactation massage above.

5. Cold packs

Place frozen wet towels, ice packs, or even bags of frozen vegetables on and around your breasts or chest. Use a thin cloth between your skin and the ice to prevent damaging the skin. This helps to decrease the swelling and can be done between feedings, whenever you feel swelling or pain.

6. Gentle heat before nursing

Warm compresses placed around the breast just before nursing or expressing milk can help your milk ‘let down’ or come out more easily. You do not need to apply heat except right before nursing. Be sure to test any heat on your cheek before placing it on your breast and chest skin – we don’t want a burn!

7. Wear a comfortable, supportive bra

Do not wear an overly tight bra that compresses the breast and chest tissue. This can lead to worsened swelling of the breast tissue, causing the problem to escalate. Even if you want to stop lactating, it is not a good idea to compress the breast tissue in this way.

8. Get help with latching your baby and/or expressing milk
Lactation may be natural, but that doesn’t mean it is easy. Pain with nursing or pumping is common but it is not normal and should NEVER be ignored.

Seek help quickly if you are having any problems. There are many techniques a Lactation Consultant, Breastfeeding and Lactation Medicine physician or other lactation professionals can show you to help make things easier.

9. If things get worse, seek help!

If the swelling and pain is not improving with the above tips, do NOT start massaging harder even though it’s tempting! Instead, seek care from a breastfeeding medicine specialist. They will do a full in person exam and evaluation to determine what is making your case more severe, as well as whether specialized techniques such as therapeutic ultrasound nay be of benefit.