Treating breast engorgement

What should I do if I am engorged?

Breast engorgement should be treated as soon as possible. Treatment starts with effective breastfeeding. Mothers should make sure the nipple root is soft, using massage if necessary, and breastfeed using proper positioning. Breast massage and expression are then used to decrease swelling and further empty the breasts. Cool compresses help reduce swelling and pain between feeding times. Various products are marketed for this, but our clinic has found the best cool compresses are green cabbage leaves. Mothers can also use pain medication if needed. If babies cannot breastfeed, mothers need to express and supplement their babies.

A) Describing the treatment of breast engorgement

Breast engorgement is a sign that breastfeeding is not effective or that a mother is not expressing effectively. This allows milk to accumulate and causes inflammation which increases the amount of lymph, a watery, clear fluid that is similar to blood but does not contain red blood cells. Breast milk, inflammation, and lymph combine to make the breast firm and tender (engorgement).

1) Describing the breast lymphatic system  

The lymphatic system is a passive system that has one-way valves and relies on external pressure from muscles and joints to help lymph move around the body. Most breast lymph flows upwards and outwards, through the armpit, but as much as one quarter leaves upwards along the breast bone (sternum) (Estourgie et al. 2004).

Many of the tubes of the breast lymph system are superficial and light touch is sufficient to move the lymph along.

2) Treatment overview

Treatment should be started as soon as possible as untreated engorgement can lead to breast pain, nipple pain and damage, latching problems, a low milk supply, or a breast infection (mastitis or an abscess).

There is little research on the best way to treat engorgement (Zakarija-Grkovic 2020).

Based on the experience at our clinic, we recommend:

  1. Effective breastfeeding or if not possible, effective expressing.
  2. Breast massage, expression, or both to soften the breast after feeding.
  3. Cool compresses between feeds.
  4. Pain medication such as acetaminophen or ibuprofen with the latter also acting as an anti-inflammatory. The latter has the added benefit of also acting as an anti-inflammatory.

Treated breast engorgement settles in one to two days. Untreated engorgement can last up to one week as the body needs this time to clear the milk and the inflammation.

B) Effective breastfeeding

Treatment of engorgement starts with effective breastfeeding. Mothers who are not breastfeeding should ensure they are expressing regularly and effectively.

1) Make sure the nipple root is soft

If a pinch test shows the nipple root is firm, it must be softened. Options include:

We have found that nipple root massage is the quickest and most effective method.

2) Breastfeed

Proper positioning with the sandwich technique to latch the baby can be helpful. Mothers can also try the laid-back hold.

3) Address latching problems

If the baby cannot latch, this must be addressed. If the baby cannot breastfeed, mothers need to supplement the baby.

C) Breast massage and expressing

Mothers can soften their breasts by:

  1. Expressing.
  2. Breast massage.
  3. Combining the two.

The choice should be based on how well each one works. Ideally, both breasts are softened within 30 minutes. Massage can be done by another person such as a partner or a health-care provider (Witt 2016).

1) Breast massage

Breast massage can:

  • Stimulate a let-down to move milk towards the nipple.
  • Push excess milk out of the breast through the nipple.
  • Push lymph into the lymphatic system and away from the breast.

Breast massage can be done by:

  1. Gentle, steady pressure on the breast.
  2. Gently stroking using the thumb and fingers coated with a small bit of cooking oil:
    1. Towards the nipple.
    2. Towards the armpit.
    3. Upwards and towards the middle of the chest.

We recommend any stroking should start towards the nipple. Stroking towards the armpit and upwards and towards the middle of the chest can be used for remaining fullness.

The pressure is similar to pressures used to apply lotion or stroke a pet. Pain can impair the let-down and should be avoided.

Pressure is applied for five seconds and then released. Similarly, each stroke should take about five seconds. The hands are moved around the breast as it softens.

Most mothers will leak significant amounts of milk while massaging effectively. This helps to empty the breast but can be messy. To prevent this, the milk can be caught in a bowl or towel.  

2) Combining massage and expression

Mothers may benefit from using both breast massage and expression after breastfeeding and can:

  1. Alternate a little massage and a little expression (manual expression or pumping)
  2. Massage first and then express.
  3. Express first and then massage.

They should choose approach that is the most comfortable, effective, and quick. 

One example of combining massage and expressing is as follows:

  1. Gently massage the breast for about five seconds, then release.
  2. Only use as much pressure as is comfortable.  
  3. Massage ten times; this should take about one minute.
  4. Monitor the breast’s response to see which technique is most effective at softening and when to change the location of the hands on the breast.
  5. Express until the milk no longer runs quickly. 
  6. Continue alternating massaging and expressing.
  7. Stop if:
    1. Your breast is not softening.
    2. Your breast is soft.
    3. Fifteen minutes have passed.
    4. It causes more than mild discomfort.
  8. Use the same technique on the other breast.

