Breast Engorgement

Breast engorgement is painful swelling and hardness of both breasts caused by milk accumulation, increased blood flow and tissue oedema, when milk comes in on days 3 to 5 after birth or when feeds are missed. It is common in breastfeeding women, and it also occurs in women who do not breastfeed. It matters because it makes latching hard, reduces milk transfer and can progress to blocked ducts and mastitis.

• Risk factors: delayed or infrequent feeding, poor latch, scheduled feeds, supplementation, separation from the baby, abrupt weaning, oxytocin or IV fluid overload in labour, caesarean section.
• Peaks at days 3 to 5 and settles within 24 to 48 hours with good milk removal.
• Fever up to 38.4 degrees Celsius can occur without infection.

Women have firm, full, warm, tender and sometimes shiny breasts with a flattened nipple that makes latching hard, and mild fever. Both breasts are usually affected.

• Diffuse swelling and tenderness without a red wedge.
• Low grade temperature below 38.5 degrees Celsius.
• Differential diagnosis: mastitis, blocked milk duct, breast abscess, galactocele, normal breast fullness, breast cellulitis, inflammatory breast cancer, tuberculous mastitis.
• Complications: blocked ducts, mastitis, breast abscess, nipple damage, early weaning, low milk supply.

The diagnosis is clinical, with a check of feeding technique.

• Inspect both breasts for redness, swelling and nipple shape; palpate for wedge-shaped lumps and fluctuance.
• Observe a feed for latch, positioning and swallowing; check infant weight and wet nappies.
• Temperature and pulse to separate engorgement from mastitis.
• Breast ultrasound only if a lump persists after 48 hours or fluctuance is present.

The principle is to remove milk frequently and relieve pain until swelling settles, with suppression of lactation only if breastfeeding is not planned.

• Supportive: feed 8 to 12 times in 24 hours, starting on the less painful side; softening before feeds by warm compress or warm shower for 3 to 5 minutes and hand expression of a small amount; reverse pressure softening (pressing around the nipple with fingertips for 1 to 2 minutes) to help latching; cold compresses or chilled cabbage leaves for 15 to 20 minutes after feeds; well-fitting, nonrestrictive bra; gentle massage toward the nipple; express to comfort after feeds for 5 minutes only.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); ibuprofen 400 mg oral 8-hourly with food for 3 to 5 days if no contraindication; for women who are not breastfeeding or have lost the baby: cabergoline 1 mg oral as a single dose within 24 hours of birth, or 0.25 mg oral 12-hourly for 2 days.
• Procedures: none.
• Special groups: women who do not breastfeed (stillbirth, neonatal death, medical reasons) have a supportive bra, cold packs, paracetamol and ibuprofen, with cabergoline unless they have hypertension, preeclampsia or heart disease, and avoid expressing milk because it prolongs lactation.
• Red flags: fever above 38.5 degrees Celsius for more than 24 hours, wedge-shaped red area, fluctuant lump, pus from the nipple, chills, no improvement after 48 hours, infant not feeding.
• Follow-up: review at 48 hours by phone or visit; review at 1 week with infant weight; referral to a lactation counsellor if feeding remains difficult.