Your Full Guide to Breast Engorgement

Beast engorgement remains one of the biggest reasons why mothers seek the assistance of a lactation consultant.

Please note that this is part of our series on ‘ The Updated Protocols on Engorgement, Mastitis and Breast Tissue Complications’. Please click here to visit the main article in the series, which explains the how’s and why’s. This feature will also give you access to all our other supportive content.

Engorgement is a term used for any type of breast fullness and swelling.  It is a symptom of mastitis, but you may also experience engorgement without having mastitis yet. 

The signs and symptoms of breast engorgement include:

• • Breasts that feel full, heavy and tender.

• • Your breasts may feel warm and throbbing.

• • Your skin may be stretched tight and appear shiny.

• • In severe engorgement the nipple and areola will also be hard, and baby may be unable to draw it into his mouth for a proper latch.

• • It may affect only one or both breasts.

• • It can involve the whole breast, or certain areas of the breast.

• • It can occasionally extend into the armpit area.

We explain two ‘types’ of engorgement

• • Primary engorgement, which occurs in the early days of breastfeeding, occurs equally in both breasts, and is considered a physiologically normal event.

• • Secondary engorgement which occurs after a period of comfortable feeding.

Primary Engorgement – Normal physiological engorgement in the first week of feeding

Technically this type of engorgement is not quite the same as the type causing all the problems. But the treatment is the same.

During pregnancy the placenta manufactures the hormones progesterone and oestrogen. These hormones suppress the hormone prolactin that is responsible for making breast milk. And with good reason – you don’t need milk if your baby is not born yet.

After birth your breasts contain colostrum. This amazing substance is concentrated and strong, and only a few milliliters are sufficient to fulfil baby’s needs.

With the placenta out of the way, prolactin levels will rise and your breasts can start making your normal breast milk. In addition to milk production starting there is also a rapid increase of blood flow to the breasts. Lymphatic drainage becomes overwhelmed and there will be some swelling of the breast tissue.

This initial ‘coming in’ of milk happens 3-4 days (or 72-96 hours to be exact) after delivery. Sometimes this can take longer (up to 7 days), especially after a caesarean section where this initially process may be delayed (although not uncommon you should contact a lactation consultant  to ensure that you are managing this phase correctly).

Your milk will come in whether you are breastfeeding baby or not. Mothers who are not going to breastfeed will be given a tablet to stop this process.

In the early days of feeding, you need to establish breast milk production. By feeding baby on demand, you give your body queues of how much milk to produce. This will take a few days to settle.

And therefore fullness 3-4 days after birth is completely normal. In fact, it shows that everything is working as it should. And if baby is latching and sucking well, and feeding on demand, it will clear within 12-48 hours.

When is primary engorgement abnormal?

Sometimes engorgement can go beyond what is considered physiologically normal. The following signs show that you need more specialized help; follow our tips, but if it doesn’t improve you should see a lactation consultant as soon as possible to prevent longer-term breastfeeding difficulties.

• • If your breasts are so hard and full that baby is unable to latch.

• • If your breasts don’t feel substantially emptier after a feed (this means baby is not effectively draining the breast and that there may be a latching problem).

• • If you have a lump or area in the breast that stays hard or keep coming back.

• • If you have fever, or other symptoms of mastitis. 

• • If none of the below tips seem to help (in which case you may actually be suffering from breast oedema and not engorgement).

Factors that complicate normal, primary engorgement

Most of these are linked to infrequent and ineffective milk removal.

• • If for whatever reason your baby is not latching – read our guide on what to do if a newborn refuses to latch.

• • If baby is latching incorrectly, which can also lead to baby not emptying the breast well. The biggest sign of an incorrect latch is nipple pain. You can read our complete guide to nipple pain for more information. 

• • Oral structure problems like tongue and lip ties in baby.

• • If baby is sleepy and not feeding well. This can be due to pain medication given to mom during labour, or to prematurity, jaundice or an infection.

• • If you are feeding baby on a schedule instead of on demand, or if you are limiting time spent on the breast.

• • Using a dummy to ‘stretch’ times between feeding sessions.

• • Giving baby formula top-ups (which will reduce the amount of milk that baby takes from the breast).

• • If you are expressing (for example for a baby in NICU) but using a faulty pump or an ill-fitting flange (see our guides on how to choose a breast pump and on how to measure your flange size).

• • Wearing tight-fitting underwear that restricts milk flow (see our Carriwell range for excellent quality underwear that provides support without restriction).

• • Occasionally previous breast surgery may lead to some areas of the breast not draining well.

Secondary Engorgement – Engorgement after a period of comfortable feeding

Sometimes a mom may develop full breasts after weeks or months of comfortable breastfeeding. This usually has a definite cause, for example:

• • Skipping feeds due to a busy schedule (often happens on holiday or while traveling as people’s normal routines and patterns are disrupted).

