Engorgement

Note: New research has changed our understanding of engorgement, and the treatment recommendations changed in 2022. However, many sources on the internet have not been updated. These are the newest guidelines! You may still find older advice from other sites.

Engorgement refers to swelling and tenderness of the breasts during the first few weeks after delivery. This is an excellent sign of a good milk supply! Some women experience only fullness or mild discomfort, and others have more severe symptoms. It is manageable and will get better in a few days.

What causes engorgement?

Swelling and tenderness of the breasts due to milk production and accumulation is common, especially during the first week or two. During pregnancy, the breasts are already making colostrum (which would be perfect if the baby was born then)! As soon as the baby is born, hormones cause the breasts to shift into high gear to make more colostrum and transition to mature breast milk.

Blood rushes into the breasts along with fluid causing swelling and edema. The glands enlarge as they ramp up production. The breasts start to make milk which is stored in the glands. The breasts often make extra milk at first and then adjust to your baby’s intake, especially if it is your first baby.

Early engorgement may also be caused by extra body fluid in the breasts (edema), which may be influenced by intravenous (IV) fluids given during labor and may be worse after Cesarean delivery.

It usually occurs 3-5 days after birth as your milk starts to “come in.” Both breasts will feel heavier, firmer, and warmer and usually feel lumpy and a little tender. This is normal and means you have reached stage 2 of milk production. This fullness does not usually last more than a day or two if you feed or express your milk at least eight times a day. It may occur 1-2 days later after Cesarean delivery.

While all women tend to have some engorgement, some have more significant fullness with hard and painful breasts. In addition to the discomfort, engorgement can cause swelling around the nipple, making it harder for your baby to latch. More severe engorgement can cause low-grade fever and poor milk flow, which may lead to mastitis.

It may be worse in the morning with longer periods between feedings or if a feeding is missed or skipped.

Treatment

The primary treatment for engorgement is to follow good breastfeeding practices that also help to ensure a well-fed baby and a good milk supply.

If possible, do skin-to-skin after delivery and breastfeed during the first few hours of life.
Feed your baby or hand express your milk at least eight times a day, around every 2 hours. Many babies do not nurse very often on the first day; hand expression is essential to keep your milk moving. Rooming in makes feeding on demand easier. You can also use a hand pump.
You can express milk with your hands while taking a warm shower or express it into a cup or spoon and feed it to your baby. It is OK to express to relieve pressure; it won’t cause you to make extra milk. It is also fine to express in the shower; don’t feel guilty. You don’t have to save every drop; more is coming! You can use a hand pump to express, but don’t use an electric pump now.
Use acetaminophen or ibuprofen for pain control if needed.
You can also relieve some symptoms by applying cool or ice packs to your breasts between feedings. Many women have found that packages of frozen vegetables, such as peas, wrapped in a towel work well.
Cold cabbage leaves are often recommended; however, research shows they do not work better than ice packs.
Wear a bra with extra support. Make sure that it is not too tight. Wear it 24 hours a day while engorgement is an issue. Avoid bras with underwires.
Make sure your baby is latching correctly. Seek help if there seem to be latch problems. Engorgement itself can cause latch problems; removing some milk with hand expression or a hand pump and reverse pressure softening may help decrease swelling around the nipple and improve the latch.
Avoid nipple shields.
Don’t try to drain the breasts. Don’t overfeed or pump beyond what your baby needs right now.
Lymphatic drainage may help.

Latch problems caused by engorgement

Engorgement can cause swelling around the nipple, effectively making your nipple shorter and more difficult for your baby to get a good latch. This can worsen the problem because your breasts are not emptying as well. It can also cause painful latch and nipple trauma.

If swelling is making it hard for your baby to latch, hand express or pump a little to soften the area before nursing. Gently compress the areola between your fingers to make it easier for your baby to latch.

You can also use a technique called reverse pressure softening: take your fingers and press back on the areola around the nipple for about 30 seconds, then move to a different spot around your nipple. Do this all the way around to push the fluid back and restore the shape of your nipple.

If there is so much swelling that feeding and expression are difficult, you can feed from the other breast, then apply an ice pack to the more swollen breast and feed once the swelling decreases enough. Lymphatic draining may also help.

Preventing engorgement

Feed your baby frequently, at least eight times a day after the first day.
Avoid pacifiers the first few weeks (and feed your baby instead).
Don’t feed according to a schedule at first; follow your baby’s feeding cues.
Feed your baby overnight.
Don’t pump to save milk right now. Only feed and pump what your baby needs right now.

When to seek further care

See your lactation consultant or health care provider if:

Engorgement is not relieved by these treatments or is getting worse.
Pain is getting worse.
You develop a fever (100.4 or higher) or feel sick.
Your baby has trouble latching, is not gaining weight well, or has decreased wet or poopy diapers.
You are developing nipple pain, trauma, cracking, or bleeding.
You are not sure your baby is latching correctly and can transfer milk.
You have any other questions or concerns.

References

Mitchell KB, Johnson HM, Rodríguez JM, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeeding Medicine. 2022;17(5):360-376. doi:1089/bfm.2022.29207.kbm
Zakarija-Grkovic I, Stewart F. Treatments for breast engorgement during lactation. Cochrane Database of Systematic Reviews. 2020;(9). doi:10.1002/14651858.CD006946.pub4
Berens P, Brodribb W. ABM Clinical Protocol #20: Engorgement, Revised 2016. Breastfeeding Medicine. 2016;11(4):159-163. doi:10.1089/bfm.2016.29008.pjb