If milk does not flow with expression, mothers can lightly tap the breast with fingertips around the areola or use other ways to improve their let-down.

a) Therapeutic breast massage

Therapeutic breast massage is a combination of light massage towards the armpit with manual expression. It has been reported to treat swelling caused by breast engorgement, a plugged duct, mastitis, or a breast abscess (Witt 2016).

In theory, massaging towards the armpit should help roughly three quarters of the lymph drain. It may not help the remaining quarter that needs to flow along the breast bone. If mothers notice fullness in the inner sides of the breast, they may wish to massage that area upwards and towards the centre of the chest.

D) Other options to remove milk

Some mothers cannot express if they are very engorged, because their let-down is not effective.

Mothers can consider a warm water breast bath in a constant-suction pump. This is done using a constant-suction pump filled with warm water. When the pump is attached to the breast, the nipple and central areola sit in warm water. This method uses the comfort of warm water to relieve pain and bring on a let-down and the suction created by the pump to draw out the milk. It can also draw out the nipple and soften the nipple root. This is very gentle and, when done properly, is unlikely to add to a mother's pain.

Other options to remove milk include:

  • Using other ways to obtain a let-down and get the milk to flow.
  • Expressing one breast while breastfeeding on the other.
  • Adding breast compression while expressing.

E) Apply cool compresses after breastfeeding, expression, and massage

Green cabbage (Photo by C Drying on Unsplash)

Cool compresses are used between active treatment sessions. They are very helpful in reducing swelling and relieving pain. There are a number of products marketed for this, but research supports the use of green cabbage leaves (Akanksha 2019; Arora 2008; Boi 2012; Wong 2017). Seriously!

1) Reasons for using green cabbage

Cabbage leaves:

  • Are cool but not cold.
  • Have no risk of frostbite.
  • Do not create condensation.
  • Have the right shape.
  • Have no sharp edges.
  • Are cheap.
  • Are easily available.
  • Are unlikely to cause a skin reaction.
  • Are biodegradable.

Cabbage leaves can:

  • Decrease swelling.
  • Decrease pain.
  • Increase how long mothers breastfeed.

Concerns have been raised that cabbage leaves will result in a low milk supply, possibly through absorption of cabbage compounds through the skin. There is no evidence to support this.

2) How to use green cabbage compresses

To use green cabbage leaf compresses:

  1. Use plain green cabbage (also known as cannon ball cabbage) and not Savoy or curly cabbage.
  2. Rinse the leaves thoroughly with cool, clean water before use.
  3. Gently shake dry.
  4. Cut out the harder veins or soften them by crushing them with a knife, mallet, or rolling pin.
  5. Keep the cabbage in the fridge until you are ready to use it.
  6. Put the leaves on the breast, and not on the nipple, in a single layer, and cover them with a bra.
  7. Remove the cabbage once it is wilted, which is usually after one to two hours.
  8. Replace it with fresh cabbage.
  9. Continue until your breasts are softened and comfortable.

Do not use cabbage if you are allergic and stop using it if you develop a rash.

F) Breast reduction and other aggressive breast surgery

Mothers who have had breast reduction, abscess, or other aggressive surgeries may struggle with engorgement on Days 3 to 6 after birth.

If the ducts are cut during surgery but the milk tissue is still present, the milk can’t get out and mothers may notice painful, lumpy areas.

Expressing or breastfeeding won’t empty these areas, because they can’t drain. The body will reabsorb the milk within a week. In this situation:

  • Cool compresses are usually the most effective treatment.
  • Massage to clear lymph can help if there is swelling. However, just like milk ducts, lymph ducts may be damaged and lymph removal can be delayed or difficult.
  • Pain medication may help.

References

Akanksha Y, Kavitha MPJ, Nageshwar V. Effectiveness of Cabbage Leaves Application on Breast Engorgement: Narrative Review. Indian Journal of Public Health Research & Development 2019;10(4):82-85
 
Anderson L, Kynoch K, Kildea S. Effectiveness of breast massage in the treatment of women with breastfeeding problems: a systematic review protocol. JBI Database System Rev Implement Rep. 2016 Aug;14(8):19-25
 
Arora S, Vatsa M, Dadhwal V. A Comparison of Cabbage Leaves vs. Hot and Cold Compresses in the Treatment of Breast Engorgement. Indian J Community Med. 2008 Jul;33(3):160-2

Boi B, Koh S, Gail D. 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
 
Estourgie SH, Nieweg OE, Olmos RA, et al. Lymphatic drainage patterns from the breast. Ann Surg. 2004 Feb;239(2):232-7
 
Witt AM, Bolman M, Kredit S, et al. Therapeutic Breast Massage in Lactation for the Management of Engorgement, Plugged Ducts, and Mastitis. J Hum Lact. 2016 Feb;32(1):123-31
 
Wong BB, Chan YH, Leow MQH, et al. Application of cabbage leaves compared to gel packs for mothers with breast engorgement: Randomised controlled trial. Int J Nurs Stud. 2017 Aug 31;76:92-99

Zakarija-Grkovic I, Stewart F. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev. 2020 Sep 18;9:CD006946