• • Baby suddenly sleeping through the night.

• • A physical restriction, like wearing an underwire bra or spending the whole day with a handbag/laptop bag’s strap putting pressure on the breast area.

• • A malfunctioning breast pump – check your valves and other parts; if a pump suddenly stops working it often is due to a tear in a silicone part, or due to a valve no longer sealing well. There may also be something wrong with the pump’s motor. You can contact one of our Breast Pump Demo Centres for assistance.

How to manage breast engorgement

It is important to manage engorgement well from the very start, so be sure to follow the below tips. Not treating it correctly can lead to mastitis. It can also affect your milk supply.

As mentioned on the main page of our series, the 2022 ABM protocol on mastitis and engorgement has drastically changed how we manage these conditions. As these guidelines were only published in 2022, moms are guaranteed to still get incorrect information from healthcare professionals and the internet for years to come.

New guidelines on managing engorgement

• • Breast rest – the fullness that you are experiencing is not due to milk ‘stuck’ in your breasts. It is also due to swelling, blood flow, and inflammation. Continuously feeding and expressing will not drain the breast, but will rather overstimulate further supply and may worsen symptoms. Feed baby as usual, or pump just what your baby needs (if you are exclusive pumping). Allow the breast to rest in-between.

• • Apply ice to your breasts – you can wrap ice in a cloth, use frozen veggies in a plastic bag, or use a sports ice pack. Do this as frequently as possible, throughout the day. Do not put ice or a frozen ice pack directly on your skin. If you find the cold really difficult to cope with (especially on colder days), hold a warm water bottle or heat pack somewhere else against your body, away from your breasts (like your lower back). Ice to your breasts is one of the key treatment methods for engorgement and mastitis as it calms down inflammation and swelling, enabling milk to flow. 

• • If your areolas are too hard and tight for baby to latch you may need to first hand express a bit, or do reverse pressure softening.

• • You can try changing the position in which you hold baby; sometimes baby can empty the breast more effectively from the different angle offered by another feeding position. However, ultimately you should use the position most comfortable to you, and the position in which baby latches best.

• • Breast massage is no longer recommended. In fact, it is the one treatment method that will cause most harm to your engorged breasts. Instead, what you want is to increase lymphatic drainage. This is a different massage method aimed at reducing the swelling in-between your breast glands and milk ducts that are causing all the discomfort. Click here to read more on what happens when you massage engorged breasts, and click here for advice on lymphatic drainage.

• • I personally recommend gently applying Natura’s Arnica Gel or Heel’s Traumeel Gel to your breasts – these are homeopathic remedies and are safe to use in breastfeeding. Do not let the gel come onto your nipples.

• • Natura’s tissue salts number 4, 9 and 12 is a fantastic mix to encourage milk flow and prevent/treat mastitis. Use a tablet of each tissue salt every hour until you feel relief, and then gradually reduce it to three times a day.

• • Use an anti-inflammatory medication like ibuprofen to relief pain and inflammation. You can add paracetamol for further relief.

• • Use a sunflower lecithin supplement, as this is a natural fat emulsifier that can help to reduce the “stickiness” of the milk and deter fats from lumping together.

• • Rest in bed (as you are probably also not feeling too great), eat well and drink enough fluids.

Traditional advice that is no longer recommended

• • Applying heat in the form of compresses, warm showers and warm water soaks. This will simply worsen swelling and inflammation.

• • Any form of massage to get rid of plugs and clogs.

• • Applying saline soaks or castor oil to the skin. 

• • Trying to empty the breast through pumping – this often doesn’t empty much and simply stimulates even more supply. 

• • Using any form of vibrating device like a breast massager, an electric toothbrush or a vibrator.

• • Dangling over baby or feeding baby in any other unusual position. Rather just choose a position comfortable to you and baby.

• • Using silicone milk collectors to drain the breast – this will once again increase supply and may cause additional swelling.

• • Applying cabbage leaves to the breasts – there is no evidence that this will work better than ice packs, and it carries the risk of listeria infections.

Should your symptoms not clear in 2-3 days you should consider seeing a lactation consultant. You are welcome to contact us on info@allthingsbreastfeeding.co.za for more support of to help you find a lactation consultant in your area.

You are also welcome to contact us on info@allthingsbreastfeeding.co.za for more support of to help you find a lactation consultant in your area.

Read more

More info by La Leche League (always a fantastic resource) – https://www.llli.org/breastfeeding-info/engorgement/

Reverse pressure softening – https://kellymom.com/bf/concerns/mother/rev_pressure_soft_cotterman/

The physician’s guide to engorgement: https://physicianguidetobreastfeeding.org/engorgement/