ABM Clinical Protocol #20: Engorgement, Revised 2016

Abstract

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Purpose

The Purpose of this protocol is to evaluate the state of evidence as to the prevention, recognition, and management of breast engorgement to encourage successful breastfeeding.

Background

Engorgement has been defined as “the swelling and distension of the breasts, usually in the early days of initiation of lactation, caused by vascular dilation as well as the arrival of the early milk.” The concept put forward by Newton and Newton in 1951 suggested that alveolar distension from milk then led to compression of surrounding ducts, which subsequently led to secondary vascular and lymphatic compression. Some degree of breast fullness in the second stage of lactogenesis (secretory activation) is considered physiologic and should be reassuring for the mother and healthcare provider that milk is present. A recent study suggested considering distinguishing between “breast engorgement” and “breast edema” although both may cause significant issues for mothers and infants in the postpartum period. (II-2) (Quality of evidence [Levels of evidence I, II-1, II-2, II-3, and III] is based on the U.S. Preventive Services Task Force Appendix A Task Force Ratings and is noted in parentheses.) Breast edema is fluid accumulation in the interstitial space caused by generalized fluid accumulation late in pregnancy or as a result of large amounts of intravenous fluids during labor and may be responsible for edema around the areola and nipple. (III, III).

Engorgement symptoms occur most commonly between days 3 and 5 postpartum, with more than two-thirds of women experiencing tenderness by day 5, but the onset may be as late as days 9–10. (II-2, III) In the 2008 Infant Feeding Practices Survey, 36.6% of women reported overly full breasts within the first 2 weeks postpartum, while other studies indicate that up to two-thirds of women experience at least moderate symptoms of engorgement. (III) The incidence of engorgement may depend on breastfeeding management within the first few days following birth. Engorgement occurs less commonly when infants spend more time breastfeeding in the first 48 hours (III) and when mother and infant are rooming in. One difficulty when evaluating incidence and treatment options for this condition involves the spectrum of engorgement, from expected physiologic breast fullness through to severely symptomatic engorgement. In addition, more optimal lactation management and support that are available in some healthcare facilities may reduce the frequency of significant symptoms compared to less supportive environments.

Assessment of Engorgement